5/5/2015

SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS USING THE DSM-5: WEBINAR SERIES AMERICAN COUNSELING ASSOCIATION TODD F. LEWIS, PH.D., LPC, NCC

POLL QUESTION

1

5/5/2015

SYMPTOMS OF PSYCHOSIS • Person is out of touch with reality; psychosis manifests in one or more of the following 5 basic symptoms:

• Delusions • Hallucinations • Disorganized Speech • Disorganized Behavior • Negative Symptoms

• These comprise “Criterion A” in the diagnosis of Schizophrenia

DISTINGUISHING SCHIZOPHRENIA FROM OTHER DISORDERS ON THE SPECTRUM • Psychotic symptoms •

First task in diagnosing psychosis: what is the extent of psychotic symptoms?

•

How many symptoms present (1 or more) has implications for differential diagnosis

• Course of symptoms •

Duration of illness is a significant factor in differentiating schizophrenia from other spectrum disorders; in general, the longer the symptoms have been present, the more likely the diagnosis is schizophrenia

• Consequences of symptoms •

With schizophrenia, significant and lasting impairment in social and occupational functioning is required; other psychotic disorders do not require this criterion

• Exclusions •

Schizophrenic symptoms cannot be caused by physical symptoms, substance-related disorders, or mood disorders

2

5/5/2015

SCHIZOPHRENIA: KEY FEATURES • “mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated), with some signs of the disorder persisting for at least 6 months.” • Symptoms are associated with marked social or occupational dysfunction • Onset = generally mid-20s • Up to 1% of general population • Variable course

CRITERIA: 295.90 (F20.9) SCHIZOPHRENIA A. Criterion “A” •

At least 2 of 5 psychotic symptoms be present for a significant amount of time for at least 1 month

•

At least one symptom must be delusions, hallucinations, or disorganized speech

B. Criterion B. Social/occupational/self-care dysfunction •

School, work, social, self-care below premorbid levels

C. Criterion C. Duration •

Criterion A x 1 month (less if treated)

•

Continuous disturbance x 6 months (either negative symptoms and/or two other symptoms in attenuated form)

D. Other criteria: Exclusions • Schizoaffective, Mood D/O – No mood symptoms can occur during active phase psychotic symptoms or, if they do, they don’t last for long • Substance use, GMC

3

5/5/2015

WHAT HAPPENED TO THE SUBTYPES?

• Little evidence that they were predictive or helpful • Patients rarely held to one type across episodes of the disorder • Catatonia (discussed later), once thought to be exclusive to schizophrenia, is now relegated as a specifier not only for schizophrenia, but for mood disorders and physical illnesses.

Morrison (2014)

POSITIVE SYMPTOMS • Reflect an excess or distortion of normal functions Examples: • Delusions • Deeply held false belief that patient holds on to despite strong evidence to the contrary or the opinions of others; cannot be explained by person’s culture or education (Morrison, 2014). • Distinguish from overvalued ideas

• Hallucinations • Sensory perception, in a full waking state, that one experiences in the absence of a sensory stimuli • Distinguish from illusions

• Disorganized speech • Grossly impaired speech that cannot be understood

• Grossly disorganized or Catatonic behavior • Behavior not goal-directed; often repetitive acts; catatonia

4

5/5/2015

DELUSIONS AND HALLUCINATIONS Many types of delusions Persecution, guilt, referential, somatic, religious, grandeur, bizarre, poverty, erotomanic, control, jealousy, passivity, thought broadcasting, thought insertion Note: DSM 5 does not require that a patient only needs 1 symptom from criterion A if delusions are bizarre; all patients with schizophrenia must now have 2 or more from criterion A, no matter how “far out” one’s symptoms are

Hallucinations • Can occur in any sensory modality •

Auditory (most common)

•

Visual (most common)

•

Olfactory

•

Gustatory

•

Tactile

DISORGANIZED THINKING/SPEECH AND GROSSLY DISORGANIZED BEHAVIOR Disorganized Thinking/Speech • Derailment/loose associations/flight of ideas

Disorganized Behavior • Ranging from childlike silliness to unpredictable/un-triggered agitation

= One topic to the next • Difficulty completing activities of daily life • Tangientiality = Unrelated answers to questions

• Appearing disheveled

• Incoherence/word salad = Nearly incomprehensible

• Unusual, bizarre dress

• Pressured speech

• Inappropriate sexual behavior

• Ideas of reference

• Catatonia (explained later)

5

5/5/2015

NEGATIVE SYMPTOMS • Reflect a diminution or loss of normal functions • Affective flattening = restriction in emotional expression---flat, blunted • Alogia = impoverishment of thinking evidenced by speech patterns • Poverty of speech/content • Brief, laconic, empty replies • Avolition = inability to initiate and persist in goal-directed activities of daily living

SEVERAL “COURSE SPECIFIERS” • The specifiers in the DSM-5 are significantly different than DSM-IV • Specifiers are based on whether the client is in a “first episode” or has had “multiple episodes”; cannot use these until at least one year of diagnosis • Once you determine if patient is in first or has had multiple episodes, then determine: • Currently in acute episode – criteria are met for disorder • Currently in partial remission – improvement; defining criteria are partially fulfilled • Currently in full remission – no “disorder specific” criteria are present • Continuous – symptoms remain for the majority of the illness course • Unspecified

• Specifiers are not associated with code types (just write out the words)

6

5/5/2015

OTHER SPECIFIERS • With catatonia • Look at criteria for catatonia specifier on pg. 119-120 • Use additional code: 293.89 (F06.1)

• Current severity (optional): • Based on “Clinician Rated Dimensions of Psychosis Symptom Severity” in section III of DSM-V

DIAGNOSIS EXAMPLES

295.90 (F20.9) Schizophrenia, Multiple episodes, currently in acute episode 295.90 (F20.9) Schizophrenia, First episode, currently in partial remission 295.90 (F20.9) Schizophrenia, With catatonia, Continuous 293.89 (F06.1) Catatonia associated with schizophrenia

7

5/5/2015

PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA 295.40 (F20.1) Schizophreniform Disorder • Looks like Schizophrenia, EXCEPT for duration (from 1 to 6 months) and dysfunction (does not require evidence of life interference) • Requires 2 of the 5 symptoms from criterion “A”, at least one of which must be delusions, hallucinations, or disorganized speech • Full recovery within 6 months. • Specify if: • With/Without Good Prognostic Features • Psychotic symptoms begin early in disorder; Confusion at peak of psychosis; Good premorbid functioning; Affect is not blunted or flat (i.e., no emotional negative symptoms) • If 2 to 4 are present = With Good Prognostic Features; None to 1 = Without Good Prognostic Features. • With Catatonia

PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA • Schizophreniform Disorder, Con’t. • If within 6 months and patient is still experiencing symptoms, use “provisional” in diagnosis. Once full recovery is achieved, this specifier can be removed (Morrison, 2014) • Severity (optional) • Examples: • 295.40 (F20.1) Schizophreniform Disorder, With good prognostic features, Provisional • 295.40 (F20.1) Schizophreniform Disorder, Without good prognostic features, With catatonia, provisional

• If symptoms persist for more than 6 months, need to consider alternative diagnoses.

8

5/5/2015

PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA • 298.8 (F23) Brief Psychotic Disorder • • • •

At least one symptom from “criterion A” 1-30 days in duration recovers completely If still waiting for recovery, then append the diagnosis with “provisional”

• Specify if: • With postpartum onset = symptoms start within 4 weeks of giving birth • With/Without marked stressors • Stress must cause symptoms, occur shortly before onset, and must be of such severity that almost anyone would feel stressed

• With catatonia • Severity – optional!

• Example: • 298.8 (F23) Brief psychotic disorder, with marked stressors

PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA • 297.1 (F22) Delusional Disorder • Involves delusions for at least one month; never met criterion “A”; functioning is not markedly affected • Can specify the type of delusion: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified • Can specify content of delusions • With bizarre content (delusions that are impossible or improbable, such as aliens controlling one’s brain from the moon).

• As with schizophrenia, if disorder has lasted one year, specify: • First episode, currently in acute episode, currently in partial remission, OR currently in full remission • Multiple episodes, currently in acute episode, currently in partial remission, OR currently in full remission • Continuous • Unspecified • Severity – optional!

9

5/5/2015

PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA

Schizoaffective Disorder (number coding depends on type) • Confusing diagnosis! • Many consider this a mixture of prominent mood and psychotic symptoms • A period of illness in which the patient has prominent mood symptoms (manic episode or major depressive episode) for the majority of the syndrome. During the same continuous period, the patient also meets “criterion A” for schizophrenia without a mood episode (Morrison, 2014). • Coding notes: • 295.70 (F25.0) Bipolar type (if manic episode) • 295.70 (F25.1) Depressive type

PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA Schizoaffective Disorder, Con’t. • Specify: • With catatonia

• If disorder has lasted at least a year, same course specifiers as schizophrenia and delusional disorder • Example: • 295.70 (F25.1) Schizoaffective Disorder, Depressive type, First episode, currently in partial remission

10

5/5/2015

PSYCHOTIC DISORDERS OTHER THAN SCHIZOPHRENIA Substance/Medication Induced Psychotic Disorder Psychotic Disorder Due to a General Medical Condition • In general, psychotic symptoms can emerge as a result of substance/medication use (during intoxication or withdrawal) or a general medical condition

• Coding can be tricky here •

For substance use/medication, need to determine if induced psychotic disorder is comorbid with a substance use disorder or not; coding also depends on substance; pg. 111 in DSM

•

For general medical conditions, code 293.81 (F06.2) With delusions OR 293.82 (F06.0) With hallucinations; always list general medical condition BEFORE the psychotic disorder in diagnosis •

162.9 (C34.90) malignant lung neoplasm; 293.81 (F06.2) psychotic disorder due to malignant lung neoplasm, with delusions

RECORDING CATATONIA • Examples of catatonic behavior: • Catatonic stupor =unawareness of environment • Catatonic rigidity =maintaining rigid posture, resistance to efforts to be moved • Catatonic posturing =assumption of inappropriate or bizarre postures • Catatonic negativism =active resistance to instructions/attempts to be moved • Catatonic excitement =purposeless and unstipulated excessive motor activity • Echopraxia = abnormal repetition of the actions of another person • Echolalia = and meaningless repetition of the words of another person

11

5/5/2015

RECORDING CATATONIA • 293.89 (F06.1) Catatonia Associated with Another Mental Disorder (catatonia specifier) • Need 3 or more catatonic symptoms • Can apply this specifier to: manic, hypomanic, or major depressive episodes; schizophrenia, schizophreniform, schizoaffective, and brief psychotic disorders; substance-induced psychotic disorder; autism spectrum disorder • List mental disorder, then the code, then catatonia associated with . . . • Example: • 295.90 (F20.9) Schizophrenia, first episode, currently in partial remission, With catatonia • 293.83 (F06.1) Catatonia associated with schizophrenia

RECORDING CATATONIA

• 293.89 (F06.1) Catatonic Disorder Due to Another Medical Condition • A general medical condition seems to have caused the symptoms of catatonia • At least 3 symptoms of catatonia • Coding note: List name of general medical condition and then record the catatonia diagnosis • Example (Morrison, 2014): • 225.2 (D32.9) Cerebral meningioma, benign • 293.89 (F06.1) Catatonic disorder due to cerebral meningioma

12

5/5/2015

References: •

American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders (DSM-5), Fifth edition. Washington, DC: APA.

•

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York: Guilford.

THANK YOU!! Todd F. Lewis, Ph.D., LPC, NCC Associate Professor North Dakota State University [email protected]

For technical questions [email protected] For content questions [email protected]

PLEASE JOIN US FOR THE REMAINING SESSIONS OF THE SERIES: USING THE DSM-5: COUNTDOWN TO OCTOBER 1, 2015 AT 1PM ET

• May 13th Assessment/Emerging Measure/Recording-Coding Casey A. Barrio Minton Ph.D

• May 20th Wrap Up/Bonus Session Stephanie F. Dailey, EdD, LPC, NCC, ACS

13