Psychotic Disorders & Schizophrenia

Neurodevelopmental Disorders

• Significant global intellectual impairment results in a full-scale IQ of 75, with a persistent reading deficit and mild impairment in adaptive functioning, leading to a diagnosis of Major Neurocognitive Disorder due to Traumatic Brain Injury.

Diagnosis of Global Developmental Delay

• A diagnosis of global developmental delay is inappropriate when the patient's scores on psychometric tests suggest intellectual disability, but there is insufficient information about adaptive functional skills.
• The diagnosis is typically made in children younger than 5 years of age, and the etiology can usually not be determined.

DSM-5 Introduction

• DSM-5 has moved to a non-axial documentation of diagnosis, replacing the multiaxial system in DSM-IV.
• The Global Assessment of Functioning (GAF) Scale (DSM-IV Axis V) is no longer a separate category and should not be coded in DSM-5.
• DSM-5 replaced the "not otherwise specified" (NOS) designation with two options for clinical use: Other Specified [disorder] and Unspecified [disorder].

Autism Spectrum Disorder

• Symptoms of autism spectrum disorder include deficits in nonverbal communicative behaviors, restricted and repetitive patterns of behaviors, and social and communication impairments.
• A 15-year-old boy with a long history of nonverbal communication deficits, odd speech tonality and phrasing, and awkward body language may be diagnosed with autism spectrum disorder.
• A 10-year-old boy with hand-flapping, finger flicking, repetitive behaviors, and restricted interests may also be diagnosed with autism spectrum disorder.

Speech Sound Disorder

• A 4-year-old boy who struggles with speech articulation and has a normal IQ may be diagnosed with a speech sound disorder.
• A 6-year-old boy who struggles with grammar, sentence construction, and vocabulary, and interjects "and" between words, may be diagnosed with a language disorder or an expressive language disorder.

Psychotic Disorders

• DSM-5 criteria for childhood-onset fluency disorder (stuttering) no longer include disturbance in normal speech fluency/time patterning.
• Psychotic symptoms that persist for a substantial period after cessation of severe intoxication or acute withdrawal may be diagnosed as substance/medication-induced psychotic disorder.
• A 55-year-old man with a history of alcohol dependence and schizophrenia who is brought to the emergency department with frank delusions and visual hallucinations may have a diagnosis of schizophrenia, substance/medication-induced psychotic disorder, or psychotic disorder due to another medical condition.

Schizophrenia Spectrum and Other Psychotic Disorders

• Psychotic disorder associated with systemic lupus erythematosus is an example of a psychotic disorder due to another medical condition.

Diagnostic Criteria

• Brief psychotic disorder is not diagnosed if the psychotic symptoms have lasted for less than 1 month but have not yet remitted.
• Postpartum psychosis that does not meet criteria for a depressive or bipolar disorder with psychotic features, brief psychotic disorder, psychotic disorder due to another medical condition, or substance/medication-induced psychotic disorder is classified as "other specified schizophrenia spectrum and other psychotic disorder".

Psychotic Symptoms

• Hearing a voice that tells someone they are a special person is an example of a psychotic symptom.
• Believing one is being followed by a secret police organization is an example of a psychotic symptom.
• Flashbacks to a war experience that feel like they are happening again are not necessarily psychotic symptoms.
• Disorganized speech and stopping responding in the middle of an interview can be indicative of psychotic symptoms.

Disorders with Psychotic Symptoms

• Bipolar and depressive disorders can have psychotic symptoms.
• Substance use disorders can have psychotic symptoms.
• Posttraumatic stress disorder can have psychotic symptoms.
• Psychotic symptoms can occur during a period of sustained substance abstinence.

Diagnostic Possibilities

• A 55-year-old man with a history of alcohol dependence and schizophrenia who presents with delusions and hallucinations could be diagnosed with schizophrenia, substance/medication-induced psychotic disorder, or psychotic disorder due to another medical condition.

Substance/Medication-Induced Psychotic Disorder

• Specifiers for substance/medication-induced psychotic disorder include "with onset during intoxication" and "with onset during withdrawal".

Schizoaffective Disorder

• Schizoaffective disorder is less common than schizophrenia.
• A 30-year-old woman who experiences auditory and persecutory delusions followed by a major depressive episode with suicidal ideation could be diagnosed with schizoaffective disorder.
• The incidence of schizoaffective disorder is higher in women than in men.

Schizophrenia Spectrum and Other Psychotic Disorders

• Brief Psychotic Disorder: lasts for at least 1 day and remits by 1 month.
• Delusional Disorder: characterized by at least 1 month of delusions.
• Schizophreniform Disorder: lasts for less than 6 months.
• Schizophrenia: lasts for at least 6 months.
• Schizoaffective Disorder: meets Criterion A for Schizophrenia and has a major mood episode;
  • delusions or hallucinations must be present for at least 2 weeks without a major mood episode.