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
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
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
Changes to the schizophrenia category
Requires at least two symptoms: Including at least one of: • Delusions • Hallucinations • Disorganized Di i d speech h
•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
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
Negative g symptoms y p
THE NEW CRITERIA: OTHER PSYCHOTIC DISORDERS
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
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
Bipolar type Depressive type With catatonia
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.
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.
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
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
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
Possible early-stage dysfunction
Prodromal phase Early at-risk of psychosis state
Late at-risk of psychosis state
Basic symptom criterion (BS)
Attenuated positive symptoms (APS)
Functional state– biological trait criterion
Brief limited intermittent psychotic episode (BLIP) Psychosis
Fusar-Poli P, et al. JAMA Psychiatry 2013; 70(1):107-20. Correll CU. Presented at APA 2013, San Francisco.
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
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