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Schizophrenia
Diagnostic criteria
Must have two of the following (including 1, 2, or 3)
1) Delusions
2) Prominent hallucinations
3) Disorganized speech
4) Grossly disorganized or catatonic behavior
5) Negative symptoms (i.e. affective flattening, alogia, or avolition)
2 of 5 criteria
Subtypes of Schizophrenia
1) Paranoid
a. Most common (40%)
b. Prominent, well-formed delusions
2) Disorganized
a. Problems in thinking and communicating
3) Catatonic
4) Undifferentiated type
a. Prominent hallucinations
4 of these
Schizophreniform disorder definition
Typical symptoms of schizophrenia (prodromal, active, and residual) present < 6 months
Positive/negative symptom dichotomy of Schizophrenia
· Positive: those of active psychosis
o Common, but not specific to schizophrenia
· Negative: more pathognomonic of schizophrenia
Pathophysiology of schizophrenia
Based on specific observations
o Positive vs. negative symptom dichotomy
Psychotic Disorders
Benjamin Rosenbaum
Page 3 of 7 October 2005
o Dopamine hypothesis: dopamine agonists tend to worsen sx, antagonists
improve
Schizophrenia general definition
Disorders of thought, behavior, and emotional responsiveness
Progressive deterioration after the onset of symptoms (psychological and social)
Delusional Disorder general definition
Presence of delusions without hallucinations or psychosocial impairment
Delusional disorder diagnostic criteria
1) Nonbizarre delusions = 1 month duration
a. Real life events
2) Not met “criterion A” for schizophrenia
3) Functioning not markedly impaired
4) Behavior not obviously odd or bizarre
Delusional disorder Subtypes
1) Erotomanic (deClerambault’s Syndrome)
a. In love with secretary
2) Grandiose
a. Inflated status or relationship with God or famous person
3) Jealous
a. Sexual partner is unfaithful
4) Persecutory
a. Being treated malevolently
5) Somatic
a. Have some defect or disease
6) Unspecified
a. Capgras’ Syndrome: People replaced by identical impostors
b. Lycantrhopy: You are a werewolf
c. Fregoi’s Phenomenon: Persecutor changes faces or makeup
d. Cotard’s Syndrome: Lost everything
Schizoaffective Disorder General Definition
Psychotic sx consistent with schizophrenia coexisting with sx of depression
and/or mania
Schizoaffective diagnostic criteria
1) Major depressive or manic syndrome concurrent with “A criterion of
schizophrenia”
2) Delusions or hallucinations > 2 weeks, but no mood symptoms
3) Schizophrenia ruled out
Schizoaffective Disorder Subtypes
Subtypes
1) Bipolar
a. Cycles of depression and mania. Good prognosis.
2) Depressive
a. Poorer prognosis
Brief Psychotic Disorder general definition
· Impaired reality testing (hallucinations or delusions) lasting < 1 month
Brief Psychotic disorder diagnostic criteria
1) Presence of at least one:
a. Hallucinations
b. Delusions
c. Disorganized speech (severely)
d. Disorganized or catatonic behavior
2) Duration: 1 day – 1month
3) Not due to another disorder, substance, medical condition
Brief Psychotic disorder Subtypes
1) With marked stressors
2) Without market stressors
3) Postpartum onset
Brief psychotic episode predisposing factors
· Low SES
· Young age
· Disasters
· Culture shock
· Personality disorders
Shared Psychotic Disorder description and diagnostic criteria
Presence of delusions that grow out of close relationship with another delusional
person
Diagnostic criteria
1) Delusion develops in context of close relationship w/ someone with established
delusion
2) Delusion in second person is similar to the primary case
Depression Diagnostic Criteria
Diagnostic Criteria
· Sx cause significant distress/impairment in social, occupation, etc functioning
· Five of the following for = 2 weeks (must include 1, 2)
1) Depressed mood*
2) Loss of interest or pleasure (anhedonia)*
3) Significant weight/appetite loss/gain (= 5 pounds)
4) Sleep disturbance (hypo/hyper)
5) Psychomotor agitation or retardation
6) Fatigue or loss of energy
7) Feeling worthless or excessive/inappropriate guilt
8) ? ability to think/concentrate
9) Thoughts of death/suicide/etc
Subtypes of Depression
1) Melancholic
a. Prominent physical features
2) Atypical
a. “atypical features”
3) Seasonal
a. Exclusive and repeatable
b. Same time of year for = 3 consecutive years
4) Chronic
a. Present continuously for = 2 years
5) Psychotic
6) Postpartum
a. Within four weeks of delivery
Depression Presentation in primary care
· Typically not mood complaints
· Typically physical sx: fatigue, sleep, weight, pain, bowel*, memory*
o *common in elderly
· Multiple vague or repeated complaints
· Keep your eyes out
Depression Differential Diagnosis
Differential diagnosis
1) Endocrine
a. Hypothyroidism
b. Cushing’s Disease
c. Menstrual
i. Premenstrual dysphoric disorder (PMS)
ii. Menopause
d. Post-partum
2) Neurologic
a. Parkinsons Disease
b. Post-CVA
c. Huntington’s Disease
3) Other
a. Post-MI, CABG
b. HIV/AIDS
c. CT diseases
d. Pancreatic cancer
e. Porphyria
Drugs causing depression
· Antihypertensives
· Sedatives and tranquilizers
· Alcohol
Depression Course
· Most commonly chronic and relapsing
· Progressively more severe and frequent
· Risk of more episodes ? with each subsequent episode
o Some increasingly resistant to treatment
· Treatment: cognitive-behavioral psychotherapy
Bipolar Disorder general definition
“manic-depressive illness”
· Typified by periods when mood is abnormally high and expansive interspersed
with periods of typical depression
Bipolar Diagnostic criteria
1) Cycling episodes of mania and depression
2) Mania sx:
a. Inflated self-esteem or grandiosity
b. Decreased sleep need
c. More talkative
d. Flight of ideas (or “thoughts are racing”)
e. Distractible
f. Increased goal-oriented behavior
g. Excessive involvement in pleasurable activities (spending sprees, sex,
driving fast)
3) Mood disturbance sufficiently severe to impair occupational/social/relationship;
need hospitalization; or psychotic features
Subtypes of bipolar disorder
1) Bipolar I
a. Classic. History of full manic and depressive episodes
2) Bipolar II
a. History of hypomania and full depressive episodes
3) Mixed
Differential for bipolar disorder
1) Seizure disorders
2) Huntington’s disease
3) CNS infections (HIV, neurosyphillis)
4) Multiple sclerosis
5) Central neoplasm
6) Post-partum
7) CVA (especially right cortex)
Drugs causing mania
· Stimulants: cocaine, ephedrine
· Dopamine agonists: L-DOPA
· Corticosteroids
· Antidepressants
List of Mood/Affective disorders
Depression & Bipolar
DSM IV Anxiety Disorders
· Generalized
· Adjustment disorder with anxious mood
· OCD
· Acute stress disorder
· Posttraumatic stress disorder
· Specific phobia
· Social phobia
· Panic disorder/Agoraphobia
Anxiety Disorder due to Medical Condition Diagnostic Criteria
1) Prominent anxiety, panic attacks, or obsessions/compulsions
2) Evident that the disturbance is consequence of medical condition
(physiologically)
3) Not better accounted for by another mental disorder
4) Not exclusively during delirium
5) Significant distress/impairment socially, occupationally, etc
Specifiers of Anxiety Disorder due to Medical Condition
· With generalized anxiety
· With panic attacks
· With obsessive-compulsive sx
Anxiety Disorder due to Medical Condition
1) Cardiovascular à infarction
2) Pulmonary à COPD, asthma
3) Neurological à vertigo, MS
4) Neoplastic à pheochromocytoma
5) Endocrine à thyroid, Cushing’s, menopause, PMS
6) Substance abuse
7) Concomitant with other psychiatric disorders à affective disorders (esp.
depression)
Adjustment Disorder with Anxious Mood general definition
· Characterized by persistent, high anxiety w/o physical cause associated w/ worry,
vigilance, and autonomic hypereactivity
· Emotional reaction to a stressor that is maladaptive in intensity and duration
Adjustment Disorder with Anxious Mood Diagnostic criteria
1) Sx in response to an identifiable stressor w/in 3 months of onset
2) The sx are clinically significant as evidence by:
a. Distress in excess of what’s expected
b. Significant impairment in normal functioning
3) Does not meet criteria for another Axis I disorder
4) Sx do not represent bereavement
5) One stressor (or consequences terminated), sx do not persist for more than 6
months
6) Acute < 6 months; chronic > 6 months
Generalized Anxiety Disorder general definition
· Characterized by persistent, high anxiety w/o physical cause associated w/ worry,
vigilance, and autonomic hypereactivity
· Persistent anxiety related to worry about life issues (marriage, work, finances,
family)
· Shares many features with depression
Generalized Anxiety Disorder diagnostic criteria
1) Excessive anxiety = 6 months about a number of events/activities
2) Three or more of following (notice similarity to depression)
a. Restlessness (feeling keyed up on edge)
b. Easily fatigued
c. Difficulty concentrating
d. Irritability
e. Muscle tension
f. Sleep disturbance
3) Not another disorder
4) Significant normal impairment
5) Not due to substance or medical conditions
Obsessive-compulsive disorder (OCD) general definition
· Recurring obsessive thoughts and/or compulsive behaviors that are timeconsuming
and impair normal functioning
Obsessive-compulsive disorder (OCD) diagnostic criteria
1) Obsessions or compulsions
a. Obsessions
i. Recurrent and persistent thoughts or impulses
ii. Not simply excessive worries about life problems
iii. Person attempts to ignore or neutralize them w/ other thoughts
iv. Person recognizes thoughts are product of own mind (i.e. not
psychotic)
b. Compulsions
i. Repetitive behaviors
ii. Behavior/acts aimed at preventing/reducing distress or preventing
some catastrophic event
2) Person recognizes sx are excessive/unreasonable
3) Cause distress, are time consuming (> 1 hr/day), or significantly affect normal
functioning
OCD differential
1) Eating obsessions or compulsions
2) Body dysmorphic disorder
a. Obsessive preoccupation with perceived body defect
b. Do not recognize that worry is excessive or unreasonable
3) Monosymptomatic hypochondriasis
4) Bowel and urinary obsessions
5) Tourette’s syndrome
a. Probably genetic relationship with OCD
6) Trichotillomaina
a. Compulsive hair-pulling
Post-traumatic Stress Disorder (PTSD)
[acute stress disorder] general descrition
· A reaction to a stressor that is out of the normal range of human experience
· Involves a maladaptive process of managing the memories of the event(s)
Post-traumatic Stress Disorder (PTSD)
[acute stress disorder] diagnostic criteria
1) Exposure to a traumatic event:
a. Experienced, witnessed, or confronted with events that involved
actual/threatened death, serious injury, or threat to physical integrity
b. Response involved intense fear, helplessness, or horror
2) Traumatic event persistently re-experienced in = 1 of the following ways:
a. Recurrent and intrusive distressing recollections of the events
b. Recurrent distressing dreams of the event
c. Acting/feeling like event was recurring
d. Intense distress/reactivity at exposure to cues that symbolize/resemble an
aspect of the event
3) Persistent avoidance of stimuli associated with the trauma or numbing of
general responsiveness, indicated by = 3 of the following:
a. Efforts to avoid thoughts/feelings associated with the trauma
b. Efforts to avoid activities, places, or people that arouse recollections
c. Inability to recall an important aspect of the trauma
d. ? interest/participation in significant activities
e. Feelings of detachment from others
f. Restricted range of affect
g. Sense of foreshortened future
4) Persistent symptoms of increased arousal, by = 2 of the following:
a. Difficulty falling/staying asleep
b. Irritability or outbursts of anger
c. Difficulty concentrating
d. Hypervigilance
e. Exaggerated startle response
5) Duration of = 1 month
PTSD contributing factors
· Severity and duration of stressor
· Age of victim (young and old especially sensitive)
· Physical trauma
· Pre-existing psychiatric disorder or substance abuse
Phobic Disorders general definition
1) Marked and persistent fear that is excessive or unreasonable—cued by
specified object or situation
2) Exposure to stimulus provokes immediate anxiety response
3) Stimulus avoided or endured with intense anxiety
4) Anxiety/avoidant behavior interferes with normal
social phobia diagnostic criteria
1) Persistent fear of = 1 situation(s) where person is exposed to unfamiliar people
or possible scrutiny by others and fears that person will do something/act or
show anxiety sx that will be humiliating or embarrassing
2) Exposure to stimulus provokes immediate anxiety response
3) Recognizes fear is excessive/unreasonable
4) Situation avoided or endured with intense anxiety
5) Anxiety/avoidance interferes with normal
Panic Disorders / Agoraphobia general definition
· Recurring, severe anxiety attacks that may result in avoidance behavior
Panic Disorder – Diagnostic criteria
1) Recurrent, unexpected panic attacks: a discreet period of intense fear or
discomfort, in which = 4 of the following develop abruptly and peak w/in 10
minutes (think of what happens when you avoid car accident…)
a. Palpation, pounding heart, ? HR
b. Sweating
c. Trembling/shaking
d. Sensations of shortness of breath/smothering
e. Feeling of choking
f. Chest pain/discomfort
g. Nausea or abdominal distress
h. Feeling dizzy, unsteady, lightheaded, or faint
i. Derealization or depersonalization (out of body experience)
j. Fear of losing control or going crazy
k. Fear of dying
l. Paresthesisas (numbness or tingling)
m. Chills or hot flashes
2) At least one of the attacks followed by = 1 month of one of the following:
a. Persistent concern about having additional attacks
b. Worry about the implications of the attack or its consequences
c. Significant change in behavior related to attacks (avoidance)
Panic Disorder with Agoraphobia – Diagnostic criteria
2) Presence of agoraphobia
a. Anxiety about being in places or situation from which escape might be
difficult or in which help may not be available in the event of having a
panic attack
3) Situations avoided or endured with distress/anxiety about having panic attack or
require presence of a companion
A
goraphobia Without History of Panic Disorder– Diagnostic criteria
1) Meets criteria for Agoraphobia
2) Has never met criteria for panic disorder
Stages of Panic/Agoraphobia
1) Limited symptom attacks (i.e. mild panic)
2) Followed by full-blown panic attack
3) “Help-seeking”
a. Visits EDs / physicians
4) Limited phobias develop
5) Social phobias develop
6) Extensive phobic avoidance
7) Demoralized / depression