DSM-IV TRSchizophrenia & Other Psychotic Disorders

Siva Devarajan

Associate Professor of Psychiatry

University of Western Ontario

Schizophrenia & Other Psychotic Disorders

295.XX Schizophrenia

.30 Paranoid Type

.10 Disorganized Type

.20 Catatonic Type

.90 Undifferentiated Type

.60 Residual type

295.40 Schizophreniform Disorder

295.70 Schizoaffective Disorder

297.1 Delusional Disorder

298.8 Brief Psychotic Disorder

297.3 Shared Psychotic Disorder

293.XX Psychotic Disorders due to GMC.81 with Delusions.82 with Hallucinations

(. . .)Substance induced Psychotic Disorders

(Refer to substance specific codes)298.9 Psychotic Disorders

NOS

DSM-IV TR

Psychotic Symptoms- Presence of Delusions and Hallucinations- Severely disorganized behavior, speech and thought- Also occurs in Mood Disorders- May be associated with substance use- May be due to medication side effects- May be due to Delirium, GMC

DSM-IV TR

DSM-IV-TR Criteria for Schizophrenia 295.XX

A – Characteristic symptoms - *two or more of the following, one month, less if treated:

1. Delusions2. Hallucinations3. Disorganized Speech4. Disorganized or Catatonic Behavior5. Negative symptomsB – Social/Occupations Dysfunction*One or more areas of functioning, work, self care or interpersonal relationship.C – Duration- continuous signs of disturbance for six months- Continuous criteria for a month, less if treated- May also include Prodromal / residual symptoms

DSM-IV-TR Criteria for Schizophrenia (Cont’d)

D – Schizoaffective and mood disorder exclusion- if present, duration is very brief

E – Substance and GMC exclusion

F – Relationship to PDD- Diagnosis of schizophrenia made if criteria A is met.

DSM-IV-TR Diagnostic Criteria for Schizophrenia

Classification of Longitudinal course (at least one year has elapsed since the initial onset)

- Episodic with Interepisode Residual symptoms- As above, with prominent negative symptoms- Episodic with no interepisode residual symptoms- Continuous with or without negative symptoms- Single episode – Full/partial remission- Single episode - with or without negative symptoms- Other or unspecified pattern

DSM-IV-TR

Subtypes of Schizophrenia- Pure types are less common- Mixtures of symptoms more common- Catatonic type – rare- Disorganized type *speech, behavior, affect- Paranoid type *diagnosis of exclusion- Undifferentiated type- Residual type

Case Study

- Young female, poor functioning- Lives with parents, unemployed- Two previous hospitalizations- Antipsychotics recently reduced- Can control behavior of others- Others can read her mind and being watched- Multiple voices, threatening in nature- Low energy, motivation, unable to think- Unable to care for herself- Depressed, decreased appetite and sleep

DSM-IV-TR

Case Study (Cont’d)

- Enemy knew her thoughts- She could control other

people’s activities- Thoughts were “stopping in

mid stream”- Mind was “going blank”- Felt listless, depressed,

unable to concentrate- Social contacts parents and

boyfriend- Symptoms responded to

Trifluoperazine

- readmitted following non-compliance

- Overtly suspicious- Felt threatened by voices- Sad, exhausted, unable to

enjoy anything- Chronically apprehensive

“incapable of working”- Symptoms responded to

Trifluoperazine- Returned home with parents- Switched to Risperidone as

an outpatient

DSM-IV-TR

DSM-IV-TR Diagnosis

Axis I – 295.30 – Schizophrenia, Paranoid typeInterepisode Residual SymptomsDepressive Disorder – NOS

Axis II – V71.09 – No diagnosisAxis III – NoneAxis IV - ? Less contact with BFAxis V – GAF 30

DSM-IV-TR

DSM-IV-TR Criteria for Schizophreniform Disorders

A Criteria A, D and E of schizophrenia are metB Episode last *one month to six months (provisional or

not). - without good prognostic features

- with * good Prognostic features (two or more)1. Absence of blunted or flat effect2. Good premorbid features3. Confusion on perplexity at the height of episode4. *onset of psychotic symptoms within 4 weeks

( behavior or functioning). DSV-IV-

TR

Case History

30 year old lawyer –Disheveled, hypervigilant, easily startled.Seems to be responding to voices.Has been well until 3 months ago.Excellent vocational and social activity.GF broke up recently, began to follow her.Problems with attendance, punctuality,

productivity.Criticized by his boss.Thought he was unduly criticized and

humiliated.Voices “faggot”, “a jerk off”.Convinced office staff were scheming

against him.Believed his life was in danger.

Considered buying a gun/police protection.

Depressed, poor sleep, no biological features.

Not hyperactive, energetic or expansive mood.

No H/O substance use/GMC.Responded to treatment as an

inpatient.

DSM-IV TR

DSM-IV-TR Diagnosis

Axis I 295.40 Schizophreniform disorder – Good prognosis two features

Axis II V71.09 No diagnosis.Axis III NoneAxis IV Breakup with girlfriendAxis V GAF 30 Admission

GAF 60 DischargeGAF 90 Highest level past year

Differential Diagnosis:- Schizophrenia- Depression with psychotic symptoms- Brief psychotic disorder- Psychosis due to GMC/substance use DSM-IV TR

Schizoaffective DisorderDSM-IV-TR Criteria 295.75A. An uninterrupted period of illness with MDE, Manic Episode or mixed Episode

with criteria A for schizophrenia.B. *Delusions or Hallucinations for two weeks in the absence of prominent

mood symptoms.C. Criteria for a mood episode are present, during the active and residual phase

of the illness.D. Not due to effects of substance or GMC.

Specify Type

Bipolar Type- Disturbance includes Manic or Mixed Episode or Depressive episode.Depressive Type- Disturbance only include MDE DSM-IV-TR

Schizoaffective Disorder – Case Study26 year old female bank officer- No relevant family, past or medical history- Separated from husband for 4 months- Brother was jailed a month ago.- Moved in with her parents a month ago.- Gradual deterioration in her functioning.- Found in a “confused” state in a railway

station.- Agitated, hallucinating with marked

thought disorder- Voices making comments about her.- Command hallucinations to kill herself. - Hospitalized and treated with

antipsychotics.- Discharged c/o mother with follow up.- Readmitted after 6 months.- Anxiety, insomnia and auditory

hallucinations.

- Convinced mother was going to hurt her. - TV is controlling her, others can read

her mind.- Also, prominent manic symptoms for 3

wks.- Shopping sprees, not sleeping, pacing

for much of the night.- Convinced that God, too, was talking to

her.- Someone was touching and arousing

her sexuality.- Hardly slept for 3 nights prior to

admission.- Hyperactive, disruptive, excites and

irritable.- Hypersexual, convinced she would heal

everyone.- Treated with Fluphenazine & Lico3.- Improved within the next 6 months.

DSM-IV-TR

DSM-IV-TR Diagnosis

Axis I Schizoaffective Disorder – Bipolar Type

Axis II V71.09 No diagnosis

Axis III None

Axis IV Brother in jail, separation from husband

Axis V GAF = 30 upon admissionGAF = 70 upon discharge DSM-IV TR

Differential Diagnoses

- Schizoaffective Disorder least reliable diagnosis in DSM-IV.

- ?Mood symptoms are of sufficient duration and severity.

- Mood Disorder with Psychotic features.- Schizophrenia.- Brief Psychotic Disorder.- Schizophreniform Disorder- Due to substance use/GMC.

DSM-IV TR

Delusional Disorder

DSM-IV-TR Diagnostic Criteria 297.1A Nonbizarre delusions (involving situations that occur in real life)

of at least one month duration.B *Criterion A for Schizophrenia has never been met.C Functioning or behavior not markedly impaired.D If mood episodes have occurred, they are brief.E Not related to effects of substances or GMC.

Specify Type:- Eratomanic Type - Somatic Type- Grandoise Type - Mixed Type- Jealous Type - Unspecified Type- Persecutory Type DSM-IV TR

Differential Diagnosis of Delusional Disorder

*For several reasons, diagnosis is much harder.Over valued ideasObsessive Compulsive DisorderSocial PhobiaHypochondriasisMay be part of cultural or religious systemMay be part of other Psychotic disorderRelated to Substance useRelated to GMCMood Disorder with Psychotic symptomsParanoid Personality Disorder DSM-IV-TR

Delusional Disorder – Case Study

39 year old woman referred by a Dermatologist

- No objective evidence of skin disease.- Patient insists she is plagued with

insects.- 12 years of infestation, skin itch, spread

all over her body- Convinced itch is due to bugs.- Feel them under the skin, feel pain from

bites.- Has seen several physicians over last 12

years.- Distressed and angry no one has been

able to help.- Washed her skin very frequently.- Resorted to assorted applications

including bleach.

- Few serious overdoses as she felt so wretched.

- Stopped work, withdrew socially, sleeps very poorly.

- Convinced people are avoiding her because she is dirty.

- Agitated and totally preoccupied with bugs.

- Otherwise charming and engaging, converse intelligently.

- No other psychotic or Mood symptoms.

DSM-IV-TR

DSM-IV-TR Diagnosis

Axis I 297.1 Delusional Disorder, Somatic Type 311 Depressive Disorder NOSAxis II V71.09 No DiagnosisAxis III NoneAxis IV Social Isolation, Inability to workAxis V GAF = 30 (current)

GAF = 40 (Highest in past year)

DSM-IV-TR

Brief Psychotic Disorder

- Has replaced “Brief Reactive Psychoses”- Duration less than a month, at least a day.- Result of a stressor or not- Not related to Mood Disorder, substance use, GMC- Associated with Good Premorbid Functioning- Associated with a Good Prognosis.- It is a “retrospective” diagnosis- If in doubt, Psychotic Disorder NOS.

DSM-IV-TR

Brief Psychotic DisorderDSM-IV-TR Diagnostic Criteria 298.8A Presence of ONE or more of the following:

1. Delusions2. Hallucinations3. Disorganized Speech4. Disorganized on Catatonic Behavior

B Duration of Disturbance one day to one monthEventual full return to premorbid functioning

C Not related to Schizophrenia, Schizoaffective Disorder, Mood Disorder, Substance us or GMC.

Specify: with marked stressorswithout marked stressorswith Post partum onset (within 4 weeks postpartum) DSM-IV-TR

DSM-IV-TR Diagnostic Criteria for Shared Psychotic Disorders – 297.3

A. A delusion develops in an individual in the context of a close relationship with another person who is already has an established delusion.

B. The delusion is similar in context.

C. Not better accounted for by another Psychotic disorder, Mood Disorder OR Direct effect of a substance.

DSM-IV-TR

DSM-IV-TR Diagnostic Criteria for Psychotic Disorder due to GMC-293.xx

A. Prominent Hallucinations OR DelusionsB. Evidence form History, Physical Examination of Laboratory

Findings.C. Not better accounted for by another mental disorderD. Does not occur EXCLUSIVELY during a course of a deliriumCode based on predominant symptom:• 81 with delusions• 82 with hallucinations(Name of GMC in Axis I AND the GMC in Axis III (use ICD-9-CM Code)

Example: Axis I- 293.81 Psychotic Disorder due to Ca Lung with DelusionsAxis III- Ca Lung

Substance Induced Psychotic DisordersDSM-IV-TR Diagnostic CriteriaA Prominent Hallucinations or Delusions (do not include if the patient has insight).B History, Examination or laboratory finding

1. Symptoms in Criteria A developed during or within a month of Intoxication/withdrawal.2. Medication use is related to disturbance.

C Disturbance is NOT better accounted for by a Psychotic Disorder that is NOT substance induced.

D Disturbance does not occur exclusively during a course of Delirium.

Code for Specific Substance:291.5 Alcohol, with delusions. Specify:291.3 Alcohol, with hallucations with onset during Intoxication292.11 Cannabis, with delusions with onset during withdrawal292.12 Cannabis, with hallucinations

DSM-IV-TR

Differential Diagnosis – Substance induced Psychosis

- Delirium- Substance intoxication ONLY- Substance withdrawal ONLY- Psychotic symptoms may NOT be substance induced

1. Symptoms predates substance use.2. Symptoms persist after intoxication/withdrawal (usually 4 weeks)3. Not related to type or amount of substance used.4. Family history of Primary Psychotic Disorder

- Dual Diagnoses- Recurrent flashbacks involving LSD- Substance may precipitate symptoms in “vulnerable patients”

DSM-IV-TR

DSM-IV-TR Criteria for Psychotic Disorders Nos.-298.9

- Psychotic symptomology- Inadequate information to make specific diagnosis- Contradictory information- Symptoms do not meet criteria for ANY specific Psychotic Disorder- Multiple examples:

1)Delusions with periods of overlapping ME2) Post Partum Psychosis3) Psychotic Disorders with less than one month duration with no remission4) Psychotic Disorder with unknown etiology5) Persistent Auditory Hallucinations

DSM-IV-TR