DSM-IV TR Schizophrenia Other Psychotic Disorders

1. DSM-IV TRSchizophrenia & Other Psychotic Disorders Saeed Moradian September2008

2. Have we been able to operationalize mental disorders? �Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision� (DSM-IV-TR) Published by the American Psychiatric Association Primarily used in the United States Includes information only on mental illnesses Classifies mental illnesses into different types of disorders (Mood disorders, psychotic disorders, eating disorders, etc.) International Classification of Diseases (ICD) Created by the World Health Organization Used throughout the rest of the world Includes information on both mental and physical illnesses

3. What is the DSM-IV-TR? Multiaxial Classification Axis I � Clinical disorders- comparable to general medical disorders (Like adjustment disorder with anxious mood) Axis II �Personality disorders and mental retardation (obsessive-compulsive personality) Axis III �General medical conditions, general medical illnesses or injuries ( Crohn�s disease, acute bleeding episodes) Axis IV �Psychosocial and environmental problems (recent remarriage, death of father) Axis V �Global assessment of functioning (GAF) (GAF=80)

4. Assumptions of the DSM How was the DSM developed? DSM-I (1952) Created around the same time as ICD-6 Purpose: �create a classification that was a consensus of contemporary thinking� Diagnoses were created by committees and revised by 10% of the members of the American Psychological Association Included approximately 60 disorders Definitions were vague, wordy descriptions Based on psychoanalytic theory

5. How was the DSM developed? DSM-II (1968) Created around the same time as ICD-8 Purpose: �created to promote international consensus in the realm of mental health� Similar to DSM-I in terms of its development and the presentation of disorders 180 disorders were included Homosexuality was included as a psychological diagnosis

6. How was the DSM developed? DSM-III (1980) & DSM-III-R (1987): First attempt to use research in the development of diagnostic categories, but still mostly based on clinical judgment Definitions were changed to be more specific Both inclusion and exclusion criteria Homosexuality no longer considered a mental disorder

7. How was the DSM developed? DSM-IV (1994) & DSM-IV-TR (2000): Attempted to systematize the way diagnostic criteria are developed 175 psychologists did literature reviews of the research on each diagnosis Field trials were conducted that tested the reliability of the diagnoses There is still the criticism that the diagnoses are based on the clinical judgment of a few psychologists in the individual field Added Culture Bound Syndromes to address cultural differences in presentation of symptoms

8. Evaluation of the DSM-IV-TR Is each diagnosis unique and distinct??? Fluidity of diagnoses � Comorbidity Two or more disorders occurring in the same individual Disorders co-occur at rates greater than expected by chance alone

9. Evaluation of the DSM-IV-TR Homogeneity: Do all people with the disorder have similar symptoms, follow a similar course, etc?

10. Evaluation of the DSM-IV-TR Specificity and Sensitivity: Can we use these definitions to distinguish between people who do and do not have the disorder?

11. 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

12. 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

13. DSM-IV-TR Criteria for Schizophrenia 295.XX A � Characteristic symptoms - *two or more of the following, one month, less if treated: Delusions Hallucinations Disorganized Speech Disorganized or Catatonic Behavior Negative symptoms B � 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

14. 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.

15. 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

16. 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

17. 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

18. 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