Assessment and Differential Assessment and Differential Diagnosis of Abnormal Experience Diagnosis of Abnormal Experience

GoalsGoals

• Describe psychosis as a clinical Describe psychosis as a clinical phenomenonphenomenon

• Discuss clinical pearls that will help you to Discuss clinical pearls that will help you to distinguish between types of abnormal distinguish between types of abnormal experienceexperience

• Develop differentiation of psychosis by Develop differentiation of psychosis by time course and co-morbiditiestime course and co-morbidities

Chronic PsychosisChronic Psychosis

• Often develops slowly, during adolescence Often develops slowly, during adolescence and young adulthoodand young adulthood

• Early on, shares many Sx with other Early on, shares many Sx with other psychiatric disorderspsychiatric disorders

• Eventually leads to significant morbidity Eventually leads to significant morbidity and mortalityand mortality

Chronic PsychosisChronic Psychosis

• Begins slowlyBegins slowly

• Emerges non-specificallyEmerges non-specifically

• Relates to subjective experience of selfRelates to subjective experience of self

How best to diagnoseHow best to diagnose

• 90% of people who have a parent with 90% of people who have a parent with schizophrenia will not develop the schizophrenia will not develop the disorder; 1/3 of all people diagnosed with disorder; 1/3 of all people diagnosed with schizophrenia have no family historyschizophrenia have no family history

• Laboratories and imaging are often only Laboratories and imaging are often only minimally helpfulminimally helpful

• Clinical Interview is Important!Clinical Interview is Important!

Psychosis is Psychosis is notnot::

• One thingOne thing

• One processOne process

Psychosis MythsPsychosis Myths

Chronic psychosis is a return to a core, Chronic psychosis is a return to a core, primitive level of brain processingprimitive level of brain processing

Chronic psychosis is a cliff: once you fall Chronic psychosis is a cliff: once you fall over it, you can never get backover it, you can never get back

Chronic psychosis is an understandable Chronic psychosis is an understandable reaction to society or parentsreaction to society or parents

Clinical ChallengeClinical Challenge

• Balancing two factors:Balancing two factors:

• Subjective patient experienceSubjective patient experience

• Specificity of symptom presentationSpecificity of symptom presentation

PsychosisPsychosis

HallucinationsHallucinations

Delusions or Delusions or ParanoiaParanoia

DisorganizationDisorganization

CatatoniaCatatonia

HallucinationsHallucinations

Hallucination = a sensory experience that Hallucination = a sensory experience that occurs in the absence of a stimulusoccurs in the absence of a stimulus– Illusion: a sensory experience that Illusion: a sensory experience that

misinterprets a stimulusmisinterprets a stimulus

HallucinationsHallucinations

Who Who

What What

WhenWhen

WhereWhere

HowHow

HallucinationsHallucinations

“ “Why is it when I hear Why is it when I hear someone ask ‘are you finished’ someone ask ‘are you finished’ that it’s a voice talking down to that it’s a voice talking down to me? That voice should be me? That voice should be talking across to me – it isn’t talking across to me – it isn’t better than me.”better than me.”

Delusional ThinkingDelusional Thinking

Delusion = a fixed, false belief that resists Delusion = a fixed, false belief that resists evidence to the contrary evidence to the contrary andand is not shared is not shared by a particular sub-cultureby a particular sub-culture

Delusional ThinkingDelusional Thinking

Who Who

What What

WhenWhen

WhereWhere

HowHow

Delusional ThinkingDelusional Thinking

“ “Did that one stupid scene Did that one stupid scene from ‘The Passion of the from ‘The Passion of the Christ’ really do this to me – Christ’ really do this to me – turn me into a f*&*ing baby? turn me into a f*&*ing baby? Simon is awesome because Simon is awesome because he believes I’m evil, like I he believes I’m evil, like I believe I’m evil and he forgives believe I’m evil and he forgives me.”me.”

ParanoiaParanoia

Paranoia = suspiciousness and mistrust Paranoia = suspiciousness and mistrust that occur out of proportion to realitythat occur out of proportion to reality

ParanoiaParanoia

Who Who

What What

WhenWhen

WhereWhere

HowHow

ParanoiaParanoia

““Why do sounds at night Why do sounds at night make me jump? Why do I make me jump? Why do I notice this?”notice this?”

Disorganized LanguageDisorganized Language

Disorganization = speech or writing that Disorganization = speech or writing that does not follow a linear or logical patterndoes not follow a linear or logical pattern– Tangential, “loose associations”Tangential, “loose associations”

Disorganized ThinkingDisorganized Thinking

Who Who

What What

WhenWhen

WhereWhere

HowHow

Disorganized ThinkingDisorganized Thinking

“ “Where do my thoughts end Where do my thoughts end and my feelings begin? Will I and my feelings begin? Will I ever get over this sickness? ever get over this sickness? Will I ever have an uncorrupt Will I ever have an uncorrupt ego? No, then I’d be God. Do ego? No, then I’d be God. Do I care about God? Why do I I care about God? Why do I care about God?”care about God?”

Clinically Useful ConceptsClinically Useful Concepts

• Positive SxPositive Sx• Hallucinations, delusions, paranoia, Hallucinations, delusions, paranoia,

disorganized communicationdisorganized communication

• Cognitive SxCognitive Sx• Poor attention and concentration, memory Poor attention and concentration, memory

problems, executive impairmentproblems, executive impairment

• Negative SxNegative Sx• Social withdrawal, affect flattening, avolitionSocial withdrawal, affect flattening, avolition

Clinically Useful Concepts:Clinically Useful Concepts:

Positive SymptomsPositive Symptoms– Most specific for predicting psychosisMost specific for predicting psychosis

Negative SymptomsNegative Symptoms– Mildly correlated with chronic prognosisMildly correlated with chronic prognosis

Cognitive SymptomsCognitive Symptoms– Strongly correlated with chronic prognosisStrongly correlated with chronic prognosis

DiagnosisDiagnosis

The basics:The basics:– Primary vs. SecondaryPrimary vs. Secondary– Other SymptomsOther Symptoms– Symptom Time CourseSymptom Time Course

Differential Dx of PsychosisDifferential Dx of Psychosis

Secondary Psychotic DisordersSecondary Psychotic Disorders

Substance induced psychotic disorderSubstance induced psychotic disorder

Psychosis secondary to a general medical Psychosis secondary to a general medical conditioncondition

DeliriumDelirium

DementiaDementia

Psychosis secondary to a mood disorderPsychosis secondary to a mood disorder

Differential Diagnosis of Differential Diagnosis of PsychosisPsychosis

Mood DisordersMood Disorders

Bipolar I disorder, manic episodeBipolar I disorder, manic episode

Major depression with psychotic featuresMajor depression with psychotic features

Differential Diagnosis of Differential Diagnosis of PsychosisPsychosis

Primary Psychotic DisordersPrimary Psychotic Disorders

SchizophreniaSchizophrenia

Schizoaffective disorderSchizoaffective disorder

Brief psychotic disorderBrief psychotic disorder

Delusional disorderDelusional disorder

The Real IssueThe Real Issue

If you were to explain to a family member why If you were to explain to a family member why someone has a diagnosis of a primary someone has a diagnosis of a primary psychotic disorder, how would you do so?psychotic disorder, how would you do so?

Chronic Primary PsychosisChronic Primary Psychosis

Schizophrenia Schizophrenia

Schizoaffective DisorderSchizoaffective Disorder

Schizophrenia: “definition”Schizophrenia: “definition”

Schizophrenia is a chronic or recurrent Schizophrenia is a chronic or recurrent disorder characterized bydisorder characterized by– Sustained periods of psychosisSustained periods of psychosis

DSM = at least one monthDSM = at least one month

– Long-term functional deteriorationLong-term functional deteriorationDSM = at least six monthsDSM = at least six months

Schizophrenia: DiagnosisSchizophrenia: Diagnosis

Two or more Two or more Criterion ACriterion A Sx: Sx:– hallucinations hallucinations – delusions delusions – disorganized speech disorganized speech – disorganized/catatonic behavior disorganized/catatonic behavior – ““negative symptoms”negative symptoms”

Flat affect, lack of motivation, social withdrawalFlat affect, lack of motivation, social withdrawal

Psychotic TimelinesPsychotic Timelines

Brief Psychotic DisorderBrief Psychotic Disorder– At least one Criterion A SxAt least one Criterion A Sx– At least one day but less than one month of At least one day but less than one month of

functional disturbancefunctional disturbance

Other “schizos”Other “schizos”

SchizophreniformSchizophreniform– At least one Criterion A SxAt least one Criterion A Sx– At least one month, but less than six months At least one month, but less than six months

of functional deteriorationof functional deterioration

Other psychotic syndromesOther psychotic syndromes

Delusional DisorderDelusional Disorder– At least one monthAt least one month– ““Non-bizarre”Non-bizarre”– No other psychotic SxNo other psychotic Sx– Impairment related specifically to delusionImpairment related specifically to delusion

yes

no

no

no

yes

yes

yes

no

Program Director: Rachel Loewy, PhDProgram Director: Rachel Loewy, PhDScientific Director: Sophia Vinogradov, MDScientific Director: Sophia Vinogradov, MDMedical Director: Demian Rose, MD, PhDMedical Director: Demian Rose, MD, PhD

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