DSM 5 Changes in Schizophrenia Spectrum and Other Psychotic Disorders

Transcription

1 DSM 5 Changes in Schizophrenia Spectrum and Other Psychotic Disorders Toba Oluboka, FRCPC, Consultant Psychiatrist and Site Chief, Addiction and Mental Health, South Health Campus; Alberta Health Services Assistant Clinical Professor of Psychiatry, University of Calgary.

2 DSM 5 Changes in Schizophrenia Objective Examine the changes in the DSM 5 regarding 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

3 DSM-5 Kappa (κ) = test-retest reliability κ = = very good Autism spectrum disorders Attention deficit-hyperactivity y disorder (ADHD) Post-traumatic stress disorder (PTSD) Complex somatic symptom disorder (hypochondriasis) Neurocognitive disorder (dementia) κ = = good Schizophrenia and schizoaffective disorder Bipolar disorder Alcohol-related disorders Borderline personality disorder κ = = low, but acceptable e Major depression Generalized anxiety disorder

4 The spectrum of schizophrenia and other psychotic disorders d Schizotypal personality disorder Delusional disorder Brief psychotic disorder Schizophreniform disorder Schizophrenia Schizoaffective disorder Substance-/drug-induced psychotic disorder Psychotic disorder due to a medical condition Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

5 DSM-5 Changes to the schizophrenia category Requires at least two symptoms: Including at least one of: Delusions Hallucinations Disorganized i speech Disorganized behaviour Negative Symptoms Elimination of: Notion of bizarre in reference to delusions Two hallucinatory voices in conversation (Schneider s first-rank symptoms) Types (paranoid, disorganized, undifferentiated) Only with catatonic features has been preserved Does not include cognitive disordersd

6 DSM-5 Dimensions In the DSM-IV: The symptom is either present or absent Goal of the DSM-5: provide additional information in the aim of Assessing severity Planning treatment Determining results of treatment Dimension Absent Equivocal Mild Moderate Severe Hallucinations Delusions Disorganized speech Disorganized behaviour Negative symptoms Cognitive impairment Depression Mania

7 THE NEW CRITERIA: OTHER PSYCHOTIC DISORDERS

8 Substance-Induced Psychoses Clarified distinction between substance-induced psychotic disorder and other psychotic disorders accompanied by comorbid substance use by rewording 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 that t was documented d before using substances.

9 Delusional Disorders 1. Deleted shared delusional disorder (folie à 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

10 Brief Psychotic Disorder and Schizophreniform Disorder a. Brief Psychotic Disorder: Sx at least 1 day but < 1 month. No major changes. Added catatonia specifier. b. Schizophreniform Disorder: Sx at least 1 month (or less if successfully treated) but < 6 months. No major changes aside from those consistent with meeting the revised schizophrenia Criterion A. Added catatonia specifier.

11 Schizoaffective Disorder: Subtypes and Specifiers Subtypes Bipolar type Depressive type Specifier With catatonia Course Specifiers Same as schizophrenia h i

12 Summary of Schizoaffective Disorder: A, B and C Criteria 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 least 2 weeks in the absence of major mood symptoms at some point. C. The mood symptoms have to be present for the majority of the total illness. (Note -majority is not defined.)

13 Course Specifiers: DSM-5 First Episode: Currently in acute episode Currently in partial remission Currently in full remission Multiple Episodes: Currently in acute episode Currently in partial remission Currently in full remission Continuous Unspecified

14 Attenuated psychotic disorder A. At least one of the following symptoms is present but attenuated; contact with reality remains intact 1. Delusions 2. Hallucinations, perceptual disorders 3. Disorganized speech 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. E. The symptoms cannot be explained by another diagnosis, nor by substance abuse

15 Evolution of Psychosis Various stages of High Risk State with implications for Prevention and Treatment: Premorbid Phase: With possible early-stage dysfunction Prodromal Phase Early at-risk of psychosis state Basic symptom criterion (BS) Functional state biological trait criterion Late at-risk of Psychosis State Attenuated Positive Symptoms (APS) Brief Limited Intermittent Psychosis (BLIP) Early Psychosis Transition i criterion i Symptom severity

16 Evolution of Psychosis Premorbid phase Prodromal phase Early at-risk of Late at-risk of Early psychosis state psychosis state psychosis Symptom sev verity Possible early-stage dysfunction Basic symptom criterion (BS) Functional state biological trait criterion Attenuated positive symptoms (APS) Brief limited intermittent psychotic episode (BLIP) Transition criterion Psychosis APS BLIP BS Prevention Treatment Fusar-Poli P, et al. JAMA Psychiatry 2013; 70(1): Correll CU. Presented at APA 2013, San Francisco.

17 Predictors of progression toward psychosis Severity of negative symptoms Severity of cognitive disorders Severity of functional impairment But not positive symptoms

18 Progression of attenuated psychosis: One year post-diagnosis i 40% depression, anxiety disorder, OCD, eating disorder, etc. 35% psychosis py 25% no Axis I diagnosis

19 DSM 5 Attenuated Psychosis Disorder-Controversy Pros: Cons: Longitudinal proof of conversion (high true positives) Severity of psychotic disorders probably at risk, but certainly ill Increased community education and research focus Over-diagnosis (low specificity, high false positives, declining conversion rates) Stigma Over (mal-)treatment (adverse effects, focus on APs) Lack of scalability of research findings (training, expertise, time

20 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`` Diagnoses 1 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 months 2 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 psychoses 3 1. Gaudiano BA & Zimmermann M, Fusar-Poli P. et al, Fusar-Poli P. et al, 2012

21 Conclusions Changes are modest and generally improve clarity and remove excessive verbiage or subtypes. The drive to use dimensional ratings of psychosis py severity is reinforced, and DSM-5 provides an 8 item list in the appendix. The introduction of Attenuated Psychosis syndrome do will remain controversial... o esa