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Basic Psychopathology and Diagnosis Class 4 (March 27, 2014)

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  1. Basic Psychopathology and DiagnosisClass 4 (March 27, 2014) Funto Oluwafemi, PsyD

  2. Specific Learning Disorder • Diagnostic Criteria • A- Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties: • Inaccurate or slow and effortful word reading • Difficulty understanding the meaning of what is read • Difficulties with spelling • Difficulties with written expression • Difficulties with mastering number sense, number facts, or calculation • Difficulties with mathematical reasoning • B- The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living (confirmed by individually administered standardized achievement measures and comprehensive clinical assessment.) (APA, 2013, pg. 66)

  3. Specific Learning Disorder • Diagnostic Criteria Contd. • C- The learning difficulties begin during school-age years but may not be fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities. • D- Not better accounted for by intellectual disabilities, uncorrected visual and auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate education instruction. • The criteria are to be met based on a clinical synthesis of the individual’s history (developmental, medical, family, educational), school reports, and psychoeducational assessment. • When coding, all academic domains and subskills that are impaired must be specified. Each one must be coded individually. • 315.00 (F81.0) With impairment in reading: (Dyslexia) • Word reading accuracy • Reading rate fluency • Reading comprehension • 315.2 (F81.1) With impairment in written expression: • Spelling accuracy • Grammar and punctuation accuracy • Clarity or organization of written expression • 315.1 (F81.2) With impairment in mathematics: (Dyscalculia) • Number sense • Memorization of arithmetic facts • Accurate or fluent calculation • Accurate math reasoning (APA, 2013, pg. 67)

  4. Specific Learning Disorder • Specify current severity: • Mild: some difficulties in one or two academic domains, but mild enough that the individual may be able to compensate or function well when provided with appropriate accommodations or support services, especially during the school years. • Moderate: marked difficulties in one or two academic domains, so that the individual is unlikely to become proficient without some intervals of intensive and specialized teaching during the school years. • Severe: affecting several academic domains, so that the individual is unlikely to learn those skills without ongoing intensive and specialized teaching for most of the school years. Even with an array of appropriate accommodations or services at home, at school, or in the workplace, the individual may not be able to complete all activities efficiently. (APA, 2013, pg. 68)

  5. Specific Learning Disorder • Has a biological origin that is the basis for abnormalities at a cognitive level that are associated with the behavioral signs of the disorder. • Affects the brain’s ability to perceive and process verbal or nonverbal information efficiently and accurately. • Prevalence is 5%-15% among school-age children across different language and cultures. • Prevalence in adults is unknown, but appears to be approximately 4%. • Onset, recognition, and diagnosis usually occurs during the elementary school years. • Lifelong but course and clinical presentation is variable. • Changes in manifestation of symptoms occurs with age, so an individual may have a persistent or shifting array of difficulties across the lifespan.

  6. Specific Learning Disorder • Risk & Prognostic Factors: • Prematurity or very low birth weight and exposure to nicotine increases risk. • Appears to aggregate in families (reading, mathematics, and spelling). 4-8 times higher risk for reading and 5-10 time higher risk for mathematics in first-degree relatives of individuals with this disorder. • Comorbidity with ADHD is predictive of worse mental health outcome than for that with specific learning disorder without ADHD. • Occurs across languages, cultures, races, and socioeconomic conditions but may vary in its manifestation according to the nature of spoken and written symbol systems, cultural, and educational practices. • More common in males than in females (range from 2:1 to 3:1) • Lower academic attainment, higher rates of school dropout, lower rate of postsecondary education, high levels of psychological distress and poorer overall mental health, higher rates of unemployment and under-employment, lower incomes. • School dropout and co-occurring depressive symptoms increase the risk for poor mental health outcomes (suicidality). High levels of social and emotional support predict better mental health outcomes.

  7. Specific Learning Disorder • Differential Diagnosis: • Normal variations in academic attainment • Intellectual disability (intellectual developmental disorder) • Learning difficulties due to neurological or sensory disorders • Neurocognitive disorders • ADHD • Psychotic Disorders • Commonly co-occurs with other neurodevelopmental disorders (e.g. communicative disorders, ADHD, Autism Spectrum Disorder). • If there is an indication that another diagnosis could account for the difficulties in criterion A, specific learning disorder should not be diagnosed.

  8. Motor Disorders 315.4 (F82) Developmental Coordination Disorder • Diagnostic Criteria • A- Acquisition and execution of coordinated motor skills is substantially below that expected given the individual’s chronological age and opportunity for skill learning and use. Difficulties are manifested as clumsiness • B- The motor skills deficit in (A) significantly and persistently interferes with activities of daily living appropriate to chronological age and impacts academic/social productivity, prevocational and vocational activities, leisure, and play • C- Onset in early developmental period • D- Not better explained by intellectual disability or visual impairment and are not attributable to a neurological condition affecting movement. (APA, 2013, pg. 74)

  9. Motor Disorders Developmental Coordination Disorder • Prevalence in children 5-11 years is 5%-6% • Males are more often affected than females. (Ratio between 2:1 and 7:1). • Risk and Prognostic Factors: • More common following prenatal exposure to alcohol and in preterm and low-birth-weight children. • Individuals with comorbid ADHD demonstrate more impairment than those who do not have comorbid ADHD. • Occurs across cultures, races, and socioeconomic conditions. • Reduced participation in play and sports, poor self-esteem and self-worth, emotional or behavioral problems, impaired academic achievement, poor physical fitness, reduced physical activity, and obesity.

  10. Motor Disorders • Differential Diagnosis • Motor impairments due to another medical condition • Intellectual disability (intellectual developmental disorder) • ADHD • Autism spectrum disorder • Joint hypermobility syndrome • Commonly co-occur with: • Speech and language disorder • ADHD • Autism spectrum disorder

  11. Motor Disorders 307.3 (F98.4) Stereotypic Movement Disorder • Diagnostic Criteria • A- Repetitive , seemingly driven, and apparently purposeless motor behavior. • B- Repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury. • C- Onset is in early developmental period. • D- Not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental or mental disorder • Specify if: • With self-injurious behavior (or behavior that would result in an injury if preventive measures were not used). • Without self-injurious behavior (APA, 2013, pg. 77)

  12. Motor Disorders Stereotypic Movement Disorder • Specify if: • Associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor. (Use additional code to identify the associated condition, disorder, or factor). • E.g. Stereotypic movement disorder associated with intrauterine alcohol exposure. • Specify current severity: • Mild – symptoms are easily suppressed by sensory stimulus or distraction. • Moderate – symptoms require explicit protective measures and behavioral modification. • Severe – symptoms require explicit protective measures and behavioral measures to prevent serious injury. (APA, 2013, pg. 78)

  13. Motor Disorders Stereotypic Movement Disorder • Common in young typically developing children. • Complex stereotypic movements are much less common. • Typically begin with the first 3 years of life. • In most typically developing children, these movements resolve over time or can be suppressed. • Risk & Prognostic factors: • Social isolation and environmental stress • Lower cognitive functioning linked to greater risk and poorer response to interventions. • Occurs in all races and cultures

  14. Motor Disorders Stereotypic Movement Disorder • Differential Diagnosis • Normal development • Autism spectrum disorder • Tic disorders (later onset) • Obsessive-compulsive and related disorders • Other neurological and medical conditions

  15. Tic Disorders 307.23 (F95.2)Tourette’s Disorder • Diagnostic Criteria • A- Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessary concurrently. • B- The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. • C- Onset is before the age of 18 years. • D- Not attributable to the physiological effects of a substance (e.g. cocaine) or another medical condition (e.g. Huntington’s disease). (APA, 2013, pg. 81)

  16. Tic Disorders 307.22 (F95.1) Persistent (Chronic) Motor or Vocal Tic Disorder • Diagnostic Criteria • A- Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal. • B- The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. • C- Onset is before the age of 18 years. • D- Not attributable to the physiological effects of a substance (e.g. cocaine) or another medical condition (e.g. Huntington’s disease). • E- Criteria have never been met for Tourette’s disorder. • Specify if: • With motor tics only • With vocal tics only (APA, 2013, pg. 81)

  17. Tic Disorders 307.21 (F95.0) Provisional Tic Disorder • Diagnostic Criteria • A- Single or multiple motor and/or vocal tics • B- The tics have been present for less than 1 year since first tic onset. • C- Onset is before the age of 18 years. • D- Not attributable to the physiological effects of a substance or another medical condition. • E- Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder. (APA, 2013, pg. 81)

  18. Tic Disorders • Common in childhood but transient is most cases. • Estimated prevalence of Tourette’s disorder ranges from 3 to 8 per 1,000 in school-age children. • Males more commonly affected than females (2:1 to 4:1) • Frequency of identified cases was found to be lower among African Americans and Hispanic Americans (may be due to differences in access to care). • Onset typically between 4 and 6 years. • Peak severity between ages 10 and 12 years. • Decline in severity in adolescence. • A small percentage will have persistently severe or worsening symptoms in adulthood. • Manifest similarly in all age groups and across lifespan • Tics wax and wane in severity over time.

  19. Tic Disorders • Risk & Prognostic factors: • Worsened by anxiety, excitement, and exhaustion • Better during calm, focused activities • Observing a gesture or sound in another person may result in making a similar gesture or sound which may be incorrectly perceived by others as purposeful. • Can be problematic when interacting with authority figures. • Obstetrical complications, older paternal age, lower birth weight, maternal smoking during pregnancy • Associated with worse tic severity • Although there are no differences in clinical characteristics, course, or etiology by race, ethnicity, and culture, race, ethnicity and culture may impact how tic disorders are perceived and managed in the family and community and also influence patterns of help seeking, and choices of treatment.

  20. Tic Disorders • Males more commonly affected than females but no gender differences in the kinds of tics, age at onset, or course. • Women with persistent tic disorders may be more likely to experience anxiety and depression. • Many with mild to moderate tic severity experience no distress or impairment in functioning and may not even be aware of their tics. • People with more severe symptoms generally have more impairment in daily living. • Some individual with moderate to severe tic disorders may function well. • Co-occurring condition such as ADHD or OCD • Can lead to social isolation, interpersonal conflict, peer victimization, inability to work or go to school, lower quality of life. • Rare cases of Tourette’s disorder include physical injury and orthopedic and neurological injury

  21. Tic Disorders • Differential diagnosis: • Abnormal movements that may accompany other medical conditions and stereotypic movement disorder. • Substance-induced and paroxysmal dyskinesias. • Myoclonus • Obsessive-compulsive and related disorders. • Often co-occurswith: • ADHD • Obsessive-compulsive and other related disorders • Movement disorders • Depressive disorder • Bipolar disorders • Substance use disorder (APA, 2013, pg.85)

  22. Tic Disorders • 307.20 (F95.8) Other Specified Tic Disorder • Symptoms are characteristic of a tic disorder that cause clinically significant distress but do not meet the full criteria for a tic disorder or any disorder in the neurodevelopmental disorders diagnostic class. Used when the clinician chooses to communicate the reason that the criteria are not met. • 307.20 (F95.9) Unspecified Tic Disorder • Symptoms are characteristic of a tic disorder that cause clinically significant distress but do not meet the full criteria for a tic disorder or any disorder in the neurodevelopmental disorders diagnostic class. Used when the clinician chooses not to specify the reason that the criteria are not met and include situations where there is insufficient information to make a more specific diagnosis.

  23. Other Neurodevelopmental Disorders • 315.8 (F88) Other Specified Neurodevelopmental Disorder • Symptoms are characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the disorders in the neurodevelopmental disorders diagnostic class. Used when the clinician chooses to communicate the reason that the criteria are not met. • E.g. Neurodevelopmental disorder associated with prenatal alcohol exposure. • 307.20 (F95.9) Unspecified Tic Disorder • Symptoms are characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the disorders in the neurodevelopmental disorders diagnostic class. Used when the clinician chooses not to communicate the reason that the criteria are not met or when there is insufficient information to make a more specific diagnosis.

  24. Childhood Psychopathology • Many children suffer from the effects of psychopathology. • Not responsible for their own suffering. • Assessment and treatment should focus on the family— the system out of which they have come. • It is critical that the church take a more active role in seeking understanding of the developmental processes of childhood and their impact on the behaviors, thoughts and emotions of children. • Childhood issues need to be a focus of ministry training and parent education. • Disruptive behavior of children may become the criminal behavior of adults. • Suffering is more likely to multiply to family members, succeeding generations and society. • Increase in financial costs for the society (treatment, disability, unemployment, litigation, etc.).

  25. Schizophrenia Spectrum and Other Psychotic Disorders • Defined by abnormalities in one or more of these domains: • Delusions – beliefs that are not amenable to change in light of conflicting evidence. Have a variety of themes (e.g. persecutory[most common], referential [common], somatic, religious, grandiose, erotomanic, nihilistic). • Can be bizarre or nonbizarre • Hallucinations – perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. Can occur in any sensory modality • Auditory (Most common) • Visual • Tactile • Disordered thinking (Speech) • Formal thought disorder. • Typically inferred from the individual’s speech • Derailment or loose association • Tangentiality • Incoherence or word salad • Must be severe enough to substantially impair effective communication

  26. Schizophrenia Spectrum and Other Psychotic Disorders • Grossly disorganized or abnormal motor behavior (including catatonia) • Manifest in varying ways (ranging from childlike “silliness” to unpredictable agitation) • Catatonic behavior – marked decreased in reactivity to the environment • Resistant to instructions (negativism) • Maintain a rigid, inappropriate, or bizarre posture • Lack of verbal and motor responses (mutism & stupor) • Purposeless and excessive motor activity without obvious cause (catatonic excitement) • Other – staring, grimacing, mutism, echoing of speech • Can occur in other mental disorders and in medical conditions • Negative symptoms – more common in schizophrenia than in other psychotic disorders • Diminished emotional expression – reductions in the expression of emotions in the face, eye contact, intonation of speech and bodily movements that normally give an emotional emphasis to speech • Avolition – decrease in motivated self-initiated purposeful activities • Alogia – diminished speech output • Anhedonia – decreased ability to experience pleasure from positive stimuli • Asociality – apparent lack of interest in social interactions and may be associated with avolition

  27. Schizophrenia Spectrum and Other Psychotic Disorders 297.1 (F22) Delusional Disorder • Diagnostic Criteria • A- Presence of one (or more) delusions with a duration of 1 month or longer • B- Criteria for schizophrenia has never been met • Hallucinations, if present, are not prominent and are related to the delusional theme. • C- Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. • D- If manic or major depressive episodes have occurred, they have been brief relative to the duration of the delusional periods. • E- Not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder • Specify whether: • Erotomanic type • Grandiose type • Jealous type • Persecutory type • Somatic type • Mixed type • Unspecified type (APA, 2013, pg. 90-91)

  28. Schizophrenia Spectrum and Other Psychotic Disorders 297.1 (F22) Delusional Disorder • Diagnostic Criteria contd. • Specify if: • With bizarre content • Specify if: (only to be used after a 1-year duration of the disorder) • 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 • Specify severity (not necessary for this disorder) • Rated by a quantitative assessment of the primary symptoms of psychosis. • Rate each symptom for its current severity (most severe in the last 7 days) on a 5-point scale from 0 (not present) to 4 (present and severe) (APA, 2013, pg. 91)

  29. Schizophrenia Spectrum and Other Psychotic Disorders 297.1 (F22) Delusional Disorder • Can result in social, marital, or work problems • They may be able to factually describe that others find their beliefs as irrational but are unable to accept this fact themselves • May develop irritable and dysphoric mood • May be angry and engage in violent behavior • May engage in litigious or antagonistic behaviors • Most common subtype – persecutory • Jealous type is more common in males than females • Average global functioning is generally better than those with schizophrenia. • Tend to go on to develop schizophrenia • Take into account the individual’s cultural and religious background • Differential Diagnosis • OCD • Delirium, major neurocognitive disorder, psychotic disorder due to another medical condition, & substance/medication-induced psychotic disorder • Schizophrenia & schizophreniform disorder • Depressive & Bipolar disorders and schizoaffective disorder

  30. Schizophrenia Spectrum and Other Psychotic Disorders 2978.8 (F23) Brief Psychotic Disorder • Diagnostic Criteria • A- Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3) • (1)Delusions • (2)Hallucinations • (3)Disorganized speech • (4)Grossly disorganized or catatonic behavior • B- Duration is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning • C- Not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder and is not attributable to the physiological effects of a substance or another medical condition • Specify if: • With marked stressor(s) [brief reactive psychosis] • Without marked stressor(s) • With postpartum onset • With catatonia (use additional code 293.89 (F06.1)Catatonia associated with brief psychotic disorder to indicate the presence of comorbid catatonia) • Specify current severity (not necessary for this disorder). (APA, 2013, pg.94)

  31. Schizophrenia Spectrum and Other Psychotic Disorders 297.1 (F22) Delusional Disorder • Typically experience emotional turmoil or overwhelming confusion • May have rapid shifts from one intense affect to another • Although disturbance is brief, it can cause severe impairment, and supervision may be required • Increased risk of suicidal behavior (particularly during the acute episode) • May account for 9% of cases of first-onset psychosis • May appear in adolescence or early adulthood, and onset can occur across the lifespan (average age mid 30s). • To meet this diagnosis, all symptoms must be in full remission and return to premorbid level of functioning within 1 month of onset • Pre-existing personality disorders and traits may predispose an individual to develop this disorder. • Differential diagnosis • Other medical conditions • Substance-related disorders • Depressive and bipolar disorders • Other psychotic disorders • Malingering and factitious disorders • Personality disorders

  32. Schizophrenia Spectrum and Other Psychotic Disorders 295.40 (F20.81) Schizophreniform Disorder • Diagnostic Criteria • A- Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these muse be (1), (2), or (3): • (1)Delusions • (2)Hallucinations • (3)Disorganized speech • (4)Grossly disorganized or catatonic behavior • (5) Negative symptoms • B- An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.” • C- Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because: • 1) No major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or • 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration f the active and residual periods of the illness. • D- Not attributable to the physiological effects of a substance or another medical condition. • Specify if: • With good prognostic features (at least 2 of the following: onset of prominent psychotic features within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity; good premorbid social and occupational functioning; and absence of blunted or flat affect). • With catatonia (use additional code 293.89 (F06.1)Catatonia associated with brief psychotic disorder to indicate the presence of comorbid catatonia) • Specify current severity (APA, 2013, pg. 96-97)

  33. Schizophrenia Spectrum and Other Psychotic Disorders 295.40 (F20.81) Schizophreniform Disorder • Incidence is low in the United states and other developed countries (5 times less than that of schizophrenia). • Incidence may be higher in developing countries. • About 1/3 of people diagnosed with this disorder recover within the 6-month period. • Majority of the remaining 2/3 go on to receive a diagnosis of schizophrenia or schizoaffective disorder • Relatives of individuals with this disorder have an increased risk for schizophrenia. • Dysfunction in several areas of daily functioning, such as school or work, interpersonal relationships, and self-care • Differential diagnosis: • Other mental disorders and medical conditions • Brief psychotic disorder

  34. Schizophrenia Spectrum and Other Psychotic Disorders 295.90 (F20.9) Schizophrenia • Diagnostic Criteria • A- Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these muse be (1), (2), or (3): • (1)Delusions • (2)Hallucinations • (3)Disorganized speech • (4)Grossly disorganized or catatonic behavior • (5) Negative symptoms • B- For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (when onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). • C- Continuous signs of the disturbance persist for at least 6 months. This must include 1 months of symptoms (or less if successfully treated) and may include periods of prodomal or residual symptoms. (APA, 2013, pg.99)

  35. Schizophrenia Spectrum and Other Psychotic Disorders 295.90 (F20.9) Schizophrenia • Diagnostic Criteria • D- Schizoaffective disorder 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, or 2)if mood episodes have occurred during the active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. • E- Not attributable to the physiological effects of a substance or another medical condition. • 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 of schizophrenia, are also present for at least 1 month (or less if successfully treated). • Specify if: • 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 • With catatonia (use additional code 293.89 [F06.1]) • Specify current severity (APA, 2013, pg.99-100)

  36. Schizophrenia Spectrum and Other Psychotic Disorders 295.90 (F20.9) Schizophrenia • May display inappropriate affect (e.g. laughing in the absence of an appropriate stimulus), a dysphoric mood, a disturbed sleep pattern and a lack of interest in eating or food refusal. • Depersonalization, derealization, and somatic concerns may occur and sometimes reach delusional proportions. • Anxiety and phobias are common. • Cognitive deficits are common and strongly linked to vocational and functional impairments. • Some individual with psychosis may lack insight or awareness of their disorder (typically a symptom of schizophrenia). • Hostility and aggression can be associated, but spontaneous or random assault is uncommon (More frequent in younger males and for individuals with a past history of violence, non-adherence with treatment, substance abuse, and impulsivity). • Note: The vast majority of persons with schizophrenia are not aggressive and are more frequently victimized than individuals in the general population.

  37. Schizophrenia Spectrum and Other Psychotic Disorders 295.90 (F20.9) Schizophrenia • Symptoms typically emerge between late teens and mid-30s. • Onset prior to adolescence is rare • Age of onset is later in female • Risk & Prognostic factors: • Season of birth is linked to the incidence of schizophrenia (late winter/early spring in some locations) • Pregnancy and birth complications with hypoxia and greater paternal age are associated with higher risk of schizophrenia. • Other prenatal and perinatal adversities • Stress, infection, malnutrition, maternal diabetes, and other medical condition (a vast majority of offspring with these risk factors do not develop schizophrenia) • Consider cultural and socioeconomic factors. Ideas that may be delusional in one culture may be commonly held in another. • About 5%-6% of individuals with schizophrenia die by suicide • About 20% attempt suicide on one or more occasions • Many more have significant suicidal ideation • Associated with significant social and occupational dysfunction • Many do not marry or have limited social contacts outside of their family.

  38. Schizophrenia Spectrum and Other Psychotic Disorders 295.90 (F20.9) Schizophrenia • Differential diagnosis: • Major depressive or bipolar disorder with psychotic or catatonic features • Schizoaffective disorder • Schizophreniform disorder and brief psychotic disorder • Delusional disorder • Schizotypal personality disorder • Obsessive-compulsive disorder and body dysmorphic disorder • Posttraumatic stress disorder • Autism spectrum disorder or communication disorders • Other mental disorders associated with a psychotic episode • High comorbidity rate with substance-related disorders • Over half have tobacco use disorder and smoke cigarettes regularly • Life expectancy is reduced because of associated medical conditions • Weight gain, diabetes, metabolic syndrome, & cardiovascular and pulmonary disease • Poor engagement in health maintenance behaviors

  39. Schizophrenia Spectrum and Other Psychotic Disorders Schizoaffective Disorder • Diagnostic Criteria • A- An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. • Note: The major depressive episode must include Criterion A1: Depressed mood. • B- Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness • C- Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. • D- Not attributable to the effects of a substance or another medical condition. • Specify whether: • 295.70 (F25.0) Bipolar Type – if a manic episode is part of the presentation. Major depressive episodes may also occur • 295.70 (F25.1) Depressive type – if only major depressive episodes are part of the presentation. • Specify if: • With catatonia • Specify if: • 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 • With catatonia (use additional code 293.89 [F06.1]) • Specify current severity (APA, 2013, pg.105-106)

  40. Schizophrenia Spectrum and Other Psychotic Disorders Schizoaffective Disorder • About 1/3 as common as schizophrenia • Higher in females than males (Depressive type) • Typical age at onset is early adulthood • Increased risk in first-degree relatives and first degree relatives with schizophrenia or bipolar disorder. • Consider cultural and socioeconomic factors • 5% lifetime risk for suicide. • Higher risk in the presence of depressive symptoms • Higher in North American populations than European, Eastern European, South American and Indian population with schizophrenia or schizoaffective • Differential Diagnosis • Other mental disorders and medical conditions • Psychotic disorder due to another medical condition • Schizophrenia, bipolar, and depressive disorder • Often diagnosed with other mental disorders, especially substance use disorders and anxiety disorders.

  41. Schizophrenia Spectrum and Other Psychotic Disorders Substance/Medication-induced Psychotic Disorder • Diagnostic Criteria • A- Presence of one or both of the following symptoms: • Delusions • Hallucinations • B- There is evidence from the history, physical examination, or laboratory findings of both (1) and (2): • 1. Symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. • 2. The involved substance/medication is capable of producing the symptoms in Criterion A • C- Not better explained by a psychotic disorder that is not substance/medication-induced • D- Disturbance does not occur exclusively during the course of a delirium • E- Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 2013, pg.110)

  42. Schizophrenia Spectrum and Other Psychotic Disorders Substance/Medication-induced psychotic Disorder Specify if: with onset during intoxication or with onset during withdrawal (APA,2013, pg.111)

  43. Schizophrenia Spectrum and Other Psychotic Disorders Substance/Medication-Induced Psychotic Disorder • Some of the medication reported to evoke psychotic symptoms • Anesthetics and analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobial medications, antiparkisonian medications, chemotherapeutic agents, antiparkisonian medications, muscle relaxants, nonsteroidal anti-inflammatory medications, some over-the-counter medications, antidepressants, and disulfiram. • Some toxins can also evoke psychotic symptoms • Anticholinesterase, organophosphate insecticides, sarin and other nerve gases, carbon monoxide, carbon dioxide, and volatile substances such as fuel or paint. • Between 7% and 25% of individuals presenting with a first episode of psychosis in different settings are reported to have substance/medication-induced psychotic disorder. • Initiation of disorder can vary considerably with the substance • Psychotic symptoms may persist even after the offending agent is removed (amphetamines, phencyclidine, and cocaine – for weeks or longer). • Differential Diagnosis • Substance intoxication or substance withdrawal (reality testing) • Primary psychotic disorder • Psychotic disorder due to another medical condition.

  44. Schizophrenia Spectrum and Other Psychotic Disorders Psychotic Disorder Due to Another Medical Condition • A- Prominent hallucinations or delusions • B- There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. • C- The disturbance is not better explained by another mental disorder. • D- The disturbance does not occur exclusively during the course of a delirium. • E- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Specify whether: • 293.81 (F06.2) With delusions: If delusions are the predominant symptom. • 293.82 (F06.0) With hallucinations; If hallucinations are the predominant symptom. • Include the name of the other medical condition (e.g. 293.81[F06.2] psychotic disorder due to malignant lung neoplasm, with delusions). The other medical condition should be coded and listed separately immediately before the psychotic disorder due to medical condition. • Specify current severity (APA, 2013, pg. 115-116)

  45. Schizophrenia Spectrum and Other Psychotic Disorders Psychotic Disorder Due to Another Medical Condition • May be a single transient state or it may be recurrent, cycling with exacerbation and remission of the underlying medical condition. • Individuals older than 65 have a significant greater prevalence of 0.74% compared to those in younger age group (Higher prevalence in females). • Conditions commonly associated with psychosis • Untreated endocrine and metabolic disorders, autoimmune disorders, temporal lobe epilepsy. • Differential Diagnosis: • Delirium • Substance/Medication-Induced Psychotic Disorder • Psychotic Disorder • Often associated with a concurrent major neurocognitive disorder (e.g. dementia).

  46. Schizophrenia Spectrum and Other Psychotic Disorders Catatonia • Can occur in the context of several disorders • DSM-5 does not treat it as an independent class but recognizes it as a) catatonia associated with another mental disorder or b) catatonic disorder due to another medical condition, and c)unspecified catatonia • Defined by the presence of 3 or more of 12 psychomotor features in the diagnostic criteria. • Potential risk from malnutrition, exhaustion, hyperpyrexia, and self-inflicted injury. (APA, 2013, pg.119)

  47. Schizophrenia Spectrum and Other Psychotic Disorders 293.89 (F06.1) Catatonia Associated With Another Mental Disorder (Catatonia Specifier) • Diagnostic Criteria • A- The clinical picture is dominated by 3 (or more) of the following symptoms • Stupor (i.e., no psychomotor activity; not actively relating to environment) • Cataplexy (i.e., passive induction of a posture held against gravity) • Waxy flexibility (i.e., slight, even resistance to positioning by examiner) • Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]) • Negativism (i.e., opposition or no response to instructions or external stimuli) • Posturing (i.e., spontaneous and active maintenance of a posture against gravity) • Mannerism (i.e., odd, circumstantial caricature of normal actions) • Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements) • Agitation, not influenced by external stimuli • Grimacing • Echolalia (i.e., mimicking another’s speech) • Echopraxia (i.e., mimicking another’s movements) • Indicate the name of the associated mental disorder when recording the name of the condition (e.g. 293.89 [F06.1] Catatonia associated with major depressive disorder). Code the associated mental disorder first. (APA, 2013, pg.119-120)

  48. Schizophrenia Spectrum and Other Psychotic Disorders 293.89 (F06.1) Catatonia Disorder Due to Another Medical Condition • Diagnostic Criteria • A- The clinical picture is dominated by 3 (or more) of the following symptoms • Stupor (i.e., no psychomotor activity; not actively relating to environment) • Cataplexy (i.e., passive induction of a posture held against gravity) • Waxy flexibility (i.e., slight, even resistance to positioning by examiner) • Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]) • Negativism (i.e., opposition or no response to instructions or external stimuli) • Posturing (i.e., spontaneous and active maintenance of a posture against gravity) • Mannerism (i.e., odd, circumstantial caricature of normal actions) • Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements) • Agitation, not influenced by external stimuli • Grimacing • Echolalia (i.e., mimicking another’s speech) • Echopraxia (i.e., mimicking another’s movements) • B- There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. • C- The condition is not better explained by another mental disorder • D- The disturbance does not occur exclusively during the course of a delirium • E- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Include the name of the medical condition (e.g., 293.89 [F06.1] Catatonic disorder due to hepatic encephalopathy). The other medical condition should be coded and listed separately immediately before the catatonic disorder due to the medical condition. (APA, 2013, pg.120)

  49. Schizophrenia Spectrum and Other Psychotic Disorders Unspecified Catatonia • Category for when symptoms of catatonia cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but either the nature of the underlying mental disorder or other medical condition is unclear, full criteria for catatonia are not met, or there is insufficient information to make a more specific diagnosis • Code first 781.99 (R29.818) other symptoms involving nervous and musculoskeletal systems, followed by 293.89 (F06.1) unspecified catatonia. (APA, 2013, pg.121)

  50. Schizophrenia Spectrum and Other Psychotic Disorders • 298.8 (F28) Other Specified Schizophrenia Spectrum and Other Psychotic Disorder • Applies to situations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the diagnostic class. • Used when the clinician chooses to communicate the reason that the presentation does not meet full criteria for any specific disorder in this diagnostic class. • 298.9 (F29) Unspecified Schizophrenia Spectrum and Other Psychotic Disorder • Applies to situations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the diagnostic class. • Used when the clinician chooses not to specify the reason that the criteria are not met for a specific disorder in this diagnostic class. (APA, 2013, pg.122)