Schizophrenia Spectrum Disorders: DSM-5

Question 1

Schizoaffective Disorder

Answer 1

A:
Uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A schizophrenia
*MDE must include A1. Depressed Mood

B:
Delusions or hallucinations for 2 or more weeks in the absence of the major mood episode during the lifetime duration of the illness

C:
Symptoms that meet criteria for major mood episode are present for the majority of the total duration of the active and residual portions of the illness

Question 2

Schizoaffective: Diagnostic Features

Answer 2

Diagnosis is usually, but not necessarily, made during the period of psychotic illness

MDE must include pervasive depressed mood

*Presence of markedly diminished interest or pleasure is not sufficient

Question 3

Schizoaffective: Associated Features

Answer 3

Occupational functioning is frequently impaired
*However, not a defining criterion (unlike SZ)

Anosognosia is common, but deficits in insight may be less severe and pervasive

Increased risk for MDD or BP if mood symptoms continue following remission SZ symptoms

Question 4

Schizoaffective: Prevalence

Answer 4

1/3 as common as SZ

Lifetime prevalence 0.3%

More common in females, due to an increased incidence of the depressive type among females

Question 5

Schizoaffective: Onset

Answer 5

Anywhere from adolescence to late in life

Typically early adulthood

Many initially diagnosed with another psychotic illness will later receive schizoaffective dx when pattern of mood episodes becomes more apparent

Question 6

Schizoaffective: Course

Answer 6

Typical pattern:

2 months of auditory hallucinations and persecutory delusions for two months before a MDE

3 months of psychotic symptoms and full MDE

Complete recovery from MDE, but psychotic symptoms persist for another month before they also disappear

Question 7

Schizoaffective Differential Diagnosis: Bipolar, and depressive disorders

Answer 7

Presence of prominent delusions and/or hallucinations for at least 2 weeks in the absence of a major mood episode

In depressive or bipolar disorder with psychotic features, the psychotic features primarily occurred during the mood episode

As proportion of mood to psychotic symptoms changes, dx may change from and to schizoaffective disorder

Question 8

Delusional Disorder

Answer 8

A:
Presence of 1 or more delusions with a duration of 1 month or longer

B:
Criteria for schizophrenia has never been met
*hallucinations, if present, are not prominent and are related to the delusional theme

C:
Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd

D:
If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods

Question 9

Delusional Disorder Subtypes

Answer 9

Erotomanic

Grandiose

Jealous

Persecutory

Somatic

Mixed

Unspecified

Question 10

Delusional Disorder Differential Diagnosis: SZ

Answer 10

Delusion(s) only

Absence of the other characteristic symptoms of the active phase of schizophrenia

Question 11

Delusional Disorder Differential Diagnosis: Depressive, Bipolar, Schizoaffective

Answer 11

Total duration of all mood episodes remains brief relative to the total duration of the delusional disturbance

If delusions occur exclusively during mood episodes, the diagnosis is depressive or bipolar disorder with psychotic features

Question 12

Brief Psychotic Disorder

Answer 12

A:
Presence of one or more of the following symptoms (at least one must be A1, A2 or A3):
1. Delusions
2. Hallucinations
3. Disorganized speech (frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior

B:
Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning

Specifiers:
*With marked stressor(s)- (brief reactive psychosis)
Without marked stressors
With postpartum onset

With catatonia

Question 13

Brief psychotic disorder prevalence

Answer 13

Brief psychotic disorder may account for 9% of cases of first-onset psychosis

Question 14

Brief psychotic disorder: Onset

Answer 14

Brief psychotic disorder may appear in adolescence or early adulthood, and onset can occur across the lifespan

Average age at onset being the mid-30s

Question 15

Brief psychotic disorder: Course

Answer 15

Dx of brief psychotic disorder requires a full remission of all symptoms and an eventual full return to the premorbid level of functioning within 1 month of onset

In some individuals, the duration of psychotic symptoms may be quite brief – e.g. a few days

Question 16

Brief psychotic disorder: Risk Factors

Answer 16

Pre-existing personality disorders and traits:

Schizotypal personality disorder

Borderline personality disorder

Traits in the psychoticism domain such as perceptual dysregulation

Traits in the negative affectivity domain such as suspiciousness

Question 17

Brief psychotic disorder: functional consequences

Answer 17

Despite high rates of relapse, for most individuals, outcome is excellent in terms of social functioning and symptomatology

Question 18

Schizophreniform Disorder

Answer 18

Same Criterion A as Schizophrenia, but DURATION is at least 1 month but less than 6 months

When dx is made without waiting for recovery, it should be qualified as “provisional”

Rule out Schizoaffective and Bipolar with psychotic features if:
1. No Manic or MDE have occurred during 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

Specifiers:
With / Without good prognostic features
With Catatonia

Question 19

Schizophreniform Disorder: Diagnostic Features

Answer 19

Characteristic symptoms are identical to those of schizophrenia Criterion A

Difference in duration: at least 1 month but less than 6 months
(Intermediate between that for brief psychotic disorder)

Diagnosis of schizophreniform disorder is made under two conditions:

1. Episode of illness last between 1 and 6 months and the individual has already recovered
2. When an individual is symptomatic for less than the six months duration required for the diagnosis schizophrenia but has not yet recovered
   “schizophreniform disorder (provisional)”

Question 20

Schizophreniform Disorder: Prevalence

Answer 20

5x less than schizophrenia

Question 21

Schizophreniform Disorder: Course

Answer 21

1/3 of individuals with an initial diagnosis of schizophreniform disorder (provisional) recover within the 6-month period

2/3 will eventually receive a diagnosis of schizophrenia or schizoaffective disorder

Question 22

Schizotypal Personality Disorder: General

Answer 22

Pervasive pattern of social and interpersonal deficits

Acute discomfort and reduced capacity for close relationships

Cognitive or perceptual distortions

Eccentricities of behavior

Beginning by early adulthood

Question 23

Schizotypal Personality Disorder: DSM-Criteria

Answer 23

5 or more of the following:

1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs or magical thinking that influences behavior and is consistent with subcultural norms
   e. g. superstitious mess, belief in clairvoyance, telepathy, or “sixth sense”
   * in children and adolescents – bizarre fantasies or preoccupations
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech
   e. g. vague, circumstantial, metaphorical, over elaborate, or stereotyped
5. Suspiciousness or paranoid ideation
6. Inappropriate were constricted affect
7. Behavior or appearance that is odd, eccentric, or peculiar
8. Lack of close friends or confidants other than first-degree relatives
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

Question 24

Schizotypal Personality Disorder: Ideas of reference

Answer 24

Incorrect interpretations of casual incidents and external events as having a particular an unusual meaning specifically for the person

• Different from delusions of reference, in which the beliefs are held with delusional conviction

Question 25

Schizotypal Personality Disorder: Associated Features

Answer 25

Individuals with schizotypal personality disorder often seek treatment for the associated symptoms of anxiety or depression rather than for the personality disorder features per se

In response to stress, individuals may experience transient psychotic episodes (lasting minutes to hours)
*usually insufficient integration to warrant an additional diagnosis such as brief psychotic disorder or schizophreniform disorder

Over half may have a history of at least one major depressive episode

30% to 50% have a concurrent diagnosis of major depressive disorder one admitted to a clinical setting

Considerable co-ocurrence with schizoid, paranoid, avoid ant, and borderline personality disorders

Question 26

Schizotypal Personality Disorder: Prevalence

Answer 26

Clinical populations: 0% – 1.9%

Estimated prevalence in general population: 3.9%

Question 27

Schizotypal Personality Disorder: Onset and Course

Answer 27

Schizotypal personality disorder has a relatively stable course

*Only a small proportion of individuals go on to develop schizophrenia or another psychotic disorder

It may first be apparent in childhood and adolescence with:

• solitariness
• poor peer relationships
• social anxiety
• underachievement in school
• hypersensitivity
• peculiar thoughts and language
• bizarre fantasies

*Children may appear odd or eccentric and may attract teasing

Question 28

Schizotypal vs. Paranoid and Schizoid Diagonsis

Answer 28

Paranoid and schizoid personality disorders may also be characterized by social detachment and restricted affect

Schizotypal personality disorder can be distinguished by the presence of cognitive perceptual distortions and marked eccentricity or oddness

Question 29

Schizotypal vs. Narcissistic and Borderline Diagnosis

Answer 29

More likely to have enduring psychotic-like symptoms that may worsen under stress

*Though less likely to be invariably associated with pronounced affective symptoms

Question 30

Schizotypal and Borderline Personality Disorders

Answer 30

Don’t usually demonstrate the impulsive or manipulative behaviors associated with BPD

High rate of co-occurrence between the two disorders *making such distinctions is not always feasible

Question 31

Schizoid Personality Disorder

Answer 31

Pervasive pattern of detachment from social relationships

Restricted emotional expression

No desire or enjoyment in close relationships (including family)

Chooses solitary activities

Little to no interest in sexual experiences

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Indifferent to praise or criticism of others

Shows emotional coldness, detachment, or flattened affectivity