Affective Psychotic Disorders Flashcards
What are affective psychotic disorders?
Disorders that ARE NOT in the Schizophrenia Spectrum and Other Psychotic Disorder Module of the DSM-5
This category of psychiatric disorders typically refers to disorders that are described in the Mood Disorders Module of the DSM-5
Specifically, those mood disorders that present with psychotic symptoms including:
Bipolar I or Bipolar II Disorder with psychotic features
Major Depressive Disorder with psychotic features
These disorders are characterized by the presence of significant affective symptoms, meeting the criteria for a mood “episode” that interfere with the ability to function
These episodes may be characterized as:
Depressive episodes
Hypomanic episodes
Manic episodes
What are the diagnostic criteria for a major depressive episode?
Diagnostic Criteria
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note:Do not include symptoms that are clearly attributable to another medical condition.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note:In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note:In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying); recurrent suicidal ideation without a specific plan; a specific suicide plan; or a suicide attempt.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.
Note:Criteria A–C represent a major depressive episode…
What are the diagnostic criteria for a Hypomanic episode?
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:
- Inflated self-esteem or grandiosity.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition.
Note:Criteria A–F constitute a hypomanic episode…
What are the diagnostic criteria for a Manic Episode?
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
- Inflated self-esteem or grandiosity.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition.
Note: Criteria A–D constitute a manic episode…
How can each type of mood episode be characterized as?
Without psychotic features
With psychotic features - delusions and/or hallucinations are present at any time in the episode. If psychotic features are present, specify if mood-congruent or mood incongruent
What are psychotic features with mood-congruent psychotic features?
The content of all delusions and hallucinations is consistent with typical depressive themes (i.e. guilt, nihilism) or typical manic themes (i.e. grandiosity, persecution)
What is psychotic features with mood-incongruent psychotic features?
The content of the delusions or hallucinations does not fit with the quality of the mood symptoms.
What is the relationship between affective and non-affective psychotic disorders?
Bipolar disorders are separated from the depressive disorders in DSM-5 and placed between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders
The separation was intentional!
It was meant to recognize bipolar “as a bridge between the two diagnostic classes in terms of symptomatology, family history, and genetics”.
Major Depressive Disorder, even with psychotic features, has not been linked in many meaningful ways to SZ (possibly because depression is more common and more variable…), but Bipolar Disorder typically includes major depressive episodes
It hasn’t always been this way though….
What are the early views of psychosis: Unitary Psychosis?
The concept of unitary psychosis can be traced back to the German psychiatrist Zeller
In 1834 he had already declared that the different varieties of mental illness were simply differing stages in a common morbid process
He asserted that both organic and moral (or psychological) causes combined to produce mental illness and that mental illness was “a single universal madness”
Thus, unitary psychosis connotes an absence of psychopathologically ascertainable nosological entities and points to a wide variety of disease processes that lead to a similar outcome
This idea did not lend itself to scientific study, however…
What is endogenous psychosis vs exogenous psychosis?
MÖbius distinguished between exogenous and endogenous psychoses in 1892.
- Exogenous psychosis referred to the causation of mental disease through affective disturbances, originating from external factors
- Endogenous psychosis referred to some underlying, yet unobservable, biological cause
However, we didn’t have the tools to differentiate these…
What is the Kraepelinian Dichotomy?
The “Kraepelinian Dichotomy” was introduced for the first time in the sixth edition (1899) of Emil Kraepelin’s Textbook of Psychiatry
Criteria for diagnosis and delimitation of 2 different forms of psychosis
- Dementia Praecox (now known as Schizophrenia)
- Manic-Depressive Disorder (now known as Bipolar Disorder).
Who was Emil Kraepelin? What was he known for?
Kraepelin, was a scientist however and recognized that diagnostic formulations stand or fall on the basis of objective empirical validation and since no biological disease markers had been identified, he sought to provide empirical validation by demonstrating their ability to accurately predict disease course and outcome.
His decade long follow-up studies of more than a thousand cases confirmed that these two diagnostic groups displayed their own characteristic pattern (i.e. the two groups revealed a distinct clinical picture, course and outcome)
His work resulted in almost 100 years of psychiatric research focusing on the differences between schizophrenia (non-affective psychosis) and bipolar disorder with psychotic features (affective psychosis)
“Schizoaffective psychosis” was introduced by Kasanin in 1933 and was seen as an intermediary between the symptoms of schizophrenia and affective disorders (albeit, not without considerable debate!)
Why do we need schizoaffective disorder?
The “Kraepelinian dichotomy” has always sat uneasily…
A substantial proportion of individuals meeting the criteria for schizophrenia ALSO experience mood episodes
This is why the DSM originally employed the concept of Schizoaffective
What are the origins of schizoaffective disorder?
Since its initial description by Kasanin in 1933 the diagnosis of schizoaffective disorder has been at the center of controversy regarding the relation between psychotic and affective disorders
It was originally described as a form of illness in which individuals presented with concomitant and equally severe affective and psychotic symptoms
The schizoaffective “form” of schizophrenia was conceptualized as a “good outcome” sub-type of schizophrenia
When did schizoaffective disorder become its own diagnosis?
Schizoaffective Disorder only became its own diagnosis in the 3rd edition of the DSM in 1980 but without any clear diagnostic criteria!!!
Diagnostic criteria for Schizoaffective Disorder were not introduced until the revision of the DSM-3 in 1987
They remain basically unchanged in the 5th edition…
What is the diagnostic criteria for Schizoaffective Disorder?
A. An uninterrupted duration of illness during which there is a major mood episode (manic or depressive) in addition to criterion A for schizophrenia; the major depressive episode must include depressed mood
Criterion A for schizophrenia: Two or more of the following presentations, each present for a significant amount of time during a 1-month period (or less if successfully treated). At least one of these must be from the first three below:
- Delusions
- Hallucinations
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior
- Negative symptoms (i.e., diminished emotional expression or avolition.)
B. Hallucinations and delusions for two or more weeks in the absence of a major mood episode (manic or depressive) during the entire lifetime duration of the illness.
C. Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of both the active and residual portions of the illness.
D. The disturbance is not the result of the effects of a substance (e.g., a drug of misuse or a medication) or another underlying medical condition
- The following are specifiers based on the primary mood episode as part of the presentation
- Bipolar type: includes episodes of mania and sometimes major depression
- Depressive type: includes only major depressive episodes
How do you diagnosis schizoaffective disorder in reality?
If a person has symptoms that both:
- Meet the A criteria for schizophrenia (hallucinations and delusion)
- Meet the criteria for a manic episode
They could receive a diagnosis of:
- Schizophrenia spectrum disorder with the additional diagnosis of Unspecified Bipolar Disorder
- Bipolar disorder with psychotic features
- Schizoaffective Disorder
The critical distinction in these diagnoses is the relative time course of psychotic and affective symptoms:
- If psychotic symptoms are not present for at least 2 weeks in the absence of manic symptoms, a diagnosis of Bipolar with psychotic features is warranted
- If psychotic symptoms are present for at least 2 weeks in the absence of manic symptoms AND manic symptoms are “relatively brief” in comparison to the total duration of illness then a diagnosis of schizophrenia spectrum disorder with the additional diagnosis of Unspecified Bipolar would be warranted
- If none of these criteria are met, a diagnosis of Schizoaffective Disorder is then appropriate
Thus, Schizoaffective Disorder is often used as a “diagnosis by exclusion”
Is the diagnosis of schizoaffective reliable?
NO!
It is one of the most misdiagnosed psychiatric disorders in clinical practice
Why?
Criterion C: Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of both the active and residual portions of the illness
What does the DSM-5 Criterion C say?
“Criterion C requires the assessment of mood symptoms for the entire lifetime course of a psychotic illness. If the mood symptoms are present for only a relatively brief period, the diagnosis is schizophrenia, not schizoaffective disorder. When deciding whether an individual’s presentation meets Criterion C, the clinician should review the total duration of psychotic illness (i.e., both active and residual symptoms) and determine when significant mood symptoms (untreated or in need of treatment with antidepressant and/or mood-stabilizing medication) accompanied the psychotic symptoms. This determination requires sufficient historical information and clinical judgment.
For example, an individual with a 4-year history of active and residual symptoms of schizophrenia develops depressive and manic episodes that, taken together, do not occupy more than 1 year during the 4-year history of psychotic illness. This presentation would not meet Criterion C.”
