The video below is the section for Schizophrenia from Part 7 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 7, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Schizophrenia
This is a chapter in the DSM-5 that includes Schizophrenia, other psychotic disorders (e.g., Delusional Disorder, Schizoaffective Disorder), and Schizotypal Personality Disorder. They are characterized by prominent psychotic symptoms, with abnormalities in one or more of five domains: delusions, hallucinations, disorganized thinking (as evidenced by speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms. Psychosis is a symptom or feature of mental illness that leads to radical changes in personality, impaired functioning, and most characteristically, a distorted sense of objective reality, and that result from a variety of causes (genetic, drug or medication, psychosocial factors).
Psychotic disorders are often described by contrasting positive symptoms and negative symptoms. Positive symptoms are those that indicate an excess or distortion of normal functions, such as delusions and hallucinations, while negative symptoms are used in reference to a significant decrease or loss of normal functions, such as blunted affect, lack of fluidity of speech, and avolition.
The key features that define the psychotic disorders:
Delusions – these are fixed beliefs that are not amenable to change in light of conflicting evidence.
Their content varies by themes, such as persecutory delusions (the belief that one is going to be harmed), referential delusions (belief that environmental cues are directed at oneself), grandiose delusions (the false belief that one has exceptional abilities, wealth or fame), erotomanic delusions (when a person believes erroneously that someone is in love with him/her), nihilistic delusions (the conviction that a major catastrophe will occur), and somatic delusions (preoccupations regarding health and organ function). Delusions are said to be bizarre if they do not derive from ordinary life experiences, are not understandable by same-culture peers, and are clearly implausible. Delusions that express a loss of control over mind and body are generally considered bizarre, which include thought withdrawal and thought insertion (believing that an outside force has removed one’s thoughts or has put someone else’s thoughts into one’s mind, respectively), as well as delusions of control (one’s body or actions are being controlled by an outside force).
Hallucinations – they are related to sensory modalities, but occur without external stimulus, such as seeing things that are not there (different from illusions, which are distortions or misinterpretation of something that is there to be seen).
The most common hallucination reported in Schizophrenia is auditory, where the individual hears voices when alone, or talks to voices that do not belong to anyone around, and that others do not hear.
Note that hallucinations may be considered a normal part of religious experiences in some cultural contexts. Experiences similar to hallucinations which occur while falling asleep or waking up are also within the range of normal experience, and are not considered psychotic symptoms, hallucinations must occur in the context of clear sensory capacity.
Disorganized thinking – disorganized thinking, also referred to as a formal thought disorder, is inferred from the person’s speech. During prodromal and residual phases, these symptoms tend to be less severe. Recognizable characteristics of disorganized thinking include jumping from one topic to another (loose associations), or giving answers that are unrelated or only indirectly related to the questions (tangentiality), and in rare instances, speech is linguistically disorganized and incomprehensible (incoherence).
Grossly disorganized or abnormal motor behavior – include a range of manifestations, from childlike “silliness” to unpredictable agitation, and can become apparent in any form of goal-directed behavior and affecting the performance of activities of daily living.
Catatonia is behavior with marked decrease in reactivity to the environment. Catatonic behavior ranges from resistance to instructions (negativism), to maintaining a rigid or inappropriate or bizarre posture, to a lack of verbal and motor responses (mutism and stupor).
It may also appear as purposeless or excessive motor activity (catatonic excitement), or of repetitive stereotyped movements (staring or grimacing) or echoing of speech. Although classically associated with Schizophrenia, catatonia may occur in other mental disorders (i.e., depressive and bipolar disorders, or resulting from medical conditions.
Negative Symptoms – they are closely associated with Schizophrenia, and less prominent in other psychotic disorders. Negative symptoms include diminished emotional expression in the face, eye contact, intonation of speech, as well as reduction in the movements of the hands, head and face that usually accompany conversations and social interactions.
There is also avolition (decrease in motivation for self-initiated purposeful activities; alogia (diminished speech output), anhedonia (decreased ability to feel pleasure even when involved in positive stimuli), asociality (apparent lack of interest in social interactions).
A mnemonic to help you remember the symptoms in psychotic disorders:
DELUSIONS HERALD SCHIZOPHRENICS BAD NEWS
The initials DHSBN stand for symptom domains of
Schizophrenia is a Psychotic Disorder characterized by discrete periods of psychotic symptoms involving a variety of cognitive, behavioral and emotional dysfunctions, associated with marked decline over time in social and occupational functioning. No symptoms is pathognomonic of the disorder, meaning, there is no symptom that is so characteristic of Schizophrenia, that its presence means that the diagnosis is present without a doubt.
To diagnose schizophrenia, there must be the presence of 2 psychotic symptoms from among 5 domains:
delusion, hallucination, disorganized speech, grossly disorganized behavior, catatonia, or any of the negative symptoms, with at least one of them being delusion, hallucination or disorganized thought).
The symptoms must have been present for a significant amount of time for at least one month. The onset of symptoms leads to disturbance of the person’s prior level of functioning in at least one major area (work, interpersonal relations, self-care) and signs of the disturbance must last at least 6 months. The psychotic symptoms cannot be attributable to the effects of a substance or a medication, nor another mental disorder.
When diagnosing schizophrenia, the clinician must specify if:
– first episode, currently in acute episode = the first manifestation of the disease, which most frequently occurs between late teen and 30 years of age. An acute episode is the period during which the symptoms criteria are fulfilled;
– first episode, currently in partial remission = there are improvements after an acute period, and diagnostic criteria are only partially fulfilled;
– First episode currently in full remission = full remission is said to occur after an acute period, and during which no disorder-specific symptoms are present.
– multiple episodes, currently in acute episode = multiple episodes requires at least two episodes in the individual’s personal history;
– multiple episodes, currently in partial remission;
– multiple episodes, currently in full remission;
– continuous = symptoms fulfilling diagnostic criteria remain for the majority of the course of illness;
Specify if “with catatonia” in which case an additional code is used for catatonia associated with Schizophrenia.
Specify severity of symptoms – not required, but descriptive and clinically relevant. It consists of a quantitative assessment that rates on a 5-point scale the severity of each primary symptom of psychosis, where 0 indicates the symptom being rated is not present, and 4 indicates that the symptoms is present and severe. (See Clinician-Rated Dimensions of Psychosis Symptoms Severity, found in the DSM-5 chapter on “Assessment Measures,” on pages 743 and 744).
The lifetime prevalence of schizophrenia is between .3% and .7%, with variations by ethnicity, across countries, and by geographic origin of immigrants and children of immigrants. There is a strong contribution of genetic factors in the development of symptoms, although most cases are diagnosed in the absence of family history of this or related disorders.
Specifically, having a first-degree biological relative with Schizophrenia increases one’s risk of developing the disorder by 10%. In the case of identical twins, the risk ranges from 40-65% (NIMH, 2012). Indeed, heritability is moderate to strong (50 to 60%). Although men and women are equally likely to develop Schizophrenia, the disorder seems to manifest itself differently based on gender. Men tend to develop Schizophrenia earlier in life: age of onset typically occurs in the early to mid-20s for men and in the late 20s for women. Women have better premorbid functioning and display more affective symptoms during the course of illness, while men with the disorder are more likely to experience negative symptoms, which presage worse outcomes.
Season of birth has been linked to incidence of schizophrenia (including late winter/early spring, as well as in summer for forms with prominent negative symptoms). Adverse pregnancy factors (stress, malnutrition, maternal diabetes) and birth complications with hypoxia, as well as greater paternal age are risk factors for the development of symptoms of schizophrenia.
There are no current radiological, laboratory, or psychometric tests for the disorder, although research has indicated there are multiple brain differences between those with schizophrenia when compared to healthy individuals, as evidenced in neuroimaging, neuropathology and neurophysiological studies. however, none of the these findings are diagnostic of schizophrenia, which remains a disorder diagnosed clinically, by its symptoms and the course of illness.
The suicide risk is significant. About 5% to 6% of individuals with schizophrenia die by suicide, about 20% attempt suicide one or more times (often in response to command hallucinations), and many more report suicidal ideation at some time during their illness. The likelihood of a suicide attempt appears to be higher with young males with comorbid substance use. Other higher risk periods include the period immediately following an acute psychotic episode or a hospital discharge, associated depressive symptoms or feelings of hopelessness, and being unemployed. Rates of comorbidity with substance-related disorders, including high tobacco use, are high in schizophrenia. Anxiety disorders, obsessive-compulsive disorder, panic disorder appear in higher rates in individuals with schizophrenia than in the general population. Life expectancy is reduced, in part due poor engagement in health maintenance behaviors, and a high association with medical conditions such as weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary diseases.
Differential diagnosis with other psychotic disorders include: symptoms of schizophrenia that last more than one day but less 1 month is suggestive of Brief Psychotic Disorder; if the symptoms resemble those of schizophrenia with less than 6 months duration, Schizophreniform Disorder may the correct diagnosis; when a major depressive or a manic episode occur concurrently with the active-phase symptoms, Schizoaffective Disorder must be considered; and a person with Delusional Disorder exhibits prominent delusions in the absence of other psychotic symptoms. Non-psychotic mental disorder may also need to be ruled out: schizophrenia is distinguished from Schizotypal Personality Disorder due to the latter’s subthreshold symptoms and their association with persistent personality features; PTSD may include flashbacks that mimic hallucinations, and there may be symptoms that resemble paranoia, but onset and triggers of symptoms are related to a past traumatic experience; Delirium and neurocognitive disorder may present with delusions or hallucinations, but these have a temporal association with the onset of cognitive changes characteristic of these diagnoses. Major depressive or bipolar disorder with psychotic features are differentiated from Schizophrenia in that the prominent symptoms in the overall course of illness are mood symptoms, while psychotic symptoms occur exclusively during the depressive or manic episodes.
1. Prominent psychotic symptoms, with abnormalities in one or more of five domains: delusions, hallucinations, disorganized thinking, grossly disorganized behavior, and negative symptoms
2. Positive symptoms: excess or distortion of normal functions, e.g., delusions and hallucinations
3. Negative symptoms: decrease or loss of normal functions, e.g., blunted affect, lack of fluidity of speech, avolition, alogia, anhedonia, asociality
4. Delusions: fixed beliefs unamenable to change: persecutory, referential, grandiose, erotomanic, nihilistic, somatic
5. Hallucinations: sensory modalities without external stimulus: auditory, tactile
6. Disorganized thinking: formal thought disorder inferred from speech
7. Grossly disorganized or abnormal motor behavior: range of manifestations: silliness to unpredictable agitation; catatonia
8. Mnemonic for symptoms: DELUSIONS HERALD SCHIZOPHRENIA BAD NEWS: The initials DHSBN stand for symptoms domains: Delusions, Hallucinations, Speech-disorganized, Behavior- disorganized, Negative symptoms
Negative or deficit symptoms of schizophrenia include all of the following, except:
A. auditory hallucinations.
B. impoverished thought or speech.
C. low motivation.
D. social isolation.
A is correct, as hallucinations are a positive or excess symptom; Answers B, C, and D are incorrect, as they all depict negative or deficit symptoms.