Schizophrenia: DSM-5

Question 1

Delusions

Answer 1

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

Question 2

Hallucinations

Answer 2

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

Question 3

Disorganized Thinking

Formal Thought Disorder

Answer 3

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

Question 4

Grossly Disorganized or Abnormal Motor Behavior

Including Catatonia

Answer 4

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

Question 5

Catatonic behavior range

Answer 5

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

Question 6

Negative Symptoms

Answer 6

Particularly prominent in SZ:
Diminished Emotional Expression
Avolition

Other Negative Symptoms:
Alogia
Anhedonia
Asociality

Question 7

Diminished Emotional Expression

Answer 7

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

Question 8

Avolition

Answer 8

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

Question 9

Alogia

Answer 9

Diminished speech output

Question 10

Anhedonia

Answer 10

Decreased ability to experience pleasure from positive stimuli

and/or

Degradation in the recollection of pleasure previously experienced

Question 11

Asociality

Answer 11

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

Question 12

Schizophrenia

DSM-5 Critera

Answer 12

A:
2 or more of the following, each present for a significant portion of time during a 1-month period:

1. Delusions
2. Hallucinations
3. Disorganized speech (e.g. frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. 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)

Question 13

Associated Features Supporting Diagnosis of Schizophrenia

Answer 13

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

Question 14

Cognitive deficits in schizophrenia

Answer 14

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

Question 15

Social cognition deficits associated with schizophrenia

Answer 15

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

Question 16

Anosognosia

Answer 16

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

Question 17

Prevalence of Schizophrenia

Answer 17

0.3% – 0.7%

Question 18

SZ Onset

Answer 18

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

Question 19

SZ Course

Answer 19

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

Question 20

SZ Risk Factors: Environmental

Answer 20

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

Question 21

SZ Risk Factors: Genetics

Answer 21

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

Question 22

SZ Gender Related DX Issues

Answer 22

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

Question 23

SZ Suicide Risk

Answer 23

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

Question 24

Functional consequences of schizophrenia

Answer 24

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

Question 25

SZ Differential diagnosis: MDD or Bipolar with psychotic or catatonic features

Answer 25

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

Question 26

SZ Differential diagnosis: Schizoaffective disorder

Answer 26

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

Question 27

SZ Differential diagnosis: Schizophreniform disorder and brief psychotic disorder

Answer 27

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

Question 28

SZ Differential diagnosis: Delusional Disorder

Answer 28

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

Question 29

SZ Differential diagnosis: Schizotypal personality disorder

Answer 29

Schizotypal :

sub-threshold symptoms that are associated with persistent personality features

Question 30

SZ Differential diagnosis: OCD and BDD

Answer 30

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

Question 31

SZ Differential diagnosis: PTSD

Answer 31

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

Question 32

SZ Differential diagnosis: ASD or Communication Disorders

Answer 32

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,

Question 33

SZ Differential diagnosis: Other mental disorders associated with a psychotic episode

Answer 33

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

Question 34

SZ Comorbidity

Answer 34

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

Question 35

SZ Life expectancy

Answer 35

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