Definitions and Diagnosis​

Presentation

Definitions and Diagnosis​

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Definitions and Diagnosis​
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Definitions​
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Schizophrenia: a definition​
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Schizophrenia: a definition (cont’d)​
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The trajectory to schizophrenia – evolution of symptoms and main risk factors​
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Negative Symptoms: something “missing”​
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Positive Symptoms: Hallucinations​
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Delusions​ ​
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What is optimal functioning for a patient with schizophrenia?​
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Take home points​
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Functioning is complex and multifactorial​
Slide information
References

Please note, this slide builds.​

Key message: Functioning is complex and multifactorial, and there are many different domains of function e.g. social, everyday, community and psychological functioning, some which are defined on this slide.​

Background ​
Definitions of the various types of functioning have been taken from a variety of different sources, as listed in the references. Additional details: ​

Social functioning: has been defined globally as the capacity of a person to function in different societal roles such as homemaker, worker, student, spouse, family member or friend. The definition also takes account of an individual’s satisfaction with their ability to meet these roles, to take care of themselves, and the extent of their leisure and recreational activities​

Cognitive functioning: cognitive dysfunction is a core feature of schizophrenia. Deficits are moderate to severe across several domains, including attention, working memory, verbal learning and memory and executive functions​

Community functioning: the MCAS (Multnomah Community Abilities Scale) is a 17-item community functioning scale that addresses social competence, behavioral problems, independent living skills and overall adjustment to community living​

Vocational functioning: successful employment for at least half time in a job in the competitive sector or successful attendance in a school for at least half time for two consecutive years. If of retirement age, participating actively in recreational, family or volunteer activities​​

  1. Brissos S, et al. Ann Gen Psychiatry. 2011;24;10:18.​
  2. Bowie CR, Harvey PD . Neuropsychiatr Dis Treat. 2006;2(4):531–536.​
  3. Dickinson D, Coursey RD. Schizophr Res. 2002;56(1-2):161–70.​
  4. Preedy, Victor R. Handbook of Disease Burdens and Quality of Life Measures. New York: Springer, 2010. ​
  5. Harvey PD. Cognitive Impairment in Schizophrenia. Cambridge: Cambridge University Press , 2013.​
  6. Liberman RP, et al. Int Rev Psychiatry. 2002;14(4):256–272.​
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A variety of factors contribute to functional impairment ​ in patients with schizophrenia​
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References

Please note, this slide builds.​

Key message: A variety of factors contribute to impairment in everyday functioning in patients with schizophrenia, including functional capacity, social cognition, symptoms, environmental factors, and health status. ​

  • The figure on this slide shows a theoretical summary of the multiple potential influences on everyday functional disability identified across multiple research studies in people with schizophrenia.

Background​
Impaired everyday functioning is a complex phenomenon, because many factors contribute to adequate outcomes. These factors include:​

  • The ability to perform functional skills​
  • The motivation to perform the skills​
  • Recognition of the situations where skilled performance is likely to be successful​
  • Factors that interfere with ability, motivation, and the situation recognition required to optimize skills performance​
  • These interfering factors include symptoms, health status (i.e. the status of physical health), and medication side effects. ​
  • Further, there are environmental factors that directly and indirectly influence functioning in the real-world. ​​

  1. Harvey PD, Strassnig M. World Psychiatry 2012;11:73–79. ​
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Multiple measures of patient functioning exist, but may not always help to understand the impact on the patient1​
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References

Key message: Although many measures of functioning exist, little is known about how these measures help to understand the impact of functional impairment1 ​

  • To comprehensively evaluate functional outcome in schizophrenia, a combination of performance-based and other assessment modalities may be required5​

Background ​
Global Assessment of Functioning (GAF)2​

  • The GAF is a subjective measure based on a clinician's opinion of a patient's level of functioning and has been found to be a reliable and valid tool​
  • Impairments in psychological, social and occupational/school functioning are considered, but those related to physical or environmental limitations are not​
  • The clinical rated scale ranges from 0 (inadequate information) to 100 (superior functioning)​
  • Personal and Social Performance scale (PSP)3​
  • The PSP was developed through focus groups and reliability studies​
  • 27 different areas of personal and social dysfunction  were identified by focus groups and these were incorporated into four domains (“socially useful activities”, “personal and social relationships”, “self-care”, and “disturbing and aggressive behaviors”)​
  • PSP provides an overall rating score from 1 to 100, with higher scores representing better personal and social functioning​
  • University of California San Diego Performance-Based Skills Assessment (UPSA)4​
  • The UPSA is a performance-based measure of capacity to perform everyday functioning​
  • Patient performance in 5 domains is assessed (Household Chores; Communication; Finance; Transportation; and Planning Recreational Activities)​
  • The total time required to complete the UPSA is ~30 minutes​
  • Total scores for each subscale are calculated by transforming raw scores into a 0–10 scale, yielding comparable scores on each scale. Each score is multiplied by 2 to give a 100-point summary score​​
  1. Wilson C, et al. Early Interv Psychiatry. 2016;10(1):81–7.​
  2. Robertson DA, et al. Schizophr Res. 2013;146(1–3):363–5. ​
  3. Nasrallah H, et al. Psychiatry Res. 2008;161(2):213–24. ​
  4. Patterson TL, et al. Schizophr Bull. 2001;27(2):235–45.​
  5. McKibbin CL, et al. Schizophr Res. 2004;72(1):53–67.​
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Quality of life can be measured using different scales​
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References

Key message: Quality of life can be measured using different scales​

Background ​
Heinrichs-Carpenter Quality of Life Scale (QLS)1,2​

  • The QLS balances subjective questions regarding life satisfaction and occupational role functioning​
  • It consists of a 21-item scale, with behavioral anchors presented for each item, scored on a 0 (severe impairment) to 6 (high functioning) scale  ​
  • The four independent theoretical constructs assessed are intrapsychic foundations (measures related to sense of purpose and motivation), interpersonal relations (examining social experience), instrumental role (related to work functioning), common objects and activities (which measures engagement in the community by possession of common objects and participation in a range of activities)​
  • When administered by a trained clinician as a semi-structured interview, the scale provides information on symptoms and functioning during the 4 weeks prior to assessment​

Health-related quality of life among people with schizophrenia (S-QoL)3​

  • The S-QoL, based on Calman’s approach to the subject’s point of view, is a multidimensional instrument that is sensitive to change​
  • It consists of a 41-item questionnaire with eight subscales (psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life) and a total score​
  • Each item is scored on a five-point Likert scale, anchored at the ends from 1 (less than expected) to 5 (more than expected). The negatively worded item scores are reversed​
  • All scales are linearly transformed to a 0–100 scale, with 100 indicating the most favourable quality of life, and 0 the least favourable​
  • The S-QoL is administered by subject self-report; it is not intended to replace conventional outcome measures, however, it adds important information to that traditionally collected in psychiatry​
  1. Bilker WB, et al. Neuropsychopharmacology. 2003;28(4):773–7. ​
  2. Cramer J, et al. Schizophr Bull. 2001;27(2):227–34.​
  3. Auquier P, et al. Schizophr Res. 2003;63(1–2):137–49.​
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Patients may have functional goals that are personal and meaningful to them​
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Key message: Goal-setting helps patients focus on improving their daily lives, and accomplishing these goals provides a sense of satisfaction and success (Med-IQ, 2014) ​

  1. Med IQ. Goal-Setting Worksheet for People with Schizophrenia. Available at: http://www.med-iq.com/files/noncme/material/pdfs/GoalSetting1.pdf; Accessed June 2016.​
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Patients may have functional goals that are personal and meaningful to them​
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References

Key message: Better social and occupational functioning are consistently identified as important self-defined treatment goals, and improved functioning may be the most meaningful and valued outcome of treatment from a patient and family perspective3 ​​

Background​
In an Australian study that combined the findings of two studies of patients with psychosis (the first in 1997–98 [n=687], the second in 2010 [n=1211]), 63.2% were found to have obvious/severe dysfunction in socializing, and 32.3% had obvious or severe dysfunction in quality of self care2​

Both the 1997−98 and 2010 surveys had similar aims, employed the same two-phase design and methodology, and used the same core instruments: the ‘Psychosis Screener’ for census month screening and the ‘Diagnostic Interview for Psychosis’ for the interview2​

Social dysfunction is one of the most important factors in the disability associated with the illness, and is a source of great distress for patients and family members3​

Most patients have significant impairments in social relationships, and are often socially isolated. When they do interact with others, they often have difficulty maintaining appropriate conversations, expressing their needs and feelings, achieving social goals, or developing close relationships3​

There is increasing recognition that deficits in functioning in the form of social isolation, unemployment and impaired self-care represent a significant component of illness burden. While symptom control is an important treatment outcome, both patients and families consistently identify better social and occupational functioning as important self-defined treatment goals3​

From the patient and family perspective, enhanced functioning may be the most meaningful and valued outcome of treatment. Given the societal costs of poor functioning, it is also a priority for society at large3​

  1. Med IQ. Goal-Setting Worksheet for People with Schizophrenia. Available at: http://www.med-iq.com/files/noncme/material/pdfs/GoalSetting1.pdf; Last accessed June 2016. ​
  2. Morgan VA, et al. Aust N Z J Psychiatry. 2012;46(8):73552. ​
  3. Bellack AS, et al. Schizophr Bull. 2007;33(3):805–22.​
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People with schizophrenia experience motivation deficits​
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References

Key message: People with schizophrenia more often refer to their goals as being driven by boredom or a desire to ‘pass time’ and report goals that are more disconnected–disengaged compared with those of healthy controls​

  • Patients with schizophrenia also have significantly lower intrinsic motivation and extrinsic positive motivation compared with healthy controls​

Background ​
Agency = ability to act in any given environment​

47 people with and 41 people without schizophrenia were provided with cell phones and were called four times a day for one week. During each call participants were asked about their goals, and about the most important reason motivating each goal. Each goal/reason was rated on a scale of specific anchors (0–3). ​

All responses were coded by independent raters (blinded to group and hypotheses) on all Self-Determination Theory (SDT) motivating factors, and ratings were correlated with patient functioning and symptoms. ​

Relative to healthy participants, people with schizophrenia reported goals that were: ​

  • less motivated by filling autonomy (motivated behavior towards agency and self-expression) and competency (motivated behavior towards knowledge, skill or learning) needs, but equivalently motivated by relatedness (interpersonal connection)​
  • less extrinsically rewarding, but equivalently motivated by punishment​
  • more disconnected–disengaged (the individual feels that their behavior is not connected to an outcome and that he or she lacks agency, choice, or direction)​

Higher rates of disconnected–disengaged goals were significantly associated with higher negative symptoms and with impairments in patient functioning​

The findings highlight the importance of intervening early and at each level of motivated behavior, with the aim of helping people with schizophrenia avoid over-engagement in disconnected–disengaged behaviors, thereby assisting them to increase their functioning and quality of life.​

  1. Gard DE et al. Schizophr Res. 2014;156(2–3):217–222.​
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Motivation deficits significantly predict poor functional outcomes in early schizophrenia​
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References

Key message: Motivational deficits are prevalent in patients with schizophrenia, and correlate significantly with each domain of functioning examined (global functional outcome, social functioning, role functioning, and number of days worked in the past 30 days). These deficits are prevalent even in the early stages of the illness, and represent one of the most robust barriers to people with schizophrenia achieving functional recovery1 ​

Motivation is defined as the energy, direction, persistence, and intentionality that direct biological, cognitive, and psychological functioning2​

Social amotivation is comprised of asociality and apathy, and is a core negative symptom of schizophrenia, possibly caused by a disruption in reward functioning, and characterized by reduced ability to anticipate and/or experience pleasure3​

Background1​
This study examined the prevalence of motivational deficits in patients early in the illness, and the impact these deficits have on community functioning​

166 patients with schizophrenia (aged 18–35 years) and within 5 years of initiating antipsychotic treatment were included. First-episode patients were excluded. Data were collected as part of the Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) schizophrenia study​

The primary measure of interest was the Heinrichs–Carpenter Quality of Life Scale (QLS). Motivation was evaluated using the sum of 3 items from the intrapsychic foundations subscale of the QLS: curiosity, goal-directed motivation and sense of purpose​

  • In the sample of patients with early schizophrenia, 15.1% experienced severe deficits in motivation and 76.5% had some degree of motivational impairment​
  • Changes in motivation were linked to changes in functioning; however, this was not the case for changes in cognitive performance​
  • Motivational deficits are prevalent in patients with schizophrenia and demonstrate a pervasive effect on patient functioning, impacting each domain of functioning examined​

A social amotivation score was derived by summing the following items from the Positive and Negative Syndrome Scale (PANSS): emotional withdrawal, passive apathetic withdrawal and active social avoidance​

Motivation was evaluated using the sum of 3 items from the intrapsychic foundations subscale of the QLS: curiosity, goal-directed motivation and sense of purpose ​

Neurocognition was evaluated using a battery of assessments, which were converted into standardized scores and combined to construct five domain scores: verbal memory, vigilance, processing speed, reasoning and problem-solving, and working memory. These were standardized and averaged to create a neurocognitive composite score. ​

  1. Fervaha G, et al. Schizophr Res. 2015;166:9–16.​
  2. Sian PC, Tan SH. IPEDR. 2012. (56)89​
  3. Horton LE, et al. Schizophr Res. 2014; 159(1): 27–30.​
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Current treatment guidelines include optimizing functioning and quality of life as important treatment goals​
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References

Note, this slide contains builds. Goals 2 and 3 change colour to red as these are the most relevant to the focus of the deck.​

Key message: Current treatment guidelines include optimizing functioning and quality of life as important treatment goals, along with symptom control, prevention of relapse and monitoring for adverse events​

Background​
WFSBP: The main goals of treatment during the stable phase are to ensure that symptom remission or control is sustained, that the patient is maintaining or improving their level of functioning and quality of life, that monitoring for adverse treatment effects continues, and relapse is prevented1​

APA: Because schizophrenia is a chronic illness that influences virtually all aspects of life of affected persons, treatment planning has three goals: 1) reduce or eliminate symptoms, 2) maximize quality of life and adaptive functioning, and 3) promote and maintain recovery from the debilitating effects of illness to the maximum extent possible2​​

  1. Hasan A, et al. World J Biol Psychiatry. 2013;14(1):2–44 [WFSBP guidelines]​
  2. Lehman AF, et al. [APA Practice Guidelines] 2010. ​
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Health-related quality of life encompasses many variables​
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References

Key message: Health-related quality of life is complex and encompasses functional abilities, well-being, social interaction, vocational status, and physical and psychological state​

Background1​
Assessment of health-related quality of life (HRQoL) has become an important aspect in the evaluation of treatment programs for people with chronic severe schizophrenia​

HRQoL encompasses several major dimensions, including psychological status, functional abilities, subjective wellbeing, social interactions, economic status, vocational status, and physical status​

HRQoL in schizophrenia can be assessed by direct patient response or by a rating based on a structured interview​

Background2​
In the proposed model shown on the slide, the QoL of individuals maintained on antipsychotic drug therapy for schizophrenia is viewed as the patient’s perception of the outcome of an interaction between severity of psychotic outcomes, side-effects (including subjective responses to antipsychotic drugs), and the level of psychotic performance​

The validity of the model was tested in a clinical setting with patients with schizophrenia (n=62) who were clinically stabilized on antipsychotic drug therapy​

The results of the study broadly endorse the key aspects of the proposed model, and suggest that improvements in patients’ subjective experiences during antipsychotic therapy can enhance patients’ QoL ​

  1. Cramer JA, et al. Schizophr Bull. 2000; 26(3):659–666.​
  2. Awad AG, et al. Qual Life Res. 1997;6(1):21–26.​
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Diagnosis​
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How to diagnose schizophrenia​
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Schizophrenia in Diagnostic Manuals​
References

Major manuals used for the diagnosis of schizophrenia:​

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th edition:  American Psychiatric Association. 1994:866; ​
  2. WHO. ICD-10 Classification .1993. Available from: http://www.who.int/classifications/icd/en/GRNBOOK.pdf. Accessed April 2016; ​
  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th edition:  American Psychiatric Association. 2013​

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DSM-5 Diagnostic Criteria for Schizophrenia​
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DSM-5 Diagnostic Criteria for Schizophrenia (cont’d)​
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Differences between DSM IV and DSM 5​
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DSM IV and DSM 5
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Organization of disorders​
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Definitions​
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Definitions​
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Disorders included​
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Differences – Schizophrenia​
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Differences – Schizophrenia​
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Differences – Schizophrenia​
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Differences – Schizophrenia​
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Differences – Delusional disorder​
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Differences – Delusional disorder​
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Differences – Brief psychotic disorder​
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Differences – schizoaffective disorder​
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Differences – Schizophreniform disorder​
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Differences – Substance/medication – Induced psychotic disorder​
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Differences – Substance/medication – Induced psychotic disorder​
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Differences – Substance/medication – Induced psychotic disorder​
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Differences – Catatonia​
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Differences – Psychotic disorder not otherwise specified​
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Differences – Other disorders​
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Differences – Other disorders​
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Summary​
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Differences between DSM 5 and IC10​
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DSM 5 and ICD 10
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Differences between DSM 5 and IC10​
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Differences between DSM 5 and IC10​
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Differences – Schizophrenia​
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Differences – Schizophrenia​
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Differences – Schizophrenia​
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Differences – Schizophrenia​
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Differences – Persistent delusional disorder​
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Differences – Persistent delusional disorder​
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Differences – Acute and transient psychotic disorders​
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Differences – Persistent delusional disorder​
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Differences – Acute and transient psychotic disorders​
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Differences – Schizophreniform disorder​
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Differences – Schizoaffective disorder​
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Differences – Induced delusional disorder​
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Differences – Other nonorganic psychotic disorders​
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Differences – Unspecified psychosis ​
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Summary​
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