Accurate Diagnosis of Primary Psychotic Disorders The Care - PowerPoint PPT Presentation

Accurate Diagnosis of Primary Psychotic Disorders The Care Transitions Network National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies

Objectives • By the completion of this webinar, participants should understand that the diagnoses of primary psychotic disorders will change early in the course of illness. • Participants will understand that when mood and psychotic symptoms overlap, diagnosis can further change over the patient’s lifetime. • Participants will be be able to use DSM-5 criteria to diagnose primary psychotic disorders and schizoaffective disorder.

What diagnoses are on your differential? Think broadly.

Differential should Include … • Schizophrenia • Schizophreniform Disorder • Brief Psychotic Disorder • Delusional Disorder • Other Specified Psychotic Disorder • Unspecified Psychotic Disorder

Differential should exclude… Symptoms due to a medical condition or the effects of a medication or substance abuse Mood disorders with psychosis

The timeline of psychotic symptoms is crucial for distinguishing between schizophrenia-spectrum disorders

For r psychotic dis isorders, th the most accurate dia iagnosis can change as s sym ymptoms change over tim time Delusional Disorder Schizophreniform Unspecified Psychotic Schizophrenia Disorder Disorder Brief Psychotic Disorder

JANUARY FEBRUARY MARCH MAY JUNE APRIL Symptoms resolve Brief Psychotic Disorder Symptoms Delusional Disorder resolve Schizophreniform Disorder Schizophrenia 6 month mark 1 month mark

Also important for distinguishing schizophrenia-spectrum disorders are … ..the psychotic symptom domains … .the frequency & severity of symptoms

Schizophrenia

Schizophrenia 5 Negative Signs & Disorganized Signs Symptoms Grossly Disorganized or Catatonic 4 Behavior Disorganized 3 Speech ≥ 2/5 key symptom domains Each present for a significant portion of time during a 1 month Positive Symptoms period. (Or less if successfully 2 treated). Delusions At least one of these must be (1), (2), or (3) 1 Hallucinations

Schizophrenia 5 Negative Signs & Disorganized Signs Symptoms Grossly Disorganized or Catatonic 4 Behavior Disorganized 3 Speech For a significant portion of the time since the onset of the disturbance, level of functioning in ≥ 1 major area , is markedly Positive Symptoms below the level achieved prior to 2 onset Delusions Work Interpersonal Relations Self-care 1 Hallucinations

Schizophrenia 5 Negative Signs & Disorganized Signs Symptoms Grossly Disorganized or Catatonic 4 Behavior Disorganized 3 Speech When the onset is in childhood or adolescence , there is failure to Positive Symptoms achieve expected level of: 2 Interpersonal Delusions Academic, or Occupational functioning 1 Hallucinations

Schizophrenia 5 Negative Signs & Disorganized Signs Symptoms Grossly Disorganized or Catatonic 4 Behavior Disorganized 3 Speech If there is a history of autism or childhood-onset communication Positive Symptoms disorder … 2 Delusions …additional diagnosis of schizophrenia is made only if there are prominent delusions or hallucinations 1 Hallucinations

Schizophrenia 6 month mark Active Residual Symptoms Symptoms Prodromal Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL Continuous signs of disturbance persist for at least 6 months This includes at least 1 month of active-phase symptoms (or less if successfully treated) The 6 month period may include periods or prodromal or residual symptoms • May manifest as only negative symptoms • May manifest as ≥ 2 symptoms in attenuated form

Schizophrenia No Mood Episode here 6 month mark Residual Prodromal Active Symptoms Symptoms Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL • No major depressive or manic episodes have occurred concurrently with the active-phase symptoms → Depressive or Bipolar disorder with psychotic features has been ruled out

Schizophrenia Mood Episode 6 month mark Residual Prodromal Active Symptoms Symptoms Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL Or • Mood episodes have occurred concurrently with active-phase symptoms (but have been present for a minority of the total duration of the active and residual periods of illness) → Schizoaffective disorder has been ruled out

Schizoaffective Disorder Requirement #1 5 4 An unin interrupted peri riod of of ill illness ss during which there is both…. 3 These criteria are ≥ 2/5 key symptom domains the same as for Major Mood Episode + schizophrenia Each present for a significant portion of (Major depressive or time during a 1 month period. (Or less if successfully treated). manic) At least one of these must be (1), (2), or 2 (3) *If major depressive, must include depressed mood 1

Schizoaffective Disorder Requirement #2 Durin ring th the lif lifetime duration of of th the illn illness, a period of ≥ 2 weeks with both…. Major Mood Episode + Delusions The absence of a or 2 Hallucinations 1

Schizoaffective Disorder Requirement #3 Mood Episode 6 month mark Residual Prodromal Active Symptoms Symptoms Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL • Major Mood episodes have been present for the majority of the total duration of the active and residual periods of illness.

Schiz izoaffectiv ive Dis isorder ▪ The disturbance is not attributable to the effects of a substance or another medical condition.

Schizoaffective disorder At least 2 weeks of Mood Episode delusions or hallucinations in 6 month mark absence of mood Residual Prodromal episode Active Symptoms Symptoms Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL Major mood episodes have occurred concurrently with active-phase symptoms (and have been present for a majority of the total duration of the active and residual periods of illness)

Schizophreniform Disorder The criteria are the same as for schizophrenia except for … … there is a shorter duration of illness, and … functional decline is not necessary for the diagnosis

Schizophreniform Disorder 5 Negative Signs & Disorganized Signs Symptoms Grossly Disorganized or Catatonic 4 Behavior Disorganized 3 Speech ≥ 2/5 key symptom domains These criteria are Each present for a significant portion of the same as for time during a 1 month period. (Or less if successfully treated). schizophrenia Positive Symptoms 2 At least one of these must be (1), (2), or (3) Delusions 1 Hallucinations

Schizophreniform Disorder Symptoms Resolve 6 month mark Residual Active Symptoms Prodromal Symptoms Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL An episode lasts at least 1 month but less than 6 months Reminder: for schizophrenia, continuous signs of disturbance persist for at least 6 months

Provisional Schizophreniform Disorder Symptoms have not yet 6 month mark resolved Active Residual Symptoms Symptoms Prodromal Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL An episode lasts at least 1 month but less than 6 months When a diagnosis must be made without waiting for recovery, it should be qualified as “provisional”

No Mood Episode here Symptoms Schizophreniform Disorder Resolve Active 6 month mark Residual Symptoms Symptoms Prodromal Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL Provisional Schizophreniform Disorder Active Residual Symptoms Symptoms Prodromal Symptoms No Mood Episode here Symptoms Either have not yet • No major depressive or manic episodes have resolved occurred concurrently with the active-phase symptoms → Depressive or Bipolar disorder with psychotic features has been ruled out

Schizophreniform Disorder Symptoms Mood Episode Resolve Active 6 month mark Residual Symptoms Symptoms Prodromal Symptoms JANUARY FEBRUARY MARCH MAY JUNE APRIL Mood Episode Provisional Schizophreniform Disorder Active Residual Symptoms Symptoms Prodromal Symptoms Or Symptoms • Mood episodes have occurred concurrently have not yet with active-phase symptoms (but have been resolved present for a minority of the total duration of the active and residual periods of illness) → Schizoaffective disorder has been ruled out

Brief Psychotic Disorder The essential feature of brief psychotic disorder is the sudden onset of at least one of the positive or disorganized symptoms .

Brie ief Psychotic Dis isorder ▪ Sudden onset is defined as change within 2 weeks from a non- psychotic state to a clearly psychotic state, usually without a prodrome. ▪ Although the disturbance is brief, the level of impairment may be severe.

Brie ief Psychotic Dis isorder ▪ The criteria for brief psychotic disorder differ from that of schizophrenia and schizophreniform disorder based on … … fewer symptoms required … there is shorter duration of illness, and … like schizophreniform, but unlike schizophrenia, functional decline is not necessary for the diagnosis