Lecture 11 - Schizophrenia Spectrum Disorders Flashcards
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion A
Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
- Delusions.
- Hallucinations.
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior.
- Negative symptoms (i.e., diminished emotional expression or avolition).
Typical symptoms (and their characteristic features)
Positive symptoms.
- Hallucinations
- Delusions
- Formal thought disorder
- Behavioural/Motor disturbances
- Lack of insight
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion C
Continuous signs of disturbance are present for at least 6 months
- May include a gradual deterioration in functioning
- Must include at least one-month of psychotic symptoms
_____________________________
Continuous signs of the disturbance persist for at least 6 months.
This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion D
Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion B
Clinically significant impact to social/occupational functioning
(functioning is below that prior to onset of the disorder)
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion E & F
D-F. Not better accounted for by other diagnosis: schizoaffective, substance, autism
_____________________________
E: The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
F: If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).
Diagnostic criteria of schizophrenia (as per DSM-5)
Specify If:
The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.
First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
Unspecified
Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119–120, for definition).
Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizophrenia to indicate the presence of the comorbid catatonia.
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of schizophrenia can be made without using this severity specifier.
What is psychosis?
Refers to loss of contact with external reality characterised by
• Impaired perceptions
• Thought processes
What are the different types of Psychotic disorders in the DSM-5?
(9)
(SSBSSSPC)
- Schizophrenia
- Schizotypal (Personality) Disorder
- Brief Psychotic Disorder (sudden, <1mth, return to functioning)
- Schizophreniform Disorder (>1mth<6mths & individual has recovered; bipolar/depressive disorder ruled out; provisional diagnosis)
- Schizoaffective Disorder (mood disorder criteria present)
- Substance-/Medication-induced Psychotic Disorder
- Psychosis due to a medical condition
- Catatonia & other unspecified (exclude neuro developmental or medical condition)
Typical symptoms (and their characteristic features)
Negative symptoms.
Affective Flattening, inc
- social withdrawal
- anhedonia (inability to feel pleasure in normally pleasurable activities)
- emotional blunting
- confusion
Avolition, inc.
- amotivation
- apathy
- self-neglect
Alogia
- poverty of speech
- poverty of content
Presence of negative symptoms suggest poorer response to treatment
What does a positive symptom refer to?
The presence of problematic (behaviours) - weird word choice because I would argue it was also cognition…
What does a negative symptom refer to?
Absence of healthy (behaviours)
What are the epidemiological characteristics of schizophrenia?
Prevalance:
- Lifetime prevalence of schizophrenia: 1-2%
- Male to Female ratio: 3:2
Age of onset
- Typical onset in late adolescence & early adulthood (tends to be later for women)
- Onset typically preceded by a gradual deterioration in functioning followed by appearance of more acute symptoms
- Onset coincides with an often stressful time of life, further complicated by impact of schizophrenia
- Early onset associated with poorer outcomes
Early treatment associated with better outcomes (yet delay in treatment common)
What do Family Therapy interventions provide?
- Education about schizophrenia and its treatment
- Realistic goal setting skills
- Communications training (empathic not critical)
- Problem Solving skills
- Promote social support
Take home messages…
- Schizophrenia is a severe neurodevelopmental disorder with prominent genetic and environmental/psychosocial aetiology
- The prognosis for people living with schizophrenia varies depending on the amount of support & the type of treatment received.
- People can function well - esp. if family is supportive and if patients adhere to medication/treatment
- It is important to promote acceptance, support and recovery for people living with schizophrenia and related psychotic disorders.
Which chapter of the DSM-5 is schizophrenia in?
Schizophrenia Spectrum and Other Psychotic Disorders
Why are Family therapy interventions good?
Family interventions shown to reduce relapse and enhance family support
Why were family therapy interventions developed?
In response to higher relapse rates for patients from families high in Expressed Emotion (EE)
TREATMENT:
Psychological Interventions
Systematic reviews & Meta-analyses
§ Lutgens et al (2017): Psychological and psychosocial
interventions for negative symptoms (72 studies)
• CBT, skills-based training, exercise, music treatment found
beneficial
§ Jauhar et al (2014):
• Evidence for only small effects on overall symptoms
TREATMENT:
Psychological Interventions
§ Need to be tailored to the stage of illness
§ Designed to target specific deficits or objectives:
• social skills training for interpersonal deficits
• medication compliance
• managing delusions/hallucinations
• stress management
• Important to work from the patient perspective
