DSMIV TR Schizophrenia

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DSM-IV TRSchizophrenia Other Psychotic
Disorders

• Saeed Moradian
• September2008

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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

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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 ( Crohns disease,
  acute bleeding episodes)
• Axis IV Psychosocial and environmental problems
  (recent remarriage, death of father)
• Axis V Global assessment of functioning (GAF)
  (GAF80)

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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

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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

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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

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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

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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

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Evaluation of the DSM-IV-TR

• Homogeneity Do all people with the disorder
  have similar symptoms, follow a similar course,
  etc?

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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?

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Schizophrenia Other Psychotic Disorders

• 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

• 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

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• 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

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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

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DSM-IV-TR Criteria for Schizophrenia (Contd)

• 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.

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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

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• 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

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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

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Case Study (Contd)

• Enemy knew her thoughts
• She could control other peoples 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