Schizophrenia Spectrum and Other Psychotic Disorders



Schizophrenia Spectrum and Other Psychotic Disorders





• INTRODUCTION TO THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

This and the next six chapters of the book focus on mental disorders. Inclusion and diagnostic criteria for these disorders are based on a consensus of current opinions and concepts in psychiatry as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a classification scheme devised by the American Psychiatric Association. The DSM is compatible with the other major psychiatric classification scheme, the International Statistical Classification of Diseases and Related Health Problems (ICD). The ICD was developed by the World Health Organization and is used mainly in Europe and other areas outside of the United States.


The DSM-5

The DSM-5 includes about 19 major diagnostic groupings, plus a grouping called “other conditions that may be a focus of clinical attention” (Table 12-1). In contrast to the DSM-IV, the DSM-5 does not use the multiaxial system that coded a patient’s condition along five axes.

Psychiatric disorders in the DSM-5 may have specifiers but do not have subtypes that in DSM-IV were based on the presentation of symptoms and defined mutually exclusive subgroupings within a diagnosis. The specifiers denote the features (e.g., major depressive disorder with atypical features) and severity of the illness and describe whether the illness is in partial or full remission. Specifiers also disclose the patient’s history of the disorder and can be provisional if the practitioner believes that the full criteria for the disorder will be met over time. Severity specifiers provide information about intensity, frequency or duration of some disorders. The specifier can also be “unspecified” for the following reasons:



  • The illness does not meet the full criteria for a specific disorder.


  • The disorder has an uncertain etiology.


  • There is inconsistent or insufficient information available to allow classification of the disorder.


Changes from the DSM-IV to the DSM-5

At least 13 work groups composed of members of the American Psychiatric Association prepared the fifth edition of the DSM. The final changes were made and published in 2013. A summary of these changes can be found in Table 12-2.









table 12.1 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION





































































CONDITION

EXAMPLES


Neurodevelopmental disorders

Attention deficit/hyperactivity disorder, autism spectrum disorder, intellectual disability (mental retardation)


Neurocognitive disorders

Delirium, major or mild neurocognitive disorder due to Alzheimer’s disease


Substance-related and addictive disorders

Alcohol-related disorders, opioid-related disorders


Schizophrenia spectrum and other psychotic disorders

Schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder


Bipolar and related disorders

Bipolar I and bipolar II disorders, cyclothymic disorder


Depressive disorders

Major depressive disorder, persistent depressive (dysthymic) disorder, premenstrual dysphoric disorder


Anxiety disorders

Panic disorder, specific phobia, social anxiety disorder (social phobia)


Obsessive-Compulsive and related disorders

Hoarding disorder, body dysmorphic disorder, trichotillomania


Trauma- and stressor-related disorders

PTSD, reactive attachment disorder, adjustment disorders


Somatic symptom and related disorders

Conversion disorder, illness anxiety disorder, somatic symptom disorder, factitious disorder


Dissociative disorders

Dissociative amnesia, depersonalization disorder


Sexual dysfunctions

Erectile disorder, premature (early) ejaculation


Gender dysphoria

Gender dysphoria in children, gender dysphoria in adolescents and adults


Paraphilic disorders

Voyeristic disorder, pedophilic disorder


Feeding and eating disorders

Anorexia nervosa, bulimia nervosa, binge-eating disorder


Elimination disorders

Enuresis, encopresis


Sleep-wake disorders

Insomnia disorder, narcolepsy, breathing-related sleep disorders, parasomnias


Disruptive, impulse-control, and conduct disorders

Intermittent explosive disorder, kleptomania, conduct disorder, oppositional defiant disorder


Paraphilic disorders

Voyeuristic disorder, exhibitionistic disorder


Personality disorders (PDs)

Paranoid PD, antisocial PD, avoidant PD


Other conditions that may be a focus of clinical attention

Spouse or partner violence, problems related to other psychosocial, personal and environmental circumstances, child maltreatment and neglect problems, housing and economic problems



• SCHIZOPHRENIA

Psychotic disorders are a group of illnesses characterized at some point during their course by gross impairment in reality testing, that is, psychosis. Schizophrenia, the most comprehensive model for a psychotic disorder, is a chronic, debilitating illness that is associated with deterioration in mental function and behavior. The disorder is rarely seen in children (prevalence <1/10,000) and usually starts in young adulthood (prevalence 1/100). Impairment in reality testing (psychosis) is the nucleus of the illness and is expressed by alterations in sensory perceptions, such as hallucinations (false perceptions), and abnormalities in thought processes, such as delusions (false beliefs) (see Table 10-3). Because the term “schizophrenia” literally means “split mind,” lay people commonly but erroneously mistake schizophrenia for multiple personality

disorder. The latter disorder, now called dissociative identity disorder, is an uncommon illness in which a person’s consciousness is divided through unconscious processes into several different but nonpsychotic personalities (see Chapter 18). In contrast, the split mind of schizophrenia refers to the nonrational divergence between behavior and thought content that patients typically demonstrate (e.g., laughing while verbally expressing fear).








table 12.2 SELECTED CHANGES FROM THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FOURTH TO THE FIFTH EDITION
















































CLASIFICATION

CHANGES


DSM-IV: Disorders usually first diagnosed in infancy, childhood, or adolescence


DSM-5: Neurodevelopmental disorders


  • Replace “mental retardation” with “intellectual disability”



  • Remove “Asperger’s syndrome”



  • Increase the age of symptoms appearance in attention-deficit hyperactivity disorder (ADHD) from before age 7 to before age 12



  • Add motor disorders such as developmental coordination disorder and Tourette’s disorder



  • Move pica and rumination disorder to “feeding and eating disorders”


DSM-IV: Delirium, dementia and amnestic and other cognitive disorders


DSM-5: Neurocognitive disorders


  • Replace “dementia” with “major neurocognitive disorders”



  • Add the category “minor neurocognitive disorders”



  • Add behavioral disturbances (e.g., depression, psychosis) associated with neurocognitive disorders


DSM-IV: Substance-related disorders


DSM-5: Substance-related and addictive disorders


  • Combine diagnoses of substance abuse and substance dependence



  • Add cannabis withdrawal and caffeine withdrawal



  • Divide substance-related disorders into substance use disorders and substance-induced disorders



  • Move gambling disorder to this category from impulse control disorders


DSM-IV: Schizophrenia and other psychotic disorders


DSM-5: Schizophrenia spectrum and other psychotic disorders


  • Remove subtypes of schizophrenia



  • Remove “shared delusional disorder”



  • Add catatonia specifier for psychotic, depressive or bipolar disorder


DSM-IV: Mood disorders


DSM-5: Bipolar disorders and depressive disorders


  • Add “disruptive mood dysregulation disorder” (in children)



  • Remove bereavement exclusion of 2 months following the death of a loved one



  • Add “premenstrual dysphoric disorder”



  • Add “anxious distress” specifier


DSM-IV: Anxiety disorders


DSM-5: Anxiety disorders, obsessive compulsive and related disorders, traumaand stressor-related disorders


  • Unlink panic disorder from agoraphobia



  • Rename “social phobia” as “social anxiety disorder”



  • Add “hoarding disorder”



  • Take obsessive compulsive disorder and post-traumatic stress disorder out of anxiety disorders and create two new categories “obsessive-compulsive and related disorders” and “trauma- and stressor-related disorders.”



  • Add “reactive attachment disorder” and “adjustment disorders” to “trauma- and stressor-related disorders



  • Add “selective mutism” and “separation anxiety disorder” to the anxiety disorders


DSM-IV: Somatoform disorders


DSM-5: Somatic symptom and related disorders


  • Replace “somatization disorder” with “somatic symptom disorder” (includes excessive health worry and somatic symptoms)



  • Replace “hypochondriasis” with “illness anxiety disorder” (includes excessive health worry without significant somatic symptoms)



  • Reclassify “body dysmorphic disorder” under obsessive-compulsive and related disorders


DSM-IV and DSM-5: Factitious disorders


  • Include factitious disorders under “somatic symptom and related disorders”



  • Change factitious disorder by proxy to “factitious disorder imposed on another”


DSM-IV and DSM-5 Dissociative disorders


  • Code dissociative amnesia as with or without dissociative fugue


DSM-IV: Sexual and gender identity disorders


DSM-5: Sexual dysfunctions, paraphilic disorders and gender dysphoria


  • Add separate categories for “sexual dysfunctions,” “paraphilic disorders” and “gender dysphoria”



  • Add specifiers “in remission” and “in controlled environment” to the paraphilic disorders



  • Remove sexual aversion disorder


DSM-IV: Eating disorders


DSM-5: Feeding and eating disorders


  • Add “binge-eating disorder”



  • Improve criteria for diagnosis of anorexia nervosa, for example, remove requirement for amenorrhea”


DSM-IV: Sleep disorders


DSM-5: Sleep-wake disorders


  • Divide “breathing-related sleep disorders” into “obstructive sleep apnea hypopnea,” “central sleep apnea,” and “sleep-related hypoventilation”



  • Add “rapid eye movement (REM) sleep behavior disorder”



  • Add “restless legs syndrome”


DSM-IV and DSM-5: Adjustment disorders


  • Include adjustment disorders in the new category of “trauma- and stressor-related disorders”


DSM-IV and DSM-5: Across categories


  • Eliminate the multiaxial system.



  • Add “dimensional assessments” to evaluate severity of symptoms and symptoms seen in more than one disorder



  • Include developmental and lifespan considerations



  • Consider culture, gender, race, and ethnicity in diagnosis


Schizophrenia is a biological illness that, although exacerbated by social stress, is not caused by any known social or environmental factor. The illness itself does, however, have serious social consequences. Theoretically, patients with schizophrenia are often found in lower socioeconomic groups (e.g., homeless people) because they drift down the socioeconomic scale because of their social deficits (the “downward drift” hypothesis).


Characteristics

Schizophrenia is characterized by at least one episode of psychosis and persistent disturbances of thought, behavior, appearance, speech, and affect, as well as impairment in occupational and social functioning (e.g., withdrawal). The diagnostic criteria for schizophrenia indicate that these symptoms must persist for at least 6 months (Table 12-3). Despite their debilitating symptoms and in contrast to patients with delirium or substance abuse, patients with schizophrenia are alert and do not have clouding of consciousness. Also, when not psychotic, their memory capacity is typically intact and they are oriented to person, place, and time.


Positive and negative symptoms

The symptoms of schizophrenia are classified as positive or negative. These classifications help describe the characteristics of the disorder and predict the effects of antipsychotic medication. Positive symptoms are those additional to expected behavior (i.e., “excessive” function) and include delusions, hallucinations, agitation, and talkativeness.Negative (deficit) symptoms are those missing from expected behavior (i.e., decreased function) and include lack of motivation, social withdrawal, flattened affect, cognitive disturbances, poor grooming, and poor or impoverished speech content (see later text). Positive symptoms respond well to most traditional and atypical antipsychotic agents. Negative symptomsrespond better to atypical than to traditional antipsychotics (see Chapter 19).









table 12.3 DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA



























Criterion A. Symptoms: At least two of the following, each present for a significant portion of a 1-month period (less if successfully treated):


1. Delusions


2. Hallucinations


3. Disorganized speech


4. Grossly disorganized or catatonic behavior


5. Negative symptoms


Criterion B. Social/occupational dysfunction: Present for a significant portion of the time since the onset of illness


Decreased level of achievement (in adults)


Failure to achieve expected level of achievement (in children and adolescents)


Criterion C. Duration: Continuous signs of disturbance for at least 6 months


At least 1 month of symptoms that meet Criterion A (less if successfully treated)


Prodromal or residual symptoms (negative symptoms or attenuated forms of Criterion A symptoms) for the rest of the 6-month period



Course

The course of schizophrenia can be divided into three phases: prodromal, psychotic, and residual. The prodromal phase occurs before the first psychotic episode. Typically, in the prodromal phase, the patient avoids social activities and is quiet and passive. However, he also can be quite irritable. The patient may have physical complaints and show a sudden interest in religion, the occult, or philosophy. In contrast to the psychotic phase of the illness, in the prodromal phase, the patient is in touch with reality. In the psychotic or active phase of the illness, the patient loses touch with reality. This loss is commonly associated with additional or positive symptoms such as hallucinations and delusions. In the residual phase (the period between psychotic episodes) of schizophrenia, the patient is in touch with reality but does not behave normally. Rather, he or she shows deficit or negative symptoms such as flat or inappropriate affect (e.g., a bland reaction to disturbing news), peculiar thinking, eccentric behavior (e.g., reading personal meaning into natural phenomena), and withdrawal from social interactions (e.g., choosing to be alone rather than with others). These and other symptoms of schizophrenia can be categorized into disorders of perception, thought content, thought processes, and form of thought (Table 12-4).


Etiology

Adoption and twin studies support the role of genetic factors in the etiology of schizophrenia (see also Chapter 5); the concordance rate in monozygotictwins is close to 50% versus 10% for dizygotic twins. De novo mutations arising in paternal germ cells could explain the intriguing finding that advanced paternal age is more commonly seen in the history of patients with schizophrenia than in people without the disorder (Malaspina et al., 2001). Gender differences also occur in schizophrenia. Although schizophrenia occurs equally in men and women, the peak age of onset differs between the sexes (i.e., 15 to 25 years of age in men and 25 to 35 years of age in women). It is of interest also, that women tend to respond better to antipsychotic medications than men.

Environmental factors during development, such as viral infection and exposure to drugs, have been implicated in the etiology of schizophrenia. The finding that more people with schizophrenia are born during cold-weather months (i.e., January through April in the northern hemisphere and July through September in the southern hemisphere) than during warm-weather months (Mortensen et al., 1999) has been attributed to viral infections that occur seasonally. Specifically, viral infection of the mother during pregnancy may negatively affect the
developing fetal brain. Third-trimester maternal exposure to diuretics or, alternatively, severe maternal hypertension that requires use of these agents has been implicated in the etiology of schizophrenia (Sørensen et al., 2003).


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Jun 16, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Schizophrenia Spectrum and Other Psychotic Disorders

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