Schizophrenia Spectrum and Other Psychotic Disorders

Question 1

Delusion definition; types of delusions

Answer 1

Fixed beliefs that are not amenable to change in light of conflicting evidence.

Types:
* Persecutory: Belief that one is going to be harmed/harassed by an individual, organization, or group
* Referential: Belief that certain gestures, comments, environmental cues, etc. are directed at oneself
* Gradiose: Belief that one has exceptional abilities, wealth, or fame
* Erotomanic: Belief that another person is inlove with the individual
* Nihilistic: Conviction that a major catastrophe will happen
* Somatic: Preoccupations regarding health and organ function
* Jealous: Belief that spouse or lover in unfaithful
* Mixed: When no one delusional theme predominates
* Unspecified type: When the delusional belief cannot be clearly determined or isn’t captured by one of the other types

Question 2

“Bizarre” delusions

Answer 2

Delusions that are clearly implausible and not understandable to same-culture peers. Do not derive from ordinary life experiences.

E.g., belief that one’s organs have been replaced with someone else’s without any scars being left; thought insertion and withdrawals, mind/body control delusions

Question 3

Hallucination definition

Answer 3

Perception-like experience that occurs without an external stimulus; vivid and clear, with the full force of normal perceptions; involuntary.

May occur in any modality, but auditory is the most common in schizophrenia.

Question 4

Disorganized thinking definition

Answer 4

Normally inferred from speech. Rapid switching between topics; tangential responses to questions.

Not to be confused with glossolalia (“speaking in tongues” as a religious experience)

Question 5

Delusional Disorder Diagnostic Criteria

Answer 5

A. The presence of ≥1 delusion(s) with a duration of ≥1 month(s).
B. Criterion A for schizophrenia has never been met.
C. Apart from the impact of the delusion(s) or its ramificaitons, functioning is not markedly impaired, behaviour is not obviously bizarre or odd.
D. If manic episodes or MDEs have occurred, they are short compared to the periods of delusion.
E. Not attributable to substances/medication/another medical condition.

Question 6

Delusional Disorder specifiers

Answer 6

Type of delusion:
* Erotomanic type
* Grandiose type
* Jealous type
* Persecutory type
* Somatic type
* Mixed type
* Unspecified type

Presence of bizarre content:
* With bizarre content

After 1-year duration of the disorder:
* First episode, curently in acute episode
* First episode, currently in partial remission: period after an episode in which criteria are only partially fulfilled
* First episode, currently in full remission: period after an episode during which no disorder-specific symptoms are present
* Multiple episodes, currently in acute episode
* Multiple episodes, currently in partial remission
* Multiple episodes, currently in full remission
* Continuous: Diagnostic criteria have been met for the majority of illness course, with short periods of subthreshold symptoms present in between
* Unspecified

Severity: (based on Clinican-Rated Dimensions of Psychosis Symptom Severity)

Question 7

Differentiation of Delusional Disorder from OCD and related disorders

Answer 7

• If an individual with OCD is completely convinced of their OCD belief, then OCD, with absent insight/delusional belief specifier should be given

Question 8

Differentiation of Delusional Disorder from Schizophrenia and Schizophreniform Disorder

Answer 8

• Delusional Disorder does not have characteristic symptoms of active phase of schizophrenia
• In schizoprhenia, delusions show greater disorganization (less internally consistent)
• In delusional disorder, there is greater conviction, greater extension (i.e., the delusion is more tied to areas of the individual’s life) and greater pressure (i.e., preoccupation/concern)

Question 9

Differentiation of Delusional Disorder from Mood Disorders and Schizoaffective Disorder

Answer 9

• If delusions occur exclusively during a major mood episode, then it’s likely not delusional disorder
• Mood symptoms may be present, but only relatively briefly compared to the delusions for delusional disorder to be appropriate (otherwise it would be other specified/unspecified schizophrenia spectrum and other psychotic disorder, accomparnied by other specified/unspecified depressive/bipolar disorder)

Question 10

Brief Psychotic Disorder Diagnostic Criteria

Answer 10

A. Presence of ≥1 of the followning. ≥1 must be 1-3:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behaviour

B. Duration ≥1 day but <1 month, with eventual return to premorbid functioning.
C. Not better explaind by MDD/bipolar with psychotic features and not attributable to substances/medication/other medical condition

Question 11

Brief Psychotic Disorder Specifiers

Answer 11

Conditions at onset:
* With marked stressor(s) (brief reactive psychosis)
* Without marked stressor(s)
* With peripartum onset: If onset is during pregnancy or ≤4 weeks postpartum

Additional features:
* With catatonia

Severity (based on Clinician-Rated Dimensions of Psychosis Symptom Severity

Diagnosis can be made without a severity specifier

Question 12

Differentiation of Brief Psychotic Disorder from other psychotic disorders

Answer 12

• If symptoms persist ≥1 monthm diagnosis is either schizophreniform disorder, delusional disorder, MDD/bipolar with psychotic features, or other specified/unspecified schizophrenia spectrum and other psychotic disrder
• Differentiation is challenging when symptoms have remitted in less than a month with successful treatment

Question 13

Schizophreniform Disorder Diagnostic Criteria

Answer 13

A. ≥2 of hte following, present for a significant portion during a 1-month period (or less if successfully treated). ≥1 must be 1-3:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behaviour
5. Negative symptoms

B. An episode of the disorder lasts ≥1 month but < 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional”.
C. Schizoaffective disorder or depressive/bipolar disorder with psychotic features have been ruled out either because:
1. No MDE or manic episodes have occurred concurrently with active-phase symptoms
2. If mood episodes have occurred with active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of illness

D. Not attributable to substances/medication/other medical condition.

Question 14

Schizophreniform Disorder specifiers

Answer 14

Prognostic features:
* With good prognostic features: Requires the presence or ≥2 of the following:
1. Onset of prominent psychotic symptoms within 4 weeks of first noticeable change in behaviour
2. Confusion or perplexity
3. Good premorbid functioning
4. Absence of blunted/flat affect
* Without good prognostic features

Other features:
* With catatonia

Severity

Diagnosis can be made without severity specifier

Question 15

Schizophrenia Diagnostic Criteria

Answer 15

A. ≥2 of the following, present for a significant portion during a 1-month period (or less if successfully treated). ≥1 must be 1-3:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behaviour
5. Negative symptoms

B. For a significant portion of time sine onset, functioning in ≥1 major areas is markedly below baseline
C. Continuous signs of disturbance for >6 months; must include ≥1 month of symptoms (less if successfully treated) that meet criterion A and may include prodromal or residual symptoms (during this time, signs may only be manifested or attenuated versions of symptoms in A).
D. Schizoaffective and mood disorders with psychotic features have been ruled out because either:
1. No mood episodes have occurred concurrently with active-phase symptoms
2. If mood episodes have occurred with active-phase symptoms, they have been presen for a minority of the total duration of the active and residual portions of the illness

E. Not attributable to substances/medication/other medical condition
F. If history of ASD or communication disorder with childhood onset, additional diagnosis of schizophrenia is made only if prominent hallucinations/delusions are present for ≥1 month (less if treated successfully)

Question 16

Schizophrenia Specifiers

Answer 16

After a 1-year duration:
* First episode, currently in acute episode
* First episode, currently in partial remission
* First episode, currently in full remission
* Multiple episodes, currently in acute episode
* Multiple episodes, currently in partial remission
* Multiple episodes, currently in full remission
* Continuous
* Unspecified

Other features:
* With catatonia

Severity

Question 17

Differentiation of schizophrenia from OCD and body dysmorphic disorder

Answer 17

Both sets of diagnoses can come with poor insight and reach delusional levels of preoccupation
* OCD and body dysmoprhic disorder are distinguishable by prominent obsessions, compulsions, preoccupations with appearance or odor, hoarding, or body-focused repetitive behaviours

Question 18

Differentiation of schizophrenia from other psychotic disorders

Answer 18

• Delusional disorder lacks other psychotic symptoms
• Brief psychotic and scchizophreniform disorder have different duration requirements
• Schizoaffective disorder requires a concurrent mood episode with active-phase symptoms, and mood symptoms to be present for most of the total duration of active phase

Question 19

Schizoaffective Disorder Diagnostic Criteria

Answer 19

A. Uninterrupted period of illness during which there is a major mood episode (depressed mood must be present if MDE) concurrent with Criterion A of schizophrenia
B. Delusions/hallucinations for ≥2 weeks in the absence of a major mood episode
C. Mood disorder episode symptoms are present for the majority of the active/residual portions of the illness
D. Not attributable to substances/medication/other medical condition

Question 20

Schizoaffective Disorder specifiers

Answer 20

Mood type:
* Bipolar type: If a manic episode is part of the presentation
* Depressive type

Other features:
* With catatonia

After 1-year duration:
* First episode, currently in acute episode
* First episode, currently in partial remission
* First episode, currently in full remission
* Multiple episodes, currently in acute episode
* Multiple episodes, currently in partial remission
* Multiple episodes, currently in full remission
* Continuous
* Unspecified

Severity

Question 21

Distinguishing Schizoaffective Disorder from schizophrenia or mood disorders with psychotic features

Answer 21

• Criterion B distinguishes from mood disorders: delusions/hallucinations are present for ≥2 weeks outside of mood episodes
• Criterion C distinguishes from schizophrenia: mood episodes are present for most of the active/residual phases of the illness

Question 22

Substance/Medication-Induced Psychotic Disorder Diagnostic Criteria

Answer 22

A. Presence of one/both of the following:
1. Delusions
2. Hallucinations

B. Evidence from history/examination/lab work of both of the following:
1. Symptoms developed during or soon after substance/medication intoxication/use/withdrawal
2. The involved substance/medication is capable of producing the symptoms

C. Not better explained by another psychotic disorder (i.e., symptom onset was before substance/medication use; symptoms persist ~1 month after medication/substance withdrawal; other evidence of the presence of a psychotic disorder)
D. Does not occur exclusively in the context of delirium
E. Causes clinically significanty distress/functional impairment

Diagnois should only be made instead of intoxication if psychotic symptoms predominate the clinical picture

Question 22

Substance/Medication-Induced Psychotic Disorder Diagnostic Criteria

Answer 22

A. Presence of one/both of the following:
1. Delusions
2. Hallucinations

B. Evidence from history/examination/lab work of both of the following:
1. Symptoms developed during or soon after substance/medication intoxication/use/withdrawal
2. The involved substance/medication is capable of producing the symptoms

C. Not better explained by another psychotic disorder (i.e., symptom onset was before substance/medication use; symptoms persist ~1 month after medication/substance withdrawal; other evidence of the presence of a psychotic disorder)
D. Does not occur exclusively in the context of delirium
E. Causes clinically significanty distress/functional impairment

Diagnois should only be made instead of intoxication if psychotic symptoms predominate the clinical picture

Question 23

Substance/Medication-Induced Psychotic Disorder specifiers

Answer 23

Onset:
* With onset during intoxication
* With onset during withdrawal
* With onset after medication use

Severity

Question 24

Psychotic Disorder Due to Another Medical Condition Diagnostic Criteria

Answer 24

A. Prominent hallucinations or delusions B. Evidence from history/examination/lab findings that symptoms are a direct pathophysiological consequence of the medical condition C. Not better explained by another mental disorder. D. Does not occur exclusively in the context of delirium. E. Causes clinically significant distress/functional impairment

Question 25

Psychotic Disorder Due to Another Medical Condition Specifiers

Answer 25

Code based on predominant symptom: * With delusions: If delusions are the predominant symptom * With hallucinations: If hallucinations are the predominant symptom Severity

Question 26

Catatonia Associated With Another Mental Disorder (Catatonia Specifier)

Answer 26

A. The clinical picture is dominated by ≥3 of the following: 1. Stupour (i.e., no psychomotor activity; not actively relating to the environment) 2. Catalepsy (i.e., passive induction of a posture held against gravity) 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner) 4. Mutism (i.e., no, or very little, verbal response [excluce if known aphasia]) 5. Negativism (i.e., opposition or no response to instructions or external stimuli) 6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity) 7. Mannerism (i.e., odd, circumstantial caricature of normal actions) 8. Stereotypy (i.e., repetitive, abnormally frequent, repetitive non-goal-directed movements) 9. Agitation, not influenced by external stimuli 10. Grimacing 11. Echolalia (i.e., mimicking another's speech) 12. Exchopraxia (i.e., mimicking another's movements)

Question 27

Catatonic Disorder Due to Another Medical Condition

Answer 27

A. The clinical picture is dominated by ≥3 of the following: 1. Stupour (i.e., no psychomotor activity; not actively relating to the environment) 2. Catalepsy (i.e., passive induction of a posture held against gravity) 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner) 4. Mutism (i.e., no, or very little, verbal response [excluce if known aphasia]) 5. Negativism (i.e., opposition or no response to instructions or external stimuli) 6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity) 7. Mannerism (i.e., odd, circumstantial caricature of normal actions) 8. Stereotypy (i.e., repetitive, abnormally frequent, repetitive non-goal-directed movements) 9. Agitation, not influenced by external stimuli 10. Grimacing 11. Echolalia (i.e., mimicking another's speech) 12. Exchopraxia (i.e., mimicking another's movements) B. There is evidence from history/examination/lab findings that symptoms are a direct pathophysiological consequence of another medical condition. C. Not better explained by another mental disorder (e.g., manic episode) D. Does not occur exclusively in the context of delirium. E. Causes clinically significant distress/functional impairment

Question 28

Unspecified Catatonia

Answer 28

* Applies to presentations in which catatonic symptoms cause clinically significant distress/functional impairment * The nature of the underlying mental disorder/other medical condition is unclear OR * Full criteria for catatonia are not met OR * Insufficient info to make a more specific diagnosis (e.g., in the emergency room)

Question 29

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

Answer 29

* Applies to presentations in which psychotic symptoms are present and cause clinically significant distress/functional impairment but do not meet criteria for one of the psychotic disorders. * "Other specified" is used if the clinician chooses to communicate why diagnostic criteria for another disorder aren't met * Examples of applicable presentations: * Persistent auditory hallucinations (in absence of other features) * Delusions with significant overlapping mood episodes (i.e., such that criterion stipulating only brief mood disturbance in delusional disorder is not met) * Attenuated psychosis syndrome: Psychotic-like symptoms that are below threshold for full psychosis (less severe, more transient, better insight, etc.) * Delusional symptoms in the context of a relationship with an individual with prominent delusions (i.e., taking on delusional beliefs of someone with a psychotic disorder without having other features present)

Question 30

Unspecified Schizphrenia Spectrum and Other Psychotic Disorder

Answer 30

* Applies to presentations in which psychotic symptoms cause clinically signficiant distress/functional impairment BUT * Do not meet full criteria for any of the disorders AND * The clinician chooses not to communicate why the presentation doesn't meet full criteria OR * There's not sufficient information for a more specific diagnosis (e.g., emergency room settings)