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Siva Devarajan Associate Professor of Psychiatry University of Western Ontario
Schizophrenia & Other Psychotic Disorders
295.XX .30 .10 .20 .90 .60 295.40 295.70 297.1 298.8 297.3 Schizophrenia Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual type Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder 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
Psychotic Symptoms Presence of Delusions and Hallucinations Severely disorganized behavior. GMC DSM-IV TR . 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.
one month.XX A – Characteristic symptoms . Delusions 2. Disorganized Speech 4. Negative symptoms B – Social/Occupations Dysfunction *One or more areas of functioning. C – Duration continuous signs of disturbance for six months Continuous criteria for a month.*two or more of the following.DSM-IV-TR Criteria for Schizophrenia 295. self care or interpersonal relationship. work. less if treated: 1. less if treated May also include Prodromal / residual symptoms . Hallucinations 3. Disorganized or Catatonic Behavior 5.
.Diagnosis of schizophrenia made if criteria A is met. duration is very brief E – Substance and GMC exclusion F – Relationship to PDD .if present.DSM-IV-TR Criteria for Schizophrenia (Cont’d) D – Schizoaffective and mood disorder exclusion .
Other or unspecified pattern DSM-IV-TR .Single episode . with prominent negative symptoms .As above.Episodic with Interepisode Residual symptoms .Continuous with or without negative symptoms .DSM-IV-TR Diagnostic Criteria for Schizophrenia Classification of Longitudinal course (at least one year has elapsed since the initial onset) .with or without negative symptoms .Single episode – Full/partial remission .Episodic with no interepisode residual symptoms .
Subtypes of Schizophrenia Pure types are less common Mixtures of symptoms more common Catatonic type – rare Disorganized type *speech. affect Paranoid type *diagnosis of exclusion Undifferentiated type Residual type . behavior.
threatening in nature Low energy. unemployed Two previous hospitalizations Antipsychotics recently reduced Can control behavior of others Others can read her mind and being watched Multiple voices. unable to think Unable to care for herself Depressed. decreased appetite and sleep DSM-IV-TR .Case Study Young female. poor functioning Lives with parents. motivation.
Symptoms responded to Trifluoperazine .Sad.Felt threatened by voices .Enemy knew her thoughts .Social contacts parents and boyfriend .Returned home with parents . unable to enjoy anything .Overtly suspicious .Chronically apprehensive “incapable of working” .Symptoms responded to Trifluoperazine .readmitted following noncompliance . depressed.Felt listless. unable to concentrate .Case Study (Cont’d) .Mind was “going blank” .Switched to Risperidone as an outpatient DSM-IV-TR .She could control other people’s activities .Thoughts were “stopping in mid stream” . exhausted.
30 – Schizophrenia.DSM-IV-TR Diagnosis Axis I – 295.? Less contact with BF Axis V – GAF 30 DSM-IV-TR . Paranoid type Interepisode Residual Symptoms Depressive Disorder – NOS Axis II – V71.09 – No diagnosis Axis III – None Axis IV .
DSV-IV-TR 1. 2. 4.DSM-IV-TR Criteria for Schizophreniform Disorders A B Criteria A. D and E of schizophrenia are met Episode last *one month to six months (provisional or not).with * good Prognostic features (two or more) Absence of blunted or flat effect Good premorbid features Confusion on perplexity at the height of episode *onset of psychotic symptoms within 4 weeks ( behavior or functioning). 3.without good prognostic features . . .
energetic or expansive mood. Responded to treatment as an inpatient. Depressed. Not hyperactive. DSM-IV TR . no biological features. Seems to be responding to voices. poor sleep. GF broke up recently. Excellent vocational and social activity. easily startled. Convinced office staff were scheming against him. No H/O substance use/GMC. Believed his life was in danger. “a jerk off”. Considered buying a gun/police protection. began to follow her. Problems with attendance. Voices “faggot”. productivity. punctuality.Case History 30 year old lawyer – Disheveled. Thought he was unduly criticized and humiliated. Has been well until 3 months ago. hypervigilant. Criticized by his boss.
Psychosis due to GMC/substance use DSM-IV TR .Schizophrenia .40 Schizophreniform disorder – Good prognosis two features Axis II V71.DSM-IV-TR Diagnosis Axis I 295.Depression with psychotic symptoms .Brief psychotic disorder .09 No diagnosis. Axis III None Axis IV Breakup with girlfriend Axis V GAF 30 Admission GAF 60 Discharge GAF 90 Highest level past year Differential Diagnosis: .
Specify Type Bipolar Type Disturbance includes Manic or Mixed Episode or Depressive episode. Criteria for a mood episode are present. Depressive Type Disturbance only include MDE DSM-IV-TR .75 A. *Delusions or Hallucinations for two weeks in the absence of prominent mood symptoms. B.Schizoaffective Disorder DSM-IV-TR Criteria 295. An uninterrupted period of illness with MDE. Manic Episode or mixed Episode with criteria A for schizophrenia. D. Not due to effects of substance or GMC. during the active and residual phase of the illness. C.
Brother was jailed a month ago. disruptive.Convinced mother was going to hurt her.Schizoaffective Disorder – Case Study 26 year old female bank officer . Hyperactive. . Someone was touching and arousing her sexuality. too.Voices making comments about her. .Found in a “confused” state in a railway station. .Readmitted after 6 months. prominent manic symptoms for 3 wks.No relevant family. Improved within the next 6 months. pacing for much of the night. Convinced that God. was talking to her. .Hospitalized and treated with antipsychotics. - - - - TV is controlling her. .Anxiety. Treated with Fluphenazine & Lico3.Discharged c/o mother with follow up. excites and irritable.Agitated. . Also.Command hallucinations to kill herself.Separated from husband for 4 months . . Hypersexual. hallucinating with marked thought disorder .Moved in with her parents a month ago. DSM-IV-TR . convinced she would heal everyone. . not sleeping. Hardly slept for 3 nights prior to admission. Shopping sprees. insomnia and auditory hallucinations. others can read her mind.Gradual deterioration in her functioning. past or medical history . . .
separation from husband Axis V GAF = 30 upon admission GAF = 70 upon discharge DSM-IV TR .DSM-IV-TR Diagnosis Axis I Schizoaffective Disorder – Bipolar Type Axis II V71.09 No diagnosis Axis III Axis IV None Brother in jail.
Schizophrenia. DSM-IV TR . .Mood Disorder with Psychotic features.Schizophreniform Disorder . .Brief Psychotic Disorder.Schizoaffective Disorder least reliable diagnosis in DSM-IV.Due to substance use/GMC.Differential Diagnoses . . . .?Mood symptoms are of sufficient duration and severity.
E Not related to effects of substances or GMC.Eratomanic Type .Delusional Disorder DSM-IV-TR Diagnostic Criteria 297. B *Criterion A for Schizophrenia has never been met.Mixed Type .Jealous Type .Somatic Type .Persecutory Type . D If mood episodes have occurred. they are brief.1 A Nonbizarre delusions (involving situations that occur in real life) of at least one month duration.Grandoise Type . Specify Type: . C Functioning or behavior not markedly impaired.Unspecified Type DSM-IV TR .
diagnosis is much harder. Over valued ideas Obsessive Compulsive Disorder Social Phobia Hypochondriasis May be part of cultural or religious system May be part of other Psychotic disorder Related to Substance use Related to GMC Mood Disorder with Psychotic symptoms Paranoid Personality Disorder DSM-IV-TR .Differential Diagnosis of Delusional Disorder *For several reasons.
feel pain from bites. Washed her skin very frequently. converse intelligently. Few serious overdoses as she felt so wretched. Stopped work. DSM-IV-TR - .Delusional Disorder – Case Study 39 year old woman referred by a Dermatologist No objective evidence of skin disease. Distressed and angry no one has been able to help. No other psychotic or Mood symptoms. Convinced people are avoiding her because she is dirty. Has seen several physicians over last 12 years. Feel them under the skin. Resorted to assorted applications including bleach. Otherwise charming and engaging. Patient insists she is plagued with insects. skin itch. withdrew socially. 12 years of infestation. Agitated and totally preoccupied with bugs. sleeps very poorly. spread all over her body Convinced itch is due to bugs.
Inability to work Axis V GAF = 30 (current) GAF = 40 (Highest in past year) DSM-IV-TR .09 No Diagnosis Axis III None Axis IV Social Isolation. Somatic Type 311 Depressive Disorder NOS Axis II V71.DSM-IV-TR Diagnosis Axis I 297.1 Delusional Disorder.
substance use. It is a “retrospective” diagnosis If in doubt. GMC Associated with Good Premorbid Functioning Associated with a Good Prognosis. Psychotic Disorder NOS. at least a day. DSM-IV-TR .Brief Psychotic Disorder Has replaced “Brief Reactive Psychoses” Duration less than a month. Result of a stressor or not Not related to Mood Disorder.
8 A Presence of ONE or more of the following: 1.Brief Psychotic Disorder DSM-IV-TR Diagnostic Criteria 298. Disorganized on Catatonic Behavior B Duration of Disturbance one day to one month Eventual full return to premorbid functioning C Not related to Schizophrenia. Specify: with marked stressors without marked stressors with Post partum onset (within 4 weeks postpartum) DSM-IV-TR . Substance us or GMC. Hallucinations 3. Disorganized Speech 4. Schizoaffective Disorder. Mood Disorder. Delusions 2.
A delusion develops in an individual in the context of a close relationship with another person who is already has an established delusion.DSM-IV-TR Diagnostic Criteria for Shared Psychotic Disorders – 297. The delusion is similar in context. C. Not better accounted for by another Psychotic disorder.3 A. Mood Disorder OR Direct effect of a substance. DSM-IV-TR . B.
81 Psychotic Disorder due to Ca Lung with Delusions Axis III.Ca Lung .xx A. Does not occur EXCLUSIVELY during a course of a delirium Code 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. Not better accounted for by another mental disorder D. B.293.DSM-IV-TR Diagnostic Criteria for Psychotic Disorder due to GMC-293. C. Prominent Hallucinations OR Delusions Evidence form History. Physical Examination of Laboratory Findings.
11 Cannabis. Symptoms in Criteria A developed during or within a month of Intoxication/withdrawal. D Disturbance does not occur exclusively during a course of Delirium. with delusions. Examination or laboratory finding 1.Substance Induced Psychotic Disorders DSM-IV-TR Diagnostic Criteria A Prominent Hallucinations or Delusions (do not include if the patient has insight). 2. with hallucations 292. Medication use is related to disturbance. with delusions 292. C Disturbance is NOT better accounted for by a Psychotic Disorder that is NOT substance induced.5 Alcohol.3 Alcohol.12 Cannabis. with hallucinations Specify: with onset during Intoxication with onset during withdrawal DSM-IV-TR . B History. Code for Specific Substance: 291. 291.
Family history of Primary Psychotic Disorder .Substance may precipitate symptoms in “vulnerable patients” DSM-IV-TR . Not related to type or amount of substance used.Recurrent flashbacks involving LSD . Symptoms persist after intoxication/withdrawal (usually 4 weeks) 3.Dual Diagnoses . 4.Differential Diagnosis – Substance induced Psychosis Delirium Substance intoxication ONLY Substance withdrawal ONLY Psychotic symptoms may NOT be substance induced 1. 2. Symptoms predates substance use.
DSM-IV-TR Criteria for Psychotic Disorders Nos.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 ME 2) Post Partum Psychosis 3) Psychotic Disorders with less than one month duration with no remission 4) Psychotic Disorder with unknown etiology 5) Persistent Auditory Hallucinations DSM-IV-TR .-298.