Biopsychosocial and Diagnosis
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SWK7705-Chapter3-PowerPoint.pptxSWK 7705 – Assessment & psychopathology
Chapter 3
Schizophrenia spectrum & other Psychotic disorders
“When psychosis is a prominent reason for a mental health evaluation, the diagnosis will be one of the disorders or categories listed” from the schizophrenia spectrum (Morrison, 2014, p. 55) and other psychotic disorders, and schizotypal (personality) disorder.
These disorders are defined by abnormalities in one or more of the 5 key domains (Gray, 2013):
Delusions
Hallucinations
Disorganized thinking (speech)
Grossly disorganized or abnormal motor behavior (including catatonia)
Negative symptoms
Symptoms of psychosis
Delusions – a belief that is false and cannot be explained by the patient’s culture or education, and the patient cannot be persuaded that the belief is false despite contrary evidence or the opinion of others.
There are different types of delusions.
Erotomanic – the belief that someone is in love with that person (often someone of a higher station)
Grandeur – the belief that they are special, famous, or of an exalted station (such as a movie star or God)
Guilt – the belief that they have committed an unpardonable sin
Jealousy – the belief a partner has been unfaithful
Passivity – the belief that they are being manipulated or controlled by outside forces (such as radio waves)
Persecution – the belief they are being followed or that others intend them harm
Poverty – the belief that they face destitution contrary to evidence otherwise (such as money in the bank)
Symptoms of psychosis
Different types of delusions (cont’d).
Reference – the belief that they are being talked about (such as in the press or on tv) or that certain gestures, comments, or environmental cues are directed towards them
Somatic – the belief that their body functions have been altered, they smell bad, or that they have a terrible disease; they are preoccupied with their health
Thought control – the belief that others are putting ideas into their minds
Nihilistic – the belief that a major catastrophe will occur
Symptoms of psychosis
Hallucinations – a false sensory perception that occurs in the absence of a related sensory stimulus (Morrison, 2014). They have the same impact and force of normal perceptions and are vivid and clear, but they are not under voluntary control. They occur with the person is alert and awake, and the individual must believe the hallucination to be true and lack insight into its unreality.
Hallucinations can impact any of the 5 senses, but auditory and visual are the most common
Two different types (Gray, 2013):
Auditory – or hearing voices
Somatic (or tactile) – experiencing sensations similar to electrical tingling or burning
Symptoms of psychosis
Disorganized Speech (APA, 2013, p. 88) – is disorganized thinking that is typically inferred from the individual’s speech
Derailment or Loose Association – individual switches from one topic to another
Tangentiality – answers to questions may be obliquely related or completely unrelated
Incoherence or “word salad” – speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganizations
Symptoms must be severe enough to substantially impair effective communication
Symptoms of psychosis
Grossly Disorganized or Abnormal Motor Behavior (including Catatonia) (APA, 2013, p. 88) – may manifest itself in a variety of ways ranging from childlike “silliness” to unpredictable agitation. Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living.
Catatonic Behavior: is a marked decrease in reactivity to the environment
Negativism: resistance to instruction
Mutism & Stupor: maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and motor responses
Catatonia excitement: it can include purposeless and excessive motor activity without obvious cause
Additional features include repeated stereotyped movements, staring, grimacing, mutism, and echoing of speech
Symptoms of psychosis
Negative Symptoms (APA, 2013, p. 88) – account for a substantial portion of the morbidity associated with schizophrenia but are less prominent in other psychotic disorders
Diminished emotional expression – reduced expression of emotions in the face, eye contact, intonation of speech, and movements of the hand, head, and face
Avolition – decrease in motivation of self-initiated purposeful activities; might include sitting for long periods of time with little interest shown in work or social activities
Alogia – diminished output of speech
Anhedonia – diminished ability to experience pleasure from positive stimuli or a reduction in the ability to recall pleasure that was previously experienced
Negative symptoms can be difficult to differentiate from dullness due to depression, drug use, or ordinary lack of interest (Morrison, 2014)
schizophrenia
Schizophrenia is a chronic brain disorder that affects less than one percent of the U.S. population (APA, 2020).
When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation. However, with treatment, most symptoms of schizophrenia will greatly improve and the likelihood of a recurrence can be diminished.
While there is no cure for schizophrenia, research is leading to innovative and safer treatments.
Experts also are unraveling the causes of the disease by studying genetics, conducting behavioral research, and using advanced imaging to look at the brain’s structure and function.
schizophrenia
The complexity of schizophrenia may help explain why there are misconceptions about the disease (APA, 2020). Schizophrenia does not mean split personality or multiple-personality.
Most people with schizophrenia are not any more dangerous or violent than people in the general population.
While limited mental health resources in the community may lead to homelessness and frequent hospitalizations, it is a misconception that people with schizophrenia end up homeless or living in hospitals.
Most people with schizophrenia live with their family, in group homes or on their own.
Research has shown that schizophrenia affects men and women fairly equally but may have an earlier onset in males.
Rates are similar around the world. People with schizophrenia are more likely to die younger than the general population, largely because of high rates of co-occurring medical conditions, such as heart disease and diabetes.
Schizophrenia – diagnostic criteria
Criteria (A)
Two (or more) of the following which should each be present for a lengthy portion of time during a 1-month period; can be less if successfully treated.
At least one of these must be (1), (2), or (3):
Delusions
Hallucinations
Disorganized Speech
Grossly Disorganized or Catatonic Behavior
Negative Symptoms
Criteria (B)
Level of functioning within one (or more) areas (work, interpersonal relations, or self-care) is significantly below the level achieved prior to onset for a large portion of the time since onset
If onset is in childhood or adolescence, there is a failure to achieve expected levels of interpersonal, academic, or occupational functioning
Schizophrenia – diagnostic criteria
Criteria (C)
Continuous signs of the disturbance for at least 6 months which must include at least 1 month of symptoms that meet Criterion A (Active Phase)
May include periods of prodromal or residual periods where signs of the disturbance may be manifested by only negatives symptoms or by two or more from Criterion A in a reduced form
Prodromal – period prior to features of schizophrenia becoming very apparent & a person’s functioning deteriorates
Residual – individual no longer has enough features to determine presence of schizophrenia
Criteria (D)
Schizoaffective and depressive or bipolar disorder with psychotic features have been ruled out because either:
1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms
2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness
Schizophrenia – diagnostic criteria
Criteria (E)
The disturbance is not attributable to the physiological effects of a substance or another medical condition
Criteria (F)
If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms are also present for at least 1 month (less if successfully treated)
Refer to the cases of Rudy Rosen, Sarah McDonald, and Joey Esterson highlighting Schizophrenia in the text
Specifiers
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
schizophrenia
Symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six months for a diagnosis to be made (APA, 2020).
Men often experience initial symptoms in their late teens or early 20s while women tend to show first signs of the illness in their 20s and early 30s. More subtle signs may be present earlier, including troubled relationships, poor school performance and reduced motivation.
Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms mimic schizophrenia.
Risk Factors
Researchers believe that a number of genetic and environmental factors contribute to causation, and life stressors may play a role in the start of symptoms and their course. Since multiple factors may contribute, scientists cannot yet be specific about the exact cause in each individual case.
Delusional Disorder
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
This disorder can be similar to schizophrenia, but the age of onset is often later in life (mid-to late 30s), and infrequent hallucinations take a back seat to the delusions, and are understandable in the context of those delusions (Morrison, 2014)
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
Essential features:
The patient develops then recovers completely from an episode of psychosis all within the course of one month which include delusions, hallucinations, or disorganized speech (Morrison, 2014).
The episode lasts at least 1 day but less than 1 month.
Coding notes: If a diagnosis is made without waiting for recovery, then the term will have to be appended
Schizophreniform Disorder
For 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
Essential features:
Characterized by relatively rapid onset and offset (Morrison, 2014)
Typically a young person (late teens or 20s)
Has experienced at least 2 of the 5 psychotic symptoms for 30 days to 6 months
At least 1 of the psychotic symptoms must be delusions, hallucinations, or disorganized speech
The individual recovers fully within 6 months
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
Essential features:
There is a period of illness where a manic episode or a major depressive episode lasts half of more of the total time involved (Morrison, 2014)
During this same time for at least 2 weeks, they meet criterion A requirements for schizophrenia without have a mood episode
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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
