Unspecified Schizophrenia Spectrum and Other Psychotic Disorder DSM-5 298.9 (298.9) (298.9)

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DSM-5 Category: Psychotic Disorder

Introduction

USS & OPD (Unspecified Schizophrenia Spectrum and Other Psychotic Disorder) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who are experiencing symptoms of schizophrenia or other psychotic symptoms, but do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder. The symptoms cause distress, and impair functioning in social, occupational, or other major areas of functioning. The diagnosis can be assigned when the clinician decides not to specify the reason the diagnostic criteria are unmet, or if there is insufficient information available at the time of the evaluation to make a more specific diagnosis (American Psychiatric Association, 2013). This diagnosis could be applied, for example, if the patient is experiencing visual hallucinations, but does not describe or present with any other psychotic symptoms, or deficits in reality testing. This diagnosis could also be applied in the event of a patient with one or more psychotic symptoms, but there is insufficient history or collateral information available at the time of the evaluation to make a more specific diagnosis.

Symptoms of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

According to the DSM-5, (American Psychiatric Association, 2013), the symptoms of a psychotic disorder are primarily characterized by gross deficits in reality testing. The individual is experiencing a rift in perception of objective reality. This is typically manifested as hallucinations, which can be in any part of the sensorium, but are most frequently expressed as auditory, or less frequently, visual. The individual will be experiencing delusions, which will be almost impervious to logical or rational counterpoint, and are typically of a paranoid, somatic, or persecutory nature. (American Psychiatric Association, 2013). A delusion has little or no grounding in objective reality, and in a psychotic individual, is typically centered on a grandiose, persecutory, or somatic theme. These symptoms will be distressing. The individual will feel typically fear, confusion, may panic, and will be distracted and preoccupied by their internal dialogue. They will have difficulty functioning and completing required tasks of daily living. However, in the case of USS & OPD, the symptoms are not present in sufficient quantity or severity for a diagnosis of Schizophrenia, but are too enduring for Brief Psychotic Disorder (American Psychiatric Association, 2013).

There are a number of considerations when diagnosing psychosis:

  • The clinician’s awareness of other cultural norms, which may be misinterpreted as pathological.
  • The causality of the psychosis, as many conditions, including substance use can induce psychotic symptoms.
  • Knowledge of risk factors for schizophrenia, as opposed to indicators of substance abuse.
  • The comorbidity of psychosis and substance abuse- sometimes there is dual causality.
  • The shame and stigma that is associated with schizophrenia and other psychotic disorders- the patient may be deliberately withholding or minimizing symptoms- this can also apply to family/associates that are in denial of the severity of the problem.
  • Unreliable self- report due to cognitive impairment.

Another consideration is that in a forensic setting, malingering for secondary gains must be explored. An expansion of the criteria for pathology, or a vague definition of pathology, can create more opportunity for malingering. A malingering patient may use this as an opportunity to minimize criminal culpability. This could also be used to avoid general adult life responsibilities by seeking disability benefits for a condition that does not exist.

Risk Factors for Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

The risk factors for USS & OPD are not specified in the DSM-5 (American Psychiatric Association, 2013). The risk factors will vary depending on the exact causality of the psychotic symptoms.

Onset of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Typically, the onset of psychotic symptoms or first time schizophrenic episode occurs in the late teens or early twenties (American Psychiatric Association, 2013). It is possible that USS & OPD are early indicators of a first time psychotic break which the clinician is not recognizing as such (See Differential Diagnosis). There is also evidence that subclinical psychotic symptoms may progress to a clinical level (Dominguez, Wichers, Lieb, Wittchen, and Os, 2011). The definition of subclinical can be ambiguous, in that there will be individual differences in anxiety tolerance for emergent psychotic symptoms. Factors in resistance to reporting symptoms can be shame, fear of involuntary commitment, or concerns about social perception, or reputation. This could be especially true in the event of insidious-onset schizophrenia, where psychotic symptoms unfold over a period of months, with day-to-day waxing and waning, but with overall gradually increasing intensity. The question is at what point the patient will find the symptoms distressing enough so they can no longer tolerate them, and will present for treatment. The psychotic symptoms may not be fully expressed at the time of evaluation to meet specific diagnostic criteria. However, if they produce distress sufficient for a patient to present for assistance, or to impair functioning, they are clinically significant (Large, Sharma, Compton, Slade, and Nielssen, 2011).

Differential Diagnosis in Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

The clinician must be knowledgeable of, and skilled at recognizing subtle variations in the hallucinatory or delusional content of a patient to make an accurate diagnosis. A thorough history, collateral information from associates, and the collaboration of medical staff providing a urine toxicology screen or neurological exam may be indicated as well. Psychotic symptoms can result from multiple causes:

  • Schizophrenia- A clinician may be seeing emergent symptoms of schizophrenia, or schizophrenia with an insidious onset. In addition to positive symptoms, negative symptoms, e.g., social withdrawal, apathy, neglect of hygiene, and loss of motivation- should be noted as potentially diagnostic of the onset of schizophrenia.
  • Manic state of bipolar disorder- During a manic state, psychotic symptoms, primarily delusions of a grandiose nature can emerge.
  • Brief Psychotic Disorder- Transient psychotic symptoms can occur due to an identifiable, recent stressor.
  • ETOH (Ethanol) withdrawal- Acute withdrawal from ethanol can result in DT's (Delirium Tremens), a short-term psychosis partly resulting from prolonged REM (Rapid Eye Movement) sleep suppression. It typically resolves within 72 hours, although medical monitoring and support is required.
  • Cocaine/methamphetamine abuse – prolonged use of cocaine, methamphetamine and other sympathomimetic agents can result in paranoia, auditory hallucinations, and tactile hallucinations (parisitosis, or the sensation of insects or parasites crawling on the skin or under the skin). The auditory hallucinations are often of the person's name being called, and the paranoia is usually somewhat reality based- e.g. - fear of surveillance by law enforcement, Metabolites of cocaine and methamphetamine are readily detectable on urine toxicology screens.
  • Psychedelic intoxication- there is numerous psychedelic compounds that can induce visual and auditory hallucinations, and well as other distortions and alterations in perception. Typically, psychedelics agents do not produce neoperceptions- but rather distorted perceptions of objects that are actually present. Psychedelic compounds may or may not be detectable on a urine toxicology screen if they are obscure/uncommon. Serotonergic agonist hallucinogens- e.g. - LSD (Lysergic Acid Diethylamide) will tend to produce widely dilated pupils, which is a diagnostic indicator of recent use.
  • PTSD (Post- traumatic Stress Disorder) - can result in psychotic symptoms, but they tend to be situational and related to the trauma- e.g., a combat vet hearing automatic weapons fire. Typically, insight is retained that the experience is a product of ones’ own mind.
  • TBI (Traumatic Brain Injury) – a TBI can produce psychotic symptoms, which will vary depending on the location and severity. Visual, Olfactory, or less frequently gustatory hallucinations are associated with TBI.

Treatment of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

The DSM-5 does not specify a treatment for USS & OPD (American Psychiatric Association, 2013). Before the best treatment for a psychotic disorder can be provided, an accurate diagnosis must be assigned. If the diagnostic picture is uncertain, the patient should be observed further, or another clinician should be consulted. Collateral reports from family/friends may be obtained. If a patient presents at an ER with psychotic symptoms of unclear etiology, they can generally be stabilized on an antipsychotic and a benzodiazepine, whether the symptoms are the result of a psychotic disorder, or substance abuse. While an accurate diagnosis is critical for effective treatment of psychosis, individual symptoms can often be treated, and this may serve to stabilize the patient, facilitating communication, and clarifying diagnosis. Longer-term treatment will rely on finalizing the diagnosis.

Comorbidity of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

What may initially appear to be comorbid conditions may actually be one of the differential diagnosis listed above (See Differential Diagnosis). The DSM-5 notes that substance abuse disorders are also common comorbid conditions associated with schizophrenia and other psychotic disorders, (American Psychiatric Association, 2013) as people will attempt to self-medicate symptoms with substances. Depression and increased risk of suicidality are also important to consider.

Prognosis of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

The DSM-5 does not note a prognostic outcome for USS & OPD (American Psychiatric Association, 2013). The prognosis of USS & OPD will depend on the clarified diagnosis. Dominguez et al, (2011) found that most individuals with subclinical psychotic symptoms do not progress to a full psychotic episode, but 30-40 % will. Pina-Camacho, Garcia-Prieto, Parellada, Castro-Fornieles, Gonzalez-Pinto, Bombin, and Graell, et al, (2014) noted that when psychotic symptoms were accompanied by neuropsychological factors such as motor incoordination, impaired attention, and impaired overall cognitive performance, this was predictive of a diagnosis of schizophrenia. Cannabis use may be a prognostic factor for poorer outcome. It has been found that cannabis use is predictive of earlier onset of psychosis, and causal of psychosis in some individuals (Large, Sharma, Compton, Slade, and Nielssen, 2011). However, the nature of causality is complex, in that persons with a genetic predisposition to psychosis may hasten the onset of a psychotic episode through use of cannabis, but this would not occur in the absence of said genetic predisposition.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.

(5th Edition). Washington, DC.

Dominguez, M.D.G., Wichers, M., Lieb, R., Wittchen H.U, and Os, J.V. (2011). Evidence That Onset of Clinical Psychosis Is an Outcome of Progressively More Persistent Subclinical Psychotic Experiences: An 8-Year Cohort Study. Schizophrenia Bulletin. 37 (1): 84-93. doi: 10.1093/schbul/sbp022.

Large, M., Sharma, S., Compton, M.T., Slade, T., and Nielssen, O. (2011).Cannabis Use and Earlier Onset of Psychosis: A Systematic Meta-analysis. Archives of General Psychiatry. doi:10.1001/archgenpsychiatry.2011.5

Pina-Camacho, L., Garcia-Prieto, J., Parellada, M., Castro-Fornieles, J., Gonzalez-Pinto, A.M., Bombin. I., Graell, M., Paya, B., Rapado-Castro M., Janssen, J., Baeza, I., Pozo, F.D., Desco, M., and Arango, C. (2014). Predictors of schizophrenia spectrum disorders in early-onset first episodes of psychosis: A support vector machine model. European Child and Adolescent Psychiatry. [Abstract]. PMID: 25109600.

Woods, S.W., Walsh, B.C, Saksa, J.R., and McGlashan. T.H. (2010). The case for including Attenuated Psychotic Symptoms Syndrome in DSM-5 as a psychosis risk syndrome.

Schizophrenia Research. 123(2-3): 199–207. doi: 10.1016/j.schres.2010.08.012


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