Biopsychosocial and Diagnosis

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Susan W. Gray

Psychopathology: A Competency-Based Assessment Model for Social Workers

Chapter 3 Schizophrenia Spectrum and Other Psychotic Disorders

…are defined by abnormalities in one or more of the following 5 key domains:

Delusions

Hallucinations

Disorganized thinking (speech)

Grossly disorganized or abnormal motor behavior (including catatonia)

Negative symptoms

Key Domains of the Psychotic Disorders

Delusions – or fixed beliefs not amenable to change in light of conflicting evidence

Types:

Persecutory delusions - belief that others intend harm

Grandiose delusions - belief that one is special, famous, or important

Referential delusions - belief that certain gestures, comments, environmental cues and the like are directed to the person

Erotomanic delusions - the erroneous belief that someone is in love with the person

Nihilistic delusions - or the conviction that a major catastrophe will happen

Somatic delusions - a preoccupation with one’s health.

There are a number of delusions that are clearly implausible and thus seen as bizarre and include: thought withdrawal (belief that the person’s thoughts have been removed from them by some kind of outside force, thought insertion (the belief that thoughts have been put into the person’s mind), and delusions of control (where the person believes his or her body is being affected by some outside force)

Key Domains of the Psychotic Disorders - continued

Hallucinations – perception-like experiences that occur without an external stimulus

Types:

Auditory – or hearing voices

Somatic (or tactile) – experiencing sensations similar to electrical tingling or burning

Disorganized thinking – seen in echolalia, derailment, tangentiality, loose associations, neologisms, perseveration, clanging or incoherence

Disorganized behavior – catatonic behavior

Negative symptoms – diminished emotional expression, avolition (lack of goal directed behavior), flat affect, alogia (poverty of speech), anhedonia (lack of pleasure), asociality (lack of interest in social interactions)

Schizophrenia

Seen as a complicated and variable condition best thought of as a syndrome or a cluster of symptoms that may or may not have related causes

Specific patterns or features that tend to appear together which generally includes three phases:

Prodromal - refers to the period before the features of schizophrenia become very apparent and a person’s functioning deteriorates

Active phase – where the disorder persists for at least 6 months with impaired functioning and the individual is exhibiting 2 symptoms for one month with at least one of the following psychotic features - delusions, hallucinations, and/or grossly disorganized speech and behavior – a second symptom could be from the negative symptoms

Residual phase – a person no longer has enough features for the practitioner to ascertain the presence of schizophrenia

Specifiers for Schizophrenia

Episodes and remission status

Catatonia (note that catatonia can occur in the context of several disorders or unspecified)

Clinician-rated assessment of primary symptoms of psychosis – including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior and negative symptoms – on a 5-point scale (detailed in the DSM-5 Assessment Measures)

Currently the diagnosis of schizophrenia can be made without using this specifier

Refer to the cases of Rudy Rosen, Sarah MacDonald, and Joey Esterson highlighting schizophrenia

Delusional Disorder

Refers to the person’s persistent belief about something that is contrary to reality

The main feature is the presence of delusions lasting for at least one month or longer

Types (assigned based on the delusion):

Erotomanic

Grandiose

Jealous

Persecutory

Somatic

Mixed

Unspecified

Refer to the case of Scott Markam featuring delusional disorder

Brief Psychotic Disorder

Also known as brief reactive psychosis, and seldom assessed in clinical practice

Differentiated from the other related psychotic disorders by its sudden onset, its relatively short duration, and the individual’s full return to functioning

Specifically lasts more than one day, but less than 30 days

Must always include at least one major psychotic symptom of delusions, hallucinations, disorganized speech

Grossly disorganized or catatonic behavior may also be present and considered to support the diagnosis, as appropriate

3 Forms – with marked stressors, without marked stressors, and with peripartum onset

Schizophreniform Disorder

The symptom picture is akin to schizophrenia, but not at the same level as those found in full-blown schizophrenia

Psychotic features must last less than 6 months

Features must include a prodromal, active, and residual phase

It appears as if the person has schizophrenia, but he or she subsequently recovers completely with no residual effects

The case of Claudia Benjamin illustrates schizophreniform disorder

Schizoaffective Disorder

Schizoaffective disorder revolves around the presence of a major mood episode - either major depressive or manic - that must be present after criterion for schizophrenia have been met

There must be at least 2 (or more) weeks of delusions or hallucinations in the absence of a major mood episode

Rule out the presence of substance use (such as a drug of abuse or medication) or another medical condition

Specifiers: revolve around episodes and remission status

The case of Sydney Sutherland illustrates schizoaffective disorder

Other Disorders of Diagnostic Importance

Substance/Medication-Induced Psychotic Disorder - associated with the use of alcohol, drugs or medications - this diagnosis is evident by two major symptoms (delusions and hallucinations) though other features of the psychotic disorders may be seen

Psychotic Disorder due to Another Medical Condition - also characterized by the presence of hallucinations or delusions - a medical condition (supported by history, examination, and/or laboratory findings) supports the diagnosis

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder - used when the practitioner finds an incomplete symptom picture characteristic of schizophrenia and other psychotic disorder

Comparing the DSM-IV-TR Multiaxial System and the DSM-5

All subtypes of schizophrenia have been deleted – the paranoid, disorganized, catatonic, undifferentiated, and residual

A major mood episode is required for the DSM-5 diagnosis of schizoaffective disorder (and for a majority of the disorder’s duration) after the defining criterion for schizophrenia is met – key features of delusions, hallucinations, disorganized speech, disorganized or catatonic behavior and negative symptoms (i.e.: diminished emotional expression or avolition)

Diagnostic criteria for delusional disorder changed and is no longer separate from shared delusional disorder

Catatonia is now seen in the context of several disorders (i.e.: neurodevelopmental, psychotic, bipolar, depressive disorders, and other medical conditions) and the clinical picture requires 3 or more of a total of 12 symptoms listed

Catatonia may be part of another medical condition or unspecified when full criteria are not met