Schizophrenia: DSM-5 Flashcards
Delusions
Fixed beliefs that are not amenable to change in light of conflicting evidence
Content may include a variety of themes:
- persecutory (most common)
- referential
- somatic
- religious
- grandiose
Distinction between a delusion and a strongly held idea: degree of conviction despite clear or reasonable contradictory evidence
Hallucinations
Perception-like experiences that occur without an external stimulus
Vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control
Auditory hallucinations are the most common in schizophrenia and related disorders, but they may occur in any sensory modality
*usually experienced as voices that are perceived as distinct from the individual’s own thoughts
*hallucinations that occur while falling asleep (hypnagogic) were waking up (hypnopompic) are considered to be within the range of normal experience
Hallucinations may be a normal part of religious experience in certain cultural contexts
Disorganized Thinking
Formal Thought Disorder
Typically inferred from the individual’s speech
The individual may switch from one topic to another
- derailment
- loose associations
Answers to questions may be obliquely related or completely unrelated
*tangentiality
Rarely, speech may be so severely disorganized that it is nearly incomprehensible and resembles aphasia
*incoherence or ‘word salad’
*less severe disorganized thinking her speech may occur during the prodromal and residual periods of schizophrenia
Grossly Disorganized or Abnormal Motor Behavior
Including Catatonia
Grossly disorganized or abnormal motor behavior may manifest in a variety of ways, ranging from childlike “silliness” to unpredictable agitation
Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living
Catatonic behavior is a marked decrease in reactivity to the environment
Catatonic behavior range
Negativism – resistance to instructions
Maintaining a rigid, inappropriate or bizarre posture
Mutism and Stupor – complete lack of verbal and motor responses
Catatonic Excitement –purposeless and excessive motor activity without obvious cause
Repeated catatonic stereotyped movements
Staring, grimacing, mutism, echoing of speech
*although catatonia has historically been associated with schizophrenia, catatonic symptoms are nonspecific and may occur in other mental disorders
Negative Symptoms
Particularly prominent in SZ:
Diminished Emotional Expression
Avolition
Other Negative Symptoms:
Alogia
Anhedonia
Asociality
Diminished Emotional Expression
Reductions in the expression of:
- emotions in the face
- eye contact
- intonation of speech (prosody)
- movements of the hand and face that normally give an emotional emphasis to speech
Avolition
Decrease in motivated self-initiated purposeful activities
The individual may sit for long periods of time and show little interest in participating in work or social activities
Alogia
Diminished speech output
Anhedonia
Decreased ability to experience pleasure from positive stimuli
and/or
Degradation in the recollection of pleasure previously experienced
Asociality
Apparent lack of interest in social interactions
May be associated with evolution, but it can also be a manifestation of limited opportunities for social interactions
Schizophrenia
DSM-5 Critera
A:
2 or more of the following, each present for a significant portion of time during a 1-month period:
- Delusions
- Hallucinations
- Disorganized speech (e.g. frequent derailment or incoherence)
- Grossly disorganized or catatonic behavior
- Negative symptoms (diminished emotional expression or avolition)
* At least one symptom must be A1, A2 or A3
* Continuous signs of the disturbance persist for at least 6 months
* 6-month period, must include at least 1 month of symptoms that meet criterion A (active-phase symptoms) and may include periods of prodromal or residual symptoms
* During these prodromal residual periods, the signs of the disturbance may be manifested by only negative symptoms or by 2 or more symptoms listed in criterion A in an attenuated form (odd beliefs, unusual perceptual experiences)
Associated Features Supporting Diagnosis of Schizophrenia
Inappropriate affect
Dysphoric mood that can take the form of depression, anxiety or anger
Disturbed sleep pattern
Lack of interest in eating or food refusal
Depersonalization
Derealization
Somatic concerns that sometimes reach delusional proportions
Anxiety and phobias are common
Cognitive deficits in schizophrenia
Decrements in:
Declarative memory
Working memory
Language function
Other executive functions
Slower processing speed
Also:
Abnormalities in sensory processing and inhibitory capacity
Reductions in attention
Social cognition deficits associated with schizophrenia
Theory of mind – the ability to infer the intentions of other people
May attend to and then interpret irrelevant events or stimuli as meaningful, perhaps leading to the generation of explanatory delusions
Anosognosia
Lack of insight or awareness of their disorder
This lack of insight includes unawareness of symptoms of schizophrenia and may be present throughout the entire course of the illness
Unawareness is typically a symptom of schizophrenia itself rather than a coping strategy
Most common predictor of non-adherence to treatment
Predicts:
Higher relapse rates
Increased number of involuntary treatments
Poorer psychosocial functioning
Aggression
Poorer course of illness
Prevalence of Schizophrenia
0.3% – 0.7%
SZ Onset
Psychotic features typically emerge between the late teens and the mid-30s
Onset prior to adolescence is rare
First psychotic episode:
Males – early-to mid-20s
Females – late-20s
Majority of individuals manifest the slow and gradual development of a variety of clinically significant signs and symptoms
Half of these individuals complain of depressive symptoms
Earlier age at onset has traditionally been seen as a predictor of worse prognosis
Late-onset (after 40) are overrepresented by single females
SZ Course
Course appears to be favorable in about 20% of SZ patients
A small number are reported to recover completely
Most individuals require formal or informal daily living supports
Many remain chronically ill with exacerbations and remissions of active symptom
Some have a course of progressive deterioration
*Psychotic symptoms tend to diminish over the life course (possibly related to decreased dopamine activity)
Negative symptoms are more closely related to prognosis and tend to be the most persistent
Cognitive deficits may not improve over the course of the illness
SZ Risk Factors: Environmental
Season of birth has been linked to incidence, including late winter/early spring
Higher risk for children growing up in an urban environment and for some minority ethnic groups
SZ Risk Factors: Genetics
Strong contribution for genetic factors, although most individuals have been diagnosed have no family history of psychosis
Certain risk alleles have been identified, which are also associated with bipolar disorder, depression and ASD
SZ Gender Related DX Issues
General incidence tends to be slightly lower in females
Age of onset is later and females, with a second midlife peak
Symptoms tend to be more affect-laden among females, and there are more psychotic symptoms as well as a greater propensity for psychotic symptoms to worsen in later life
Social functioning tends to be better preserved in females
Less frequent negative symptoms and disorganization and females
SZ Suicide Risk
5-6% suicide completion
20% attempt suicide on one or more occasions
Suicidal behavior is sometimes in response to command hallucinations to harm oneself or others
Suicide risk remains high over the whole lifespan for males and females
*especially high for younger males with comorbid substance abuse
**Increased risk in the period after a psychotic episode or hospital discharge
Functional consequences of schizophrenia
Significant social and occupational dysfunction
Educational progress and employment are impaired by avolition or other disorder manifestations, even when the cognitive skills are sufficient for the tasks at hand
Most are employed a lower level than their parents
Most, particularly men, do not marry or have limited social contacts outside of their family
SZ Differential diagnosis: MDD or Bipolar with psychotic or catatonic features
Depends on the temporal relationship between the mood disturbance and the psychosis, and on the severity of the depressive or manic symptoms
If delusions or hallucinations occur exclusively during a major depressive or manic episode, the diagnosis is depressive or bipolar disorder with psychotic features
SZ Differential diagnosis: Schizoaffective disorder
Dx of Schizoaffective disorder requires that a major depressive or manic episode occur concurrently with the active-phase symptoms and that the mood symptoms be present for a majority of the total duration of the active periods
SZ Differential diagnosis: Schizophreniform disorder and brief psychotic disorder
Schizophreniform and brief psychotic disorder are of shorter duration (less than 6 months)
Schizophreniform – disturbance is present less than 6 months
Brief psychotic disorder – symptoms are present at least 1 day but less than 1 month
SZ Differential diagnosis: Delusional Disorder
Delusional disorder is distinguished by the absence of other symptoms characteristic of schizophrenia, such as delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms
SZ Differential diagnosis: Schizotypal personality disorder
Schizotypal :
sub-threshold symptoms that are associated with persistent personality features
SZ Differential diagnosis: OCD and BDD
Individuals with OCD and BDD may present with poor or absent insight, and the preoccupations may reach delusional proportions
But these disorders are distinguished by their prominent obsessions, compulsions, preoccupations with appearance or body odor, hoarding, or body-focused repetitive behaviors
SZ Differential diagnosis: PTSD
PTSD may include flashbacks that have a hallucinatory quality, and hyper vigilance may reach paranoid proportions
But a traumatic event and characteristic symptom features relating to reliving or reacting to the event are required to make the diagnosis
SZ Differential diagnosis: ASD or Communication Disorders
ASD and Communication disorders may also have symptoms resembling a psychotic episode
They are distinguished by their respective deficits in social interaction with repetitive and restricted behaviors and other cognitive and communication deficits
Co-moribidity requisites:
symptoms that meet full criteria for schizophrenia, with prominent hallucinations or delusions for at least 1 month,
SZ Differential diagnosis: Other mental disorders associated with a psychotic episode
The diagnosis of schizophrenia is made only when:
Psychotic episode is persistent
Psychotic episode is not attributable to the physiological effects of a substance or another medical condition
SZ Comorbidity
Substance-related disorders
Over half smoke cigarettes regularly
Elevated rates of OCD and panic disorder
Schizotypal or paranoid personality disorder may sometimes precede the onset of schizophrenia
SZ Life expectancy
Life expectancy is reduced due to…
Associated medical conditions:
- weight gain
- diabetes
- metabolic syndrome
- cardiovascular and pulmonary disease
Increased risk of chronic disease:
- medications
- lifestyle
- cigarette smoking
- diet
