DSM 5 Changes in Schizophrenia Spectrum andd O Other h P Psychotic h i Di Disorders d
Toba Oluboka, FRCPC, Consultant Psychiatrist and Site Chief, Addiction and Mental Health, South Health Campus; p ; Alberta Health Services Assistant Clinical Professor of Psychiatry, University of Calgary.
DSM 5 Changes in Schizophrenia
Objective
Examine the changes g in the DSM 5 regarding g g the clinical diagnoses of schizophrenia Spectrum and other Psychotic Disorders Discuss the pros and cons of the introduction of Attenuated Psychosis Syndrome to the DSM 5
DSM-5
κ = 0.6-0.79 = very good
Autism spectrum disorders Attention deficit-hyperactivity yp y disorder (ADHD) ( ) Post-traumatic stress disorder (PTSD) Complex somatic symptom disorder (hypochondriasis) Neurocognitive disorder (dementia)
κ = 0.4-0.59 = good
Kappa (κ) = test-retest reliability
Schizophrenia and schizoaffective disorder Bipolar p disorder Alcohol-related disorders Borderline personality disorder
κ = 0. 0.2-0.39 0.39 = low, ow, but bu “acceptable” ccep b e
Major depression Generalized anxiety disorder
The spectrum of schizophrenia and other psychotic h ti disorders di d
Schizotypal personality disorder Delusional disorder Brief psychotic disorder Schizophreniform disorder Schizophrenia Schizoaffective disorder Substance /drug induced psychotic disorder Substance-/drug-induced Psychotic disorder due to a medical condition Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
DSM-5
Changes to the schizophrenia category
Requires at least two symptoms: Including at least one of: • Delusions • Hallucinations • Disorganized Di i d speech h
Elimination of:
•Disorganized behaviour •Negative Symptoms
Notion of “bizarre” in reference to delusions Two hallucinatory voices in conversation (Schneider’s first-rank symptoms) y p ) Types (paranoid, disorganized, undifferentiated) Only “with catatonic features” has been preserved
D Does nott include i l d cognitive iti di disorders d
DSM-5
Dimensions
IIn the h DSM DSM-IV: IV The Th symptom is i either i h present or absent b Goal of the DSM-5: provide additional information in the aim of Assessing g severityy Planning treatment Determining results of treatment Dimension
Absent
Equivocal
Mild
Moderate
Severe
Hallucinations
0
1
2
3
4
Delusions
0
1
2
3
4
Disorganized speech
0
1
2
3
4
Disorganized behaviour
0
1
2
3
4
Negative g symptoms y p
0
1
2
3
4
Cognitive impairment
0
1
2
3
4
Depression
0
1
2
3
4
Mania
0
1
2
3
4
THE NEW CRITERIA: OTHER PSYCHOTIC DISORDERS
Substance-Induced Psychoses
Clarified distinction between substance-induced psychotic disorder and other psychotic disorders accompanied by comorbid substance use by rewording g the C criterion to mandate that other possible cause for the psychosis do not exist.
DSM-5 provides examples of scenarios to suggest an independent psychotic disorder including psychosis that persists for more than a month after substance exposure, and psychosis th t was documented that d t db before f using i substances. b t
Delusional Disorders
1. Deleted shared delusional disorder (folie à 1 deux) as a separate subtype • Unspecified type covers this and other delusional disorders that are not erotomanic, grandiose, persecutory, jealous or somatic 2. May have specifier of bizarre content 3 Course specifiers same as schizophrenia 3.
Brief Psychotic Disorder and Schizophreniform Disorder
a. Brief Psychotic Disorder: Sx at least 1 day but a < 1 month. No major changes. Added catatonia specifier. p
b. Schizophreniform Disorder: Sx at least 1 b month (or less if successfully treated) but < 6 months No major changes aside from those months. consistent with meeting the revised p Criterion A. Added catatonia schizophrenia specifier.
Schizoaffective Disorder: Subtypes and Specifiers
Subtypes
Specifier
Bipolar type Depressive type With catatonia
Course Specifiers
S Same as schizophrenia hi h i
Summary of Schizoaffective Disorder: ‘A ’ ‘B’ and ‘A,’ d ‘C’ C Criteria i i A.
As before one must have a major depressive or manic episode together with the A criteria of schizophrenia.
B.
Hallucinations or delusions must persist for at l least t 2 weeks k iin th the absence b off major j mood d symptoms at some point.
C.
The mood symptoms have to be present for the “majority” majority of the total illness illness. (Note -majority majority is not defined.)
Course Specifiers: DSM-5
First Episode:
Multiple Episodes:
Currently y in acute episode p Currently in partial remission Currently y in full remission Currently y in acute episode p Currently in partial remission Currently y in full remission
Continuous Unspecified
Attenuated psychotic disorder A. At least one of the following symptoms is present but attenuated; contact with reality remains intact 1 1. Delusions 2. Hallucinations, perceptual disorders 3. Disorganized g speech p B. Criterion A symptoms B. Have occurred at least once (1) a week for one (1) month C. Appeared or worsened in the past year D. Are distressing or incapacitating enough to cause the person or a loved one to seek help help. E. The symptoms cannot be explained by another g nor byy substance abuse diagnosis,
Evolution of Psychosis
Symptom s S severity
Various stages of High Risk State with implications for Prevention and Treatment: Premorbid P bid Ph Phase: With possible ibl early-stage l t dysfunction d f ti Prodromal Phase Early at-Risk at Risk of psychosis state Basic symptom criterion (BS) Functional state – biological g trait criterion Late at-Risk of Psychosis State Attenuated Positive Symptoms (APS) Brief Limited Intermittent Psychosis (BLIP) Early Psychosis Transition T i i criterion i i
Evolution of Psychosis
Symptom sevverity
Premorbid phase
Possible early-stage dysfunction
Prodromal phase Early at-risk of psychosis state
Late at-risk of psychosis state
Early psychosis
Basic symptom criterion (BS)
Attenuated positive symptoms (APS)
Transition criterion
Functional state– biological trait criterion
Brief limited intermittent psychotic episode (BLIP) Psychosis
APS
BLIP
BS Prevention
Fusar-Poli P, et al. JAMA Psychiatry 2013; 70(1):107-20. Correll CU. Presented at APA 2013, San Francisco.
Treatment
Predictors of progression toward psychosis
Severity of negative symptoms y g y p
Severity of cognitive disorders
Severity of functional impairment
But not positive symptoms
Progression of attenuated psychosis: One year post-diagnosis di i
40% depression, anxiety disorder, OCD, eating disorder, etc.
35% psychosis p y
25% no Axis I diagnosis
DSM 5 Attenuated Psychosis Disorder Disorder-Controversy Controversy
Pros: Longitudinal g proof p of conversion (high ( g true positives) p ) Severity of psychotic disorders “probably at risk, but certainly ill” Increased community education and research focus
Cons: Over-diagnosis (low specificity, high false positives, declining conversion rates) Stigma Over (mal-)treatment (adverse effects, focus on APs) Lack of scalability y of research findings g (training, ( g, expertise, time
DSM 5 Attenuated Psychosis Disorder-Controversy
Prevalence of ≥ 1 Reported Psychotic Experience in Adults in a General Psychiatric Outpatient Setting Fulfilling Attenuated Psychotic Sx Status (n=1218) was 28.3% in ``non-Psychotic`` Diagnoses1 Transition Risk to Psychosis Over Time (in 27 studies involving 2502 subjects) varies from 17.7% in six moths to 35.8% in over 36 months2 Of those who converted to psychosis: 26% converted over 2.4 years. 73% converted to Schizophrenia Spectrum Disorders, 11% to Mood Disorders with Psychosis and 16% to other psychoses3 1. Gaudiano BA & Zimmermann M, 2013 2. Fusar-Poli P. et al, 2012 3. Fusar-Poli P. et al, 2012
Conclusions
Changes are modest and generally improve clarity and remove excessive verbiage or subtypes.
The drive to use dimensional ratings of psychosis p y severity y is reinforced, and DSM-5 provides an 8 item list in the appendix.
The introduction of Attenuated Psychosis syndrome sy d o e will remain e a co controversial.... o e sa
