Initial Assessment

· Chapter 2: Schizophrenia Spectrum and Other Psychotic Disorders

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· View details for highlighted text: "CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders Quick Guide to the Schizophrenia Spectrum and Psychotic Disorders When psychosis is a prominent reason for a mental health evaluation, the diagnosis will be one of the disorders or categories listed below. The link indicates where a more detailed discussion begins. (To facilitate discussion, I have not adhered to the order in which DSM-5 presents these conditions.) Schizophrenia and Schizophrenia-Like Disorders Schizophrenia. For at least 6 months, these patients have had two or more of these five types of psychotic symptom: delusions, disorganized speech, hallucinations, negative symptoms, and catatonia or other markedly abnormal behavior. Ruled out as causes of the psychotic symptoms are significant mood disorders, substance use, and general medical conditions. Catatonia associated with another mental disorder (catatonia specifier). These patients have three or more of several behavioral characteristics. The specifier can be applied to disorders that include psychosis, mood disorders, autistic spectrum disorder, and other medical conditions. Schizophreniform disorder. This category is for patients who have the basic symptoms of schizophrenia but have been ill for only 1–6 months—less than the time specified for schizophrenia. Schizoaffective disorder. For at least 1 month, these patients have had basic schizophrenia symptoms; at the same time, they have prominent symptoms of mania or depression. Brief psychotic disorder. These patients will have had at least one of the basic psychotic symptoms for less than 1 month. Other Psychotic Disorders Delusional disorder. These patients have delusions, but not the other symptoms of schizophrenia. Psychotic disorder due to another medical condition. A variety of medical and neurological conditions can produce psychotic symptoms that may not meet criteria for any of the conditions above. Substance/medication-induced psychotic disorder. Alcohol or other substances (intoxication or withdrawal) can cause psychotic symptoms that may not meet criteria for any of the conditions above. Other specified, or unspecified, schizophrenia spectrum and other psychotic disorder. Use one of these categories for patients with psychoses that don’t seem to fit any of the categories above. Unspecified catatonia. Use when a patient has symptoms of catatonia but there isn’t enough information to substantiate a more definitive diagnosis. Disorders with Psychosis as a Symptom Some patients have psychosis as a symptom of mental disorders discussed in other chapters. These disorders include the following: Mood disorder with psychosis. Patients with a severe major depressive episode or manic episode can have hallucinations and mood-congruent delusions. Cognitive disorders with psychosis. Many patients with delirium or major neurocognitive disorder have hallucinations or delusions. Personality disorders. Patients with borderline personality disorder may have transient periods (minutes or hours) when they appear delusional. Patients with schizophrenia may have premorbid schizoid or (especially) schizotypal personality disorder. Disorders That Masquerade as Psychosis The symptoms of some disorders appear to be psychotic, but are not. These disorders include the following: Specific phobia. Some phobic avoidance behaviors can appear quite strange without being psychotic. Intellectual disability. Patients with intellectual disability may at times speak or act bizarrely. Somatic symptom disorder. Sometimes these patients will report pseudohallucinations or pseudodelusions. Factitious disorder imposed on self. These patients may feign delusions or hallucinations in order to obtain hospital or other medical care. Malingering. These persons may feign delusions or hallucinations in order to obtain money (insurance or disability payments), avoid work (such as in the military), or avoid punishment. Whatever happened to folie à deux (“madness of two”)? For generations, this rarely encountered condition was a staple of mental health diagnostic schemes. It was termed shared psychotic disorder in recent DSMs, where it denoted patients who develop delusions similar to those held by a relative or other close associate. Often the second patient’s delusions cleared up, once association with the first patient was severed. There are several reasons why this condition has been excluded from DSM-5. Through the decades, there has been precious little research that would help us understand shared psychotic disorder. We have case reports, some describing multiple secondary patients dependent on one primary source (folie à trois, à quatre, à famille), but not much in the way of data. Although most of these patients live with someone who has schizophrenia or delusional disorder, the phenomenon has also been linked to somatic symptom disorder, obsessive–compulsive disorder, and the dissociative disorders. In other words, folie à deux may be better conceptualized as a descriptive syndrome similar to the Capgras phenomenon (in which patients believe that close associates have been replaced by exact doubles). Most patients who would formerly have been diagnosed as having folie à deux (shared psychotic disorder) will fulfill criteria for delusional disorder, which is how they should now be categorized. Otherwise, you’d have to diagnose them with other specified psychotic disorder and explain why. INTRODUCTION During the second half of the 20th century, one of the great leaps forward in mental health was to recognize that psychosis can have many causes. At least in part, this progress can be credited to DSM-III and its forebears and successors, which have established and popularized criteria for many forms of psychosis. The existence of psychosis is usually not hard to determine. Delusions, hallucinations, and disorganized speech or behavior are generally obvious; they often represent a dramatic change from a person’s normal behavior. But differentiating the various causes of psychosis can be difficult. Even experienced clinicians cannot definitively diagnose some patients, perhaps even after several interviews. Symptoms of Psychosis A psychotic patient is out of touch with reality. This state of mind can manifest in one or more of five basic types of symptom. These are DSM-5’s criterion A inclusion requirements for schizophrenia. Delusions A delusion is a false belief that cannot be explained by the patient’s culture or education; the patient cannot be persuaded that the belief is incorrect, despite evidence to the contrary or the weight of opinion of other people. Delusions can be of many types, including these: Erotomanic. Someone (often of higher social station) is in love with a patient. Grandeur. A patient is a person of exalted station, such as God or a movie star. Guilt. A patient has committed an unpardonable sin or grave error. Jealousy. A spouse or partner has been unfaithful. Passivity. A patient is being controlled or manipulated by some outside influence, such as radio waves. Persecution. A patient is being hounded, followed, or otherwise interfered with. Poverty. Contrary to the evidence (a job and ample money in the bank), a patient faces destitution. Reference. A patient is being talked about, perhaps in the press or on TV. Somatic. Patients’ body functions have altered, they smell bad, or they have a terrible disease. Thought control. Others are putting ideas into patients’ minds. Delusions must be distinguished from overvalued ideas, which are beliefs that are not clearly false but continue to be held despite lack of proof that they are correct. Examples include belief in the superiority of one’s own race or political party. Hallucinations A hallucination is a false sensory perception that occurs in the absence of a related sensory stimulus. Hallucinations are nearly always abnormal and can affect any of the five senses, though auditory and visual hallucinations are the most common. But they don’t always mean that the person experiencing them is psychotic. To count as psychotic symptoms, hallucinations must occur when a person is awake and fully alert. This means that hallucinations occurring only during delirium cannot be taken as evidence of one of the psychotic disorders discussed in this chapter. The same can be said for hallucinatory experiences that occur when someone is falling asleep (hypnagogic) or awakening (hypnopompic). These common experiences (which are not true hallucinations) are normal; they are better referred to as imagery. Another requirement for a psychotic symptom is that a person must lack insight into its unreality. You might think that this would apply to pretty much everyone, but you’d be wrong. Consider, for example, the Charles Bonnet syndrome, in which people who have significant loss of vision see complex visual imagery—but with full realization that the experience is unreal. Hallucinations must be discriminated from illusions, which are simply misinterpretations of actual sensory stimuli. They usually occur during conditions of decreased sensory input, such as at night. (For example, a person awakens to the impression that a burglar is bending over the bed; when the light comes on, the “burglar” is only a pile of clothes on a chair.) Illusions are common and usually normal. Disorganized Speech Even without delusions or hallucinations, a psychotic patient may have disorganized speech (sometimes also called loose associations), in which mental associations are governed not by logic but by rhymes, puns, and other rules not apparent to the observer, or by no evident rule at all. Some disorganization of speech is quite common (try reading an exact transcript of a politician’s off-the-cuff remarks, for example). But by and large, when those words were spoken, listeners understood perfectly well what was intended. To be regarded as psychotically disorganized, the speech must be so badly impaired that it interferes with communication. Abnormal Behavior (Such as Catatonia) Disorganized behavior, or physical actions that do not appear to be goal-directed—disrobing in public (without theatrical or, perhaps, political intent), repeatedly making the sign of the cross, assuming and maintaining peculiar and often uncomfortable postures—may indicate psychosis. Again, note how hard it can be to identify a given behavior as disorganized. There are plenty of people who do strange things; lots of these folks aren’t psychotic. Most patients whose behavior qualifies as psychotic will have actual catatonic symptoms, each of which has been carefully defined (see the sidebar later in this chapter). Negative Symptoms Negative symptoms include reduced range of expression of emotion (flat or blunted affect), markedly reduced amount or fluency of speech, and loss of the will to do things (avolition). They are called negative because they give the impression that something has been taken away from the patient—not added, as would be the case with hallucinations and delusions. Negative symptoms reduce the apparent textural richness of a patient’s personality. However, they can be hard to differentiate from dullness due to depression, drug use, or ordinary lack of interest. Distinguishing Schizophrenia from Other Disorders DSM-5 uses four classes of information to distinguish among the various types of psychosis: type of psychotic symptom, course of illness, consequences of illness, and exclusions. Each of these categories (plus a few other features) can help you distinguish schizophrenia, the most common psychotic disorder, from other disorders that include psychosis among their symptoms. The reason for this emphasis is that the differential diagnosis of psychosis very often boils down to schizophrenia versus nonschizophrenia. In terms of the numbers of patients affected and the seriousness of implications for treatment and prognosis, it is the single most important cause of psychotic symptoms. Psychotic Symptoms Any form of psychosis must include at least one of the five types of psychotic symptoms described above, but to be diagnosed as having schizophrenia, a patient must have two or more. Therefore, the first task in diagnosing any psychosis is to determine the extent of the psychotic symptoms. When two or more of these types of psychotic symptoms have been present for at least 1 month, and at least one of them is hallucinations, delusions, or disorganized speech, criterion A for schizophrenia is said to be satisfied. DSM-5 specifies that these two or more psychotic symptom types must be present for a “significant portion of time” during that month. But what does significant mean in this context? It could be interpreted to mean that (1) these symptoms have been present on more than half the days in the month; (2) several persons independently may have observed on several days that the patient is having symptoms; or (3) the symptoms may have occurred at times when they are especially likely to affect the patient or the environment—as with, for example, a patient who has repeatedly interrupted a social gathering by screaming. Finally, note that a duration of less than 1 month is allowed if treatment has caused the symptoms to remit. For behavior to be psychotic, it must be grossly abnormal, and the patient must lack insight into its nature. Examples of psychotic behavior would include symptoms of catatonia, such as mutism, negativism, mannerisms, or stereotypies—without apparent recognition that the behaviors in question are abnormal. (For definitions of these symptoms, see the sidebar.) An example of bizarre behavior that is not psychotic would be obsessive–compulsive rituals, which patients usually recognize as excessive or unreasonable. Delusions and hallucinations are the most commonplace symptoms of psychosis. As noted earlier, delusions must be discriminated from overvalued ideas, and hallucinations from illusions. Disorganized speech means speech that goes beyond the merely circumstantial—it must show marked loosening of associations. Examples: “He tells me something in one morning and out the other,” “Half a loaf is better than the whole enchilada.” Or, in response to the question, “How long did you live in Wichita?”: “Even anteaters like to Frenchkiss.” Negative symptoms can be hard to pinpoint, unless you ask an informant about changes in affective lability, volition, or amount of speech. Negative symptoms can also be mistaken for the stiffening of affect sometimes caused by neuroleptic medications. For a diagnosis of schizophrenia, earlier DSM versions required only one type of psychotic symptom if it was either a bizarre delusion or hallucinated voices that talk to one another. We can feel pretty clear about the hallucinated voices, but what exactly does bizarre mean, anyway? Unhappily, the definition is neither exact nor constant across different studies. It isn’t even consistent across different versions of the DSM, which refer to it with decreasing degrees of certitude: “with no possible basis in fact” (DSM-III), “totally implausible” (DSM-III-R), and “clearly implausible” (DSM-IV-TR). DSM-5 has nearly stepped away from the fray altogether, except as regards delusional disorder, where bizarre content is a specifier. There, bizarre is taken to mean not only “clearly implausible,” but also neither understandable nor in accord with usual life experience. So we might as well adopt the original sense that came to us several hundred years ago from French: odd or fantastic. Examples of delusions we could call bizarre include falling down a rabbit hole to Wonderland, being controlled (in thoughts or actions) by aliens from Halley’s Comet, or having one’s brain replaced by a computer chip. Examples of nonbizarre delusions include being spied upon by neighbors or betrayed by one’s spouse. (The assessment of what is and is not bizarre may vary with our distance from those we seek to judge: “I am unique, you are odd, they are bizarre.”) The recent weight of opinion is that the quality of bizarreness has little importance when it comes to diagnosis or prognosis. Therefore, in DSM-5, all patients with schizophrenia must have two or more types of psychotic symptoms, no matter how fantastic any one of them might be. Course of Illness Cross-sectional symptoms are less important to the differential diagnosis of psychosis than is the course of illness. That is, the type of psychosis is largely determined by the longitudinal patterns and associated features of the disorder. Several of these factors are noted here: Duration. How long has the patient been ill? A duration of at least 6 months is required for a DSM-5 diagnosis of schizophrenia. This rule was formulated decades ago, in response to the observation that psychotic patients who have been ill a long time tend at follow-up to have schizophrenia. Patients with a briefer duration of psychosis may turn out to have some other disorder. For years, we’ve operationally defined the time required as 6 months or longer. Precipitating factors. Severe emotional stress sometimes precipitates a brief period of psychosis. For example, the stress of childbirth precipitates what we call a postpartum psychosis. A chronic course is less likely if there are precipitating factors, including this one. Previous course of illness. A prior history of complete recovery (no residual symptoms) from a psychosis suggests a disorder other than schizophrenia. Premorbid personality. Good social and job-related functioning before the onset of psychotic symptoms directs our diagnostic focus away from schizophrenia and toward another psychotic disorder, such as a psychotic depression or a psychosis due to another medical condition or substance use. Residual symptoms. Once the acute psychotic symptoms have been treated (usually with medication), residual symptoms may persist. These are often milder manifestations of the person’s earlier delusions or other active psychotic symptoms: odd beliefs, vague speech that wanders off the point, a reduced lack of interest in the company of others. They augur for the subsequent return of psychosis. Consequences of Illness Psychosis can seriously affect the functioning of both patient and family. The degree of this effect can help discriminate schizophrenia from other causes of psychosis. To be diagnosed as having schizophrenia, the patient must have materially impaired social or occupational functioning. For example, most patients with schizophrenia never marry and either don’t work at all or hold jobs that require a lower level of functioning than is consistent with their education and training. The other psychotic disorders do not require this criterion for diagnosis. In fact, the criteria for delusional disorder even specify that functioning is not impaired in any important way except as it relates specifically to the delusions. Exclusions Once the fact of psychosis is established, can it be attributed to any mental disorder other than schizophrenia? We must consider at least three sets of possibilities. First, the top place in any differential diagnosis belongs to disorders caused by physical conditions. History, physical examination, and laboratory testing must be scrutinized for evidence. See the table “Physical Disorders That Affect Mental Diagnosis” in the Appendix for a listing of some of these disorders. Next, rule out substance-related disorders. Has the patient a history of abusing alcohol or street drugs? Some of these (cocaine, alcohol, psychostimulants, and the psychotomimetics) can cause psychotic symptoms that closely mimic schizophrenia. The use of prescription medications (such as adrenocorticosteroids) can also produce symptoms of psychosis. See the table “Classes (or Names) of Medications That Can Cause Mental Disorders” in the Appendix for more information. Finally, consider mood disorders. Are there prominent symptoms of either mania or depression? The history of mental health treatment is awash in patients whose mood disorders have for years been diagnosed as schizophrenia. Mood disorders should be included early in the differential diagnosis of any patient with psychosis. Other Features You should also think about some features of psychosis that are not included in the DSM-5 criteria sets. Some of these can help predict outcome. They include the following: Family history of illness. A close relative with schizophrenia increases your patient’s chances of also having schizophrenia. Bipolar I disorder with psychotic features also runs in families. Always learn as much as you can about the family history, so you can form your own judgment; accepting another clinician’s opinion about diagnosis can be risky. Response to medication. Regardless of how psychotic the patient appears, previous recovery with, say, lithium treatment suggests a diagnosis of mood disorder. Age at onset. Schizophrenia usually begins by a person’s mid-20s. Onset of illness after the age of 40 suggests some other diagnosis. It could be delusional disorder, but you should consider a mood disorder. However, late onset does not completely rule out a schizophrenia diagnosis, especially of the type we used to call paranoid. I have intentionally written up the material that follows in a different order from that adopted by DSM-5. The stated intention of that manual is to order its material along “a gradient of psychopathology” that clinicians should generally follow, so that they consider first conditions that don’t attain full status as psychotic disorders or that affect relatively fewer aspects of a patient’s life. Hence DSM-5 begins with schizotypal personality disorder and progresses next to delusional disorder and catatonia. Here’s the reasoning for my approach. As a general matter, I agree that we should evaluate our patients along a safety continuum, beginning with disorders that can be more readily treated (such as a substance-induced psychotic disorder) or those that have a relatively better prognosis (such as mood disorders with psychosis). However, from an educational point of view, it helps me to describe first a condition (schizophrenia) that includes all conceivable symptoms and then fiddle with variations. I believe that my approach is more likely to help you learn the basic features of psychosis. THE SCHIZOPHRENIA SPECTRUM F20.9 [295.90] Schizophrenia In an effort to achieve precision, the DSM criteria for schizophrenia have become more complicated over the years. But the basic pattern of diagnosis remains so straightforward that it can be outlined briefly. 1. Before becoming ill, the patient may have a withdrawn or otherwise peculiar personality. 2. For some time (perhaps 3–6 years) before becoming clinically ill, the patient may have experiences that, while not actually psychotic, portend the later onset of psychosis. This prodromal period is characterized by abnormalities of thought, language, perception, and motor behavior. 3. The illness proper begins gradually, often imperceptibly. At least 6 months before a diagnosis is made, behavior begins to change. Right from the start, this may involve delusions or hallucinations; or it may be heralded by milder symptoms, such as beliefs that are peculiar but not psychotic. 4. The patient has been frankly psychotic during at least 1 month of those 6. There have been two or more of the five basic symptom types described at the start of this chapter; hallucinations, delusions, or disorganized speech must be one of the two. 5. The illness causes important problems with work and social functioning. 6. The clinician can exclude other medical disorders, substance use, and mood disorders as probable causes. 7. Although most patients improve with treatment, relatively few recover to such an extent that they return completely to their premorbid state. There are several reasons why it is important to diagnose schizophrenia accurately: Frequency. It is a common condition: Up to 1% of the general adult population will contract this disorder. For unknown reasons, males become symptomatic several years younger than do females. Chronicity. Most patients who develop schizophrenia continue to have symptoms throughout their lives. Severity. Although most patients do not require months or years of hospitalization, as was the case before neuroleptic medications were developed, incapacity for social and work functioning can be profound. Psychotic symptoms can vary in their degree of severity (see sidebar). Management. Adequate treatment almost always means using antipsychotic drugs, which, despite their risk of side effects, often must be taken lifelong. Although nearly everyone does so, it is probably incorrect to speak of schizophrenia as if it were one disease. It is almost certainly a collection of several underlying etiologies, for which the same basic diagnostic criteria are used. It is also important to note that many symptoms in addition to the formal criteria are often found in patients with schizophrenia. Here are a few: Cognitive dysfunction. Distractibility, disorientation, or other cognitive problems are often noted, though the symptoms of schizophrenia are classically described as occurring in a clear sensorium. Dysphoria. Anger, anxiety, and depression are some of the common emotional reactions to ensuing psychosis. Other patients show inappropriate affect (such as giggling when nothing appears to be funny). Anxiety attacks and disorders are increasingly identified. Absence of insight. Many patients refuse to take medicine in the mistaken belief that they are not ill. Sleep disturbance. Some patients stay up late and arise late when they are attempting to deal with the onset of hallucinations or delusions. Substance use. Especially common is tobacco use, which affects 80% of all patients with schizophrenia. Suicide. Up to 10% of these patients (especially newly diagnosed young men) take their own lives. Because schizophrenia can present in so many different ways, and because it is so important (to individuals, society, and the history of mental disorder), I will illustrate with the stories of four patients. Essential Features of Schizophrenia The classic picture of a patient with schizophrenia is of a young person (late teens or 20s) who has had (1) delusions (especially persecutory) and (2) hallucinations (especially auditory). However, some patients will have (3) speech that is incoherent or otherwise disorganized, (4) severely abnormal psychomotor behavior (catatonic symptoms), or (5) negative symptoms such as restricted affect or lack of volition (they don’t feel motivated to do work, maintain family life). Diagnosis requires at least two of these five types of psychotic symptoms, at least one of which must be delusions, hallucinations, or disorganized speech (criterion A). The patient is likely to have some mood symptoms, but they will be relatively brief. Illness usually begins gradually, perhaps almost imperceptibly, and builds across at least 6 months in a crescendo of misery and chaos. The Fine Print Don’t dismiss the D’s: • Duration (6+ months, with criterion A symptoms for at least a month) • Disability (social, occupational, or personal impairment) • Differential diagnosis (other psychotic disorders, mood or cognitive disorders, physical and substance-induced psychotic disorders, peculiar ideas—often political or religious—shared by a community) Coding Notes Specify: With catatonia If the disorder has lasted at least 1 year, specify course: First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous Unspecified You may specify severity, though you don’t have to (see the sidebar). Whereas DSM-IV (and each of its predecessors) listed several subtypes of schizophrenia, DSM-5 has largely done away with them. Why is this? And why were they there in the first place? Sadly, the venerable categories of hebephrenic (disorganized), catatonic, and paranoid types, each of which has roots deep in the 19th century, simply didn’t predict much—not enough, at any rate, to justify their existence. Furthermore, they didn’t necessarily hold true to type from one episode of psychosis to the next. Catatonia, always encountered more often in illnesses other than schizophrenia, has now been demoted to a specifier denoting behaviors that apply not just to schizophrenia but to mood disorders as well as to physical illnesses. And the other old categories, while interesting to discuss (at least by clinicians old enough to have been weaned on these concepts), have been relegated to history’s dust bin, along with fever therapy and wet sheet packs. Lyonel Childs When he was young, Lyonel Childs had always been somewhat isolated, even from his two brothers and his sister. During the first few grades in school, he seemed almost suspicious if other children talked to him. He seldom seemed to feel at ease, even with those he had known since kindergarten. He never smiled or showed much emotion, so that by the time he was 10, even his siblings thought he was peculiar. Adults said he was “nervous.” For a few months during his early teens, he was interested in magic and the occult; he read extensively about witchcraft and casting spells. Later he decided he would like to become a minister. He spent long hours in his room learning Bible passages by heart. Lyonel had never been much interested in sex, but at age 24, still attending college, he was attracted to a girl in his poetry class. Mary had blonde hair and dark blue eyes, and he noticed that his heart skipped a beat when he first saw her. She always said “Hello” and smiled when they met. He didn’t want to betray too great an interest, so he waited until an evening several weeks later to ask her to a New Year’s Eve party. She refused him, politely but firmly. As Lyonel mentioned to an interviewer months later, he thought that this seemed strange. During the day Mary was friendly and open with him, but when he ran into her at night, she was reserved. He knew there was a message in this that eluded him, and it made him feel shy and indecisive. He also noticed that his thoughts had speeded up so that he couldn’t sort them out. “I noticed that my mental energy had lessened,” he told the interviewer, “so I went to see the doctor. I told him I had gas forming on my intestines, and I thought it was giving me erections. And my muscles seemed all flabby. He asked me if I used drugs or was feeling depressed. I told him neither one. He gave me a prescription for some tranquilizers, but I just threw it away.” Lyonel’s skin was pasty white and he was abnormally thin, even for someone so slightly built. Casually dressed, he sat quietly without fidgeting during that interview. His speech was entirely ordinary; one thought flowed logically into the next, and there were no made-up words. By summer, he had become convinced that Mary was thinking about him. He decided that something must be keeping them apart. Whenever he had this feeling, his thoughts seemed to become so loud that he felt sure other people must be able to hear. He neglected to look for a summer job that year and moved back into his parents’ house, where he kept to his room, brooding. He wrote long letters to Mary, most of which he destroyed. In the fall, Lyonel realized that his relatives were trying to help him. Although they would wink an eye or tap a finger to let him know when she was near, it did no good. She continued to elude him, sometimes only by minutes. At times there was a ringing in his right ear, which caused him to wonder whether he was becoming deaf. His suspicion seemed confirmed by what he privately called “a clear sign.” One day while driving he noticed, as if for the first time, the control button for his rear window defroster. It was labeled “rear def,” which to him meant “right-ear deafness.” When winter deepened and the holidays approached, Lyonel knew that he would have to take action. He drove off to Mary’s house to have it out with her. As he crossed town, people he passed nodded and winked at him to signal that they understood and approved. A woman’s voice, speaking clearly from just behind him in the back seat, said, “Turn right!” and “Atta boy!” Evaluation of Lyonel Childs Two of the five symptoms listed in DSM-5’s criterion A must be present for a diagnosis of schizophrenia, and Lyonel did have two—delusions (criterion A1) and hallucinations (A2). Note this new feature in DSM-5: A diagnosis of schizophrenia requires that at least one of delusions, hallucinations, and disorganized speech be among the patient’s psychotic symptoms. As with Lyonel, the hallucinations of schizophrenia are usually auditory. Visual hallucinations often indicate a substance-induced psychotic disorder or psychotic disorder due to another medical condition; they can also occur in major neurocognitive disorder (dementia) and delirium. Hallucinations of sense or smell are more commonly experienced by a person whose psychosis is due to another medical condition, but their presence would not rule out schizophrenia. As with Lyonel, auditory hallucinations are typically clear and loud; patients will often agree with the examiner who asks, “Is it as loud as my voice is right now?” Although the voices may seem to come from within a patient’s head, the source may be located elsewhere—the hallway, a household appliance, the family’s cat. The special messages that Lyonel received (finger tapping, eye winking) are called delusions of reference. Patients with schizophrenia may also experience other sorts of delusions. Often delusions are to some extent persecutory (that is, the patient feels in some way pursued or interfered with). None of Lyonel’s delusional ideas were so far from normal human experience that I’d call them bizarre. Lyonel did not have disorganized speech, catatonic behavior, or negative symptoms, but others with schizophrenia may. His illness significantly interfered with his work (he didn’t get a summer job) and his relationships with others (he stayed in his room and brooded). We can infer that in each of these areas he functioned much less well than before he became ill (B). Although Lyonel had heard voices for only a short time, he had been delusional for several months. The prodromal symptoms (his concerns about intestinal gas and feeling of reduced mental energy) had begun a year or more earlier. As a result, he easily fulfilled the requirement of a total duration (prodrome, active symptoms, and residual period) of at least 6 months (C). The doctor Lyonel consulted found no evidence of another medical condition (E). Auditory hallucinations that may exactly mimic those encountered in schizophrenia can occur in alcohol-induced psychotic disorder. People who are withdrawing from amphetamines may even harm themselves as they attempt to escape terrifying persecutory delusions. We might suspect either of these disorders if Lyonel had recently used substances. Lyonel also denied feeling depressed. Major depressive disorder with psychotic features can produce delusions or hallucinations, but often these are mood-congruent (they center around feelings of guilt or deserved punishment). Schizoaffective disorder could be excluded because he had no prominent mood symptoms (depressive or manic, D). From the duration of his symptoms, we know not to diagnose schizophreniform disorder. Many patients with schizophrenia also have an abnormal premorbid personality. Often this takes the form of schizoid or, especially, schizotypal personality disorder. As a child, Lyonel had at least five features of schizotypal personality disorder. These included constricted affect, no close friends, odd beliefs (interest in the occult), peculiar appearance (as judged by peers), and suspiciousness of other children. However, he had no history that would cause us to consider autism spectrum disorder (F). With two psychotic symptoms and a duration of more than 6 months, Lyonel’s illness easily matches the prototype for typical schizophrenia. Note that (as with most DSM-5 disorders) medical and substance use causes must be ruled out, and other, more treatable mental etiologies must be deemed less likely. Throughout his current episode, Lyonel had had no change of symptoms that might suggest anything other than a continuous course. He had been ill for just about 1 year. I’d peg his current GAF score at 30, and his overall diagnosis would be as follows: F20.9 [295.90] Schizophrenia, first episode, currently in acute episode F21 [301.22] Schizotypal personality disorder (premorbid) Z56.9 [V62.29] Unemployed In evaluating patients who have delusions or hallucinations, be sure to consider the cognitive disorders. This is especially true in an older patient whose psychosis has developed quite rapidly. And patients with schizophrenia who have active hallucinations or delusions should be asked about symptoms of dysphoria. They are likely to have depression or anxiety (or both) that could require additional treatment. Bob Naples As his sister told it, Bob Naples was always quiet when he was a kid, but not what you’d call peculiar or strange. Nothing like this had ever happened in their family before. Bob sat in a tiny consulting room down the hall. His lips moved soundlessly, and one bare leg dangled across the arm of his chair. His sole article of clothing was a red-and-white-striped pajama top. An attendant tried to drape a green sheet across his lap, but he giggled and flung it to the floor. It was hard for his sister, Sharon, to say when Bob first began to change. He was never very sociable, she said; “You might even call him a loner.” He hardly ever laughed and always seemed rather distant, almost cold; he never appeared to enjoy anything he did very much. In the 5 years since he’d finished high school, he had lived at their house while he worked in her husband’s machine shop, but he never really lived with them. He had never had a girlfriend—or a boyfriend, for that matter, though he sometimes used to talk with a couple of high school classmates if they dropped around. About a year and a half ago, Bob had completely stopped going out and wouldn’t even return phone calls. When Sharon asked him why, he said he had better things to do. But all he did when he wasn’t working was stay in his room. Sharon’s husband had told her that at work, Bob stayed at his lathe during breaks and talked even less than before. “Sometimes Dave would hear Bob giggling to himself. When he’d ask what was funny, Bob would kind of shrug and just turn away, back to his work.” For over a year, things didn’t change much. Then, about 2 months earlier, Bob had started staying up at night. The family would hear him thumping around in his room, banging drawers, occasionally throwing things. Sometimes it sounded like he was talking to someone, but his bedroom was on the second floor and he had no phone. He stopped going in to work. “Of course, Dave’d never fire him,” Sharon continued. “But he was sleepy from being up all night, and he kept nodding off at the lathe. Sometimes he’d just leave it spinning and wander over to stare out the window. Dave was relieved when he stopped coming in.” In the last several weeks, all Bob would say was “Gilgamesh.” Once Sharon asked him what it meant and he answered, “It’s no red shoe on the backspace.” This astonished her so much that she wrote it down. After that, she gave up trying to ask him for explanations. Sharon could only speculate how Bob came to be in the hospital. When she’d come home from the grocery store a few hours earlier, he was gone. Then the phone rang and it was the police, saying that they were taking him in. A security guard down at the mall had taken him into custody. He was babbling something about Gilgamesh and wearing nothing but a pajama top. Sharon blotted the corner of her eye with the cuff of her sleeve. “They aren’t even his pajamas—they belong to my daughter.” Evaluation of Bob Naples Do take a few moments to review Bob’s history for the elements of the typical schizophrenia prototype. This is the picture to carry around in your head, against which you’ll match future patients. With several psychotic symptoms, Bob fully met the basic criteria for schizophrenia. Besides his badly disorganized speech (criterion A3) and behavior (going out nude, A4), he had the negative symptoms of not speaking and lack of volition (he stopped going to work—A5). Although he had had active symptoms for perhaps only a few months, his decreased (even for him) sociability had begun well over a year before, extending the total duration of his illness (C) well beyond the 6-month threshold. The vignette makes clear the devastating effect of symptoms on his work and social life (B). However, even with these typical features, there are still several exclusions to be ruled out. Bob would say only one word when he was admitted, so it could not be determined whether he had a cognitive deficit, as would be the case in a delirium or in an amphetamine- or phencyclidine-induced psychotic disorder. Only after treatment was begun might his cognitive status be known for sure. Other evidence of gross brain disease (E) could be sought with skull X-rays, MRI, and blood tests as appropriate. Patients with bipolar I disorder can show gross defect of judgment by refusing to remain clothed, but Bob did not have any of the other typical features of mania, such as euphoric mood or hyperactivity—certainly not pressured speech. The absence of prominent mood symptoms would rule out major depressive episode and schizoaffective disorder (D). Over a year earlier, Bob had been found giggling to himself at his lathe, so the early manifestations of his illness had been present for far longer than the 6-month minimum for schizophrenia; we can therefore dismiss schizophreniform disorder. Several of Bob’s symptoms are typical for what used to be called disorganized schizophrenia. His affect was inappropriate (he laughed without apparent cause), although reduced lability (termed flat or blunted) would also qualify as a negative symptom. By the time of his evaluation, his speech had been reduced to a single word, but earlier it had been incoherent (and peculiar enough that his sister even wrote some of it down). Finally, there was loss of volition (the will to do things): He had stopped going to work and spent most of his time in his room, apparently accomplishing nothing. From Sharon’s information, a premorbid diagnosis of some form of personality disorder would also seem warranted. Bob’s specific symptoms included the following: no close friends, not desiring relationships, choosing solitary activities, lack of pleasure in activities, and no sexual experiences. This is a pattern, often noted in patients with schizophrenia, called schizoid personality disorder. Although Bob’s eventual diagnosis would seem evident, we should await the results of lab testing to rule out causes of psychosis other than schizophrenia. Therefore, we’ll add the qualifier (provisional) to his diagnosis. I’d give him a GAF score of just 15. F20.9 [295.90] Schizophrenia, first episode, currently in acute episode (provisional) F60.1 [301.20] Schizoid personality disorder (premorbid) Disorganized schizophrenia was first recognized nearly 150 years ago. It was originally termed hebephrenia because it began early in life (hebe is Greek for youth). Patients with disorganized schizophrenia can appear the most obviously psychotic of all. They often deteriorate rapidly, talk gibberish, and neglect hygiene and appearance. More recent research, however, has determined that the pattern of symptoms doesn’t predict enough to make disorganized schizophrenia a useful diagnostic subcategory—other than as a description of current symptoms. Natasha Oblamov “She’s nowhere near as bad as Ivan.” Mr. Oblamov was talking about his two grown children. At 30 years of age, Ivan had such severe disorganized schizophrenia (as it was then known) that, despite neuroleptics and a trial of electroconvulsive therapy, he could not put 10 words together so they made sense. Now Natasha, 3 years younger than her brother, had been brought to the clinic with similar complaints. Natasha was an artist. She specialized in oil-on-canvas copies of the photographs she took of the countryside near her home. Although she had had a one-woman exhibition in a local art gallery 2 years earlier, she had never yet earned a dollar from her artwork. She had a room in her father’s apartment, where the two lived on his retirement income. Her brother lived on a back ward of the state mental hospital. “I suppose it’s been going on for quite a while now,” said Mr. Oblamov. “I should have done something earlier, but I didn’t want to believe it was happening to her, too.” The signs had first appeared about 10 months ago, when Natasha stopped attending class at the art institute and gave up her two or three drawing pupils. Mostly she stayed in her room, even at mealtimes; she spent much of her time sketching. Her father finally brought Natasha for evaluation because she kept opening the door. Perhaps 6 weeks earlier she had begun emerging from her room several times each evening, standing uncertainly in the hallway for several moments, then opening the front door. After peering up and down the hallway, she would retreat to her own room. In the past week, she had reenacted this ritual a dozen times each evening. Once or twice, her father thought he heard her mutter something about “Jason.” When he asked her who Jason was, she only looked blank and turned away. Natasha was a slender woman with a round face and watery blue eyes that never seemed to focus. Although she volunteered almost nothing, she answered every question clearly and logically, if briefly. She was fully oriented and had no suicidal ideas or other problems with impulse control. Her affect was as flat as one of her canvases. She would describe her most frightening experiences with no more emotion than she would making a bed. Jason was an instructor at the art institute. Some months earlier, one afternoon when her father was out, he had come to the apartment to help her with “some special stroking techniques,” as she put it (referring to her brush). Although they had ended up naked together on the kitchen floor, she had spent most of that time explaining why she felt she should put her clothes back on. He left unrequited, and she never returned to the art institute. Not long afterward, Natasha “realized” that Jason was hanging about, trying to see her again. She would sense his presence just outside her door, but each time she opened it, he had vanished. This puzzled her, but she couldn’t say that she felt depressed, angry, or anxious. Within a few weeks she started to hear a voice quite a bit like Jason’s, which seemed to be speaking to her from the photographic enlarger she had set up in the tiny second bathroom. “It usually just said the ‘C word,’ ” she explained in response to a question. “The ‘C word’?” “You know, the place on a woman’s body where you do the ‘F word.’ ” Unblinking and calm, Natasha sat with her hands folded in her lap. Several times in the past several weeks, Jason had slipped through her window at night and climbed into her bed while she slept. She had awakened to feel the pressure of his body on hers; it was especially intense in her groin area. By the time she had fully awakened, he would be gone. The previous week when she went in to use the bathroom, the head of an eel—or perhaps it was a large snake—emerged from the toilet bowl and lunged at her. She lowered the lid on the animal’s neck and it disappeared. Since then, she had only used the toilet in the hall bathroom. Evaluation of Natasha Oblamov Natasha had a variety of psychotic symptoms. They included visual hallucinations (the eel in the toilet—criterion A2) and a nonbizarre delusion about Jason (A1). She also had the negative symptom of flat affect (she talked about eels and her private anatomy without a hint of emotion—A5). Although her active symptoms had been evident for only a few months, the prodromal symptom of staying in her room had been present for about 10 months (C). I can’t identify anything in the vignette I’d call lack of volition, but her disorder obviously interfered with her ability to complete a canvas (B). Nothing in Natasha’s history would suggest another medical condition (E) that could explain her symptoms. However, a certain amount of routine lab testing might be ordered initially: complete blood count, routine blood chemistries, urinalysis. No evidence is given in the vignette to suggest that she had a substance-induced psychotic disorder, and her affect, though flat, was pleasant enough—nothing like the severely depressed mood of a major depressive disorder with psychotic features (D). Furthermore, she had never had suicidal ideas, and nothing suggested a manic episode. Duration of illness longer than 6 months rules out schizophreniform disorder and brief psychotic disorder. Finally, her brother had schizophrenia. About 10% of the first-degree relatives (parents, siblings, and children) of patients with schizophrenia also develop this condition. Of course, this is not a criterion for diagnosis, but it does help point the way. Natasha fulfilled all elements of the prototype: psychotic symptoms, duration, and absence of other causes (especially medical and substance use disorders). Although age of onset isn’t included in the DSM-5 criteria, I’ve mentioned it in the prototype. Anyone who becomes psychotic after, say, age 35 needs an evaluation even more careful than usual—for other, possibly treatable causes. In an earlier time (DSM-IV), Natasha’s symptoms would have earned her a diagnostic subtype of undifferentiated; now everyone’s diagnosis is undifferentiated. Because she’d been ill less than a year (though well over the 6-month minimum), there would be no course specifier. I’d assign her a GAF score of 30. Her diagnosis would be simply this: F20.9 [295.90] Schizophrenia, first episode, acute DSM-5 encourages us to rate each patient’s psychotic symptoms on a 5-point scale. Each of the five criterion A symptoms is rated as 0 = absent, 1 = equivocal (not strong or long enough to be considered psychotic), 2 = mild, 3 = moderate, or 4 = severe. In addition, the manual notes that a similar rating scheme should be used for impaired cognition, depression, and mania, because each of these features is important in the differential diagnosis of psychotic patients. These ratings can be attached to several of the different psychotic disorders discussed in this chapter. But the use of this rating system for severity is (happily, in my judgment) optional. Ramona Kelt When she was 20 and had been married only a few months, Ramona Kelt was hospitalized for the first time with what was then described as “hebephrenic schizophrenia.” According to records, her mood had been silly and inappropriate, her speech disjointed and hard to follow. She had been taken for evaluation after putting coffee grounds and orange peels on her head. She told the staff about television cameras in her closet that spied upon her whenever she had sex. Since then, she had had several additional episodes, widely scattered across 25 years. Whenever she fell ill, her symptoms were the same. Each time she recovered enough to return home to her husband. Every morning Ramona’s husband had to prepare a list spelling out her day’s activities, even including meal planning and cooking. Without it, he might arrive home to find that she had accomplished nothing that day. The couple had no children and few friends. Ramona’s most recent evaluation was prompted by a change in medical care plans. Her new clinician noted that she was still taking neuroleptics; each morning her husband carefully counted them out onto her plate and watched her swallow them. During the interview, she winked and smiled when it did not seem appropriate. She said it had been several years since television cameras bothered her, but she wondered whether her closet “might be haunted.” Evaluation of Ramona Kelt Ramona had been ill for many years with symptoms that included disorganized behavior (criterion A4) and a delusion about television cameras (A1). The diagnosis of disorganized (hebephrenic) schizophrenia would at one time have been warranted, based on her inappropriate affect and bizarre speech (A3) and behavior. When acutely ill, she also met DSM-5 criteria for schizophrenia. At this evaluation she was between acute episodes, but showed peculiarities of affect (winking) and ideation (the closet might be haunted) that suggested attenuated psychotic symptoms. She did have one serious, ongoing negative symptom (A5), avolition: If her husband didn’t plan her day for her, she would accomplish pretty close to nothing (this would earn her a GAF score of 51). However, with only one current psychotic symptom, she appeared to be partly recovered from her last episode of schizophrenia. Of course, to receive a diagnosis of schizophrenia, Ramona would have to have none of the exclusions (general medical conditions, substance-induced psychotic disorder, mood disorders, schizoaffective disorder). I think we would be pretty safe in assuming that this was still the case, so her current diagnosis would be as given below. Note, too, that even the sketchy information in the vignette nicely fulfilled our typical schizophrenia prototype. The course specifier equates essentially to the old diagnosis of schizophrenia, residual type. F20.9 [295.90] Schizophrenia, multiple episodes, currently in partial remission PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA F20.81 [295.40] Schizophreniform Disorder Its name sounds as if it must be related to schizophrenia, but the diagnosis of schizophreniform disorder (SphD) was devised in the late 1930s to deal with patients who may have something quite different. These people look as if they do have schizophrenia, but some of them later recover completely with no residual effects. The SphD diagnosis is valuable because it prevents closure: It alerts all clinicians that the underlying nature of the patient’s psychosis has not yet been proven. (The -form suffix means this: The symptoms look like schizophrenia, which it may turn out to be. But with limited information, the careful clinician feels uncomfortable rushing into a diagnosis that implies lifelong disability and treatment.) The symptoms and exclusions required for SphD are identical to those of basic schizophrenia; where the two diagnoses differ is in terms of duration and dysfunction. DSM-5 doesn’t require evidence that SphD has interfered with the patient’s life. However, when you think about it, most people who have had delusions and hallucinations for a month or more have probably suffered some inconvenience socially or in the workplace. The real distinguishing point is the length of time the patient has been symptomatic: From 1 to 6 months is the period required. The practical importance of the interval is this: Numerous studies have shown that psychotic patients who have been briefly ill have a much better chance of full recovery than do those who have been ill for 6 months or longer. Still, over half of those who are initially diagnosed as having SphD are eventually found to have schizophrenia or schizoaffective disorder. SphD isn’t really a discrete disease at all; it’s a place filler that’s used about equally for males and females who are of about the age as patients with schizophrenia when they are first diagnosed. The diagnosis is made only about one-fifth as often as schizophrenia is, especially in the United States and other Western countries. In the late 1930s, the Norwegian psychiatrist Gabriel Langfeldt coined the term schizophreniform psychosis. In the United States it was perhaps more relevant at that time, when the diagnosis of schizophrenia was so often made for patients who had psychotic symptoms but not the longitudinal course typical of schizophrenia. As Langfeldt made clear in a 1982 letter in the American Journal of Psychiatry, when he devised the concept he meant to include not only psychoses that look exactly like schizophrenia except for the duration of symptoms, but other presentations as well. These include what we would today call brief psychosis, schizoaffective disorders, and even some bipolar disorders. Time and custom have narrowed the meaning of his term, to the point where it is hardly ever used. I consider that to be a great pity; it’s a useful device that helps keep clinicians on their toes and patients off chronic dosing with medication. Essential Features of Schizophreniform Disorder Relatively rapid onset and offset characterize SphD. The term usually indicates a young person (late teens or 20s) who for 30 days to 6 months has (1) delusions (especially persecutory) and (2) hallucinations (especially auditory). However, some patients will have (3) speech that is incoherent or otherwise disorganized, (4) severely abnormal psychomotor behavior (catatonic symptoms), or (5) negative symptoms such as restricted affect or lack of volition (they don’t feel motivated to do work or maintain family life). Diagnosis requires at least two of these five types of psychotic symptoms, at least one of which must be delusions, hallucinations, or disorganized speech. The patient recovers fully within 6 months. The Fine Print The D’s: • Duration (30 days to 6 months) • Differential diagnosis (physical and substance-induced psychotic disorders, schizophrenia, mood disorders, or cognitive disorders) Coding Notes Specify: {With}{Without} good prognostic features, which include: (1) Psychotic symptoms begin early (in first month of illness); (2) confusion or perplexity at peak of psychosis; (3) good premorbid functioning; (4) affect not blunted. Two to four of these = With good prognostic features; none or one = Without. With catatonia If it’s within 6 months and the patient is still ill, use the specifier (provisional). Once the patient has fully recovered, remove the specifier. If the patient is still ill after 6 months, SphD can no longer apply. Change the diagnosis to schizophrenia or some other disorder. You may specify severity, though you don’t have to (see the sidebar). Arnold Wilson When he was 3, Arnold Wilson’s family had entered a witness protection program. At least that’s what he told the mental health intake interviewer. Arnold was slim, of medium height, and clean-shaven. He wore a name tag identifying him as a medical student. His eye contact was direct and steady, and he sat quietly as he described his experiences. “It was on account of my dad,” he explained. “When we lived back East, he used to be in the Mob.” Arnold’s father, the principal informant, later remarked, “OK, I’m an investment banker. You might think that’s bad enough, but it isn’t the Mob. Well, anyway, it’s not that mob.” Arnold’s ideas had come to him as a revelation 2 months earlier. He was at his desk, studying for a physiology test, when he heard a voice just behind him. “I jumped up, thinking I must have left my door open, but there was no one in the room but me. I checked the radio and my iPod, but everything was turned off. Then I heard it again.” The voice was one he recognized. “But I can’t tell you whose. She told me not to.” The woman’s voice spoke very clearly to him and seemed to move around a lot. “Sometimes she seemed like she was just behind me. Other times, she stood outside whatever room I was in.” He agrees that she spoke in complete sentences. “Sometimes full paragraphs. What a gabby person!” he remarked with a laugh. At first, the voice told him he “needed to cover my tracks, whatever that meant.” When he tried to ignore it, she became “really angry, told me to believe her, or . . . ” Arnold didn’t finish the sentence. The voice pointed out that his last name, before he was 3, was Italian. “You know, she was really beginning to make sense.” “The name change part’s true,” his father explained. “When I married his mother, Arnold was part of the deal. His biological father had died of cancer of the kidney. We both thought it would be best if I adopted him.” That was 20 years ago. Arnold had had difficulty in middle school. His attention wandered, and so did he. As a result, he spent a lot of time in the principal’s office. Although several teachers despaired of him, in high school he’d hit his stride. There he’d made excellent grades, gotten into a good college, and then been accepted at a better medical school. That autumn, just before starting his freshman year, his physical exam (and a panel of blood tests) had been completely normal. He said his roommate would testify that he hadn’t used any drugs or alcohol. “It was pretty confusing, at first—the voice, I mean. I wondered if I was losing my mind. But then we talked it over, she and I. Now it seems pretty clear.” When Arnold talked about the voice, he became quite animated, using appropriate hand gestures and vocal inflections. Throughout, he gave full attention to the interviewer, except once when he turned his head, as though listening to something. Or someone. Evaluation of Arnold Wilson Arnold’s two psychotic symptoms—delusions and auditory hallucinations—are enough to get us past the criterion A requirements, which are the same for SphD as for schizophrenia. The vignette doesn’t describe the extent to which his social or school functioning had been compromised, but the SphD criteria set doesn’t require this information. The clinical features of Arnold’s psychosis closely resembled those of schizophrenia. Of course, that’s the whole point of SphD: At the time you make the diagnosis, you don’t know whether the outcome will be full recovery or long-term illness. Arnold’s symptoms had been present too long for brief psychotic disorder, which lasts less than 1 month, and too briefly for schizophrenia. He didn’t use alcohol to excess, and on his roommate’s evidence (OK, by proxy), he didn’t use drugs at all; this would rule out a substance-induced psychotic disorder. The usual general medical causes of psychosis would have to be investigated, but his recent physical exam had been normal. With no symptoms of mania or depression, bipolar I disorder would seem vanishingly unlikely. Whenever possible for patients with SphD, a statement of prognosis should be made. In Arnold’s case, the treating clinician noted the following evidence of good prognosis: (1) As far as anyone could tell, his illness had begun abruptly with prominent psychotic symptoms (auditory hallucinations). (2) His premorbid functioning (both work and social life) had been good. (3) Lacking flattening or inappropriateness, his affect was intact during this evaluation. The fourth good-prognosis feature specified by DSM-5 is perplexity or confusion. Arnold did say that he was confused at first, but by the time of his evaluation, at the height of his illness, his cognitive processes seemed intact. Thus he had three of the features that favor a good prognosis; only two are needed. The criteria require that a qualifier of (provisional) be appended if the diagnosis of SphD is made before the patient recovers, as was the case for Arnold. Assuming that he recovered completely within the 6-month limit, this qualifier could then be removed. However, if the illness lasted longer than 6 months and it interfered with Arnold’s work or social life, the diagnosis might need to be changed—probably to schizophrenia. Right now, Arnold’s diagnosis should read as given below. And I’d give him a GAF score of 60: Though his psychotic symptoms were serious, his behavior hadn’t been markedly affected. Yet. F20.81 [295.40] Schizophreniform disorder (provisional), with good prognostic features Do you need a place to park your patient while you collect more evidence? Even in DSM-5, there persist a couple of diagnostic “sidings” that you can use to indicate that something is wrong, but you’re waiting for more information before you commit to a diagnosis. Of course, there’s always “other specified ________” or “unspecified ________,” but even beyond those useful (and vague, and sometimes indiscriminately used) locutions, we have some other terms that gain much the same advantage. SphD is one—it can go either way, to chronicity or to recovery. And then brief psychotic disorder was manufactured to cover the month of psychosis before you can diagnose SphD. In Chapter 6, we’ll see that acute stress disorder was cobbled together to cover the month before posttraumatic stress disorder can be diagnosed. But that’s about the sum of it. The problem is, we mental health clinicians are still dependent on our patients’ appearance to inform how we view them. Other medical disciplines use lab tests, and so may avoid the diagnostic way station. F23 [298.8] Brief Psychotic Disorder Patients with brief psychotic disorder (BPsD) are psychotic for at least 1 day and return to normal within 1 month. It doesn’t matter how many symptoms they have had or whether they have had trouble functioning socially or at work. (In parallel with schizophreniform disorder, any patient who remains symptomatic longer than 1 month must be given a different diagnosis.) BPsD isn’t an especially stable diagnosis; many patients will eventually be rediagnosed with another psychotic disorder. (This is hardly surprising for a diagnosis you can have for only 30 days.). As few as 7% of first-time patients with psychotic disorders have this as the initial diagnosis. Some patients who experience a psychosis around the time of giving birth may be given this diagnosis. Even then, it is a rare condition: The incidence of postpartum psychosis is only about 1 or 2 per 1,000 women who give birth. Indeed, BPsD is overall twice as common among women as men. European clinicians are more likely to diagnose BPsD. (This doesn’t mean that the condition occurs more frequently in Europe, just that European clinicians are apparently more alert to it—or more likely to overdiagnose it.) BPsD may be more common among young patients (teenagers and young adults) and among patients who are from lower socioeconomic strata or who have preexisting personality disorders. Patients with certain personality disorders (such as borderline) who have very brief psychotic symptoms precipitated by stress do not require a separate diagnosis of BPsD. Over two decades ago, in DSM-III-R, this category was called brief reactive psychosis. That name and its criteria reflected the notion that it may occur in response to some overwhelmingly stressful event, such as death of a relative. In the DSM-5 criteria, this concept is retained only in the form of specifiers. The decision about the diagnosis of BPsD is relatively straightforward. To compensate, we face decisions about specifiers that are fraught. We must determine whether a stressor could have caused the psychosis. Of course, anything could precede the onset, and to learn what it might be could require interviewing a spouse, relative, or friend. We’d want to learn about possible traumatic events, but also about the patient’s premorbid adjustment, past history of similar reactions to stress, and the chronological relationship between stressor and the onset of symptoms. Even with all this, we’re still stuck with deciding whether the event is likely to have caused psychosis. DSM-5 tells us only that the event(s) must be severe enough to cause stress for anyone of the patient’s situation and culture. But it doesn’t help us at all to decide whether psychosis is in response to stress. My solution: Ignore the words in response; if there’s marked stress, say so, and move on. Essential Features of Brief Psychotic Disorder All within the course of a single month, the patient develops, then recovers completely from an episode of psychosis that includes delusions, hallucinations, or disorganized speech (disorganized behavior may also be present). The episode lasts at least 1 day but less than 1 month. The Fine Print The D’s: • Duration (1 day to 1 month) • Differential diagnosis (mood or cognitive disorders, psychoses caused by medical conditions or substance use, schizophrenia) Coding Notes If you make the diagnosis without waiting for recovery, you’ll have to append the term (provisional). You can specify: With postpartum onset. Symptoms begin within 4 weeks of giving birth. {With}{Without} marked stressors. The stressors must appear to cause the symptoms, must occur shortly before their onset, and must be severe enough that nearly anyone of that culture would feel markedly stressed. With catatonia You may specify severity, though you don’t have to (see the sidebar). Melanie Grayson This was Melanie Grayson’s first pregnancy, and she had been quite apprehensive about it. She had gained 30 pounds, and her blood pressure had been slightly too high. But she had needed only a spinal block for anesthesia, and her husband was in the room with her when she delivered a healthy baby girl. That night she slept fitfully; she was irritable the next day. But she breastfed her baby and seemed to listen attentively when the nurse practitioner came to instruct her on bathing and other postpartum care. The next morning, while Melanie was having breakfast, her husband came to take her and the baby home. When she ordered him to turn off the radio, he looked around the room and said he didn’t hear one. “You know very well what radio,” she yelled, and threw a tea bag at him. The mental health consultant noted that Melanie was alert, fully oriented, and cognitively intact. She was irritable but not depressed. She kept insisting that she heard a radio playing: “I think it’s hidden in my pillow.” She unzipped the pillowcase and felt around inside. “It’s some sort of a news report. They’re talking about what’s happening in the hospital. I think I just heard my name mentioned.” Melanie’s flow of speech was coherent and relevant. Apart from throwing the tea bag and looking for the radio, her behavior was unremarkable. She denied hallucinations involving any of the other senses. She insisted that the voices she heard could not be imaginary, and she didn’t think someone was trying to play a trick on her. She had never used drugs or alcohol, and her obstetrician vouched for her excellent general health. After much discussion, she agreed to remain in the hospital a day or two longer to try to get to the bottom of the mystery. Evaluation of Melanie Grayson Despite her obvious psychosis (hallucinations and delusions), the brevity of her symptoms kept Melanie from meeting the criterion A requirements for schizophrenia, schizophreniform disorder, or schizoaffective disorder. What’s left? Although Melanie remained alert and cognitively intact, any patient with abrupt onset of psychotic symptoms should be carefully evaluated for a possible delirium. (They will often be confused, which may be the fact with patients who have BPsD, too. Be careful in your evaluation.) Many general medical conditions can also produce psychotic symptoms. Anyone who becomes psychotic soon after entering the hospital should be evaluated for a substance-induced psychotic disorder with onset during withdrawal. Melanie had no prominent mood symptoms; if she had had any, a diagnosis of a mood disorder with psychotic features might have been entertained. It is worth noting that many patients who develop psychosis after delivery may have mixtures of symptoms that include euphoria, psychosis, and cognitive changes. Many of these patients have some form of mood disorder (often bipolar I disorder). Diagnosis should be made with extreme care in all cases of postpartum psychosis; the diagnosis of schizophrenia should never be made, except in the most obvious and certain of circumstances. With a very brief duration of psychosis and none of the exclusions, Melanie would fulfill the somewhat undemanding criteria for BPsD. Until she recovered, the diagnosis would have to be made provisionally. I’d put her GAF score at 40. Her full diagnosis at this time would be as follows: F23 [298.8] Brief psychotic disorder, with postpartum onset (provisional) O80 [650] Normal delivery F22 [297.1] Delusional Disorder Persistent delusions are the chief characteristic of delusional disorder. Usually they can seem entirely believable; however, it is no longer necessary that they be nonbizarre, as DSM-IV required. Still, patients tend to appear pretty normal, as long as you don’t touch on one of their delusions. There are half a dozen possible themes, which I’ve outlined in the Coding Notes. Although the symptoms can seem similar to those of schizophrenia, there are several reasons to list delusional disorder separately: • The age of onset is often later in life (mid- to late 30s) than that of schizophrenia. • Family histories of the two illnesses are dissimilar. • At follow-up, these patients are rarely rediagnosed as having schizophrenia. • The infrequent hallucinations take a back seat to the delusions, and are understandable in the context of those delusions. Most importantly, compared to that of schizophrenia, the course of delusional disorder is less fraught with intellectual and work-related deterioration. In fact, behavior won’t be much altered, outside of responses to the delusions: for instance, phoning the police for protection, or letter-writing campaigns to complain of sundry imagined insults or infractions. As you might suppose, resulting domestic problems are frequent—and, depending on their subtype, these patients may be swept up in litigation or endless medical tests. Delusional disorder is uncommon (by some estimates, schizophrenia is 30 times more frequent). Chronically reduced sensory input (being deaf or blind) may contribute to its development, as may social isolation (such as being an immigrant in a strange country). Delusional disorder may also be associated with family traits that include suspiciousness, jealousy, and secretiveness. The persecutory type is by far the most common of the subtypes; the jealous type ranks a distant second. One problem that crops up frequently is the presence of mood symptoms in patients with delusional disorder. These may be quite unsurprisingly gloomy responses to the perception that others do not agree with closely held beliefs. Depressive mood can create difficult questions of differential diagnosis: Most notably, does the patient have a primary mood disorder? The DSM-5 criteria do not provide a bright line separating the two concepts; the time course of two sets of symptoms—mood and psychotic—may help in the differentiation. Of course, in the case of serious question, I’d consider first the more conservative mood disorder, though delusional disorder may look better and better as time passes. Shared Delusions Though such instances are extremely rare, cases in which one or more persons develop delusions as a result of close association with another delusional person are dramatic and inherently interesting. DSM-IV called this condition shared psychotic disorder; as long ago as 150 years it was known as folie à deux, which means “double insanity.” Usually two people are involved, but three, four, or more can become caught up in the delusion. Shared delusions affect women more often than men, and they usually occur within families. Social isolation may play a role in the development of this strange condition. One of the persons affected is independently psychotic; through a close (and often dependent) association, the other has come to believe in the delusions and other experiences of the first. Though occasionally bizarre, the content of the delusion is usually believable, if often unconvincing. Isolating the independently psychotic patient may cure the other(s), but this remedy doesn’t always work. For one thing, the parties involved are often closely related and persist in reinforcing their mutual psychopathology. A few patients whose delusions mirror those of people with whom they are intimately associated will, for one reason or another, not fully qualify for a diagnosis of delusional disorder. For them, you’ll have to use the category of other specified (or unspecified) schizophrenia spectrum and other psychotic disorder, as described at the end of this chapter. Essential Features of Delusional Disorder For at least a month, the patient has had delusions but no other psychotic symptoms, and any mood symptoms are relatively brief. Other than consequences of the delusions, behavior isn’t much affected. The Fine Print OK, there might be some hallucinations of touch or smell, but only as they relate to the delusions. And they won’t be prominent. The D’s: • Duration (1+ months) • Distress and disability (none, except as related to the delusional content) • Differential diagnosis (physical and substance-induced psychotic disorders, mood or cognitive disorders, schizophrenia, obsessive–compulsive disorder) Coding Notes You can specify type of delusion: erotomanic, grandiose, jealous, persecutory, somatic, mixed, or unspecified. Specify if: With bizarre content. This denotes obviously improbable delusions (see sidebar). If the delusional disorder has lasted at least 1 year, specify course: First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous Unspecified You may specify severity, though you don’t have to (see the sidebar). Molly McConegal Molly McConegal, a tiny sparrow of a woman, sat perched on the front of her waiting room chair. On her lap she tightly clutched a scuffed black handbag; her gray hair was caught up in a fierce little bun at the back of her head. Through spectacles as thick as highball glasses, she darted myopic, suspicious glances about the room. She had already spent 45 minutes with the consultant behind closed doors. Now she was waiting while her husband, Michael, had a turn. Michael confirmed much of what Molly had already said. The couple had been married for over 40 years, had two children, and had lived in the same neighborhood (the same house, in fact) nearly all of their married life. Both were retired from the telephone company, and they shared an interest in gardening. “That was where it all started, in the garden,” said Michael. “It was last summer, when I was out trimming the rose bushes in the front yard. Molly said she caught me looking at the house across the street. The widow woman who lives there is younger than we are, maybe 50. We nod and say ‘Hi,’ but in 10 years, I’ve never even been inside her front door. But Molly said I was taking too long on those rose bushes, that I was waiting for our neighbor—her name is Mrs. Jessup—to come out of the house. Of course, I denied it, but she insisted. Kept talking about it for days.” In the following months, Molly pursued the idea of Michael’s supposed extramarital relationship. At first she only suggested that he had been trying to lure Mrs. Jessup out for a meeting. Within a few weeks, she “knew” that they had been together. Soon this had become a sex orgy. Molly had talked of little else and had begun to incorporate many commonplace observations into her suspicions. A button undone on Michael’s shirt meant that he had just returned from a visit with “the woman.” The adjustment of the living room Venetian blinds tipped her off that he had been trying to semaphore messages the night before. A private detective Molly hired for surveillance only stopped by to chat with Michael, submitted a bill for $500, and resigned. Molly continued to do the cooking and washing for herself, but Michael now had to take care of his own meals and laundry. She slept normally, ate well, and—when she wasn’t with him—seemed to be in good spirits. Michael, on the other hand, was becoming a nervous wreck. Molly listened in on his telephone calls and steamed open his mail. Once she told him that she would file for divorce, but she “didn’t want the children to find out.” Twice he had awakened at night to find her wrapped tightly in her bathrobe and standing beside his bed, glowering down at him. “Waiting for me to make my move,” he said. Last week she had strewn the hallway outside his room with thumbtacks, so that he would cry out and awaken her when he sneaked away for his late-night sexual rendezvous. Michael smiled and said sadly, “You know, I haven’t had sex with anybody for nearly 15 years. Since I had my prostate operation, I just haven’t had the ability.” Evaluation of Molly McConegal If you compare the features of delusional disorder with those of schizophrenia, you will note many differences. First, consider symptoms. Delusions are the only psychotic symptom found to any important degree in delusional disorder. The delusion could be any of the types listed in the Coding Notes. In Molly’s case, they were of the jealous type, but the persecutory and grandiose types are also common. Note that with the exception of occasional olfactory or tactile hallucinations that support the content of delusions, patients with delusional disorder will never fulfill criterion A for schizophrenia (this nonfulfillment constitutes delusional disorder’s criterion B). The delusions need last only 1 month; however, by the time they come to professional attention, most patients, like Molly, have been ill much longer (A). The average age of patients may be around 55. The consequences are usually relatively mild for delusional disorder. Indeed, aside from the direct effects of the delusion (in Molly’s case, her marital harmony), work and social life may not be affected much at all (C). However, the exclusions are pretty much the same as for schizophrenia. Always rule out another medical condition or cognitive disorder, especially a dementia with delusions, when evaluating delusional patients (E). This is especially important in older patients, who can be quite crafty at disguising the fact that they are cognitively impaired. Substance-induced psychotic disorders can closely mimic delusional disorder. This is especially true for amphetamine-induced psychotic disorder with onset during withdrawal, in which fully oriented patients may describe how they are being attacked by gangs of pursuers (E). Molly McConegal had neither history nor symptoms to support any of the foregoing disorders; however, laboratory and toxicology studies may be needed for many patients. Other than irritability in the company of her husband, she had no symptoms of a mood disorder. Even then, her affect was quite appropriate to her content of thought. However, many of these patients can develop mood syndromes secondary to the delusions. Then the diagnosis depends on the chronology and severity of mood symptoms. Information from relatives or other third parties is often required to determine which came first. Also, the mood symptoms must be relatively mild and brief to sustain a diagnosis of delusional disorder. Although these patients may have associated conditions—including body dysmorphic disorder, obsessive–compulsive disorder, or avoidant, paranoid, or schizoid personality disorder—there was no evidence for any of these in Molly McConegal. Molly had been ill a bit less than a full year, so no course of illness could be specified. Her GAF score would be 55 (highest level in the past year). Her diagnosis would be as follows: F22 [297.1] Delusional disorder, jealous type Miriam Phillips Miriam Phillips was 23 when she was hospitalized. She had spent nearly all her life in the Ozarks, where she sometimes attended class in a three-room school. Although she was bright enough, she had little interest in her studies and often volunteered to stay home to care for her mother, who was unwell. She dropped out of 12th grade to stay home full-time. It was lonely living in the hills. Miriam’s father, a long-distance trucker, was away most of the time. She had never learned to drive, and there were no close neighbors. Their television set received mostly snow; there was little in the way of mail; and there were no visitors at all. So she was surprised late on a Monday afternoon when two men paid a call. After identifying themselves as FBI agents, they asked if she was the Miriam Phillips who 3 weeks earlier had written a letter to the president. When she asked how they had known, they showed her a faxed copy of her own letter: Dear Mr. President, what do you plan to do about the Cubans? They have been working on mother. Their up to no good. Ive seen the police, but they say Cubans are your job, and I guess their right. You have to do your job or Ill have a dirty job to do. Miriam Phillips. When Miriam finally figured out that the FBI agents thought she had threatened the president, she relaxed. She hadn’t meant that at all. She had meant that if no one else took action, she’d have to crawl under the house to get the gravity machines. “Gravity machines?” The two agents looked at each other. She explained. They had been installed under the house by Cuban agents of Fidel Castro after the Bay of Pigs invasion in the 1960s. The machines pulled your body fluids down toward your feet. They hadn’t affected her yet, but they had bothered her mother for years. Miriam had seen the hideous swelling in her mother’s ankles. Some days it extended almost to her knees. The two agents listened to her politely, then left. As they passed through town on their way to the airport, they called at the local community mental health clinic. Within a few days, a mental health worker came to interview Miriam, who agreed to enter the hospital voluntarily for a “checkup.” On admission, Miriam appeared remarkably intact. She had a full range of appropriate affect and normal cognitive abilities and orientation. Her reasoning ability seemed good, aside from the story about the gravity machines. As far back as her teens, her mother had told her how the machines came to be installed in the crawlspace under their house. Mother had been a nurse, and Miriam had always accepted her word in medical matters. By some unspoken agreement, the two had never discussed the matter with Miriam’s father. After Miriam had been on the ward for 3 days, her clinician asked whether she thought any other explanation for her mother’s edema was possible. Miriam considered. She had never felt the gravity effects herself. She had believed that her mother told her the truth, but she now supposed that even Mother could have been mistaken. Though Miriam was given no medication, after a week she stopped talking about gravity machines and asked to be discharged. At the end of their shift that afternoon, two young attendants gave her a lift home. As they walked her to the front door, it was opened by a short woman, quite stout, with salt-and-pepper hair. Her lower legs were neatly wrapped in elastic bandages. Through the partly opened door she darted a glance at the two men. “Hmmm!” she said. “You look like Cubans.” Evaluation of Miriam Phillips Though we don’t know exactly how long, Miriam had had delusions far longer than a month (criterion A) without hallucinations or negative symptoms, and with no disordered behavior or affect. Therefore, schizophrenia could be ruled out just on the basis of insufficient variety of symptoms (B). She wasn’t depressed or manic (D), and there was no history or other evidence to support substance-induced psychotic disorder or psychotic disorder due to another medical condition (E). Her delusions hadn’t caused any occupational or social dysfunction; her own isolation appeared to have begun at least 5 years earlier, before the onset of her shared delusion (C). With an admission GAF score of 40, Miriam’s delusions became less prominent after just a few days of separation from her mother. In working further with her, a therapist would also want to consider the possibility of a personality disorder, such as dependent personality disorder. Her delusion, and that of her mother, was certainly bizarre, but I’m not confident she had been ill longer than a year, so I wouldn’t give her any other specifiers. F22 [297.1] Delusional disorder, persecutory type, with bizarre content Schizoaffective Disorder Schizoaffective disorder (SaD) is just plain confusing. (William Carpenter, chairperson of the DSM-5 psychosis study group, stated during a 2013 presentation about his committee’s work, “We don’t even know if it exists in nature.”) Over the years, it has meant many different things to clinicians. Partly because there were so many interpretations in use, DSM-III included no criteria at all in 1980. DSM-III-R first attempted to specify criteria in 1987. These endured for 7 years, until they were substantially rewritten for DSM-IV. Showing admirable restraint, DSM-5 has made relatively few changes to those criteria. Even with the (minimal) tweaking of criteria, in my opinion the value of this diagnosis remains pretty low. Most interpretations suggest that SaD is some sort of cross between a mood disorder and schizophrenia. Some writers regard it as a form of bipolar disorder, because certain patients seem to respond well to lithium. Other commentators believe that it is closer to schizophrenia. Still others hold that it is an entirely separate type of psychosis, or simply a collection of confusing, sometimes contradictory symptoms. With its various percentage and minimal time requirements, SaD could unfold in a variety of ways: mania first, depression first, psychosis first. Of course, there are the usual exclusions for substance use and general medical conditions. If you examine the various time requirements, you can determine that the entire illness must last at minimum for a bit longer than 1 month, though many patients will be ill much longer. No one really knows much about the demographic features of SaD. It is probably less common than schizophrenia; its prognosis lies between that of schizophrenia and the mood disorders. Recent studies indicate that patients with SaD whose manic symptoms predominate (the bipolar type) may have a better prognosis than those with the depressive type of this condition. I find it easier to remember the requirements for SaD if I think of them as follows: The mood symptoms are important in that they must be present during half or more of the total duration of illness. The psychosis symptoms are important in that they must be present by themselves for at least 2 weeks. (Note that the criteria are silent on whether to count psychosis symptoms that are present during the time that mood symptoms have disappeared under treatment.) In this graphic representation of the minimum time requirements that are possible, given the criteria, the overall length of the box represents the totality of the individual’s illness, not just an episode. Of course, it will be impossible for any clinician to know whether the criteria for a mood episode are met throughout the illness; we’ll have to rely on prototypes for the overall gestalt. Note that the “solo” psychotic episode (criterion B) could come at any point in the episode: the start, the end, somewhere in the middle. Unhappily, DSM-5 is silent on the question of whether, during the psychosis period, there can be mood symptoms that don’t fully qualify as an episode of mania, hypomania, or depression. (DSM-IV was more forthright; it said “in the absence of prominent mood symptoms.”) Start saving for DSM-6. Essential Features of Schizoaffective Disorder A patient has a period of illness during which a manic episode or a major depressive episode lasts half of more of the total time involved. For at least a fortnight during this same continuous period, the patient fulfills the criterion A requirements for schizophrenia without having a mood episode. The Fine Print If the patient has a major depression, one of the symptoms must be depressed mood; “mere” loss of interest doesn’t cut it. The D’s: • Duration (a total of 1+ months) • Differential diagnosis (psychotic mood disorders, substance use, and physical disorders) Coding Notes Specify: F25.0 [295.70] Bipolar type (if during a manic episode) F25.1 [295.70] Depressive type Specify: With catatonia If the disorder has lasted at least 1 year, specify course: First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous Unspecified You may specify severity, though you don’t have to (see the sidebar). Velma Dean Velma Dean’s lips curled upwards, but the smile didn’t touch her eyes. “I’m really sorry about this,” she told her therapist, “but I guess—well, I don’t know what.” She reached into the large shopping bag she had carried into the office and pulled out a 6-inch kitchen knife. First she grasped it in her hand, with her thumb along the blade. Then she tried clutching it in her fist. The therapist reached for the alarm button under the desk top, ruefully aware of yet another change of course in this patient’s multifaceted history. A month before her 18th birthday, Velma Dean had joined the Army. Her father, a colonel of artillery, had wanted a son, but Velma was his only child. Over the feeble protests of her mother, Velma’s upbringing had been strict and semimilitary. After working 3 years in the motor pool, Velma herself had just been promoted to sergeant when she became ill. Her illness started with 2 days in the infirmary for what seemed like bronchitis, but as the penicillin took effect and her fever resolved, the voices began. At first they seemed to be located toward the back of her head. Within a few days they had moved to her bedside water glass. As nearly as she could tell, their pitch depended on the contents of her glass: If the glass was nearly empty, the voices were female; if it was full to the top, they spoke in a rich baritone. They were always quiet and mannerly. Often they gave her advice on how to behave, but at times she said they “nearly drove me crazy” by constantly commenting on what she was doing. A psychiatrist diagnosed Velma’s condition as schizophrenia and prescribed neuroleptics. The voices improved, but never quite disappeared. She concealed the fact that she had “figured out” that her illness had been caused by her first sergeant, who for months had tried unsuccessfully to get her into bed. She also hid the fact that for several weeks she had been drinking nearly a pint of Southern Comfort each evening. The Army retired her as medically unfit, 100% disabled. When she was well enough to travel, her father drove her the 600 miles back home. For her treatment, Velma enrolled at her local Department of Veterans Affairs (VA) outpatient clinic. There, her new therapist verified (1) the continuing presence (now for nearly 8 months) of her barely audible hallucinations, and (2) her increasingly profound symptoms of depression. These included low self-esteem and hopelessness (much worse in the morning than in the evening); loss of appetite; a 10-pound weight loss over the past 8 weeks; insomnia that caused her to awaken early most mornings; and the guilty conviction that she had disappointed her father by “deserting” the Army before her hitch was up. She denied thoughts of injuring herself or other people. Velma’s VA clinician initially deferred making a diagnosis, noting that she had been ill too long for schizophreniform disorder and that her mood symptoms seemed to argue against schizophrenia. Physical exam and laboratory testing ruled out general medical conditions. Although Alcoholics Anonymous helped her stop drinking, her depressive and psychotic symptoms continued. Because Velma’s depressive symptoms might be secondary to a partly treated psychosis, her neuroleptic dose was increased. This completely eliminated the hallucinations and delusions, but the depressive symptoms continued virtually unabated. The antidepressant imipramine at 200 mg/day only produced side effects; after 4 weeks, lithium was added. Once a therapeutic blood level was reached, her depressive symptoms melted completely away. For 6 months she remained in a good mood and free of psychosis, though she never obtained a job or did very much with her time. Now it seemed that Velma might actually be suffering from a major depressive disorder with psychotic features. At this point, her clinician became uneasy that the neuroleptic could produce side effects such as tardive dyskinesia. With Velma’s consent, the neuroleptic was gradually reduced by about 20% per week. After 3 weeks, she began once again to hear voices commanding her to run away from home. During this time her mood remained good; with the exception of some difficulty getting to sleep at night, she developed none of the vegetative symptoms she had formerly had with depression. Her full former dose of neuroleptic medication was rapidly restored. After several months of renewed stability, Velma and her therapist decided to try again. This time they began cautiously to reduce the imipramine, by 25 mg each week. Each week they met to evaluate her mood and check for symptoms of psychosis. By December she had been free of the antidepressant for 2 months, and had remained symptom-free (except for her habitual bland, smiling affect). Now her therapist took a deep breath and decreased her lithium by one tablet per day. The following week Velma returned to the office, hallucinating and wondering whether to hold a kitchen knife in her hand or in her fist. Evaluation of Velma Dean With Velma’s story, we can illustrate the current thinking about SaD. Her condition really seemed to be a mixture of mood and psychotic symptoms, though the latter had clearly begun first. She had what appeared to be a single period of illness (her only “well” periods were when she was taking medication; even then, she had residual lack of initiative), with both psychotic symptoms (auditory hallucinations and a delusion that the sergeant had caused her illness) and a major depressive episode (criterion A). During this period her mood symptoms, which occurred both with and without psychotic symptoms, had lasted for more than half the duration of her total illness (C). Although she abused alcohol at one time during her illness, it appeared to be a consequence of her illness, not the cause; both her mood and psychotic symptoms continued long after she quit drinking (D). The psychosis had begun first and had lasted at least 2 weeks before the mood symptoms commenced (B). The prototype symptoms are also met at level 4, and say more or less the same thing. Although we can rattle off these criteria with relative ease (and, to be honest, a crib sheet), Velma’s history illustrates how difficult it can be to apply them. The therapist, whose thinking has already been described in the vignette, was smart initially to defer diagnosis; this should remind all clinicians to keep thinking about the diagnosis and to reject any label that might close their minds to further therapeutic plans. She could not be diagnosed as having schizophrenia, because it excludes prominent, lasting mood episodes. A mood disorder with psychosis could be eliminated because she had psychotic symptoms even when not depressed. After many months of care, she showed no evidence of another medical condition. The relative duration of psychosis and mood symptoms is very important in SaD. DSM-5 states that the mood symptoms must be present for a majority of the overall duration of illness. Velma’s depressive symptoms lasted for at least 2 months; there is every reason to suspect they would have gone on much longer had she not received effective treatment. Her criterion A symptoms for schizophrenia had been present for 2 weeks without mood symptoms. However carefully the criteria try to operationalize the duration of various symptoms, it remains to some degree a judgment call on the part of each clinician. (DSM-5 is silent on the issue of treated depression and SaD; I’m claiming clinician’s prerogative and declaring that because antidepressant treatment seems to have made all the difference, SaD should be her diagnosis.) Eventually, many patients with both mood and psychotic symptoms will comfortably fit the criteria for schizophrenia or a mood disorder. If they were followed long enough, perhaps the majority of patients with SaD could be rediagnosed. Given the highly restrictive nature of the current definition, it seems likely that this diagnosis will rarely be used. If you ever make the diagnosis, ask yourself, “Have I overlooked anything that is more reasonable?” SaD is a diagnosis best used for patients who have a long-standing history of both sets of symptoms. Other specified (or unspecified) schizophrenia spectrum and other psychotic disorder may prove to be much more useful to most clinicians. Velma’s mood symptoms were depressive, which defined her subtype diagnosis. At the time she was wielding her knife, I felt that her GAF score was down around 20. F25.1 [295.70] Schizoaffective disorder, depressive type Substance/Medication-Induced Psychotic Disorder This category includes all psychoses caused by mind-altering substances. The predominant symptoms are usually hallucinations or delusions; depending on the substance, they can occur during withdrawal or acute intoxication. Usually the course is brief, though they can persist long enough to cause confusion with endogenous psychoses. Although most of these psychoses are self-limiting, early recognition is crucial. Patients have died while experiencing a substance-induced psychotic disorder, several of which can closely mimic schizophrenia. Many diagnoses are possible, if we include all the possible combinations of different substances with the type and duration of psychosis and its relation to intoxication or withdrawal. The incidence is unknown, though a substantial minority of first-episode psychoses may belong to this class—enough that we should remain alert for them. See the “Classes (or Names) of Medications . . .” table in the Appendix for a list of medications associated with psychosis. Essential Features of Substance/Medication-Induced Psychotic Disorder The use of some substance appears to have caused hallucinations or delusions (or both). The Fine Print For tips on identifying substance-related causation, see sidebar. The D’s: • Distress or disability (work/academic, social, or personal impairment) • Differential diagnosis (schizophrenia and its cousins, delusional disorder, ordinary substance intoxication or withdrawal, delirium) You’d only make this diagnosis when the symptoms are serious enough to justify clinical attention and they are worse than you’d expect from ordinary intoxication or withdrawal. Coding Notes When writing down the diagnosis, use the name of the exact substance in the title: for example, methamphetamine-induced psychotic disorder. ICD-9 kept coding simple: 291.9 for alcohol, 292.9 for all other substances. Coding in ICD-10 depends on the substance used and whether symptoms are met for an actual substance use disorder—and how severe the use disorder is. Refer to Table 15.2 in Chapter 15. Specify if: With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words. It also affects the ICD-10 number. With onset after medication use. You can use this in addition to other specifiers (see the sidebar just below). You may specify severity, though you don’t have to (see the sidebar). Actually, DSM-5 mentions with onset after medication use as an optional specifier for substance/medication-induced anxiety disorder, obsessive–compulsive and related disorder, and sexual dysfunctions, but not for psychotic, mood, or sleep disorders. (This despite the fact that the titles of these disorders even begin, uniformly, “substance/medication-induced [this or that].”) I am told that there wasn’t enough communication among the different subcommittees, so that inconsistencies such as this one crept into the final version. Inasmuch as prescribed medications can cause virtually any sort of emotional or behavioral problem, I plan to go right ahead and use the medication specifier any time it seems warranted. But that’s easy for me to say—in my state, the governor has declared a moratorium on capital punishment. Danny Finch Danny Finch put up with the ear problem for 3 days before he finally called for an appointment. The doctor poked at this and that, and worried a little over his tremor. “You don’t drink, do you?” “A little. But what about my ear?” “It’s perfectly normal.” “But I hear something. It’s like someone chanting. I can almost make out what they’re saying. You’re sure no one’s put something in there, a hearing aid?” He dug at the ear with his little finger. “Nope, clean as a whistle. Here, don’t do that!” The doctor scribbled a referral to the mental health clinic down the hall. That was late on a Friday afternoon, so of course the clinic was closed. On Monday afternoon, when he finally got to his appointment, Danny could once again write his name legibly and eat solid food. But the voices were in full throat. As he talked with the interviewer, he could hardly concentrate for the shouting: “Don’t tell about the drinking!” and “Why don’t you just kill yourself?” He was so terrified that he accepted with relief a voluntary commitment to the mental health ward, where his admitting diagnosis was schizophrenia. Twice a day he was given a potent neuroleptic medication, which he tucked under his tongue and discarded in the tissue when he pretended to blow his nose. Danny slept soundly at night and cleaned his plate at every meal while the voices shouted on. At the end of the week, he was visited by a consultant who learned that the voices came from about 2 feet behind him and talked in sentences. Reluctantly, he admitted that they told him not to talk about his drinking. A rapid review of Danny’s chart revealed no mention of alcohol use, but a little coaxing soon pried loose the whole story. Since his early 20s, there had been heavy drinking, loss of two jobs (he had a shaky hold on his present one), and a divorce, all related to his fondness for bourbon. Most recently he had been drinking more than a pint each evening, often a fifth on the weekends. Usually he managed to taper off; this time, he had quit suddenly after a bout of what he called “the stomach flu.” DSM-5 repeatedly refers to classes of symptoms that may appear to be caused by a substance. It is up to you to evaluate your patient for evidence that this might not be the case. Here are several findings, mostly based on chronology, that might constitute such evidence: 1. Your patient had a prior episode of the same, or very similar, symptoms that did not occur in the context of substance use. 2. The disorder continues long after the use of (or withdrawal from) the substance is over. 3. Rather obviously, a disorder that begins before substance use begins wouldn’t be due to the substance use. 4. The symptoms are worse than you’d expect, considering the amount and duration of the substance misuse. None of these is exactly iron-clad. For example, a prior history of major depressive disorder doesn’t confer subsequent immunity to depression that originates in a bottle of Scotch. Still, the cues are there, for your thoughtful consideration. And here are some of the reasons why you should consider a substance-use causation: 1. The symptoms begin soon after (or during) the use of a substance or its withdrawal. 2. They start after a patient has begun use of a medication. 3. The drug/medication is known to be capable of causing the symptoms in question. 4. Of course, if your patient has had a prior episode of the same symptoms that did follow the use of the same substance, that’s perhaps the best evidence of all. Evaluation of Danny Finch Danny had auditory hallucinations (criterion A) that had been present far too briefly for schizophrenia, though he described them in similar terms (C). A brief psychotic disorder might be possible, except for the requirement that a substance-induced psychotic disorder does not better explain the symptoms. He had just been seen by a physician, who pronounced him fit; there was no evidence of any other general medical condition. The fact that he seemed fully oriented and maintained his attention would rule out delirium and other cognitive disorders (D). Though he appeared (appropriately) frightened by his experiences, he presented no evidence of mood disorder. Danny’s psychosis—in the distant past it was called alcoholic auditory hallucinosis—is a disorder of withdrawal that usually occurs only after weeks or months of heavy drinking (B). By about a 4:1 ratio, it occurs much more commonly in men than in women, approximating the sex ratio for alcohol use disorder itself. Auditory hallucinosis is sometimes misidentified as alcohol withdrawal delirium, though the problems with orientation and attention in the latter make the differences clear (see Substance Intoxication Delirium, Substance Withdrawal Delirium, and Medication-Induced Delirium). Withdrawal from other drugs can also produce psychosis. Barbiturates, which have many of the same effects as alcohol, are the most notorious of these. Some patients who use phencyclidine or other hallucinogens such as LSD experience prolonged psychosis, the risk for which may be greater in people who have personality disorders. Danny’s symptoms were clearly more serious than we’d expect in alcohol withdrawal with perceptual disturbances (which would be diagnosed had he retained insight that his experiences weren’t “real”). His GAF score was only 35 on admission; his diagnosis (from Table 15.2 in Chapter 15) would be as follows: F10.259 [291.9] Severe alcohol use disorder with alcohol-induced psychotic disorder, with onset during withdrawal Psychotic Disorder Due to Another Medical Condition A psychosis arising in a patient who has another medical condition shouldn’t be especially rare. Many diseases can produce psychosis, and a number of them are relatively common. But few, if any, studies bear on questions of epidemiology. When such patients do appear, they are too often misdiagnosed as having schizophrenia or some other psychosis. This can lead to real tragedy: A patient who is not appropriately treated early enough may go on to experience (or cause) serious harm. Prevalence rates are not known exactly, but they’re probably low; as you might imagine, frequency increases with age. Note that a patient with mainly disorganized behavior would instead be diagnosed as having catatonic disorder due to another medical condition. It’s often a struggle to determine that a physical illness or medical condition has caused any mental disorder. Here are a few straws in the wind that can help out. • Timing of onset: Mental or behavioral symptoms that begin shortly after the start of the physical illness offer a pretty obvious etiological clue. • Remission follows treatment for the physical issue. • Proportionality of symptoms: As the physical disorder worsens, so do the behavioral or emotional symptoms. • Above all, there must be a known physiological connection between the physical condition and the symptom in question. That is, the physical disorder must be known to be capable of producing the symptom (for example, through production of chemicals, by impinging on brain structures). It cannot simply be that the prospect of having a serious illness evokes psychosis, depression, anxiety, and so forth. OK, so these pointers aren’t exactly iron-clad. Remember, they’re straws, not steel. Essential Features of Psychotic Disorder Due to Another Medical Condition A physical condition causes hallucinations or delusions. The Fine Print For pointers on deciding when a physical condition may have caused a mental disorder, see the sidebar just above. The D’s: • Distress or disability (work/academic, social, or personal impairment) • Differential diagnosis (delirium, substance-induced psychotic disorder, schizophrenia and its cousins, delusional disorder) Coding Notes In recording the diagnosis, use the name of the responsible medical condition, and list first the medical condition, with its code number. Code, based on the predominant symptoms: F06.2 [293.81] With delusions F06.0 [293.82] With hallucinations You may specify severity, though you don’t have to (see the sidebar). Rodrigo Chavez After he retired from teaching at age 65, Rodrigo Chavez spent most of his time sitting alone in his room. Sometimes he played the acoustic guitar; once or twice he shot targets at the rifle range. True to his lifelong habit, he never drank. Other than his immediate family, he had few social contacts. “My cigarettes are my best friends,” he put it during the forensic examination. When Rodrigo was nearly 70, an inoperable carcinoma of the lung was diagnosed. After a course of palliative radiotherapy, he declined further treatment and settled down in his apartment to die. Four months later, he first noticed right-sided headaches that would sometimes awaken him in the middle of the night. Because the doctors had told him he was terminally ill, he didn’t seek further medical attention. Then he began to associate the headaches with natural gas, which he smelled coming out of the ventilator duct in his bathroom. When he called to report the problem to Mrs. Riordan, his landlady, she sent around the building’s handyman, who could find nothing wrong. When his headaches and the odors increased, Rodrigo recalled that, weeks before, Mrs. Riordan had gone out several times to watch while repairmen from the power company dug up the street outside the apartment building. The logical conclusion fairly burst upon him: His landlady was trying to poison him. His anger mounted as the odor worsened. It had begun to affect his voice, which had become raspy and high-pitched. He had several shouted arguments with Mrs. Riordan. One of these they carried on through her apartment door at 2 A.M., several weeks after he first noticed the gas. He threatened to report her to the housing authority; she called him “a crazy old coot.” After he threatened her (“If I’m not safe, your life isn’t worth 15 cents!”), they both made 911 telephone calls. The police could find nothing to charge anyone with and admonished them both to behave. The night he was arrested, Rodrigo had sat just inside his open doorway, yelling insults at Mrs. Riordan. When she lumbered to the top of the stairs to investigate, he shot her once, just behind her left ear. The arresting officers noted that he seemed “strangely detached” from the murder of his landlady. One of them wrote down this statement: “It wouldn’t matter, just for me. But I couldn’t stand her gassing all those other people in the house.” The forensic examiner noted that Rodrigo Chavez was an elderly, slightly built man who was clean-shaven and neatly groomed. He was gaunt, looking as if he had lost considerable weight. His speech was clear, coherent, relevant, and spontaneous, but his voice was high-pitched and gravelly. He appeared calm, and he described his mood as “medium,” but he became angry when describing his landlady’s attempts to poison him. He was oriented to person, place, and time, and he earned a perfect score on the Mini-Mental State Exam. He was fully aware that he had lung cancer. Insight for the fact of his psychosis was nil, and his judgment by recent history had been extremely poor. An X-ray of his chest showed a right lung full of tumor; compared with a previous series, skull films suggested a metastatic lesion located in the right frontal lobe. Evaluation of Rodrigo Chavez Rodrigo Chavez was clearly psychotic: He had prominent olfactory hallucinations and an elaborate delusion about being poisoned. These had been present for several months (criterion A). (If insight is retained that the hallucinations and delusions are a product of the patient’s own mind, one would generally not diagnose a psychotic disorder. Also note that, though Rodrigo’s symptoms clearly met the criterion A inclusion requirements for schizophrenia, they didn’t have to: A person can qualify for this diagnosis with just one of either hallucinations or delusions.) Aside from his psychosis, Rodrigo’s thinking was clear. He was oriented and he scored well on the Mini-Mental State Exam, so he had no evidence of a delirium or dementia (D). He had had no history of drinking or taking drugs, ruling out a substance-induced psychotic disorder. His mood had been at times angry, but appropriately so, given the content of his delusion and hallucination, so a mood disorder with psychotic features would also seem unlikely. There was no previous history of behavior or personality change that would qualify him for a diagnosis of schizophrenia (C). Other features atypical for schizophrenia included the late age of onset and relatively brief duration. Schizophreniform disorder could be ruled out because another diagnosis was more likely. Mrs. Riordan’s unhappy end provides mute testimony to the clinical importance of his illness (E). Rodrigo had a history of a cancer that is known to metastasize to the brain; his headaches suggested that it had already done so. The findings on chest X-ray and MRI confirmed the diagnosis (B). His gravelly, high-pitched voice could be due to extension of the growth or to another metastasis within his chest or neck. (Other medical conditions that can cause psychosis include temporal lobe epilepsy, primary [that is, not metastatic] brain tumors, endocrine disorders such as thyroid and adrenal disease, vitamin deficiency states, central nervous system syphilis, multiple sclerosis, systemic lupus erythematosus, Wilson’s disease, and head trauma.) Although Rodrigo had both hallucinations and delusions, the olfactory hallucinations appeared first and seemed to predominate, resulting in the diagnosis as recorded. My assessment of his GAF score was 15. C79.31 [198.3] Cancer of the lung, metastatic to the brain F06.0 [293.82] Psychotic disorder due to metastatic carcinoma, with hallucinations Z65.3 [V62.5] Arrested for murder F06.1 [293.89] Catatonia Associated with Another Mental Disorder (Catatonia Specifier) Catatonia, which we’ve always thought of as a classic schizophrenia subtype, was first described by Karl Kahlbaum in 1874; in 1896, Emil Kraepelin included it with the disorganized (it was called hebephrenic then) and paranoid types as a major subgroup of what he termed dementia praecox. During the early part of the 20th century, each of these subtypes constituted about a third of all U.S. hospital admissions for schizophrenia. Since that time, the prevalence of the catatonic type has declined markedly, so that it is now unusual to encounter such a patient on an acute care inpatient service. When it does occur, we would now call it catatonia associated with schizophrenia. F06.1 [293.89] Catatonic Disorder Due to Another Medical Condition In recent decades, we’ve come to realize that catatonia is more often found in association with various medical disorders. Most published accounts tend to describe only a handful of patients, but the responsible illnesses include viral encephalitis, subarachnoid hemorrhage, ruptured berry aneurysm in the brain, subdural hematoma, hyperparathyroidism, arteriovenous malformation, temporal lobe tumors, akinetic mutism, and penetrating head wounds. There has even been a description of one patient who had a reaction to fluorides. A neurologist or mental health clinician who does a lot of consulting in a busy medical center may occasionally encounter a case. Catatonic symptoms (see sidebar below) are essentially the same, whether they occur in patients with a mood disorder, with schizophrenia, or with a physical disorder. A patient with another medical condition is more likely to have the characteristic symptoms of what is called retarded catatonia. These include posturing, catalepsy, and waxy flexibility. Such patients may also drool, stop eating, or become mute. The catatonic features usually associated with mania include hyperactivity, impulsivity, and combativeness. These patients may also refuse to keep their clothes on. Depressed patients may show markedly reduced mobility (even to the point of stupor), mutism, negativism, mannerisms, and stereotypies. Partly to save space, I’ve omitted definitions of catatonic symptoms from my Essential Features for these two disorders and gathered them all into one convenient place: right here. Each of these behaviors tends to be a repeated rather than a one-off occurrence. Agitation. Excessive motor activity that appears to have neither a purpose nor an external cause. Stupor would be more or less the polar opposite. Catalepsy. Maintaining an uncomfortable posture, even when told it is not necessary. Echolalia. Verbatim repetition of someone else’s words when another response is indicated. Echopraxia. Imitating another person’s physical behavior, even when asked not to do so. Exaggerated compliance. At the slightest touch, moving in the direction indicated by another person (the old German term is mitgehen). Grimace. Facial contortions not made in response to a noxious stimulus. Mannerisms. Repeated movements that seem to have a goal, but are excessive for the purpose. Mutism. Absence of speech despite apparent physical ability to speak. Negativism. Without apparent motive, the patient offers resistance to passive movement or repeatedly turns away from the examiner. Posturing. Voluntarily assuming an unnatural or uncomfortable pose. Stereotypy. Repeated movement that is a nonessential part of goal-directed behavior. Waxy flexibility. Active resistance when an examiner tries to change the patient’s position. Essential Features of Catatonia Associated with Another Mental Disorder (Catatonia Specifier) The patient has prominent symptoms of catatonia, such as catalepsy, negativism, posturing, stupor, stereotypy, grimacing, echolalia, and others (see the sidebar above for definitions). The Fine Print Relax, it’s only a specifier. No Fine Print. Coding Notes You can apply the catatonia specifier to manic, hypomanic, or major depressive episodes; to schizophrenia; and to schizophreniform, schizoaffective, brief psychotic, and substance-induced psychotic disorders. It can even be used for autism spectrum disorder. List first the other mental disorder, then F06.1 [293.89], then catatonia associated with [the other mental disorder]. Edward Clapham Edward Clapham, a 43-year-old single man, was admitted to the university hospital’s mental health service. He gave no chief complaint; he was entirely mute. He had been transferred from the state psychiatric hospital, where his diagnosis had been schizophrenia, catatonic type. For the past 8 years, he had not communicated by speech or writing. According to the transfer note, Edward had been intensively treated with neuroleptics during his entire hospitalization, though none of these medications had relieved his basic symptoms. He reportedly spent the entire day every day lying on his back, toes pointing towards the foot of his bed, fists clenched and turned inward. From years of maintaining this position, he had developed severe muscle contractures at both ankles and both wrists. Most of the time he could be spoon-fed, but occasionally he refused to swallow and had to be fed by nasogastric tube. This had often been the case during the past 6 months; despite the tube feedings, he had lost about 30 pounds. Ten days earlier Edward had developed a high fever (104.6°F) and had been transferred to the medical service, where the staff treated a Klebsiella pneumonia with tetracycline. Subsequently he was moved to the mental health service, where this evaluation took place. Very little was known about Edward’s background. He had been reared in the Midwest, the second child of a farm family. He may have attended some college, and he had worked for approximately 10 years as a tractor salesman. On admission, his mental status examination read as follows: Mr. Clapham lies flat on his back in bed. He is totally mute, so nothing can be learned of his thought content or flow of thought. Similarly, his cognitive processes, insight, and judgment cannot be assessed. His toes point down and his fists are rotated inward. There is a noticeable tremor of his feet and his hands; he contracts the muscles of his arms and legs so strongly that they actually shake. Besides being mute, he shows other signs of catatonia. Negativism: When he is approached from one side, he gradually turns his head so that he gazes in the opposite direction. Catalepsy: When a limb is placed in any position (for instance, raised high above his head), he will maintain that position for several minutes, even if told that he can drop his hand. Waxy flexibility: Any attempt to bend his arm at the elbow, where there are no contractures, is met with resistance. It is evident that the biceps and triceps muscles are contracting together, causing motion at the joint to feel as if one were bending a rod made of wax or some other stiff substance. Grimacing: Every four or five minutes, he wrinkles his nose and purses his lips. This expression lasts for 10 or 15 seconds, then relaxes. There is no apparent purpose to these motions, and they are not accompanied by any motions of the tongue or other indications of tardive dyskinesia. Evaluation of Edward Clapham Counting his negative symptoms (lack of speech and affect) and his grossly abnormal motor behavior, Edward fulfilled the criterion A requirements for schizophrenia. His illness had lasted far longer than the minimum 6 months (schizophrenia criterion C); it is hard to imagine how it could have had a greater effect on every aspect of his life (B). Nonetheless, on admission to the mental health unit, he was given a diagnosis of unspecified schizophrenia spectrum and other psychotic disorder. This provisional diagnosis was given because the clinician could not be sure from the initial presentation whether the symptoms were due to the effects of his dehydration and loss of weight (another medical condition), schizophrenia, or another cause such as a mood disorder, which is perhaps the most frequent cause of catatonic symptoms. The list of medical conditions that can produce catatonic behavior includes liver disease, strokes, epilepsy, and uncommon disorders such as Wilson’s disease (a defect of copper metabolism) and the inherited disorder (autosomal dominant), tuberous sclerosis. These possibilities should be vigorously pursued with neurological and medical consultation and with the appropriate laboratory and X-ray studies. Urine or blood screens for toxic substances or drugs of abuse should be considered a part of every such patient’s workup. Any patient who presents with a first episode of catatonia should probably have an MRI. When Edward Clapham was diagnosed, there was no MRI; we’ll have to take criterion E on faith. Many patients who have been diagnosed as having schizophrenia, catatonic type, really have a manic phase of bipolar I disorder (D). On the other hand, a patient with severe psychomotor slowing should be considered for a diagnosis of major depressive disorder with melancholic features. Although patients with somatic symptom disorder are occasionally mute or have abnormal motor activity, such episodes are usually short-lived, lasting only a few hours or days, not years. Edward had been ill for years; a chronic, psychotic, catatonic mood disorder seems unlikely. Edward’s symptoms were classic for catatonia associated with schizophrenia. He demonstrated grimacing (catatonia specifier criterion A10), muteness (A4), waxy flexibility (A3), and catalepsy (A2). He could not be called stuporous because he was alert enough to turn away from an approaching stimulus (negativism—A5). His behavior range was insufficient to demonstrate other typical catatonic behaviors. Because he had already been extensively (and unsuccessfully) treated with neuroleptics, Edward was given a course of electroconvulsive therapy. Although the first three bilateral treatments produced no noticeable effect, after the fourth he asked for a glass of water. After a total of 10 treatments, he was conversing with others on the ward, feeding himself, and walking—always on tiptoe because of the severe contractures at his ankles. Although he continued to show residual symptoms of his disease, his catatonic symptoms disappeared. He eventually left the hospital, whereupon he was lost to follow-up. Edward’s 8-year course of illness had been continuous; I scored his GAF at discharge at 60 (on admission, it would have been pretty close to 1). After appropriate medical investigations and additional history ruled out other possible causes of his abnormal behavior, his revised diagnosis was as given below. By the way, without reference to the official DSM-5 severity criteria for psychosis (see the sidebar), on admission I’d give Edward a rating of severe. I anticipate no backlash from outraged coding mavens, though I still feel that the overall global evaluation of the GAF does a better job. At discharge: F20.9 [295.90] Schizophrenia, first episode, currently in partial remission F06.1 [293.89] Catatonia associated with schizophrenia M24.573 [718.47] Contractures of ankles M24.539 [718.43] Contractures of wrists Essential Features of Catatonic Disorder Due to Another Medical Condition A physical illness appears to have caused symptoms of catatonia, such as catalepsy, negativism, posturing, stupor, stereotypy, grimacing, echolalia, and others (see sidebar just above) for definitions). The Fine Print For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar. The D’s: • Differential diagnosis (delirium or other cognitive disorder, schizophrenia and its cousins, psychotic mood disorder, obsessive–compulsive disorder) Coding Notes Using the name of the responsible medical condition, record this diagnosis after you’ve coded the actual medical condition. Marion Wright Since graduating from high school 12 years earlier, Marion Wright had worked as a sign painter. In school he had shown some aptitude for art, though not enough that he saw himself as the next Pablo Picasso. Nor did he like school enough to study for a career in commercial art. But painting signs on buildings and billboards was undemanding, well-paying, immediately available, and largely open-air. Within a few years he was married, had two kids and a small house in a subdivision, and was still painting signs. He thought he was set for life. One afternoon not long after his 30th birthday, his foreman drove by to inspect the billboard Marion had just finished. “You’ve painted the logo in script. The blueprint calls for block letters,” the foreman pointed out. Marion said that he thought the script looked better, but without much grumbling he changed it. A week later he completed an ad for a local premium beer; the female model holding the bottle was naked from the waist up. The following day he was out of work. Marion made a few efforts to find a new job, but within a week he was staying at home and watching daytime TV. His wife noted that he seemed to be talking less and less, but he ignored her suggestion to seek clinical evaluation. Although he continued to eat and sleep normally, his interest in sex had vanished. By the fourth week after losing his job, he had no spontaneous speech at all and would only answer a question if it was directly put to him. With the added persuasion of Marion’s brother, his wife finally got him to the clinic. He was immediately hospitalized. On admission Marion would answer questions appropriately, if briefly. Fully oriented, he denied feeling depressed or suicidal. He had no delusions, hallucinations, obsessions or compulsions. He earned a perfect score on the MMSE, though the examiner noted that he was slow to carry out instructions. The following morning he deliberately turned away from the nurse who approached his bedside. Although he willingly accompanied the nurse to a table in the dining room, he refused to eat and was completely mute. In fact, the clinician who examined him later that morning found that Marion would readily move in any direction at the slightest touch of an examiner’s hand. In the evening he seemed improved and even spoke a few words. But the next day, he lay on his back in bed, again silently refusing to cooperate. When his pillow was removed, his head remained elevated about two inches above the mattress. This position appeared to cause him no discomfort; he seemed willing to maintain it all day. Later, an examiner noted that when Marion’s arm was twisted into an awkward position (elevated at an angle over the bed), he maintained that position even when he was told that he could relax. Marion’s clinicians considered the diagnosis of schizophrenia, but they noted that he had been only briefly ill and had no family history of psychosis. His wife assured them that he had never abused drugs or alcohol. Despite the fact that his neurological exam remained normal, an MRI of his head was obtained. It revealed a tumor the size of a golf ball sitting on the convexity of his right frontal lobe. Once this was surgically removed, he quickly regained full consciousness. Two months later he was back on his ladder painting billboards, following instructions to the letter. Evaluation of Marion Wright Marion had several symptoms (three are required) that are classical for catatonia (criterion A). His included negativism and muteness (A5, A4), exaggerated compliance (though this is not one of the criteria DSM-5 mentions), a “psychological pillow” (a form of posturing in which he held his head unsupported above the mattress—A6), and catalepsy (A2). Marion did not have the wandering attention found in delirium (D). Catatonic behavior can be found in schizophrenia, which his clinicians correctly rejected because he had been ill too briefly (C). Too few symptoms (and better choices) ruled out schizophreniform disorder. Muteness and marked motor slowing, even to the point of immobility, can be encountered in major depressive episode, but Marion specifically denied mood symptoms. Muteness may occasionally be encountered in somatic symptom disorder and in malingering and factitious disorder, but it would be unusual to encounter a full, persisting catatonic syndrome in one of these conditions. Note that catatonic behavior can include excessive or even frenzied motor activity. Then the differential diagnosis would include manic episode and substance use intoxication. Of course, neither of these applies to Marion’s case. On laboratory examination of the surgical specimen, Marion was found to have a (benign) brain tumor, which can directly result in catatonic symptoms (B) and which caused manifest impairment (E). On admission, I’d put his GAF score at 21; his GAF score was 90 on discharge. D32.9 [225.2] Cerebral meningioma, benign F06.1 [293.89] Catatonic disorder due to cerebral meningioma F28 [298.8] Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Use this category when you want to write down the specific reason your patient cannot receive a more definite psychotic disorder diagnosis. Here’s an example: “other specified schizophrenia spectrum and other psychotic disorder, persistent auditory hallucinations.” Charles Bonnet syndrome. In this disorder (not specifically mentioned in DSM-5, but first described in 1790!), people with impaired vision, many of them elderly, report complex visual hallucinations (scenes, people) but no other hallucinations or delusions. They also have insight that what they “see” is unreal. As such, they aren’t truly psychotic, but one can argue that the condition belongs somewhere along the spectrum of psychotic disorders. Attenuated psychosis syndrome. A patient has psychotic symptoms that do not meet the full criteria for any psychotic disorder (less disabling symptoms, relatively good insight, etc.). Persistent auditory hallucinations. The patient experiences repeated auditory hallucinations without other symptoms. Delusional symptoms in partner of individual with delusional disorder. Most people who develop delusions in response to close association with someone who is independently psychotic can be diagnosed as having a delusional disorder. However, those who don’t fulfill criteria for delusional disorder can be classified here. Other. The patient appears to have a psychotic disorder, but the information is conflicting or too inadequate to permit a more specific diagnosis. F29 [298.9] Unspecified Schizophrenia Spectrum and Other Psychotic Disorder This category is for symptoms or syndromes that don’t meet guidelines for any of the disorders described earlier, and you do not wish to specify a reason. Unspecified Catatonia DSM-5 mentions unspecified catatonia as a possibility when the context is unclear or there is insufficient detail for a more precise diagnosis. But the coding itself is clear: First code R29.818 [781.99] other symptoms involving nervous and musculoskeletal systems; then code F06.1 [293.89] unspecified catatonia."

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· View details for copied text: "CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders Quick Guide to the Schizophrenia Spectrum and Psychotic Disorders When psychosis is a prominent reason for a mental health evaluation, the diagnosis will be one of the disorders or categories listed below. The link indicates where a more detailed discussion begins. (To facilitate discussion, I have not adhered to the order in which DSM-5 presents these conditions.) Schizophrenia and Schizophrenia-Like Disorders Schizophrenia. For at least 6 months, these patients have had two or more of these five types of psychotic symptom: delusions, disorganized speech, hallucinations, negative symptoms, and catatonia or other markedly abnormal behavior. Ruled out as causes of the psychotic symptoms are significant mood disorders, substance use, and general medical conditions. Catatonia associated with another mental disorder (catatonia specifier). These patients have three or more of several behavioral characteristics. The specifier can be applied to disorders that include psychosis, mood disorders, autistic spectrum disorder, and other medical conditions. Schizophreniform disorder. This category is for patients who have the basic symptoms of schizophrenia but have been ill for only 1–6 months—less than the time specified for schizophrenia. Schizoaffective disorder. For at least 1 month, these patients have had basic schizophrenia symptoms; at the same time, they have prominent symptoms of mania or depression. Brief psychotic disorder. These patients will have had at least one of the basic psychotic symptoms for less than 1 month. Other Psychotic Disorders Delusional disorder. These patients have delusions, but not the other symptoms of schizophrenia. Psychotic disorder due to another medical condition. A variety of medical and neurological conditions can produce psychotic symptoms that may not meet criteria for any of the conditions above. Substance/medication-induced psychotic disorder. Alcohol or other substances (intoxication or withdrawal) can cause psychotic symptoms that may not meet criteria for any of the conditions above. Other specified, or unspecified, schizophrenia spectrum and other psychotic disorder. Use one of these categories for patients with psychoses that don’t seem to fit any of the categories above. Unspecified catatonia. Use when a patient has symptoms of catatonia but there isn’t enough information to substantiate a more definitive diagnosis. Disorders with Psychosis as a Symptom Some patients have psychosis as a symptom of mental disorders discussed in other chapters. These disorders include the following: Mood disorder with psychosis. Patients with a severe major depressive episode or manic episode can have hallucinations and mood-congruent delusions. Cognitive disorders with psychosis. Many patients with delirium or major neurocognitive disorder have hallucinations or delusions. Personality disorders. Patients with borderline personality disorder may have transient periods (minutes or hours) when they appear delusional. Patients with schizophrenia may have premorbid schizoid or (especially) schizotypal personality disorder. Disorders That Masquerade as Psychosis The symptoms of some disorders appear to be psychotic, but are not. These disorders include the following: Specific phobia. Some phobic avoidance behaviors can appear quite strange without being psychotic. Intellectual disability. Patients with intellectual disability may at times speak or act bizarrely. Somatic symptom disorder. Sometimes these patients will report pseudohallucinations or pseudodelusions. Factitious disorder imposed on self. These patients may feign delusions or hallucinations in order to obtain hospital or other medical care. Malingering. These persons may feign delusions or hallucinations in order to obtain money (insurance or disability payments), avoid work (such as in the military), or avoid punishment. Whatever happened to folie à deux (“madness of two”)? For generations, this rarely encountered condition was a staple of mental health diagnostic schemes. It was termed shared psychotic disorder in recent DSMs, where it denoted patients who develop delusions similar to those held by a relative or other close associate. Often the second patient’s delusions cleared up, once association with the first patient was severed. There are several reasons why this condition has been excluded from DSM-5. Through the decades, there has been precious little research that would help us understand shared psychotic disorder. We have case reports, some describing multiple secondary patients dependent on one primary source (folie à trois, à quatre, à famille), but not much in the way of data. Although most of these patients live with someone who has schizophrenia or delusional disorder, the phenomenon has also been linked to somatic symptom disorder, obsessive–compulsive disorder, and the dissociative disorders. In other words, folie à deux may be better conceptualized as a descriptive syndrome similar to the Capgras phenomenon (in which patients believe that close associates have been replaced by exact doubles). Most patients who would formerly have been diagnosed as having folie à deux (shared psychotic disorder) will fulfill criteria for delusional disorder, which is how they should now be categorized. Otherwise, you’d have to diagnose them with other specified psychotic disorder and explain why. INTRODUCTION During the second half of the 20th century, one of the great leaps forward in mental health was to recognize that psychosis can have many causes. At least in part, this progress can be credited to DSM-III and its forebears and successors, which have established and popularized criteria for many forms of psychosis. The existence of psychosis is usually not hard to determine. Delusions, hallucinations, and disorganized speech or behavior are generally obvious; they often represent a dramatic change from a person’s normal behavior. But differentiating the various causes of psychosis can be difficult. Even experienced clinicians cannot definitively diagnose some patients, perhaps even after several interviews. Symptoms of Psychosis A psychotic patient is out of touch with reality. This state of mind can manifest in one or more of five basic types of symptom. These are DSM-5’s criterion A inclusion requirements for schizophrenia. Delusions A delusion is a false belief that cannot be explained by the patient’s culture or education; the patient cannot be persuaded that the belief is incorrect, despite evidence to the contrary or the weight of opinion of other people. Delusions can be of many types, including these: Erotomanic. Someone (often of higher social station) is in love with a patient. Grandeur. A patient is a person of exalted station, such as God or a movie star. Guilt. A patient has committed an unpardonable sin or grave error. Jealousy. A spouse or partner has been unfaithful. Passivity. A patient is being controlled or manipulated by some outside influence, such as radio waves. Persecution. A patient is being hounded, followed, or otherwise interfered with. Poverty. Contrary to the evidence (a job and ample money in the bank), a patient faces destitution. Reference. A patient is being talked about, perhaps in the press or on TV. Somatic. Patients’ body functions have altered, they smell bad, or they have a terrible disease. Thought control. Others are putting ideas into patients’ minds. Delusions must be distinguished from overvalued ideas, which are beliefs that are not clearly false but continue to be held despite lack of proof that they are correct. Examples include belief in the superiority of one’s own race or political party. Hallucinations A hallucination is a false sensory perception that occurs in the absence of a related sensory stimulus. Hallucinations are nearly always abnormal and can affect any of the five senses, though auditory and visual hallucinations are the most common. But they don’t always mean that the person experiencing them is psychotic. To count as psychotic symptoms, hallucinations must occur when a person is awake and fully alert. This means that hallucinations occurring only during delirium cannot be taken as evidence of one of the psychotic disorders discussed in this chapter. The same can be said for hallucinatory experiences that occur when someone is falling asleep (hypnagogic) or awakening (hypnopompic). These common experiences (which are not true hallucinations) are normal; they are better referred to as imagery. Another requirement for a psychotic symptom is that a person must lack insight into its unreality. You might think that this would apply to pretty much everyone, but you’d be wrong. Consider, for example, the Charles Bonnet syndrome, in which people who have significant loss of vision see complex visual imagery—but with full realization that the experience is unreal. Hallucinations must be discriminated from illusions, which are simply misinterpretations of actual sensory stimuli. They usually occur during conditions of decreased sensory input, such as at night. (For example, a person awakens to the impression that a burglar is bending over the bed; when the light comes on, the “burglar” is only a pile of clothes on a chair.) Illusions are common and usually normal. Disorganized Speech Even without delusions or hallucinations, a psychotic patient may have disorganized speech (sometimes also called loose associations), in which mental associations are governed not by logic but by rhymes, puns, and other rules not apparent to the observer, or by no evident rule at all. Some disorganization of speech is quite common (try reading an exact transcript of a politician’s off-the-cuff remarks, for example). But by and large, when those words were spoken, listeners understood perfectly well what was intended. To be regarded as psychotically disorganized, the speech must be so badly impaired that it interferes with communication. Abnormal Behavior (Such as Catatonia) Disorganized behavior, or physical actions that do not appear to be goal-directed—disrobing in public (without theatrical or, perhaps, political intent), repeatedly making the sign of the cross, assuming and maintaining peculiar and often uncomfortable postures—may indicate psychosis. Again, note how hard it can be to identify a given behavior as disorganized. There are plenty of people who do strange things; lots of these folks aren’t psychotic. Most patients whose behavior qualifies as psychotic will have actual catatonic symptoms, each of which has been carefully defined (see the sidebar later in this chapter). Negative Symptoms Negative symptoms include reduced range of expression of emotion (flat or blunted affect), markedly reduced amount or fluency of speech, and loss of the will to do things (avolition). They are called negative because they give the impression that something has been taken away from the patient—not added, as would be the case with hallucinations and delusions. Negative symptoms reduce the apparent textural richness of a patient’s personality. However, they can be hard to differentiate from dullness due to depression, drug use, or ordinary lack of interest. Distinguishing Schizophrenia from Other Disorders DSM-5 uses four classes of information to distinguish among the various types of psychosis: type of psychotic symptom, course of illness, consequences of illness, and exclusions. Each of these categories (plus a few other features) can help you distinguish schizophrenia, the most common psychotic disorder, from other disorders that include psychosis among their symptoms. The reason for this emphasis is that the differential diagnosis of psychosis very often boils down to schizophrenia versus nonschizophrenia. In terms of the numbers of patients affected and the seriousness of implications for treatment and prognosis, it is the single most important cause of psychotic symptoms. Psychotic Symptoms Any form of psychosis must include at least one of the five types of psychotic symptoms described above, but to be diagnosed as having schizophrenia, a patient must have two or more. Therefore, the first task in diagnosing any psychosis is to determine the extent of the psychotic symptoms. When two or more of these types of psychotic symptoms have been present for at least 1 month, and at least one of them is hallucinations, delusions, or disorganized speech, criterion A for schizophrenia is said to be satisfied. DSM-5 specifies that these two or more psychotic symptom types must be present for a “significant portion of time” during that month. But what does significant mean in this context? It could be interpreted to mean that (1) these symptoms have been present on more than half the days in the month; (2) several persons independently may have observed on several days that the patient is having symptoms; or (3) the symptoms may have occurred at times when they are especially likely to affect the patient or the environment—as with, for example, a patient who has repeatedly interrupted a social gathering by screaming. Finally, note that a duration of less than 1 month is allowed if treatment has caused the symptoms to remit. For behavior to be psychotic, it must be grossly abnormal, and the patient must lack insight into its nature. Examples of psychotic behavior would include symptoms of catatonia, such as mutism, negativism, mannerisms, or stereotypies—without apparent recognition that the behaviors in question are abnormal. (For definitions of these symptoms, see the sidebar.) An example of bizarre behavior that is not psychotic would be obsessive–compulsive rituals, which patients usually recognize as excessive or unreasonable. Delusions and hallucinations are the most commonplace symptoms of psychosis. As noted earlier, delusions must be discriminated from overvalued ideas, and hallucinations from illusions. Disorganized speech means speech that goes beyond the merely circumstantial—it must show marked loosening of associations. Examples: “He tells me something in one morning and out the other,” “Half a loaf is better than the whole enchilada.” Or, in response to the question, “How long did you live in Wichita?”: “Even anteaters like to Frenchkiss.” Negative symptoms can be hard to pinpoint, unless you ask an informant about changes in affective lability, volition, or amount of speech. Negative symptoms can also be mistaken for the stiffening of affect sometimes caused by neuroleptic medications. For a diagnosis of schizophrenia, earlier DSM versions required only one type of psychotic symptom if it was either a bizarre delusion or hallucinated voices that talk to one another. We can feel pretty clear about the hallucinated voices, but what exactly does bizarre mean, anyway? Unhappily, the definition is neither exact nor constant across different studies. It isn’t even consistent across different versions of the DSM, which refer to it with decreasing degrees of certitude: “with no possible basis in fact” (DSM-III), “totally implausible” (DSM-III-R), and “clearly implausible” (DSM-IV-TR). DSM-5 has nearly stepped away from the fray altogether, except as regards delusional disorder, where bizarre content is a specifier. There, bizarre is taken to mean not only “clearly implausible,” but also neither understandable nor in accord with usual life experience. So we might as well adopt the original sense that came to us several hundred years ago from French: odd or fantastic. Examples of delusions we could call bizarre include falling down a rabbit hole to Wonderland, being controlled (in thoughts or actions) by aliens from Halley’s Comet, or having one’s brain replaced by a computer chip. Examples of nonbizarre delusions include being spied upon by neighbors or betrayed by one’s spouse. (The assessment of what is and is not bizarre may vary with our distance from those we seek to judge: “I am unique, you are odd, they are bizarre.”) The recent weight of opinion is that the quality of bizarreness has little importance when it comes to diagnosis or prognosis. Therefore, in DSM-5, all patients with schizophrenia must have two or more types of psychotic symptoms, no matter how fantastic any one of them might be. Course of Illness Cross-sectional symptoms are less important to the differential diagnosis of psychosis than is the course of illness. That is, the type of psychosis is largely determined by the longitudinal patterns and associated features of the disorder. Several of these factors are noted here: Duration. How long has the patient been ill? A duration of at least 6 months is required for a DSM-5 diagnosis of schizophrenia. This rule was formulated decades ago, in response to the observation that psychotic patients who have been ill a long time tend at follow-up to have schizophrenia. Patients with a briefer duration of psychosis may turn out to have some other disorder. For years, we’ve operationally defined the time required as 6 months or longer. Precipitating factors. Severe emotional stress sometimes precipitates a brief period of psychosis. For example, the stress of childbirth precipitates what we call a postpartum psychosis. A chronic course is less likely if there are precipitating factors, including this one. Previous course of illness. A prior history of complete recovery (no residual symptoms) from a psychosis suggests a disorder other than schizophrenia. Premorbid personality. Good social and job-related functioning before the onset of psychotic symptoms directs our diagnostic focus away from schizophrenia and toward another psychotic disorder, such as a psychotic depression or a psychosis due to another medical condition or substance use. Residual symptoms. Once the acute psychotic symptoms have been treated (usually with medication), residual symptoms may persist. These are often milder manifestations of the person’s earlier delusions or other active psychotic symptoms: odd beliefs, vague speech that wanders off the point, a reduced lack of interest in the company of others. They augur for the subsequent return of psychosis. Consequences of Illness Psychosis can seriously affect the functioning of both patient and family. The degree of this effect can help discriminate schizophrenia from other causes of psychosis. To be diagnosed as having schizophrenia, the patient must have materially impaired social or occupational functioning. For example, most patients with schizophrenia never marry and either don’t work at all or hold jobs that require a lower level of functioning than is consistent with their education and training. The other psychotic disorders do not require this criterion for diagnosis. In fact, the criteria for delusional disorder even specify that functioning is not impaired in any important way except as it relates specifically to the delusions. Exclusions Once the fact of psychosis is established, can it be attributed to any mental disorder other than schizophrenia? We must consider at least three sets of possibilities. First, the top place in any differential diagnosis belongs to disorders caused by physical conditions. History, physical examination, and laboratory testing must be scrutinized for evidence. See the table “Physical Disorders That Affect Mental Diagnosis” in the Appendix for a listing of some of these disorders. Next, rule out substance-related disorders. Has the patient a history of abusing alcohol or street drugs? Some of these (cocaine, alcohol, psychostimulants, and the psychotomimetics) can cause psychotic symptoms that closely mimic schizophrenia. The use of prescription medications (such as adrenocorticosteroids) can also produce symptoms of psychosis. See the table “Classes (or Names) of Medications That Can Cause Mental Disorders” in the Appendix for more information. Finally, consider mood disorders. Are there prominent symptoms of either mania or depression? The history of mental health treatment is awash in patients whose mood disorders have for years been diagnosed as schizophrenia. Mood disorders should be included early in the differential diagnosis of any patient with psychosis. Other Features You should also think about some features of psychosis that are not included in the DSM-5 criteria sets. Some of these can help predict outcome. They include the following: Family history of illness. A close relative with schizophrenia increases your patient’s chances of also having schizophrenia. Bipolar I disorder with psychotic features also runs in families. Always learn as much as you can about the family history, so you can form your own judgment; accepting another clinician’s opinion about diagnosis can be risky. Response to medication. Regardless of how psychotic the patient appears, previous recovery with, say, lithium treatment suggests a diagnosis of mood disorder. Age at onset. Schizophrenia usually begins by a person’s mid-20s. Onset of illness after the age of 40 suggests some other diagnosis. It could be delusional disorder, but you should consider a mood disorder. However, late onset does not completely rule out a schizophrenia diagnosis, especially of the type we used to call paranoid. I have intentionally written up the material that follows in a different order from that adopted by DSM-5. The stated intention of that manual is to order its material along “a gradient of psychopathology” that clinicians should generally follow, so that they consider first conditions that don’t attain full status as psychotic disorders or that affect relatively fewer aspects of a patient’s life. Hence DSM-5 begins with schizotypal personality disorder and progresses next to delusional disorder and catatonia. Here’s the reasoning for my approach. As a general matter, I agree that we should evaluate our patients along a safety continuum, beginning with disorders that can be more readily treated (such as a substance-induced psychotic disorder) or those that have a relatively better prognosis (such as mood disorders with psychosis). However, from an educational point of view, it helps me to describe first a condition (schizophrenia) that includes all conceivable symptoms and then fiddle with variations. I believe that my approach is more likely to help you learn the basic features of psychosis. THE SCHIZOPHRENIA SPECTRUM F20.9 [295.90] Schizophrenia In an effort to achieve precision, the DSM criteria for schizophrenia have become more complicated over the years. But the basic pattern of diagnosis remains so straightforward that it can be outlined briefly. 1. Before becoming ill, the patient may have a withdrawn or otherwise peculiar personality. 2. For some time (perhaps 3–6 years) before becoming clinically ill, the patient may have experiences that, while not actually psychotic, portend the later onset of psychosis. This prodromal period is characterized by abnormalities of thought, language, perception, and motor behavior. 3. The illness proper begins gradually, often imperceptibly. At least 6 months before a diagnosis is made, behavior begins to change. Right from the start, this may involve delusions or hallucinations; or it may be heralded by milder symptoms, such as beliefs that are peculiar but not psychotic. 4. The patient has been frankly psychotic during at least 1 month of those 6. There have been two or more of the five basic symptom types described at the start of this chapter; hallucinations, delusions, or disorganized speech must be one of the two. 5. The illness causes important problems with work and social functioning. 6. The clinician can exclude other medical disorders, substance use, and mood disorders as probable causes. 7. Although most patients improve with treatment, relatively few recover to such an extent that they return completely to their premorbid state. There are several reasons why it is important to diagnose schizophrenia accurately: Frequency. It is a common condition: Up to 1% of the general adult population will contract this disorder. For unknown reasons, males become symptomatic several years younger than do females. Chronicity. Most patients who develop schizophrenia continue to have symptoms throughout their lives. Severity. Although most patients do not require months or years of hospitalization, as was the case before neuroleptic medications were developed, incapacity for social and work functioning can be profound. Psychotic symptoms can vary in their degree of severity (see sidebar). Management. Adequate treatment almost always means using antipsychotic drugs, which, despite their risk of side effects, often must be taken lifelong. Although nearly everyone does so, it is probably incorrect to speak of schizophrenia as if it were one disease. It is almost certainly a collection of several underlying etiologies, for which the same basic diagnostic criteria are used. It is also important to note that many symptoms in addition to the formal criteria are often found in patients with schizophrenia. Here are a few: Cognitive dysfunction. Distractibility, disorientation, or other cognitive problems are often noted, though the symptoms of schizophrenia are classically described as occurring in a clear sensorium. Dysphoria. Anger, anxiety, and depression are some of the common emotional reactions to ensuing psychosis. Other patients show inappropriate affect (such as giggling when nothing appears to be funny). Anxiety attacks and disorders are increasingly identified. Absence of insight. Many patients refuse to take medicine in the mistaken belief that they are not ill. Sleep disturbance. Some patients stay up late and arise late when they are attempting to deal with the onset of hallucinations or delusions. Substance use. Especially common is tobacco use, which affects 80% of all patients with schizophrenia. Suicide. Up to 10% of these patients (especially newly diagnosed young men) take their own lives. Because schizophrenia can present in so many different ways, and because it is so important (to individuals, society, and the history of mental disorder), I will illustrate with the stories of four patients. Essential Features of Schizophrenia The classic picture of a patient with schizophrenia is of a young person (late teens or 20s) who has had (1) delusions (especially persecutory) and (2) hallucinations (especially auditory). However, some patients will have (3) speech that is incoherent or otherwise disorganized, (4) severely abnormal psychomotor behavior (catatonic symptoms), or (5) negative symptoms such as restricted affect or lack of volition (they don’t feel motivated to do work, maintain family life). Diagnosis requires at least two of these five types of psychotic symptoms, at least one of which must be delusions, hallucinations, or disorganized speech (criterion A). The patient is likely to have some mood symptoms, but they will be relatively brief. Illness usually begins gradually, perhaps almost imperceptibly, and builds across at least 6 months in a crescendo of misery and chaos. The Fine Print Don’t dismiss the D’s: • Duration (6+ months, with criterion A symptoms for at least a month) • Disability (social, occupational, or personal impairment) • Differential diagnosis (other psychotic disorders, mood or cognitive disorders, physical and substance-induced psychotic disorders, peculiar ideas—often political or religious—shared by a community) Coding Notes Specify: With catatonia If the disorder has lasted at least 1 year, specify course: First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous Unspecified You may specify severity, though you don’t have to (see the sidebar). Whereas DSM-IV (and each of its predecessors) listed several subtypes of schizophrenia, DSM-5 has largely done away with them. Why is this? And why were they there in the first place? Sadly, the venerable categories of hebephrenic (disorganized), catatonic, and paranoid types, each of which has roots deep in the 19th century, simply didn’t predict much—not enough, at any rate, to justify their existence. Furthermore, they didn’t necessarily hold true to type from one episode of psychosis to the next. Catatonia, always encountered more often in illnesses other than schizophrenia, has now been demoted to a specifier denoting behaviors that apply not just to schizophrenia but to mood disorders as well as to physical illnesses. And the other old categories, while interesting to discuss (at least by clinicians old enough to have been weaned on these concepts), have been relegated to history’s dust bin, along with fever therapy and wet sheet packs. Lyonel Childs When he was young, Lyonel Childs had always been somewhat isolated, even from his two brothers and his sister. During the first few grades in school, he seemed almost suspicious if other children talked to him. He seldom seemed to feel at ease, even with those he had known since kindergarten. He never smiled or showed much emotion, so that by the time he was 10, even his siblings thought he was peculiar. Adults said he was “nervous.” For a few months during his early teens, he was interested in magic and the occult; he read extensively about witchcraft and casting spells. Later he decided he would like to become a minister. He spent long hours in his room learning Bible passages by heart. Lyonel had never been much interested in sex, but at age 24, still attending college, he was attracted to a girl in his poetry class. Mary had blonde hair and dark blue eyes, and he noticed that his heart skipped a beat when he first saw her. She always said “Hello” and smiled when they met. He didn’t want to betray too great an interest, so he waited until an evening several weeks later to ask her to a New Year’s Eve party. She refused him, politely but firmly. As Lyonel mentioned to an interviewer months later, he thought that this seemed strange. During the day Mary was friendly and open with him, but when he ran into her at night, she was reserved. He knew there was a message in this that eluded him, and it made him feel shy and indecisive. He also noticed that his thoughts had speeded up so that he couldn’t sort them out. “I noticed that my mental energy had lessened,” he told the interviewer, “so I went to see the doctor. I told him I had gas forming on my intestines, and I thought it was giving me erections. And my muscles seemed all flabby. He asked me if I used drugs or was feeling depressed. I told him neither one. He gave me a prescription for some tranquilizers, but I just threw it away.” Lyonel’s skin was pasty white and he was abnormally thin, even for someone so slightly built. Casually dressed, he sat quietly without fidgeting during that interview. His speech was entirely ordinary; one thought flowed logically into the next, and there were no made-up words. By summer, he had become convinced that Mary was thinking about him. He decided that something must be keeping them apart. Whenever he had this feeling, his thoughts seemed to become so loud that he felt sure other people must be able to hear. He neglected to look for a summer job that year and moved back into his parents’ house, where he kept to his room, brooding. He wrote long letters to Mary, most of which he destroyed. In the fall, Lyonel realized that his relatives were trying to help him. Although they would wink an eye or tap a finger to let him know when she was near, it did no good. She continued to elude him, sometimes only by minutes. At times there was a ringing in his right ear, which caused him to wonder whether he was becoming deaf. His suspicion seemed confirmed by what he privately called “a clear sign.” One day while driving he noticed, as if for the first time, the control button for his rear window defroster. It was labeled “rear def,” which to him meant “right-ear deafness.” When winter deepened and the holidays approached, Lyonel knew that he would have to take action. He drove off to Mary’s house to have it out with her. As he crossed town, people he passed nodded and winked at him to signal that they understood and approved. A woman’s voice, speaking clearly from just behind him in the back seat, said, “Turn right!” and “Atta boy!” Evaluation of Lyonel Childs Two of the five symptoms listed in DSM-5’s criterion A must be present for a diagnosis of schizophrenia, and Lyonel did have two—delusions (criterion A1) and hallucinations (A2). Note this new feature in DSM-5: A diagnosis of schizophrenia requires that at least one of delusions, hallucinations, and disorganized speech be among the patient’s psychotic symptoms. As with Lyonel, the hallucinations of schizophrenia are usually auditory. Visual hallucinations often indicate a substance-induced psychotic disorder or psychotic disorder due to another medical condition; they can also occur in major neurocognitive disorder (dementia) and delirium. Hallucinations of sense or smell are more commonly experienced by a person whose psychosis is due to another medical condition, but their presence would not rule out schizophrenia. As with Lyonel, auditory hallucinations are typically clear and loud; patients will often agree with the examiner who asks, “Is it as loud as my voice is right now?” Although the voices may seem to come from within a patient’s head, the source may be located elsewhere—the hallway, a household appliance, the family’s cat. The special messages that Lyonel received (finger tapping, eye winking) are called delusions of reference. Patients with schizophrenia may also experience other sorts of delusions. Often delusions are to some extent persecutory (that is, the patient feels in some way pursued or interfered with). None of Lyonel’s delusional ideas were so far from normal human experience that I’d call them bizarre. Lyonel did not have disorganized speech, catatonic behavior, or negative symptoms, but others with schizophrenia may. His illness significantly interfered with his work (he didn’t get a summer job) and his relationships with others (he stayed in his room and brooded). We can infer that in each of these areas he functioned much less well than before he became ill (B). Although Lyonel had heard voices for only a short time, he had been delusional for several months. The prodromal symptoms (his concerns about intestinal gas and feeling of reduced mental energy) had begun a year or more earlier. As a result, he easily fulfilled the requirement of a total duration (prodrome, active symptoms, and residual period) of at least 6 months (C). The doctor Lyonel consulted found no evidence of another medical condition (E). Auditory hallucinations that may exactly mimic those encountered in schizophrenia can occur in alcohol-induced psychotic disorder. People who are withdrawing from amphetamines may even harm themselves as they attempt to escape terrifying persecutory delusions. We might suspect either of these disorders if Lyonel had recently used substances. Lyonel also denied feeling depressed. Major depressive disorder with psychotic features can produce delusions or hallucinations, but often these are mood-congruent (they center around feelings of guilt or deserved punishment). Schizoaffective disorder could be excluded because he had no prominent mood symptoms (depressive or manic, D). From the duration of his symptoms, we know not to diagnose schizophreniform disorder. Many patients with schizophrenia also have an abnormal premorbid personality. Often this takes the form of schizoid or, especially, schizotypal personality disorder. As a child, Lyonel had at least five features of schizotypal personality disorder. These included constricted affect, no close friends, odd beliefs (interest in the occult), peculiar appearance (as judged by peers), and suspiciousness of other children. However, he had no history that would cause us to consider autism spectrum disorder (F). With two psychotic symptoms and a duration of more than 6 months, Lyonel’s illness easily matches the prototype for typical schizophrenia. Note that (as with most DSM-5 disorders) medical and substance use causes must be ruled out, and other, more treatable mental etiologies must be deemed less likely. Throughout his current episode, Lyonel had had no change of symptoms that might suggest anything other than a continuous course. He had been ill for just about 1 year. I’d peg his current GAF score at 30, and his overall diagnosis would be as follows: F20.9 [295.90] Schizophrenia, first episode, currently in acute episode F21 [301.22] Schizotypal personality disorder (premorbid) Z56.9 [V62.29] Unemployed In evaluating patients who have delusions or hallucinations, be sure to consider the cognitive disorders. This is especially true in an older patient whose psychosis has developed quite rapidly. And patients with schizophrenia who have active hallucinations or delusions should be asked about symptoms of dysphoria. They are likely to have depression or anxiety (or both) that could require additional treatment. Bob Naples As his sister told it, Bob Naples was always quiet when he was a kid, but not what you’d call peculiar or strange. Nothing like this had ever happened in their family before. Bob sat in a tiny consulting room down the hall. His lips moved soundlessly, and one bare leg dangled across the arm of his chair. His sole article of clothing was a red-and-white-striped pajama top. An attendant tried to drape a green sheet across his lap, but he giggled and flung it to the floor. It was hard for his sister, Sharon, to say when Bob first began to change. He was never very sociable, she said; “You might even call him a loner.” He hardly ever laughed and always seemed rather distant, almost cold; he never appeared to enjoy anything he did very much. In the 5 years since he’d finished high school, he had lived at their house while he worked in her husband’s machine shop, but he never really lived with them. He had never had a girlfriend—or a boyfriend, for that matter, though he sometimes used to talk with a couple of high school classmates if they dropped around. About a year and a half ago, Bob had completely stopped going out and wouldn’t even return phone calls. When Sharon asked him why, he said he had better things to do. But all he did when he wasn’t working was stay in his room. Sharon’s husband had told her that at work, Bob stayed at his lathe during breaks and talked even less than before. “Sometimes Dave would hear Bob giggling to himself. When he’d ask what was funny, Bob would kind of shrug and just turn away, back to his work.” For over a year, things didn’t change much. Then, about 2 months earlier, Bob had started staying up at night. The family would hear him thumping around in his room, banging drawers, occasionally throwing things. Sometimes it sounded like he was talking to someone, but his bedroom was on the second floor and he had no phone. He stopped going in to work. “Of course, Dave’d never fire him,” Sharon continued. “But he was sleepy from being up all night, and he kept nodding off at the lathe. Sometimes he’d just leave it spinning and wander over to stare out the window. Dave was relieved when he stopped coming in.” In the last several weeks, all Bob would say was “Gilgamesh.” Once Sharon asked him what it meant and he answered, “It’s no red shoe on the backspace.” This astonished her so much that she wrote it down. After that, she gave up trying to ask him for explanations. Sharon could only speculate how Bob came to be in the hospital. When she’d come home from the grocery store a few hours earlier, he was gone. Then the phone rang and it was the police, saying that they were taking him in. A security guard down at the mall had taken him into custody. He was babbling something about Gilgamesh and wearing nothing but a pajama top. Sharon blotted the corner of her eye with the cuff of her sleeve. “They aren’t even his pajamas—they belong to my daughter.” Evaluation of Bob Naples Do take a few moments to review Bob’s history for the elements of the typical schizophrenia prototype. This is the picture to carry around in your head, against which you’ll match future patients. With several psychotic symptoms, Bob fully met the basic criteria for schizophrenia. Besides his badly disorganized speech (criterion A3) and behavior (going out nude, A4), he had the negative symptoms of not speaking and lack of volition (he stopped going to work—A5). Although he had had active symptoms for perhaps only a few months, his decreased (even for him) sociability had begun well over a year before, extending the total duration of his illness (C) well beyond the 6-month threshold. The vignette makes clear the devastating effect of symptoms on his work and social life (B). However, even with these typical features, there are still several exclusions to be ruled out. Bob would say only one word when he was admitted, so it could not be determined whether he had a cognitive deficit, as would be the case in a delirium or in an amphetamine- or phencyclidine-induced psychotic disorder. Only after treatment was begun might his cognitive status be known for sure. Other evidence of gross brain disease (E) could be sought with skull X-rays, MRI, and blood tests as appropriate. Patients with bipolar I disorder can show gross defect of judgment by refusing to remain clothed, but Bob did not have any of the other typical features of mania, such as euphoric mood or hyperactivity—certainly not pressured speech. The absence of prominent mood symptoms would rule out major depressive episode and schizoaffective disorder (D). Over a year earlier, Bob had been found giggling to himself at his lathe, so the early manifestations of his illness had been present for far longer than the 6-month minimum for schizophrenia; we can therefore dismiss schizophreniform disorder. Several of Bob’s symptoms are typical for what used to be called disorganized schizophrenia. His affect was inappropriate (he laughed without apparent cause), although reduced lability (termed flat or blunted) would also qualify as a negative symptom. By the time of his evaluation, his speech had been reduced to a single word, but earlier it had been incoherent (and peculiar enough that his sister even wrote some of it down). Finally, there was loss of volition (the will to do things): He had stopped going to work and spent most of his time in his room, apparently accomplishing nothing. From Sharon’s information, a premorbid diagnosis of some form of personality disorder would also seem warranted. Bob’s specific symptoms included the following: no close friends, not desiring relationships, choosing solitary activities, lack of pleasure in activities, and no sexual experiences. This is a pattern, often noted in patients with schizophrenia, called schizoid personality disorder. Although Bob’s eventual diagnosis would seem evident, we should await the results of lab testing to rule out causes of psychosis other than schizophrenia. Therefore, we’ll add the qualifier (provisional) to his diagnosis. I’d give him a GAF score of just 15. F20.9 [295.90] Schizophrenia, first episode, currently in acute episode (provisional) F60.1 [301.20] Schizoid personality disorder (premorbid) Disorganized schizophrenia was first recognized nearly 150 years ago. It was originally termed hebephrenia because it began early in life (hebe is Greek for youth). Patients with disorganized schizophrenia can appear the most obviously psychotic of all. They often deteriorate rapidly, talk gibberish, and neglect hygiene and appearance. More recent research, however, has determined that the pattern of symptoms doesn’t predict enough to make disorganized schizophrenia a useful diagnostic subcategory—other than as a description of current symptoms. Natasha Oblamov “She’s nowhere near as bad as Ivan.” Mr. Oblamov was talking about his two grown children. At 30 years of age, Ivan had such severe disorganized schizophrenia (as it was then known) that, despite neuroleptics and a trial of electroconvulsive therapy, he could not put 10 words together so they made sense. Now Natasha, 3 years younger than her brother, had been brought to the clinic with similar complaints. Natasha was an artist. She specialized in oil-on-canvas copies of the photographs she took of the countryside near her home. Although she had had a one-woman exhibition in a local art gallery 2 years earlier, she had never yet earned a dollar from her artwork. She had a room in her father’s apartment, where the two lived on his retirement income. Her brother lived on a back ward of the state mental hospital. “I suppose it’s been going on for quite a while now,” said Mr. Oblamov. “I should have done something earlier, but I didn’t want to believe it was happening to her, too.” The signs had first appeared about 10 months ago, when Natasha stopped attending class at the art institute and gave up her two or three drawing pupils. Mostly she stayed in her room, even at mealtimes; she spent much of her time sketching. Her father finally brought Natasha for evaluation because she kept opening the door. Perhaps 6 weeks earlier she had begun emerging from her room several times each evening, standing uncertainly in the hallway for several moments, then opening the front door. After peering up and down the hallway, she would retreat to her own room. In the past week, she had reenacted this ritual a dozen times each evening. Once or twice, her father thought he heard her mutter something about “Jason.” When he asked her who Jason was, she only looked blank and turned away. Natasha was a slender woman with a round face and watery blue eyes that never seemed to focus. Although she volunteered almost nothing, she answered every question clearly and logically, if briefly. She was fully oriented and had no suicidal ideas or other problems with impulse control. Her affect was as flat as one of her canvases. She would describe her most frightening experiences with no more emotion than she would making a bed. Jason was an instructor at the art institute. Some months earlier, one afternoon when her father was out, he had come to the apartment to help her with “some special stroking techniques,” as she put it (referring to her brush). Although they had ended up naked together on the kitchen floor, she had spent most of that time explaining why she felt she should put her clothes back on. He left unrequited, and she never returned to the art institute. Not long afterward, Natasha “realized” that Jason was hanging about, trying to see her again. She would sense his presence just outside her door, but each time she opened it, he had vanished. This puzzled her, but she couldn’t say that she felt depressed, angry, or anxious. Within a few weeks she started to hear a voice quite a bit like Jason’s, which seemed to be speaking to her from the photographic enlarger she had set up in the tiny second bathroom. “It usually just said the ‘C word,’ ” she explained in response to a question. “The ‘C word’?” “You know, the place on a woman’s body where you do the ‘F word.’ ” Unblinking and calm, Natasha sat with her hands folded in her lap. Several times in the past several weeks, Jason had slipped through her window at night and climbed into her bed while she slept. She had awakened to feel the pressure of his body on hers; it was especially intense in her groin area. By the time she had fully awakened, he would be gone. The previous week when she went in to use the bathroom, the head of an eel—or perhaps it was a large snake—emerged from the toilet bowl and lunged at her. She lowered the lid on the animal’s neck and it disappeared. Since then, she had only used the toilet in the hall bathroom. Evaluation of Natasha Oblamov Natasha had a variety of psychotic symptoms. They included visual hallucinations (the eel in the toilet—criterion A2) and a nonbizarre delusion about Jason (A1). She also had the negative symptom of flat affect (she talked about eels and her private anatomy without a hint of emotion—A5). Although her active symptoms had been evident for only a few months, the prodromal symptom of staying in her room had been present for about 10 months (C). I can’t identify anything in the vignette I’d call lack of volition, but her disorder obviously interfered with her ability to complete a canvas (B). Nothing in Natasha’s history would suggest another medical condition (E) that could explain her symptoms. However, a certain amount of routine lab testing might be ordered initially: complete blood count, routine blood chemistries, urinalysis. No evidence is given in the vignette to suggest that she had a substance-induced psychotic disorder, and her affect, though flat, was pleasant enough—nothing like the severely depressed mood of a major depressive disorder with psychotic features (D). Furthermore, she had never had suicidal ideas, and nothing suggested a manic episode. Duration of illness longer than 6 months rules out schizophreniform disorder and brief psychotic disorder. Finally, her brother had schizophrenia. About 10% of the first-degree relatives (parents, siblings, and children) of patients with schizophrenia also develop this condition. Of course, this is not a criterion for diagnosis, but it does help point the way. Natasha fulfilled all elements of the prototype: psychotic symptoms, duration, and absence of other causes (especially medical and substance use disorders). Although age of onset isn’t included in the DSM-5 criteria, I’ve mentioned it in the prototype. Anyone who becomes psychotic after, say, age 35 needs an evaluation even more careful than usual—for other, possibly treatable causes. In an earlier time (DSM-IV), Natasha’s symptoms would have earned her a diagnostic subtype of undifferentiated; now everyone’s diagnosis is undifferentiated. Because she’d been ill less than a year (though well over the 6-month minimum), there would be no course specifier. I’d assign her a GAF score of 30. Her diagnosis would be simply this: F20.9 [295.90] Schizophrenia, first episode, acute DSM-5 encourages us to rate each patient’s psychotic symptoms on a 5-point scale. Each of the five criterion A symptoms is rated as 0 = absent, 1 = equivocal (not strong or long enough to be considered psychotic), 2 = mild, 3 = moderate, or 4 = severe. In addition, the manual notes that a similar rating scheme should be used for impaired cognition, depression, and mania, because each of these features is important in the differential diagnosis of psychotic patients. These ratings can be attached to several of the different psychotic disorders discussed in this chapter. But the use of this rating system for severity is (happily, in my judgment) optional. Ramona Kelt When she was 20 and had been married only a few months, Ramona Kelt was hospitalized for the first time with what was then described as “hebephrenic schizophrenia.” According to records, her mood had been silly and inappropriate, her speech disjointed and hard to follow. She had been taken for evaluation after putting coffee grounds and orange peels on her head. She told the staff about television cameras in her closet that spied upon her whenever she had sex. Since then, she had had several additional episodes, widely scattered across 25 years. Whenever she fell ill, her symptoms were the same. Each time she recovered enough to return home to her husband. Every morning Ramona’s husband had to prepare a list spelling out her day’s activities, even including meal planning and cooking. Without it, he might arrive home to find that she had accomplished nothing that day. The couple had no children and few friends. Ramona’s most recent evaluation was prompted by a change in medical care plans. Her new clinician noted that she was still taking neuroleptics; each morning her husband carefully counted them out onto her plate and watched her swallow them. During the interview, she winked and smiled when it did not seem appropriate. She said it had been several years since television cameras bothered her, but she wondered whether her closet “might be haunted.” Evaluation of Ramona Kelt Ramona had been ill for many years with symptoms that included disorganized behavior (criterion A4) and a delusion about television cameras (A1). The diagnosis of disorganized (hebephrenic) schizophrenia would at one time have been warranted, based on her inappropriate affect and bizarre speech (A3) and behavior. When acutely ill, she also met DSM-5 criteria for schizophrenia. At this evaluation she was between acute episodes, but showed peculiarities of affect (winking) and ideation (the closet might be haunted) that suggested attenuated psychotic symptoms. She did have one serious, ongoing negative symptom (A5), avolition: If her husband didn’t plan her day for her, she would accomplish pretty close to nothing (this would earn her a GAF score of 51). However, with only one current psychotic symptom, she appeared to be partly recovered from her last episode of schizophrenia. Of course, to receive a diagnosis of schizophrenia, Ramona would have to have none of the exclusions (general medical conditions, substance-induced psychotic disorder, mood disorders, schizoaffective disorder). I think we would be pretty safe in assuming that this was still the case, so her current diagnosis would be as given below. Note, too, that even the sketchy information in the vignette nicely fulfilled our typical schizophrenia prototype. The course specifier equates essentially to the old diagnosis of schizophrenia, residual type. F20.9 [295.90] Schizophrenia, multiple episodes, currently in partial remission PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA F20.81 [295.40] Schizophreniform Disorder Its name sounds as if it must be related to schizophrenia, but the diagnosis of schizophreniform disorder (SphD) was devised in the late 1930s to deal with patients who may have something quite different. These people look as if they do have schizophrenia, but some of them later recover completely with no residual effects. The SphD diagnosis is valuable because it prevents closure: It alerts all clinicians that the underlying nature of the patient’s psychosis has not yet been proven. (The -form suffix means this: The symptoms look like schizophrenia, which it may turn out to be. But with limited information, the careful clinician feels uncomfortable rushing into a diagnosis that implies lifelong disability and treatment.) The symptoms and exclusions required for SphD are identical to those of basic schizophrenia; where the two diagnoses differ is in terms of duration and dysfunction. DSM-5 doesn’t require evidence that SphD has interfered with the patient’s life. However, when you think about it, most people who have had delusions and hallucinations for a month or more have probably suffered some inconvenience socially or in the workplace. The real distinguishing point is the length of time the patient has been symptomatic: From 1 to 6 months is the period required. The practical importance of the interval is this: Numerous studies have shown that psychotic patients who have been briefly ill have a much better chance of full recovery than do those who have been ill for 6 months or longer. Still, over half of those who are initially diagnosed as having SphD are eventually found to have schizophrenia or schizoaffective disorder. SphD isn’t really a discrete disease at all; it’s a place filler that’s used about equally for males and females who are of about the age as patients with schizophrenia when they are first diagnosed. The diagnosis is made only about one-fifth as often as schizophrenia is, especially in the United States and other Western countries. In the late 1930s, the Norwegian psychiatrist Gabriel Langfeldt coined the term schizophreniform psychosis. In the United States it was perhaps more relevant at that time, when the diagnosis of schizophrenia was so often made for patients who had psychotic symptoms but not the longitudinal course typical of schizophrenia. As Langfeldt made clear in a 1982 letter in the American Journal of Psychiatry, when he devised the concept he meant to include not only psychoses that look exactly like schizophrenia except for the duration of symptoms, but other presentations as well. These include what we would today call brief psychosis, schizoaffective disorders, and even some bipolar disorders. Time and custom have narrowed the meaning of his term, to the point where it is hardly ever used. I consider that to be a great pity; it’s a useful device that helps keep clinicians on their toes and patients off chronic dosing with medication. Essential Features of Schizophreniform Disorder Relatively rapid onset and offset characterize SphD. The term usually indicates a young person (late teens or 20s) who for 30 days to 6 months has (1) delusions (especially persecutory) and (2) hallucinations (especially auditory). However, some patients will have (3) speech that is incoherent or otherwise disorganized, (4) severely abnormal psychomotor behavior (catatonic symptoms), or (5) negative symptoms such as restricted affect or lack of volition (they don’t feel motivated to do work or maintain family life). Diagnosis requires at least two of these five types of psychotic symptoms, at least one of which must be delusions, hallucinations, or disorganized speech. The patient recovers fully within 6 months. The Fine Print The D’s: • Duration (30 days to 6 months) • Differential diagnosis (physical and substance-induced psychotic disorders, schizophrenia, mood disorders, or cognitive disorders) Coding Notes Specify: {With}{Without} good prognostic features, which include: (1) Psychotic symptoms begin early (in first month of illness); (2) confusion or perplexity at peak of psychosis; (3) good premorbid functioning; (4) affect not blunted. Two to four of these = With good prognostic features; none or one = Without. With catatonia If it’s within 6 months and the patient is still ill, use the specifier (provisional). Once the patient has fully recovered, remove the specifier. If the patient is still ill after 6 months, SphD can no longer apply. Change the diagnosis to schizophrenia or some other disorder. You may specify severity, though you don’t have to (see the sidebar). Arnold Wilson When he was 3, Arnold Wilson’s family had entered a witness protection program. At least that’s what he told the mental health intake interviewer. Arnold was slim, of medium height, and clean-shaven. He wore a name tag identifying him as a medical student. His eye contact was direct and steady, and he sat quietly as he described his experiences. “It was on account of my dad,” he explained. “When we lived back East, he used to be in the Mob.” Arnold’s father, the principal informant, later remarked, “OK, I’m an investment banker. You might think that’s bad enough, but it isn’t the Mob. Well, anyway, it’s not that mob.” Arnold’s ideas had come to him as a revelation 2 months earlier. He was at his desk, studying for a physiology test, when he heard a voice just behind him. “I jumped up, thinking I must have left my door open, but there was no one in the room but me. I checked the radio and my iPod, but everything was turned off. Then I heard it again.” The voice was one he recognized. “But I can’t tell you whose. She told me not to.” The woman’s voice spoke very clearly to him and seemed to move around a lot. “Sometimes she seemed like she was just behind me. Other times, she stood outside whatever room I was in.” He agrees that she spoke in complete sentences. “Sometimes full paragraphs. What a gabby person!” he remarked with a laugh. At first, the voice told him he “needed to cover my tracks, whatever that meant.” When he tried to ignore it, she became “really angry, told me to believe her, or . . . ” Arnold didn’t finish the sentence. The voice pointed out that his last name, before he was 3, was Italian. “You know, she was really beginning to make sense.” “The name change part’s true,” his father explained. “When I married his mother, Arnold was part of the deal. His biological father had died of cancer of the kidney. We both thought it would be best if I adopted him.” That was 20 years ago. Arnold had had difficulty in middle school. His attention wandered, and so did he. As a result, he spent a lot of time in the principal’s office. Although several teachers despaired of him, in high school he’d hit his stride. There he’d made excellent grades, gotten into a good college, and then been accepted at a better medical school. That autumn, just before starting his freshman year, his physical exam (and a panel of blood tests) had been completely normal. He said his roommate would testify that he hadn’t used any drugs or alcohol. “It was pretty confusing, at first—the voice, I mean. I wondered if I was losing my mind. But then we talked it over, she and I. Now it seems pretty clear.” When Arnold talked about the voice, he became quite animated, using appropriate hand gestures and vocal inflections. Throughout, he gave full attention to the interviewer, except once when he turned his head, as though listening to something. Or someone. Evaluation of Arnold Wilson Arnold’s two psychotic symptoms—delusions and auditory hallucinations—are enough to get us past the criterion A requirements, which are the same for SphD as for schizophrenia. The vignette doesn’t describe the extent to which his social or school functioning had been compromised, but the SphD criteria set doesn’t require this information. The clinical features of Arnold’s psychosis closely resembled those of schizophrenia. Of course, that’s the whole point of SphD: At the time you make the diagnosis, you don’t know whether the outcome will be full recovery or long-term illness. Arnold’s symptoms had been present too long for brief psychotic disorder, which lasts less than 1 month, and too briefly for schizophrenia. He didn’t use alcohol to excess, and on his roommate’s evidence (OK, by proxy), he didn’t use drugs at all; this would rule out a substance-induced psychotic disorder. The usual general medical causes of psychosis would have to be investigated, but his recent physical exam had been normal. With no symptoms of mania or depression, bipolar I disorder would seem vanishingly unlikely. Whenever possible for patients with SphD, a statement of prognosis should be made. In Arnold’s case, the treating clinician noted the following evidence of good prognosis: (1) As far as anyone could tell, his illness had begun abruptly with prominent psychotic symptoms (auditory hallucinations). (2) His premorbid functioning (both work and social life) had been good. (3) Lacking flattening or inappropriateness, his affect was intact during this evaluation. The fourth good-prognosis feature specified by DSM-5 is perplexity or confusion. Arnold did say that he was confused at first, but by the time of his evaluation, at the height of his illness, his cognitive processes seemed intact. Thus he had three of the features that favor a good prognosis; only two are needed. The criteria require that a qualifier of (provisional) be appended if the diagnosis of SphD is made before the patient recovers, as was the case for Arnold. Assuming that he recovered completely within the 6-month limit, this qualifier could then be removed. However, if the illness lasted longer than 6 months and it interfered with Arnold’s work or social life, the diagnosis might need to be changed—probably to schizophrenia. Right now, Arnold’s diagnosis should read as given below. And I’d give him a GAF score of 60: Though his psychotic symptoms were serious, his behavior hadn’t been markedly affected. Yet. F20.81 [295.40] Schizophreniform disorder (provisional), with good prognostic features Do you need a place to park your patient while you collect more evidence? Even in DSM-5, there persist a couple of diagnostic “sidings” that you can use to indicate that something is wrong, but you’re waiting for more information before you commit to a diagnosis. Of course, there’s always “other specified ________” or “unspecified ________,” but even beyond those useful (and vague, and sometimes indiscriminately used) locutions, we have some other terms that gain much the same advantage. SphD is one—it can go either way, to chronicity or to recovery. And then brief psychotic disorder was manufactured to cover the month of psychosis before you can diagnose SphD. In Chapter 6, we’ll see that acute stress disorder was cobbled together to cover the month before posttraumatic stress disorder can be diagnosed. But that’s about the sum of it. The problem is, we mental health clinicians are still dependent on our patients’ appearance to inform how we view them. Other medical disciplines use lab tests, and so may avoid the diagnostic way station. F23 [298.8] Brief Psychotic Disorder Patients with brief psychotic disorder (BPsD) are psychotic for at least 1 day and return to normal within 1 month. It doesn’t matter how many symptoms they have had or whether they have had trouble functioning socially or at work. (In parallel with schizophreniform disorder, any patient who remains symptomatic longer than 1 month must be given a different diagnosis.) BPsD isn’t an especially stable diagnosis; many patients will eventually be rediagnosed with another psychotic disorder. (This is hardly surprising for a diagnosis you can have for only 30 days.). As few as 7% of first-time patients with psychotic disorders have this as the initial diagnosis. Some patients who experience a psychosis around the time of giving birth may be given this diagnosis. Even then, it is a rare condition: The incidence of postpartum psychosis is only about 1 or 2 per 1,000 women who give birth. Indeed, BPsD is overall twice as common among women as men. European clinicians are more likely to diagnose BPsD. (This doesn’t mean that the condition occurs more frequently in Europe, just that European clinicians are apparently more alert to it—or more likely to overdiagnose it.) BPsD may be more common among young patients (teenagers and young adults) and among patients who are from lower socioeconomic strata or who have preexisting personality disorders. Patients with certain personality disorders (such as borderline) who have very brief psychotic symptoms precipitated by stress do not require a separate diagnosis of BPsD. Over two decades ago, in DSM-III-R, this category was called brief reactive psychosis. That name and its criteria reflected the notion that it may occur in response to some overwhelmingly stressful event, such as death of a relative. In the DSM-5 criteria, this concept is retained only in the form of specifiers. The decision about the diagnosis of BPsD is relatively straightforward. To compensate, we face decisions about specifiers that are fraught. We must determine whether a stressor could have caused the psychosis. Of course, anything could precede the onset, and to learn what it might be could require interviewing a spouse, relative, or friend. We’d want to learn about possible traumatic events, but also about the patient’s premorbid adjustment, past history of similar reactions to stress, and the chronological relationship between stressor and the onset of symptoms. Even with all this, we’re still stuck with deciding whether the event is likely to have caused psychosis. DSM-5 tells us only that the event(s) must be severe enough to cause stress for anyone of the patient’s situation and culture. But it doesn’t help us at all to decide whether psychosis is in response to stress. My solution: Ignore the words in response; if there’s marked stress, say so, and move on. Essential Features of Brief Psychotic Disorder All within the course of a single month, the patient develops, then recovers completely from an episode of psychosis that includes delusions, hallucinations, or disorganized speech (disorganized behavior may also be present). The episode lasts at least 1 day but less than 1 month. The Fine Print The D’s: • Duration (1 day to 1 month) • Differential diagnosis (mood or cognitive disorders, psychoses caused by medical conditions or substance use, schizophrenia) Coding Notes If you make the diagnosis without waiting for recovery, you’ll have to append the term (provisional). You can specify: With postpartum onset. Symptoms begin within 4 weeks of giving birth. {With}{Without} marked stressors. The stressors must appear to cause the symptoms, must occur shortly before their onset, and must be severe enough that nearly anyone of that culture would feel markedly stressed. With catatonia You may specify severity, though you don’t have to (see the sidebar). Melanie Grayson This was Melanie Grayson’s first pregnancy, and she had been quite apprehensive about it. She had gained 30 pounds, and her blood pressure had been slightly too high. But she had needed only a spinal block for anesthesia, and her husband was in the room with her when she delivered a healthy baby girl. That night she slept fitfully; she was irritable the next day. But she breastfed her baby and seemed to listen attentively when the nurse practitioner came to instruct her on bathing and other postpartum care. The next morning, while Melanie was having breakfast, her husband came to take her and the baby home. When she ordered him to turn off the radio, he looked around the room and said he didn’t hear one. “You know very well what radio,” she yelled, and threw a tea bag at him. The mental health consultant noted that Melanie was alert, fully oriented, and cognitively intact. She was irritable but not depressed. She kept insisting that she heard a radio playing: “I think it’s hidden in my pillow.” She unzipped the pillowcase and felt around inside. “It’s some sort of a news report. They’re talking about what’s happening in the hospital. I think I just heard my name mentioned.” Melanie’s flow of speech was coherent and relevant. Apart from throwing the tea bag and looking for the radio, her behavior was unremarkable. She denied hallucinations involving any of the other senses. She insisted that the voices she heard could not be imaginary, and she didn’t think someone was trying to play a trick on her. She had never used drugs or alcohol, and her obstetrician vouched for her excellent general health. After much discussion, she agreed to remain in the hospital a day or two longer to try to get to the bottom of the mystery. Evaluation of Melanie Grayson Despite her obvious psychosis (hallucinations and delusions), the brevity of her symptoms kept Melanie from meeting the criterion A requirements for schizophrenia, schizophreniform disorder, or schizoaffective disorder. What’s left? Although Melanie remained alert and cognitively intact, any patient with abrupt onset of psychotic symptoms should be carefully evaluated for a possible delirium. (They will often be confused, which may be the fact with patients who have BPsD, too. Be careful in your evaluation.) Many general medical conditions can also produce psychotic symptoms. Anyone who becomes psychotic soon after entering the hospital should be evaluated for a substance-induced psychotic disorder with onset during withdrawal. Melanie had no prominent mood symptoms; if she had had any, a diagnosis of a mood disorder with psychotic features might have been entertained. It is worth noting that many patients who develop psychosis after delivery may have mixtures of symptoms that include euphoria, psychosis, and cognitive changes. Many of these patients have some form of mood disorder (often bipolar I disorder). Diagnosis should be made with extreme care in all cases of postpartum psychosis; the diagnosis of schizophrenia should never be made, except in the most obvious and certain of circumstances. With a very brief duration of psychosis and none of the exclusions, Melanie would fulfill the somewhat undemanding criteria for BPsD. Until she recovered, the diagnosis would have to be made provisionally. I’d put her GAF score at 40. Her full diagnosis at this time would be as follows: F23 [298.8] Brief psychotic disorder, with postpartum onset (provisional) O80 [650] Normal delivery F22 [297.1] Delusional Disorder Persistent delusions are the chief characteristic of delusional disorder. Usually they can seem entirely believable; however, it is no longer necessary that they be nonbizarre, as DSM-IV required. Still, patients tend to appear pretty normal, as long as you don’t touch on one of their delusions. There are half a dozen possible themes, which I’ve outlined in the Coding Notes. Although the symptoms can seem similar to those of schizophrenia, there are several reasons to list delusional disorder separately: • The age of onset is often later in life (mid- to late 30s) than that of schizophrenia. • Family histories of the two illnesses are dissimilar. • At follow-up, these patients are rarely rediagnosed as having schizophrenia. • The infrequent hallucinations take a back seat to the delusions, and are understandable in the context of those delusions. Most importantly, compared to that of schizophrenia, the course of delusional disorder is less fraught with intellectual and work-related deterioration. In fact, behavior won’t be much altered, outside of responses to the delusions: for instance, phoning the police for protection, or letter-writing campaigns to complain of sundry imagined insults or infractions. As you might suppose, resulting domestic problems are frequent—and, depending on their subtype, these patients may be swept up in litigation or endless medical tests. Delusional disorder is uncommon (by some estimates, schizophrenia is 30 times more frequent). Chronically reduced sensory input (being deaf or blind) may contribute to its development, as may social isolation (such as being an immigrant in a strange country). Delusional disorder may also be associated with family traits that include suspiciousness, jealousy, and secretiveness. The persecutory type is by far the most common of the subtypes; the jealous type ranks a distant second. One problem that crops up frequently is the presence of mood symptoms in patients with delusional disorder. These may be quite unsurprisingly gloomy responses to the perception that others do not agree with closely held beliefs. Depressive mood can create difficult questions of differential diagnosis: Most notably, does the patient have a primary mood disorder? The DSM-5 criteria do not provide a bright line separating the two concepts; the time course of two sets of symptoms—mood and psychotic—may help in the differentiation. Of course, in the case of serious question, I’d consider first the more conservative mood disorder, though delusional disorder may look better and better as time passes. Shared Delusions Though such instances are extremely rare, cases in which one or more persons develop delusions as a result of close association with another delusional person are dramatic and inherently interesting. DSM-IV called this condition shared psychotic disorder; as long ago as 150 years it was known as folie à deux, which means “double insanity.” Usually two people are involved, but three, four, or more can become caught up in the delusion. Shared delusions affect women more often than men, and they usually occur within families. Social isolation may play a role in the development of this strange condition. One of the persons affected is independently psychotic; through a close (and often dependent) association, the other has come to believe in the delusions and other experiences of the first. Though occasionally bizarre, the content of the delusion is usually believable, if often unconvincing. Isolating the independently psychotic patient may cure the other(s), but this remedy doesn’t always work. For one thing, the parties involved are often closely related and persist in reinforcing their mutual psychopathology. A few patients whose delusions mirror those of people with whom they are intimately associated will, for one reason or another, not fully qualify for a diagnosis of delusional disorder. For them, you’ll have to use the category of other specified (or unspecified) schizophrenia spectrum and other psychotic disorder, as described at the end of this chapter. Essential Features of Delusional Disorder For at least a month, the patient has had delusions but no other psychotic symptoms, and any mood symptoms are relatively brief. Other than consequences of the delusions, behavior isn’t much affected. The Fine Print OK, there might be some hallucinations of touch or smell, but only as they relate to the delusions. And they won’t be prominent. The D’s: • Duration (1+ months) • Distress and disability (none, except as related to the delusional content) • Differential diagnosis (physical and substance-induced psychotic disorders, mood or cognitive disorders, schizophrenia, obsessive–compulsive disorder) Coding Notes You can specify type of delusion: erotomanic, grandiose, jealous, persecutory, somatic, mixed, or unspecified. Specify if: With bizarre content. This denotes obviously improbable delusions (see sidebar). If the delusional disorder has lasted at least 1 year, specify course: First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous Unspecified You may specify severity, though you don’t have to (see the sidebar). Molly McConegal Molly McConegal, a tiny sparrow of a woman, sat perched on the front of her waiting room chair. On her lap she tightly clutched a scuffed black handbag; her gray hair was caught up in a fierce little bun at the back of her head. Through spectacles as thick as highball glasses, she darted myopic, suspicious glances about the room. She had already spent 45 minutes with the consultant behind closed doors. Now she was waiting while her husband, Michael, had a turn. Michael confirmed much of what Molly had already said. The couple had been married for over 40 years, had two children, and had lived in the same neighborhood (the same house, in fact) nearly all of their married life. Both were retired from the telephone company, and they shared an interest in gardening. “That was where it all started, in the garden,” said Michael. “It was last summer, when I was out trimming the rose bushes in the front yard. Molly said she caught me looking at the house across the street. The widow woman who lives there is younger than we are, maybe 50. We nod and say ‘Hi,’ but in 10 years, I’ve never even been inside her front door. But Molly said I was taking too long on those rose bushes, that I was waiting for our neighbor—her name is Mrs. Jessup—to come out of the house. Of course, I denied it, but she insisted. Kept talking about it for days.” In the following months, Molly pursued the idea of Michael’s supposed extramarital relationship. At first she only suggested that he had been trying to lure Mrs. Jessup out for a meeting. Within a few weeks, she “knew” that they had been together. Soon this had become a sex orgy. Molly had talked of little else and had begun to incorporate many commonplace observations into her suspicions. A button undone on Michael’s shirt meant that he had just returned from a visit with “the woman.” The adjustment of the living room Venetian blinds tipped her off that he had been trying to semaphore messages the night before. A private detective Molly hired for surveillance only stopped by to chat with Michael, submitted a bill for $500, and resigned. Molly continued to do the cooking and washing for herself, but Michael now had to take care of his own meals and laundry. She slept normally, ate well, and—when she wasn’t with him—seemed to be in good spirits. Michael, on the other hand, was becoming a nervous wreck. Molly listened in on his telephone calls and steamed open his mail. Once she told him that she would file for divorce, but she “didn’t want the children to find out.” Twice he had awakened at night to find her wrapped tightly in her bathrobe and standing beside his bed, glowering down at him. “Waiting for me to make my move,” he said. Last week she had strewn the hallway outside his room with thumbtacks, so that he would cry out and awaken her when he sneaked away for his late-night sexual rendezvous. Michael smiled and said sadly, “You know, I haven’t had sex with anybody for nearly 15 years. Since I had my prostate operation, I just haven’t had the ability.” Evaluation of Molly McConegal If you compare the features of delusional disorder with those of schizophrenia, you will note many differences. First, consider symptoms. Delusions are the only psychotic symptom found to any important degree in delusional disorder. The delusion could be any of the types listed in the Coding Notes. In Molly’s case, they were of the jealous type, but the persecutory and grandiose types are also common. Note that with the exception of occasional olfactory or tactile hallucinations that support the content of delusions, patients with delusional disorder will never fulfill criterion A for schizophrenia (this nonfulfillment constitutes delusional disorder’s criterion B). The delusions need last only 1 month; however, by the time they come to professional attention, most patients, like Molly, have been ill much longer (A). The average age of patients may be around 55. The consequences are usually relatively mild for delusional disorder. Indeed, aside from the direct effects of the delusion (in Molly’s case, her marital harmony), work and social life may not be affected much at all (C). However, the exclusions are pretty much the same as for schizophrenia. Always rule out another medical condition or cognitive disorder, especially a dementia with delusions, when evaluating delusional patients (E). This is especially important in older patients, who can be quite crafty at disguising the fact that they are cognitively impaired. Substance-induced psychotic disorders can closely mimic delusional disorder. This is especially true for amphetamine-induced psychotic disorder with onset during withdrawal, in which fully oriented patients may describe how they are being attacked by gangs of pursuers (E). Molly McConegal had neither history nor symptoms to support any of the foregoing disorders; however, laboratory and toxicology studies may be needed for many patients. Other than irritability in the company of her husband, she had no symptoms of a mood disorder. Even then, her affect was quite appropriate to her content of thought. However, many of these patients can develop mood syndromes secondary to the delusions. Then the diagnosis depends on the chronology and severity of mood symptoms. Information from relatives or other third parties is often required to determine which came first. Also, the mood symptoms must be relatively mild and brief to sustain a diagnosis of delusional disorder. Although these patients may have associated conditions—including body dysmorphic disorder, obsessive–compulsive disorder, or avoidant, paranoid, or schizoid personality disorder—there was no evidence for any of these in Molly McConegal. Molly had been ill a bit less than a full year, so no course of illness could be specified. Her GAF score would be 55 (highest level in the past year). Her diagnosis would be as follows: F22 [297.1] Delusional disorder, jealous type Miriam Phillips Miriam Phillips was 23 when she was hospitalized. She had spent nearly all her life in the Ozarks, where she sometimes attended class in a three-room school. Although she was bright enough, she had little interest in her studies and often volunteered to stay home to care for her mother, who was unwell. She dropped out of 12th grade to stay home full-time. It was lonely living in the hills. Miriam’s father, a long-distance trucker, was away most of the time. She had never learned to drive, and there were no close neighbors. Their television set received mostly snow; there was little in the way of mail; and there were no visitors at all. So she was surprised late on a Monday afternoon when two men paid a call. After identifying themselves as FBI agents, they asked if she was the Miriam Phillips who 3 weeks earlier had written a letter to the president. When she asked how they had known, they showed her a faxed copy of her own letter: Dear Mr. President, what do you plan to do about the Cubans? They have been working on mother. Their up to no good. Ive seen the police, but they say Cubans are your job, and I guess their right. You have to do your job or Ill have a dirty job to do. Miriam Phillips. When Miriam finally figured out that the FBI agents thought she had threatened the president, she relaxed. She hadn’t meant that at all. She had meant that if no one else took action, she’d have to crawl under the house to get the gravity machines. “Gravity machines?” The two agents looked at each other. She explained. They had been installed under the house by Cuban agents of Fidel Castro after the Bay of Pigs invasion in the 1960s. The machines pulled your body fluids down toward your feet. They hadn’t affected her yet, but they had bothered her mother for years. Miriam had seen the hideous swelling in her mother’s ankles. Some days it extended almost to her knees. The two agents listened to her politely, then left. As they passed through town on their way to the airport, they called at the local community mental health clinic. Within a few days, a mental health worker came to interview Miriam, who agreed to enter the hospital voluntarily for a “checkup.” On admission, Miriam appeared remarkably intact. She had a full range of appropriate affect and normal cognitive abilities and orientation. Her reasoning ability seemed good, aside from the story about the gravity machines. As far back as her teens, her mother had told her how the machines came to be installed in the crawlspace under their house. Mother had been a nurse, and Miriam had always accepted her word in medical matters. By some unspoken agreement, the two had never discussed the matter with Miriam’s father. After Miriam had been on the ward for 3 days, her clinician asked whether she thought any other explanation for her mother’s edema was possible. Miriam considered. She had never felt the gravity effects herself. She had believed that her mother told her the truth, but she now supposed that even Mother could have been mistaken. Though Miriam was given no medication, after a week she stopped talking about gravity machines and asked to be discharged. At the end of their shift that afternoon, two young attendants gave her a lift home. As they walked her to the front door, it was opened by a short woman, quite stout, with salt-and-pepper hair. Her lower legs were neatly wrapped in elastic bandages. Through the partly opened door she darted a glance at the two men. “Hmmm!” she said. “You look like Cubans.” Evaluation of Miriam Phillips Though we don’t know exactly how long, Miriam had had delusions far longer than a month (criterion A) without hallucinations or negative symptoms, and with no disordered behavior or affect. Therefore, schizophrenia could be ruled out just on the basis of insufficient variety of symptoms (B). She wasn’t depressed or manic (D), and there was no history or other evidence to support substance-induced psychotic disorder or psychotic disorder due to another medical condition (E). Her delusions hadn’t caused any occupational or social dysfunction; her own isolation appeared to have begun at least 5 years earlier, before the onset of her shared delusion (C). With an admission GAF score of 40, Miriam’s delusions became less prominent after just a few days of separation from her mother. In working further with her, a therapist would also want to consider the possibility of a personality disorder, such as dependent personality disorder. Her delusion, and that of her mother, was certainly bizarre, but I’m not confident she had been ill longer than a year, so I wouldn’t give her any other specifiers. F22 [297.1] Delusional disorder, persecutory type, with bizarre content Schizoaffective Disorder Schizoaffective disorder (SaD) is just plain confusing. (William Carpenter, chairperson of the DSM-5 psychosis study group, stated during a 2013 presentation about his committee’s work, “We don’t even know if it exists in nature.”) Over the years, it has meant many different things to clinicians. Partly because there were so many interpretations in use, DSM-III included no criteria at all in 1980. DSM-III-R first attempted to specify criteria in 1987. These endured for 7 years, until they were substantially rewritten for DSM-IV. Showing admirable restraint, DSM-5 has made relatively few changes to those criteria. Even with the (minimal) tweaking of criteria, in my opinion the value of this diagnosis remains pretty low. Most interpretations suggest that SaD is some sort of cross between a mood disorder and schizophrenia. Some writers regard it as a form of bipolar disorder, because certain patients seem to respond well to lithium. Other commentators believe that it is closer to schizophrenia. Still others hold that it is an entirely separate type of psychosis, or simply a collection of confusing, sometimes contradictory symptoms. With its various percentage and minimal time requirements, SaD could unfold in a variety of ways: mania first, depression first, psychosis first. Of course, there are the usual exclusions for substance use and general medical conditions. If you examine the various time requirements, you can determine that the entire illness must last at minimum for a bit longer than 1 month, though many patients will be ill much longer. No one really knows much about the demographic features of SaD. It is probably less common than schizophrenia; its prognosis lies between that of schizophrenia and the mood disorders. Recent studies indicate that patients with SaD whose manic symptoms predominate (the bipolar type) may have a better prognosis than those with the depressive type of this condition. I find it easier to remember the requirements for SaD if I think of them as follows: The mood symptoms are important in that they must be present during half or more of the total duration of illness. The psychosis symptoms are important in that they must be present by themselves for at least 2 weeks. (Note that the criteria are silent on whether to count psychosis symptoms that are present during the time that mood symptoms have disappeared under treatment.) In this graphic representation of the minimum time requirements that are possible, given the criteria, the overall length of the box represents the totality of the individual’s illness, not just an episode. Of course, it will be impossible for any clinician to know whether the criteria for a mood episode are met throughout the illness; we’ll have to rely on prototypes for the overall gestalt. Note that the “solo” psychotic episode (criterion B) could come at any point in the episode: the start, the end, somewhere in the middle. Unhappily, DSM-5 is silent on the question of whether, during the psychosis period, there can be mood symptoms that don’t fully qualify as an episode of mania, hypomania, or depression. (DSM-IV was more forthright; it said “in the absence of prominent mood symptoms.”) Start saving for DSM-6. Essential Features of Schizoaffective Disorder A patient has a period of illness during which a manic episode or a major depressive episode lasts half of more of the total time involved. For at least a fortnight during this same continuous period, the patient fulfills the criterion A requirements for schizophrenia without having a mood episode. The Fine Print If the patient has a major depression, one of the symptoms must be depressed mood; “mere” loss of interest doesn’t cut it. The D’s: • Duration (a total of 1+ months) • Differential diagnosis (psychotic mood disorders, substance use, and physical disorders) Coding Notes Specify: F25.0 [295.70] Bipolar type (if during a manic episode) F25.1 [295.70] Depressive type Specify: With catatonia If the disorder has lasted at least 1 year, specify course: First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous Unspecified You may specify severity, though you don’t have to (see the sidebar). Velma Dean Velma Dean’s lips curled upwards, but the smile didn’t touch her eyes. “I’m really sorry about this,” she told her therapist, “but I guess—well, I don’t know what.” She reached into the large shopping bag she had carried into the office and pulled out a 6-inch kitchen knife. First she grasped it in her hand, with her thumb along the blade. Then she tried clutching it in her fist. The therapist reached for the alarm button under the desk top, ruefully aware of yet another change of course in this patient’s multifaceted history. A month before her 18th birthday, Velma Dean had joined the Army. Her father, a colonel of artillery, had wanted a son, but Velma was his only child. Over the feeble protests of her mother, Velma’s upbringing had been strict and semimilitary. After working 3 years in the motor pool, Velma herself had just been promoted to sergeant when she became ill. Her illness started with 2 days in the infirmary for what seemed like bronchitis, but as the penicillin took effect and her fever resolved, the voices began. At first they seemed to be located toward the back of her head. Within a few days they had moved to her bedside water glass. As nearly as she could tell, their pitch depended on the contents of her glass: If the glass was nearly empty, the voices were female; if it was full to the top, they spoke in a rich baritone. They were always quiet and mannerly. Often they gave her advice on how to behave, but at times she said they “nearly drove me crazy” by constantly commenting on what she was doing. A psychiatrist diagnosed Velma’s condition as schizophrenia and prescribed neuroleptics. The voices improved, but never quite disappeared. She concealed the fact that she had “figured out” that her illness had been caused by her first sergeant, who for months had tried unsuccessfully to get her into bed. She also hid the fact that for several weeks she had been drinking nearly a pint of Southern Comfort each evening. The Army retired her as medically unfit, 100% disabled. When she was well enough to travel, her father drove her the 600 miles back home. For her treatment, Velma enrolled at her local Department of Veterans Affairs (VA) outpatient clinic. There, her new therapist verified (1) the continuing presence (now for nearly 8 months) of her barely audible hallucinations, and (2) her increasingly profound symptoms of depression. These included low self-esteem and hopelessness (much worse in the morning than in the evening); loss of appetite; a 10-pound weight loss over the past 8 weeks; insomnia that caused her to awaken early most mornings; and the guilty conviction that she had disappointed her father by “deserting” the Army before her hitch was up. She denied thoughts of injuring herself or other people. Velma’s VA clinician initially deferred making a diagnosis, noting that she had been ill too long for schizophreniform disorder and that her mood symptoms seemed to argue against schizophrenia. Physical exam and laboratory testing ruled out general medical conditions. Although Alcoholics Anonymous helped her stop drinking, her depressive and psychotic symptoms continued. Because Velma’s depressive symptoms might be secondary to a partly treated psychosis, her neuroleptic dose was increased. This completely eliminated the hallucinations and delusions, but the depressive symptoms continued virtually unabated. The antidepressant imipramine at 200 mg/day only produced side effects; after 4 weeks, lithium was added. Once a therapeutic blood level was reached, her depressive symptoms melted completely away. For 6 months she remained in a good mood and free of psychosis, though she never obtained a job or did very much with her time. Now it seemed that Velma might actually be suffering from a major depressive disorder with psychotic features. At this point, her clinician became uneasy that the neuroleptic could produce side effects such as tardive dyskinesia. With Velma’s consent, the neuroleptic was gradually reduced by about 20% per week. After 3 weeks, she began once again to hear voices commanding her to run away from home. During this time her mood remained good; with the exception of some difficulty getting to sleep at night, she developed none of the vegetative symptoms she had formerly had with depression. Her full former dose of neuroleptic medication was rapidly restored. After several months of renewed stability, Velma and her therapist decided to try again. This time they began cautiously to reduce the imipramine, by 25 mg each week. Each week they met to evaluate her mood and check for symptoms of psychosis. By December she had been free of the antidepressant for 2 months, and had remained symptom-free (except for her habitual bland, smiling affect). Now her therapist took a deep breath and decreased her lithium by one tablet per day. The following week Velma returned to the office, hallucinating and wondering whether to hold a kitchen knife in her hand or in her fist. Evaluation of Velma Dean With Velma’s story, we can illustrate the current thinking about SaD. Her condition really seemed to be a mixture of mood and psychotic symptoms, though the latter had clearly begun first. She had what appeared to be a single period of illness (her only “well” periods were when she was taking medication; even then, she had residual lack of initiative), with both psychotic symptoms (auditory hallucinations and a delusion that the sergeant had caused her illness) and a major depressive episode (criterion A). During this period her mood symptoms, which occurred both with and without psychotic symptoms, had lasted for more than half the duration of her total illness (C). Although she abused alcohol at one time during her illness, it appeared to be a consequence of her illness, not the cause; both her mood and psychotic symptoms continued long after she quit drinking (D). The psychosis had begun first and had lasted at least 2 weeks before the mood symptoms commenced (B). The prototype symptoms are also met at level 4, and say more or less the same thing. Although we can rattle off these criteria with relative ease (and, to be honest, a crib sheet), Velma’s history illustrates how difficult it can be to apply them. The therapist, whose thinking has already been described in the vignette, was smart initially to defer diagnosis; this should remind all clinicians to keep thinking about the diagnosis and to reject any label that might close their minds to further therapeutic plans. She could not be diagnosed as having schizophrenia, because it excludes prominent, lasting mood episodes. A mood disorder with psychosis could be eliminated because she had psychotic symptoms even when not depressed. After many months of care, she showed no evidence of another medical condition. The relative duration of psychosis and mood symptoms is very important in SaD. DSM-5 states that the mood symptoms must be present for a majority of the overall duration of illness. Velma’s depressive symptoms lasted for at least 2 months; there is every reason to suspect they would have gone on much longer had she not received effective treatment. Her criterion A symptoms for schizophrenia had been present for 2 weeks without mood symptoms. However carefully the criteria try to operationalize the duration of various symptoms, it remains to some degree a judgment call on the part of each clinician. (DSM-5 is silent on the issue of treated depression and SaD; I’m claiming clinician’s prerogative and declaring that because antidepressant treatment seems to have made all the difference, SaD should be her diagnosis.) Eventually, many patients with both mood and psychotic symptoms will comfortably fit the criteria for schizophrenia or a mood disorder. If they were followed long enough, perhaps the majority of patients with SaD could be rediagnosed. Given the highly restrictive nature of the current definition, it seems likely that this diagnosis will rarely be used. If you ever make the diagnosis, ask yourself, “Have I overlooked anything that is more reasonable?” SaD is a diagnosis best used for patients who have a long-standing history of both sets of symptoms. Other specified (or unspecified) schizophrenia spectrum and other psychotic disorder may prove to be much more useful to most clinicians. Velma’s mood symptoms were depressive, which defined her subtype diagnosis. At the time she was wielding her knife, I felt that her GAF score was down around 20. F25.1 [295.70] Schizoaffective disorder, depressive type Substance/Medication-Induced Psychotic Disorder This category includes all psychoses caused by mind-altering substances. The predominant symptoms are usually hallucinations or delusions; depending on the substance, they can occur during withdrawal or acute intoxication. Usually the course is brief, though they can persist long enough to cause confusion with endogenous psychoses. Although most of these psychoses are self-limiting, early recognition is crucial. Patients have died while experiencing a substance-induced psychotic disorder, several of which can closely mimic schizophrenia. Many diagnoses are possible, if we include all the possible combinations of different substances with the type and duration of psychosis and its relation to intoxication or withdrawal. The incidence is unknown, though a substantial minority of first-episode psychoses may belong to this class—enough that we should remain alert for them. See the “Classes (or Names) of Medications . . .” table in the Appendix for a list of medications associated with psychosis. Essential Features of Substance/Medication-Induced Psychotic Disorder The use of some substance appears to have caused hallucinations or delusions (or both). The Fine Print For tips on identifying substance-related causation, see sidebar. The D’s: • Distress or disability (work/academic, social, or personal impairment) • Differential diagnosis (schizophrenia and its cousins, delusional disorder, ordinary substance intoxication or withdrawal, delirium) You’d only make this diagnosis when the symptoms are serious enough to justify clinical attention and they are worse than you’d expect from ordinary intoxication or withdrawal. Coding Notes When writing down the diagnosis, use the name of the exact substance in the title: for example, methamphetamine-induced psychotic disorder. ICD-9 kept coding simple: 291.9 for alcohol, 292.9 for all other substances. Coding in ICD-10 depends on the substance used and whether symptoms are met for an actual substance use disorder—and how severe the use disorder is. Refer to Table 15.2 in Chapter 15. Specify if: With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words. It also affects the ICD-10 number. With onset after medication use. You can use this in addition to other specifiers (see the sidebar just below). You may specify severity, though you don’t have to (see the sidebar). Actually, DSM-5 mentions with onset after medication use as an optional specifier for substance/medication-induced anxiety disorder, obsessive–compulsive and related disorder, and sexual dysfunctions, but not for psychotic, mood, or sleep disorders. (This despite the fact that the titles of these disorders even begin, uniformly, “substance/medication-induced [this or that].”) I am told that there wasn’t enough communication among the different subcommittees, so that inconsistencies such as this one crept into the final version. Inasmuch as prescribed medications can cause virtually any sort of emotional or behavioral problem, I plan to go right ahead and use the medication specifier any time it seems warranted. But that’s easy for me to say—in my state, the governor has declared a moratorium on capital punishment. Danny Finch Danny Finch put up with the ear problem for 3 days before he finally called for an appointment. The doctor poked at this and that, and worried a little over his tremor. “You don’t drink, do you?” “A little. But what about my ear?” “It’s perfectly normal.” “But I hear something. It’s like someone chanting. I can almost make out what they’re saying. You’re sure no one’s put something in there, a hearing aid?” He dug at the ear with his little finger. “Nope, clean as a whistle. Here, don’t do that!” The doctor scribbled a referral to the mental health clinic down the hall. That was late on a Friday afternoon, so of course the clinic was closed. On Monday afternoon, when he finally got to his appointment, Danny could once again write his name legibly and eat solid food. But the voices were in full throat. As he talked with the interviewer, he could hardly concentrate for the shouting: “Don’t tell about the drinking!” and “Why don’t you just kill yourself?” He was so terrified that he accepted with relief a voluntary commitment to the mental health ward, where his admitting diagnosis was schizophrenia. Twice a day he was given a potent neuroleptic medication, which he tucked under his tongue and discarded in the tissue when he pretended to blow his nose. Danny slept soundly at night and cleaned his plate at every meal while the voices shouted on. At the end of the week, he was visited by a consultant who learned that the voices came from about 2 feet behind him and talked in sentences. Reluctantly, he admitted that they told him not to talk about his drinking. A rapid review of Danny’s chart revealed no mention of alcohol use, but a little coaxing soon pried loose the whole story. Since his early 20s, there had been heavy drinking, loss of two jobs (he had a shaky hold on his present one), and a divorce, all related to his fondness for bourbon. Most recently he had been drinking more than a pint each evening, often a fifth on the weekends. Usually he managed to taper off; this time, he had quit suddenly after a bout of what he called “the stomach flu.” DSM-5 repeatedly refers to classes of symptoms that may appear to be caused by a substance. It is up to you to evaluate your patient for evidence that this might not be the case. Here are several findings, mostly based on chronology, that might constitute such evidence: 1. Your patient had a prior episode of the same, or very similar, symptoms that did not occur in the context of substance use. 2. The disorder continues long after the use of (or withdrawal from) the substance is over. 3. Rather obviously, a disorder that begins before substance use begins wouldn’t be due to the substance use. 4. The symptoms are worse than you’d expect, considering the amount and duration of the substance misuse. None of these is exactly iron-clad. For example, a prior history of major depressive disorder doesn’t confer subsequent immunity to depression that originates in a bottle of Scotch. Still, the cues are there, for your thoughtful consideration. And here are some of the reasons why you should consider a substance-use causation: 1. The symptoms begin soon after (or during) the use of a substance or its withdrawal. 2. They start after a patient has begun use of a medication. 3. The drug/medication is known to be capable of causing the symptoms in question. 4. Of course, if your patient has had a prior episode of the same symptoms that did follow the use of the same substance, that’s perhaps the best evidence of all. Evaluation of Danny Finch Danny had auditory hallucinations (criterion A) that had been present far too briefly for schizophrenia, though he described them in similar terms (C). A brief psychotic disorder might be possible, except for the requirement that a substance-induced psychotic disorder does not better explain the symptoms. He had just been seen by a physician, who pronounced him fit; there was no evidence of any other general medical condition. The fact that he seemed fully oriented and maintained his attention would rule out delirium and other cognitive disorders (D). Though he appeared (appropriately) frightened by his experiences, he presented no evidence of mood disorder. Danny’s psychosis—in the distant past it was called alcoholic auditory hallucinosis—is a disorder of withdrawal that usually occurs only after weeks or months of heavy drinking (B). By about a 4:1 ratio, it occurs much more commonly in men than in women, approximating the sex ratio for alcohol use disorder itself. Auditory hallucinosis is sometimes misidentified as alcohol withdrawal delirium, though the problems with orientation and attention in the latter make the differences clear (see Substance Intoxication Delirium, Substance Withdrawal Delirium, and Medication-Induced Delirium). Withdrawal from other drugs can also produce psychosis. Barbiturates, which have many of the same effects as alcohol, are the most notorious of these. Some patients who use phencyclidine or other hallucinogens such as LSD experience prolonged psychosis, the risk for which may be greater in people who have personality disorders. Danny’s symptoms were clearly more serious than we’d expect in alcohol withdrawal with perceptual disturbances (which would be diagnosed had he retained insight that his experiences weren’t “real”). His GAF score was only 35 on admission; his diagnosis (from Table 15.2 in Chapter 15) would be as follows: F10.259 [291.9] Severe alcohol use disorder with alcohol-induced psychotic disorder, with onset during withdrawal Psychotic Disorder Due to Another Medical Condition A psychosis arising in a patient who has another medical condition shouldn’t be especially rare. Many diseases can produce psychosis, and a number of them are relatively common. But few, if any, studies bear on questions of epidemiology. When such patients do appear, they are too often misdiagnosed as having schizophrenia or some other psychosis. This can lead to real tragedy: A patient who is not appropriately treated early enough may go on to experience (or cause) serious harm. Prevalence rates are not known exactly, but they’re probably low; as you might imagine, frequency increases with age. Note that a patient with mainly disorganized behavior would instead be diagnosed as having catatonic disorder due to another medical condition. It’s often a struggle to determine that a physical illness or medical condition has caused any mental disorder. Here are a few straws in the wind that can help out. • Timing of onset: Mental or behavioral symptoms that begin shortly after the start of the physical illness offer a pretty obvious etiological clue. • Remission follows treatment for the physical issue. • Proportionality of symptoms: As the physical disorder worsens, so do the behavioral or emotional symptoms. • Above all, there must be a known physiological connection between the physical condition and the symptom in question. That is, the physical disorder must be known to be capable of producing the symptom (for example, through production of chemicals, by impinging on brain structures). It cannot simply be that the prospect of having a serious illness evokes psychosis, depression, anxiety, and so forth. OK, so these pointers aren’t exactly iron-clad. Remember, they’re straws, not steel. Essential Features of Psychotic Disorder Due to Another Medical Condition A physical condition causes hallucinations or delusions. The Fine Print For pointers on deciding when a physical condition may have caused a mental disorder, see the sidebar just above. The D’s: • Distress or disability (work/academic, social, or personal impairment) • Differential diagnosis (delirium, substance-induced psychotic disorder, schizophrenia and its cousins, delusional disorder) Coding Notes In recording the diagnosis, use the name of the responsible medical condition, and list first the medical condition, with its code number. Code, based on the predominant symptoms: F06.2 [293.81] With delusions F06.0 [293.82] With hallucinations You may specify severity, though you don’t have to (see the sidebar). Rodrigo Chavez After he retired from teaching at age 65, Rodrigo Chavez spent most of his time sitting alone in his room. Sometimes he played the acoustic guitar; once or twice he shot targets at the rifle range. True to his lifelong habit, he never drank. Other than his immediate family, he had few social contacts. “My cigarettes are my best friends,” he put it during the forensic examination. When Rodrigo was nearly 70, an inoperable carcinoma of the lung was diagnosed. After a course of palliative radiotherapy, he declined further treatment and settled down in his apartment to die. Four months later, he first noticed right-sided headaches that would sometimes awaken him in the middle of the night. Because the doctors had told him he was terminally ill, he didn’t seek further medical attention. Then he began to associate the headaches with natural gas, which he smelled coming out of the ventilator duct in his bathroom. When he called to report the problem to Mrs. Riordan, his landlady, she sent around the building’s handyman, who could find nothing wrong. When his headaches and the odors increased, Rodrigo recalled that, weeks before, Mrs. Riordan had gone out several times to watch while repairmen from the power company dug up the street outside the apartment building. The logical conclusion fairly burst upon him: His landlady was trying to poison him. His anger mounted as the odor worsened. It had begun to affect his voice, which had become raspy and high-pitched. He had several shouted arguments with Mrs. Riordan. One of these they carried on through her apartment door at 2 A.M., several weeks after he first noticed the gas. He threatened to report her to the housing authority; she called him “a crazy old coot.” After he threatened her (“If I’m not safe, your life isn’t worth 15 cents!”), they both made 911 telephone calls. The police could find nothing to charge anyone with and admonished them both to behave. The night he was arrested, Rodrigo had sat just inside his open doorway, yelling insults at Mrs. Riordan. When she lumbered to the top of the stairs to investigate, he shot her once, just behind her left ear. The arresting officers noted that he seemed “strangely detached” from the murder of his landlady. One of them wrote down this statement: “It wouldn’t matter, just for me. But I couldn’t stand her gassing all those other people in the house.” The forensic examiner noted that Rodrigo Chavez was an elderly, slightly built man who was clean-shaven and neatly groomed. He was gaunt, looking as if he had lost considerable weight. His speech was clear, coherent, relevant, and spontaneous, but his voice was high-pitched and gravelly. He appeared calm, and he described his mood as “medium,” but he became angry when describing his landlady’s attempts to poison him. He was oriented to person, place, and time, and he earned a perfect score on the Mini-Mental State Exam. He was fully aware that he had lung cancer. Insight for the fact of his psychosis was nil, and his judgment by recent history had been extremely poor. An X-ray of his chest showed a right lung full of tumor; compared with a previous series, skull films suggested a metastatic lesion located in the right frontal lobe. Evaluation of Rodrigo Chavez Rodrigo Chavez was clearly psychotic: He had prominent olfactory hallucinations and an elaborate delusion about being poisoned. These had been present for several months (criterion A). (If insight is retained that the hallucinations and delusions are a product of the patient’s own mind, one would generally not diagnose a psychotic disorder. Also note that, though Rodrigo’s symptoms clearly met the criterion A inclusion requirements for schizophrenia, they didn’t have to: A person can qualify for this diagnosis with just one of either hallucinations or delusions.) Aside from his psychosis, Rodrigo’s thinking was clear. He was oriented and he scored well on the Mini-Mental State Exam, so he had no evidence of a delirium or dementia (D). He had had no history of drinking or taking drugs, ruling out a substance-induced psychotic disorder. His mood had been at times angry, but appropriately so, given the content of his delusion and hallucination, so a mood disorder with psychotic features would also seem unlikely. There was no previous history of behavior or personality change that would qualify him for a diagnosis of schizophrenia (C). Other features atypical for schizophrenia included the late age of onset and relatively brief duration. Schizophreniform disorder could be ruled out because another diagnosis was more likely. Mrs. Riordan’s unhappy end provides mute testimony to the clinical importance of his illness (E). Rodrigo had a history of a cancer that is known to metastasize to the brain; his headaches suggested that it had already done so. The findings on chest X-ray and MRI confirmed the diagnosis (B). His gravelly, high-pitched voice could be due to extension of the growth or to another metastasis within his chest or neck. (Other medical conditions that can cause psychosis include temporal lobe epilepsy, primary [that is, not metastatic] brain tumors, endocrine disorders such as thyroid and adrenal disease, vitamin deficiency states, central nervous system syphilis, multiple sclerosis, systemic lupus erythematosus, Wilson’s disease, and head trauma.) Although Rodrigo had both hallucinations and delusions, the olfactory hallucinations appeared first and seemed to predominate, resulting in the diagnosis as recorded. My assessment of his GAF score was 15. C79.31 [198.3] Cancer of the lung, metastatic to the brain F06.0 [293.82] Psychotic disorder due to metastatic carcinoma, with hallucinations Z65.3 [V62.5] Arrested for murder F06.1 [293.89] Catatonia Associated with Another Mental Disorder (Catatonia Specifier) Catatonia, which we’ve always thought of as a classic schizophrenia subtype, was first described by Karl Kahlbaum in 1874; in 1896, Emil Kraepelin included it with the disorganized (it was called hebephrenic then) and paranoid types as a major subgroup of what he termed dementia praecox. During the early part of the 20th century, each of these subtypes constituted about a third of all U.S. hospital admissions for schizophrenia. Since that time, the prevalence of the catatonic type has declined markedly, so that it is now unusual to encounter such a patient on an acute care inpatient service. When it does occur, we would now call it catatonia associated with schizophrenia. F06.1 [293.89] Catatonic Disorder Due to Another Medical Condition In recent decades, we’ve come to realize that catatonia is more often found in association with various medical disorders. Most published accounts tend to describe only a handful of patients, but the responsible illnesses include viral encephalitis, subarachnoid hemorrhage, ruptured berry aneurysm in the brain, subdural hematoma, hyperparathyroidism, arteriovenous malformation, temporal lobe tumors, akinetic mutism, and penetrating head wounds. There has even been a description of one patient who had a reaction to fluorides. A neurologist or mental health clinician who does a lot of consulting in a busy medical center may occasionally encounter a case. Catatonic symptoms (see sidebar below) are essentially the same, whether they occur in patients with a mood disorder, with schizophrenia, or with a physical disorder. A patient with another medical condition is more likely to have the characteristic symptoms of what is called retarded catatonia. These include posturing, catalepsy, and waxy flexibility. Such patients may also drool, stop eating, or become mute. The catatonic features usually associated with mania include hyperactivity, impulsivity, and combativeness. These patients may also refuse to keep their clothes on. Depressed patients may show markedly reduced mobility (even to the point of stupor), mutism, negativism, mannerisms, and stereotypies. Partly to save space, I’ve omitted definitions of catatonic symptoms from my Essential Features for these two disorders and gathered them all into one convenient place: right here. Each of these behaviors tends to be a repeated rather than a one-off occurrence. Agitation. Excessive motor activity that appears to have neither a purpose nor an external cause. Stupor would be more or less the polar opposite. Catalepsy. Maintaining an uncomfortable posture, even when told it is not necessary. Echolalia. Verbatim repetition of someone else’s words when another response is indicated. Echopraxia. Imitating another person’s physical behavior, even when asked not to do so. Exaggerated compliance. At the slightest touch, moving in the direction indicated by another person (the old German term is mitgehen). Grimace. Facial contortions not made in response to a noxious stimulus. Mannerisms. Repeated movements that seem to have a goal, but are excessive for the purpose. Mutism. Absence of speech despite apparent physical ability to speak. Negativism. Without apparent motive, the patient offers resistance to passive movement or repeatedly turns away from the examiner. Posturing. Voluntarily assuming an unnatural or uncomfortable pose. Stereotypy. Repeated movement that is a nonessential part of goal-directed behavior. Waxy flexibility. Active resistance when an examiner tries to change the patient’s position. Essential Features of Catatonia Associated with Another Mental Disorder (Catatonia Specifier) The patient has prominent symptoms of catatonia, such as catalepsy, negativism, posturing, stupor, stereotypy, grimacing, echolalia, and others (see the sidebar above for definitions). The Fine Print Relax, it’s only a specifier. No Fine Print. Coding Notes You can apply the catatonia specifier to manic, hypomanic, or major depressive episodes; to schizophrenia; and to schizophreniform, schizoaffective, brief psychotic, and substance-induced psychotic disorders. It can even be used for autism spectrum disorder. List first the other mental disorder, then F06.1 [293.89], then catatonia associated with [the other mental disorder]. Edward Clapham Edward Clapham, a 43-year-old single man, was admitted to the university hospital’s mental health service. He gave no chief complaint; he was entirely mute. He had been transferred from the state psychiatric hospital, where his diagnosis had been schizophrenia, catatonic type. For the past 8 years, he had not communicated by speech or writing. According to the transfer note, Edward had been intensively treated with neuroleptics during his entire hospitalization, though none of these medications had relieved his basic symptoms. He reportedly spent the entire day every day lying on his back, toes pointing towards the foot of his bed, fists clenched and turned inward. From years of maintaining this position, he had developed severe muscle contractures at both ankles and both wrists. Most of the time he could be spoon-fed, but occasionally he refused to swallow and had to be fed by nasogastric tube. This had often been the case during the past 6 months; despite the tube feedings, he had lost about 30 pounds. Ten days earlier Edward had developed a high fever (104.6°F) and had been transferred to the medical service, where the staff treated a Klebsiella pneumonia with tetracycline. Subsequently he was moved to the mental health service, where this evaluation took place. Very little was known about Edward’s background. He had been reared in the Midwest, the second child of a farm family. He may have attended some college, and he had worked for approximately 10 years as a tractor salesman. On admission, his mental status examination read as follows: Mr. Clapham lies flat on his back in bed. He is totally mute, so nothing can be learned of his thought content or flow of thought. Similarly, his cognitive processes, insight, and judgment cannot be assessed. His toes point down and his fists are rotated inward. There is a noticeable tremor of his feet and his hands; he contracts the muscles of his arms and legs so strongly that they actually shake. Besides being mute, he shows other signs of catatonia. Negativism: When he is approached from one side, he gradually turns his head so that he gazes in the opposite direction. Catalepsy: When a limb is placed in any position (for instance, raised high above his head), he will maintain that position for several minutes, even if told that he can drop his hand. Waxy flexibility: Any attempt to bend his arm at the elbow, where there are no contractures, is met with resistance. It is evident that the biceps and triceps muscles are contracting together, causing motion at the joint to feel as if one were bending a rod made of wax or some other stiff substance. Grimacing: Every four or five minutes, he wrinkles his nose and purses his lips. This expression lasts for 10 or 15 seconds, then relaxes. There is no apparent purpose to these motions, and they are not accompanied by any motions of the tongue or other indications of tardive dyskinesia. Evaluation of Edward Clapham Counting his negative symptoms (lack of speech and affect) and his grossly abnormal motor behavior, Edward fulfilled the criterion A requirements for schizophrenia. His illness had lasted far longer than the minimum 6 months (schizophrenia criterion C); it is hard to imagine how it could have had a greater effect on every aspect of his life (B). Nonetheless, on admission to the mental health unit, he was given a diagnosis of unspecified schizophrenia spectrum and other psychotic disorder. This provisional diagnosis was given because the clinician could not be sure from the initial presentation whether the symptoms were due to the effects of his dehydration and loss of weight (another medical condition), schizophrenia, or another cause such as a mood disorder, which is perhaps the most frequent cause of catatonic symptoms. The list of medical conditions that can produce catatonic behavior includes liver disease, strokes, epilepsy, and uncommon disorders such as Wilson’s disease (a defect of copper metabolism) and the inherited disorder (autosomal dominant), tuberous sclerosis. These possibilities should be vigorously pursued with neurological and medical consultation and with the appropriate laboratory and X-ray studies. Urine or blood screens for toxic substances or drugs of abuse should be considered a part of every such patient’s workup. Any patient who presents with a first episode of catatonia should probably have an MRI. When Edward Clapham was diagnosed, there was no MRI; we’ll have to take criterion E on faith. Many patients who have been diagnosed as having schizophrenia, catatonic type, really have a manic phase of bipolar I disorder (D). On the other hand, a patient with severe psychomotor slowing should be considered for a diagnosis of major depressive disorder with melancholic features. Although patients with somatic symptom disorder are occasionally mute or have abnormal motor activity, such episodes are usually short-lived, lasting only a few hours or days, not years. Edward had been ill for years; a chronic, psychotic, catatonic mood disorder seems unlikely. Edward’s symptoms were classic for catatonia associated with schizophrenia. He demonstrated grimacing (catatonia specifier criterion A10), muteness (A4), waxy flexibility (A3), and catalepsy (A2). He could not be called stuporous because he was alert enough to turn away from an approaching stimulus (negativism—A5). His behavior range was insufficient to demonstrate other typical catatonic behaviors. Because he had already been extensively (and unsuccessfully) treated with neuroleptics, Edward was given a course of electroconvulsive therapy. Although the first three bilateral treatments produced no noticeable effect, after the fourth he asked for a glass of water. After a total of 10 treatments, he was conversing with others on the ward, feeding himself, and walking—always on tiptoe because of the severe contractures at his ankles. Although he continued to show residual symptoms of his disease, his catatonic symptoms disappeared. He eventually left the hospital, whereupon he was lost to follow-up. Edward’s 8-year course of illness had been continuous; I scored his GAF at discharge at 60 (on admission, it would have been pretty close to 1). After appropriate medical investigations and additional history ruled out other possible causes of his abnormal behavior, his revised diagnosis was as given below. By the way, without reference to the official DSM-5 severity criteria for psychosis (see the sidebar), on admission I’d give Edward a rating of severe. I anticipate no backlash from outraged coding mavens, though I still feel that the overall global evaluation of the GAF does a better job. At discharge: F20.9 [295.90] Schizophrenia, first episode, currently in partial remission F06.1 [293.89] Catatonia associated with schizophrenia M24.573 [718.47] Contractures of ankles M24.539 [718.43] Contractures of wrists Essential Features of Catatonic Disorder Due to Another Medical Condition A physical illness appears to have caused symptoms of catatonia, such as catalepsy, negativism, posturing, stupor, stereotypy, grimacing, echolalia, and others (see sidebar just above) for definitions). The Fine Print For pointers on deciding when a physical condition may have caused a mental disorder, see sidebar. The D’s: • Differential diagnosis (delirium or other cognitive disorder, schizophrenia and its cousins, psychotic mood disorder, obsessive–compulsive disorder) Coding Notes Using the name of the responsible medical condition, record this diagnosis after you’ve coded the actual medical condition. Marion Wright Since graduating from high school 12 years earlier, Marion Wright had worked as a sign painter. In school he had shown some aptitude for art, though not enough that he saw himself as the next Pablo Picasso. Nor did he like school enough to study for a career in commercial art. But painting signs on buildings and billboards was undemanding, well-paying, immediately available, and largely open-air. Within a few years he was married, had two kids and a small house in a subdivision, and was still painting signs. He thought he was set for life. One afternoon not long after his 30th birthday, his foreman drove by to inspect the billboard Marion had just finished. “You’ve painted the logo in script. The blueprint calls for block letters,” the foreman pointed out. Marion said that he thought the script looked better, but without much grumbling he changed it. A week later he completed an ad for a local premium beer; the female model holding the bottle was naked from the waist up. The following day he was out of work. Marion made a few efforts to find a new job, but within a week he was staying at home and watching daytime TV. His wife noted that he seemed to be talking less and less, but he ignored her suggestion to seek clinical evaluation. Although he continued to eat and sleep normally, his interest in sex had vanished. By the fourth week after losing his job, he had no spontaneous speech at all and would only answer a question if it was directly put to him. With the added persuasion of Marion’s brother, his wife finally got him to the clinic. He was immediately hospitalized. On admission Marion would answer questions appropriately, if briefly. Fully oriented, he denied feeling depressed or suicidal. He had no delusions, hallucinations, obsessions or compulsions. He earned a perfect score on the MMSE, though the examiner noted that he was slow to carry out instructions. The following morning he deliberately turned away from the nurse who approached his bedside. Although he willingly accompanied the nurse to a table in the dining room, he refused to eat and was completely mute. In fact, the clinician who examined him later that morning found that Marion would readily move in any direction at the slightest touch of an examiner’s hand. In the evening he seemed improved and even spoke a few words. But the next day, he lay on his back in bed, again silently refusing to cooperate. When his pillow was removed, his head remained elevated about two inches above the mattress. This position appeared to cause him no discomfort; he seemed willing to maintain it all day. Later, an examiner noted that when Marion’s arm was twisted into an awkward position (elevated at an angle over the bed), he maintained that position even when he was told that he could relax. Marion’s clinicians considered the diagnosis of schizophrenia, but they noted that he had been only briefly ill and had no family history of psychosis. His wife assured them that he had never abused drugs or alcohol. Despite the fact that his neurological exam remained normal, an MRI of his head was obtained. It revealed a tumor the size of a golf ball sitting on the convexity of his right frontal lobe. Once this was surgically removed, he quickly regained full consciousness. Two months later he was back on his ladder painting billboards, following instructions to the letter. Evaluation of Marion Wright Marion had several symptoms (three are required) that are classical for catatonia (criterion A). His included negativism and muteness (A5, A4), exaggerated compliance (though this is not one of the criteria DSM-5 mentions), a “psychological pillow” (a form of posturing in which he held his head unsupported above the mattress—A6), and catalepsy (A2). Marion did not have the wandering attention found in delirium (D). Catatonic behavior can be found in schizophrenia, which his clinicians correctly rejected because he had been ill too briefly (C). Too few symptoms (and better choices) ruled out schizophreniform disorder. Muteness and marked motor slowing, even to the point of immobility, can be encountered in major depressive episode, but Marion specifically denied mood symptoms. Muteness may occasionally be encountered in somatic symptom disorder and in malingering and factitious disorder, but it would be unusual to encounter a full, persisting catatonic syndrome in one of these conditions. Note that catatonic behavior can include excessive or even frenzied motor activity. Then the differential diagnosis would include manic episode and substance use intoxication. Of course, neither of these applies to Marion’s case. On laboratory examination of the surgical specimen, Marion was found to have a (benign) brain tumor, which can directly result in catatonic symptoms (B) and which caused manifest impairment (E). On admission, I’d put his GAF score at 21; his GAF score was 90 on discharge. D32.9 [225.2] Cerebral meningioma, benign F06.1 [293.89] Catatonic disorder due to cerebral meningioma F28 [298.8] Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Use this category when you want to write down the specific reason your patient cannot receive a more definite psychotic disorder diagnosis. Here’s an example: “other specified schizophrenia spectrum and other psychotic disorder, persistent auditory hallucinations.” Charles Bonnet syndrome. In this disorder (not specifically mentioned in DSM-5, but first described in 1790!), people with impaired vision, many of them elderly, report complex visual hallucinations (scenes, people) but no other hallucinations or delusions. They also have insight that what they “see” is unreal. As such, they aren’t truly psychotic, but one can argue that the condition belongs somewhere along the spectrum of psychotic disorders. Attenuated psychosis syndrome. A patient has psychotic symptoms that do not meet the full criteria for any psychotic disorder (less disabling symptoms, relatively good insight, etc.). Persistent auditory hallucinations. The patient experiences repeated auditory hallucinations without other symptoms. Delusional symptoms in partner of individual with delusional disorder. Most people who develop delusions in response to close association with someone who is independently psychotic can be diagnosed as having a delusional disorder. However, those who don’t fulfill criteria for delusional disorder can be classified here. Other. The patient appears to have a psychotic disorder, but the information is conflicting or too inadequate to permit a more specific diagnosis. F29 [298.9] Unspecified Schizophrenia Spectrum and Other Psychotic Disorder This category is for symptoms or syndromes that don’t meet guidelines for any of the disorders described earlier, and you do not wish to specify a reason. Unspecified Catatonia DSM-5 mentions unspecified catatonia as a possibility when the context is unclear or there is insufficient detail for a more precise diagnosis. But the coding itself is clear: First code R29.818 [781.99] other symptoms involving nervous and musculoskeletal systems; then code F06.1 [293.89] unspecified catatonia."