Schizophrenia Disorder DSM-5 295.90 (F20.9)

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DSM-5 Category: Schizophrenia Spectrum and Other Psychotic Disorders

Introduction

The DSM -5 describes Schizophrenia in terms of a severe, chronic, and potentially disabling thought disorder.(American Psychiatric Association, 2013). It has a robust genetic component, tends to appear during young adulthood, and is typically marked by periods of remission and relapse throughout the lifespan. Lack of medication compliance is a primary reason for relapse (Battaglia, 2014; Masand, Roca, Turner, & Kane, 2009).Anti-psychotic meds, especially older first and second generation meds produce nearly intolerable side effects in most individuals, so people are resistant to taking them. Newer atypical agents produce superior symptom management with fewer side effects, but this can lead to the conundrum of persons with schizophrenia discontinuing medication against medical advice because they believe they are “cured”.

Symptoms of Schizophrenia

According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) Schizophrenia is a disorder in which a person will experience gross deficits in reality testing, manifested with at least two or more the following symptoms, which must be present for at least one month (unless treatment produces symptom remission):

At least one symptom collectively referred to as positive symptoms: must be in categories 1, 2, or 3,

  1. Delusions- strange beliefs and ideas which are resistant to rational/logical dispute or contradiction from others.
  2. Hallucinations- typically auditory, or less frequently, visual.
  3. Disorganized Speech- incoherence, irrational content.
  4. Disorganized or Catatonic behavior- repetitive, senseless movements, or adopting a pose which may be maintained for hours. The individual may be resistant to efforts to move them into a different posture, or will assume a new posture they are placed in.
  5. Negative symptoms- flat affect, amotivation, anergia, failure to maintain hygiene (American Psychiatric Association, 2013).

1. Marked reduction in level of functioning in one or more areas, such as occupational, social, or personal care or hygiene . If symptom onset occurs during childhood or adolescence, there is inability to reach age-typical functioning in academic, social or interpersonal areas. 2. Symptoms must persist at least six months, during which at least one month of symptoms (unless treatment produces symptom remission) meet the criteria for positive symptoms and may include periods of prodromal or residual symptoms. During prodromal or residual periods, the signs of the disturbance may be manifested by negative symptoms or by two or more positive symptoms present in a less prominent form (e.g.,unusual beliefs or perceptions). 3.Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out. 4 The psychotic episode cannot be attributed to substance use (ethanol withdrawal, cocaine abuse) or a medical condition. 5. If autism spectrum disorder or a communication disorder of childhood onset has been previously diagnosed, the diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other symptoms of schizophrenia, are present for at least one month, excluding successful treatment (American Psychiatric Association, 2013).

If symptoms have persisted for one year, and if there are no contradictory diagnostic criteria, the clinician may include specifiers:

1. First episode, currently in acute episode: First apparent onset of the disorder as defined by the above diagnostic criteria. 2. First episode, currently in partial remission: First apparent onset of the disorder with a period of improvement in which the symptoms are only partially present. 3. First episode, currently in full remission: Absence of apparent symptoms after a first episode. 4. Multiple episodes, currently in acute episode: 5. Two or more episodes, current one acute. 6. Multiple episodes, currently in partial remission

7. Multiple episodes, currently in full remission 8. Continuous: maintenance of symptoms fulfilling the diagnostic symptom criteria for the majority of time. 8. Unspecified- With catatonia 9. Current severity: Severity can be rated by a quantitative assessment of positive and negative symptoms on a Five point Likert scale for the previous seven days- e.g.- zero- absent to Four, present and severe. (American Psychiatric Association, 2013).

Onset

The DSM -5 reports that Schizophrenia symptoms typically become apparent at ages 18- 35, Onset prior to adolescence is rare. The peak age at onset for the first psychotic episode is in the 20-25 for males and 26 and up for females Onset may be abrupt, appearing virtually overnight, or insidious, unfolding over several weeks or months. Depressive symptoms are reported in about 50% of cases. (American Psychiatric Association, 2013).

Prevalence

The prevalence of schizophrenia is about one percent of the general population. (American Psychiatric Association, 2013).

Risk Factors

Birth month has been correlated with schizophrenia, specifically late winter through early spring, which is also the flu season. Maternal influenza during the third trimester has been implicated as causal in schizophrenia (Brown & Patterson, 2011). Their is a higher incidence of schizophrenia in urban areas and some minority ethnic groups. Other genetic factors correlated with risk for schizophrenia include: pregnancy/labor complications with hypoxia, an older father, stress, infection, malnutrition, and maternal diabetes. The DSM -5 notes these factors are inconclusive as far as causality (American Psychiatric Association, 2013).

Comorbidity

There is a high rate of comorbidity with chemical dependency, people with Schizophrenia tend to self medicate, with ethanol and illicit drugs in an effort to relieve psychotic symptoms. They are heavy users of tobacco products as well (Hanson, 2012). There is comorbidity with anxiety disorders. Schizotypal or paranoid personality disorder may sometimes precede the onset of schizophrenia, but it could be speculated that they are not predictive discrete disorders, but rather unrecognized or misdiagnosed early onset symptoms. Persons with schizophrenia tend to have poor self care, and neglect medical and dental care. The DSM-5 notes life span is often abbreviated in individuals with schizophrenia because of comorbid medical conditions. Inability to maintain a healthy weight, and rates of adult onset diabetes, COPD ( Chronic Obstructive Pulmonary Disease) Emphysema, hypertension, and CHD ( Coronary Heart Disease) as well as dental caries are higher in people with  schizophrenia compared to the general population (American Psychiatric Association, 2013).

Treatment Options for Schizophrenia

Social skills training, (Diamond, 2012) , and case management, including instruction in ADL's (Adult Daily Living Skills) are needed to improve and maintain quality of life for persons with schizophrenia. In addition to pharmacological interventions. CBT (Cognitive Behavioral Therapy) is also indicated according to some studies, but this remains inconclusive (Morrison and Gillig, 2009).

Impact on Functioning

Without proper treatment, people with Schizophrenia do not enjoy a high quality of life. They are typically unable to complete advanced or or in some cases, minimal education. (American Psychiatric Association, 2013).They have difficulty acquiring and maintaining employment, and tend to work a series of menial low paying jobs, or find employment through supported employment, non-competitive environment through mental health agencies. (Diamond, 2012) They tend to have limited social contacts, or their primary social circle are others with severe and chronic mental illness.

Outcomes

Most individuals with schizophrenia will require lifelong daily living supports, and many remain chronically ill, with waxing and waning of symptoms, while others have a course of progressive deterioration. Psychotic symptoms tend to diminish with aging, possibly due to age-related declines in dopaminergic activity. (American Psychiatric Association, 2013).Negative symptoms tend to be more persistent. This may be due to the involvement of other neurotransmitter systems, specifically the adrenergic systems and GABA systems (Jagadeesh & Natarajan, 2013). With proper support and treatment, the impact on functioning can be minimized, and competitive employment and self care with minimal intervention - e.g.- a supported apartment program in which staff from a mental health agency visit weekly or daily to provide needed supports.

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Battaglia, J. (2014). Compliance with medication. Medscape multispeciality. Retrieved February 22, 2014, from: http://www.medscape.org/viewarticle/418612

Morrison, A.K., Gillig, P. M. (2009). Cognitive Behavior Therapy for People with Schizophrenia. 6 (12): 32–39. PMCID: PMC2811142.

Brown, A.S., Patterson, P.H. (2011). Maternal Infection and Schizophrenia. Implications for Prevention. Schizophrenia Bulletin .37(2):284-290.

Hanson, D. (2012). Smoking’s Ties to Schizophrenia. The Dana Foundation. Retrieved February 22, 2014, from: http://dana.org/News/Details.aspx?id=43220

Jagadeesh , S. J and Natarajan, S. . (2013). Schizophrenia: Interaction between Dopamine, Serotonin, Glutamate, GABA and Norepinephrine. Research Journal of Pharmaceutical, Biological and Chemical Sciences (4). 4. 267. Retrieved:February 22, 2014, http://www.rjpbcs.com/pdf/2013_4%284%29/%5B135%5D.pdf

Masand, P.S.,Roca,, M., Turner, M.S., and Kane, J.M. (2009). Partial Adherence to Antipsychotic Medication Impacts the Course of Illness in Patients With Schizophrenia: A Review Primary Care Companion Journal of Clinical Psychiatry.11(4):147–154. doi: 10.4088/PCC.08r00612 PMCID: PMC2736032

NAMI. ( 2013). What is Schizophrenia. Retrieved February 22, 2014, from: http://www.nami.org/factsheets/schizophrenia_factsheet.pdf

Ronald J Diamond, R.J. (2012). Wisconsin Public Psychiatry Network Teleconference Social Skill Training for People with Schizophrenia. Retrieved February 22, 2014, from http://www.dhs.wisconsin.gov/mh_bcmh/docs/confandtraining/2012/9-27-12SkillTraining6SlidesPerPage.pdf


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