Definitions and Diagnosis

Presentation

Definitions and Diagnosis

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Definitions and Diagnosis

Index
  1. Definitions and Diagnosis
  2. Definitions
  3. Schizophrenia: a definition
  4. Schizophrenia: a definition (cont’d)
  5. The trajectory to schizophrenia – evolution of symptoms and main risk factors
  6. Negative Symptoms: something is “missing”
  7. Positive Symptoms: Hallucinations
  8. Delusions
  9. What is optimal functioning for a patient with schizophrenia?
  10. Take home points
  11. Functioning is complex and multifactorial
  12. A variety of factors contribute to functional impairment in patients with schizophrenia
  13. Multiple measures of patient functioning exist, but may not always help to understand the impact on the patient1
  14. Quality of life can be measured using different scales
  15. Patients may have functional goals that are personal and meaningful to them
  16. Patients may have functional goals that are personal and meaningful to them
  17. Patients with schizophrenia experience motivation deficits
  18. Motivation deficits significantly predict poor functional outcomes in early schizophrenia
  19. Current treatment guidelines include optimizing functioning and quality of life as important treatment goals
  20. Health-related quality of life encompasses many variables
  21. Diagnosis
  22. How to diagnose schizophrenia
  23. Schizophrenia in Diagnostic Manuals
  24. DSM-5 Diagnostic Criteria for Schizophrenia
  25. DSM-5 Diagnostic Criteria for Schizophrenia (cont’d)
  26. Diagnostic differences between DSM-IV, DSM-5, ICD-10, and ICD-11
  27. Differences between ICD-10 and ICD-11
  28. Differences between ICD-10 and ICD-11
  29. Disorders included
  30. Differences – Schizophrenia
  31. Differences – Schizophrenia
  32. Differences – Schizophrenia
  33. Differences – Delusional disorder
  34. Differences – Delusional disorder
  35. Differences – Acute and transient psychotic disorders
  36. Differences – Schizoaffective disorder
  37. Differences – Induced delusional disorder
  38. Differences – Unspecified psychosis
  39. Differences – Schizotypal disorder
  40. Differences between DSM-5 and ICD-11
  41. Differences between DSM-5 and ICD-11
  42. Disorders included
  43. Differences – Schizophrenia
  44. Differences – Schizophrenia
  45. Differences – Schizophrenia
  46. Differences – Delusional disorder
  47. Differences – Delusional disorder
  48. Differences – Acute and transient psychotic disorders
  49. Differences – Schizoaffective disorder
  50. Differences – Induced delusional disorder
  51. Differences – Unspecified psychosis
  52. Differences – Schizotypal disorder
  53. Summary
  54. Differences between DSM-IV and DSM-5
  55. Differences between DSM-IV and DSM-5
  56. Organization of disorders
  57. Definitions
  58. Definitions
  59. Disorders included
  60. Differences – Schizophrenia
  61. Differences – Schizophrenia
  62. Differences – Schizophrenia
  63. Differences – Schizophrenia
  64. Differences – Delusional disorder
  65. Differences – Delusional disorder
  66. Differences – Brief psychotic disorder
  67. Differences – schizoaffective disorder
  68. Differences – Schizophreniform disorder
  69. Differences – Substance/medication – Induced psychotic disorder
  70. Differences – Substance/medication – Induced psychotic disorder
  71. Differences – Induced psychotic disorder – Due to another medical condition
  72. Differences – Catatonia
  73. Differences – Psychotic disorder not otherwise specified
  74. Differences – Other disorders
  75. Differences – Other disorders
  76. Summary: Updates from DSM-IV to DSM-5
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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 is “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
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Références

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.

Brissos S, et al. Ann Gen Psychiatry. 2011;24;10:18.

Bowie CR, Harvey PD . Neuropsychiatr Dis Treat. 2006;2(4):531–536.

Dickinson D, Coursey RD. Schizophr Res. 2002;56(1-2):161–70.

Preedy, Victor R. Handbook of Disease Burdens and Quality of Life Measures. New York: Springer, 2010. 

Harvey PD. Cognitive Impairment in Schizophrenia. Cambridge: Cambridge University Press , 2013.

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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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. 

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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Key message: Although many measures of functioning exist, little is known about how these measures help to understand the impact of functional impairment[Wilson C et al., 2016]

  • To comprehensively evaluate functional outcome in schizophrenia, a combination of performance-based and other assessment modalities may be required[McKibbin et al., 2004]

Background 
Global Assessment of Functioning (GAF)[Robertson et al., 2013]

  • 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)[Nasrallah et al., 2008]

  • 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)[Patterson et al., 2001]

  • 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.

Wilson C, et al. Early Interv Psychiatry. 2016;10(1):81–7.

Robertson DA, et al. Schizophr Res. 2013;146(1–3):363–5. 

Nasrallah H, et al. Psychiatry Res. 2008;161(2):213–24. 

Patterson TL, et al. Schizophr Bull. 2001;27(2):235–45.

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

Background 
Heinrichs-Carpenter Quality of Life Scale (QLS)[Bilker et al., 2003; Cramer et al., 2001]

  • 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)[Auquier et al., 2003]

  • 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.

Bilker WB, et al. Neuropsychopharmacology. 2003;28(4):773–7. 

Cramer J, et al. Schizophr Bull. 2001;27(2):227–34.

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]

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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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 perspective[Bellack et al., 2007]

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 care.[Morgan et al., 2012]
  • 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 interview.[Morgan et al., 2012]
  • 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 members.[Bellack et al., 2007]
  • 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 relationships.[Bellack et al., 2007]
  • 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 goals.[Bellack et al., 2007]
  • 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 large.[Bellack et al., 2007]

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. 

Morgan VA, et al. Aust N Z J Psychiatry. 2012;46(8):73552. 

Bellack AS, et al. Schizophr Bull. 2007;33(3):805–22.

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Patients with schizophrenia experience motivation deficits
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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[Gard et al., 2014]

  • Patients with schizophrenia also have significantly lower intrinsic motivation and extrinsic positive motivation compared with healthy controls[Gard et al., 2014]

Background 

  • Agency = ability to act in any given environment.[Gard et al., 2014]
  • 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).[Gard et al., 2014] 
  • 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.[Gard et al., 2014] 
  • Relative to healthy participants, people with schizophrenia reported goals that were:[Gard et al., 2014; Ryan & Deci, 2000] 
    • 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.[Gard et al., 2014]
  • 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.[Gard et al., 2014]

Gard DE et al. Schizophr Res. 2014;156(2–3):217–222.

Ryan & Deci. Am Psychol. 2000;55:68–78.

Deci & Ryan. Psychological Inquiry. 2000; 11(4):227–268.

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Motivation deficits significantly predict poor functional outcomes in early schizophrenia
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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 recovery[Fervaha et al., 2015]

Motivation is defined as the energy, direction, persistence, and intentionality that direct biological, cognitive, and psychological functioning.[Sian & Tan, 2012; Ryan & Deci, 2000]
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 pleasure.[Horton et al., 2014; Foussias & Remington, 2010]

Background[Fervaha et al., 2015]

  • 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. 

Fervaha G, et al. Schizophr Res. 2015;166:9–16.

Sian PC, Tan SH. IPEDR. 2012. (56):89

Ryan & Deci. Am Psychol. 2000;55:68–78.

Horton LE, et al. Schizophr Res. 2014; 159(1):27–30.

Foussias & Remington. Schizophr Bull. 2010;36(2):359–369.

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Current treatment guidelines include optimizing functioning and quality of life as important treatment goals
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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 prevented.[Hasan et al., 2013]
  • 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 possible.[Lehman et al., 2010]

 

Hasan A, et al. World J Biol Psychiatry. 2013;14(1):2–44 [WFSBP guidelines]

Lehman AF, et al. [APA Practice Guidelines] 2010. 

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

Background[Cramer et al., 2000]

  • 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.

Background[Awad AG, et al., 1997]

  • 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.

 

Cramer JA, et al. Schizophr Bull. 2000; 26(3):659–666.

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
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Major manuals used for the diagnosis of schizophrenia:

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th edition:  American Psychiatric Association. 1994:866; 

WHO. ICD-10 Classification .1993. Available from: http://www.who.int/classifications/icd/en/GRNBOOK.pdf. Accessed April 2016; 

American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th edition:  American Psychiatric Association. 2013;

WHO. ICD-11 Classification. 2018. Available from: https://icd.who.int/browse11/l-m/en

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DSM-5 Diagnostic Criteria for Schizophrenia
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Review as stated on slide

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DSM-5 Diagnostic Criteria for Schizophrenia (cont’d)
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Review as stated on slide

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Diagnostic differences between DSM-IV, DSM-5, ICD-10, and ICD-11
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Differences between ICD-10 and ICD-11
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Differences between ICD-10 and ICD-11
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Disorders included
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Schizophrenia or other primary psychotic disorders is the Parent diagnostic category for all primary psychotic disorders and their symptomatic manifestations, hence ranging from 6A20 to 6A25 and also including ‘Other specified‘ or ‘unspecified‘ categories 6A2Y and 6A2Z. The two other categories in pale grey are belonging to secondary psychotic disorders (6E61) or substance-induced psychotic disorders (with their many different subcategories) whose parent are either ‘Secondary mental or behavioural syndromes associated with disorders or diseases classified elsewhere‘ or ‘Disorders due to a specific substance‘ (e.g., … due to use of alcohol, 6C40) listed in the respective other chapters. 

The 6A25 Symptomatic manifestations of primary psychotic disorders are the symptom qualifiers on positive, negative, depressive, manic, psychomotor and cognitive symptoms as mentioned in the Coding Notes of the MMS: These categories should never be used in primary coding. The codes are provided for use as supplementary or additional codes when it is desired to identify the presence of these symptoms in primary psychotic disorders. According to a Description (which accompanies each category in the MMS): These categories may be used to characterize the current clinical presentation in individuals diagnosed with Schizophrenia or another primary psychotic disorder, and should not be used in individuals without such a diagnosis. Multiple categories may be applied. Symptoms attributable to the direct pathophysiological consequences of a health condition or injury not classified under Mental, behavioural or neurodevelopmental disorders (e.g., a brain tumour or traumatic brain injury), or to the direct effects of a substance or medication on the central nervous system, including withdrawal effects, should not be considered as examples of the respective types of symptoms. 

As can be seen in the MMS, to each of the primary psychotic categories all the symptom qualifiers can be added and also ranked for severity into mild, moderate or severe. By so-called ‚post-coordination‘, the ICD-11 Coding Tool then automatically adds this to a code string allowing for complex coding recognizing the patients individual dimensional symptom spectrum in addition to the diagnostic category: accordingly, the string for schizophrenia with severe positive symptoms the code string would be 6A20/6A25.0&XS25. All symptom qualifiers could be added here as well as the course specifiers (see S32), giving a much more individualized clinical picture than the diagnostic category alone. 

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Differences – Schizophrenia
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For each diagnostic category, in the MMS a ‘Description‘ can be found, e.g., for schizophrenia:
Schizophrenia is characterized by disturbances in multiple mental modalities, including thinking (e.g., delusions, disorganization in the form of thought), perception (e.g., hallucinations), self-experience (e.g., the experience that one's feelings, impulses, thoughts, or behaviour are under the control of an external force), cognition (e.g., impaired attention, verbal memory, and social cognition), volition (e.g., loss of motivation), affect (e.g., blunted emotional expression), and behaviour (e.g., behaviour that appears bizarre or purposeless, unpredictable or inappropriate emotional responses that interfere with the organization of behaviour). Psychomotor disturbances, including catatonia, may be present. Persistent delusions, persistent hallucinations, thought disorder, and experiences of influence, passivity, or control are considered core symptoms. Symptoms must have persisted for at least one month in order for a diagnosis of schizophrenia to be assigned. The symptoms are not a manifestation of another health condition (e.g., a brain tumour) and are not due to the effect of a substance or medication on the central nervous system (e.g., corticosteroids), including withdrawal (e.g., alcohol withdrawal).

In addition, however, detailed Clinical Descriptions and Diagnostic Guidelines (CDDG) for chapter 6 ‘Mental, behavioural or neurodevelopmental disorders‘ with a focus on clinical utility have been developed, which are not yet finalized and publicized, but can be found under GCP network (guidelines). Here you will find the essential diagnostic requirements, additional clinical features, boundaries with normality and other disorders, course features, culture- and gender-related features, and developmental presentations. However, different from DSM in ICD‚ functioning‘ in principle is not part of the defining diagnostic criteria for mental disorders, although it may be severely disturbed and should be assessed by ICF in addition to ICD.

Each of these categories are ‘pre-coordinated‘, in the sense that each category is then already further subdivided with a code for currently symptomatic, in partial remission, or in full remission. Further detailed coding is possible by post-coordination adding the symptom qualifiers.  

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Differences – Schizophrenia
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Differences – Schizophrenia
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ICD-11 coding for courses:

  • 6A20.0: Schizophrenia, first episode
  • 6A20.1: Schizophrenia, multiple episodes
  • 6A20.2: Schizophrenia, continuous
  • 6A20.Y: Other specified schizophrenia 
  • 6A20.Z: schizophrenia, unspecified

Course specifiers are organized to characterize both the longitudinal course (first episode, multiple episodes, continuous) and the cross-sectional status in the past month (currently symptomatic, in partial remission, in full remission). Course qualifiers can also become automatically coded together with the symptom qualifiers (see Slide 29), e.g., schizophrenia - first episode - currently symptomatic (6A20.00), positive symptoms (6A25.0), severe (XS25): 6A20.00/6A25.0&XS25.

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Differences – Delusional disorder
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ICD-10 ‘Induced Delusional Disorder‘ has been eliminated as a separate category and included in ICD-11 Delusional Disorder.

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Differences – Delusional disorder
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Differences – Acute and transient psychotic disorders
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For ICD-11, ICD-10 ATPD with its subcategories has been reduced to F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia, representing sudden onset of highly variable/fluctuating psychotic symptoms of brief duration (< 3 months), negative symptoms not being present, not including typical schizophrenia of insufficient duration; F23.1 and F23.2 are referred to ICD-11 “Other specified acute and transient psychotic disorder”.

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Differences – Schizoaffective disorder
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Cross-sectional concept in ICD-11 (as in ICD-10), not longitudinal as in DSM-5. Requires simultaneously meeting requirements for schizophrenia and a mood episode (depressive, manic, or mixed) – starting roughly together and are present for at least 1 month. Not longitudinal or lifelong in nature, the diagnosis applies only to the current episode.

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Differences – Induced delusional disorder
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Also see Slide 33 for more detail.

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Differences – Unspecified psychosis
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Differences – Schizotypal disorder
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Schizotypal disorder is characterized by an enduring pattern (i.e., characteristic of the person’s functioning over a period of at least several years) of eccentricities in behavior, appearance and speech, accompanied by cognitive and perceptual distortions, unusual beliefs, and discomfort with— and often reduced capacity for— interpersonal relationships. Symptoms may include constricted or inappropriate affect and anhedonia (negative schizotypy). Paranoid ideas, ideas of reference, or other psychotic symptoms, including hallucinations in any modality, may occur (positive schizotypy), but are not of sufficient intensity or duration to meet the diagnostic requirements of schizophrenia, schizoaffective disorder, or delusional disorder. The symptoms cause distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.

Symptoms are present continuously or episodically for at least 2 years, symptoms cause distress or impairment. Symptom qualifiers can be postcoordinated with this category. 

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Differences between DSM-5 and ICD-11
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Differences between DSM-5 and ICD-11
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Disorders included
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Differences – Schizophrenia
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For each diagnostic category, in the MMS a ‘Description‘ can be found, e.g., for schizophrenia:
Schizophrenia is characterized by disturbances in multiple mental modalities, including thinking (e.g., delusions, disorganization in the form of thought), perception (e.g., hallucinations), self-experience (e.g., the experience that one's feelings, impulses, thoughts, or behaviour are under the control of an external force), cognition (e.g., impaired attention, verbal memory, and social cognition), volition (e.g., loss of motivation), affect (e.g., blunted emotional expression), and behaviour (e.g.,behaviour that appears bizarre or purposeless, unpredictable or inappropriate emotional responses that interfere with the organization of behaviour). Psychomotor disturbances, including catatonia, may be present. Persistent delusions, persistent hallucinations, thought disorder, and experiences of influence, passivity, or control are considered core symptoms. Symptoms must have persisted for at least one month in order for a diagnosis of schizophrenia to be assigned. The symptoms are not a manifestation of another health condition (e.g., a brain tumour) and are not due to the effect of a substance or medication on the central nervous system (e.g., corticosteroids), including withdrawal (e.g., alcohol withdrawal).

In addition, however, detailed Clinical Descriptions and Diagnostic Guidelines (CDDG) for chapter 6 ‘Mental, behavioural or neurodevelopmental disorders‘ with a focus on clinical utility have been developed, which are not yet finalized and publicized, but can be found under GCP network (guidelines). Here you will find the essential diagnostic requirements, additional clinical features, boundaries with normality and other disorders, course features, culture- and gender-related features, and developmental presentations. However, different from DSM in ICD‚ functioning‘ in principle is not part of the defining diagnostic criteria for mental disorders, although it may be severely disturbed and should be assessed by ICF in addition to ICD.

Each of these categories are ‘pre-coordinated‘, in the sense that each category is then already further subdivided with a code for currently symptomatic, in partial remission, or in full remission. Further detailed coding is possible by post-coordination adding the symptom qualifiers.  

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Differences – Schizophrenia
Slide information

What is new in ICD-11 schizophrenia?

  • Omission of classical schizophrenia subtypes
  • De-emphasis of first-rank symptoms
  • Introduction of cognitive symptoms as symptoms of schizophrenia
  • Introduction of new symptom qualifiers (see Slide 29)
  • Introduction of new course specifiers (see Slide 32)  

 

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Differences – Schizophrenia
Slide information

Course specifiers for the chapters of spectrum/primary psychotic disorders are quite similar between DSM-5 and ICD-11 

ICD-11 coding for courses:

  • 6A20.0: Schizophrenia, first episode
  • 6A20.1: Schizophrenia, multiple episodes
  • 6A20.2: Schizophrenia, continuous
  • 6A20.Y: Other specified schizophrenia 
  • 6A20.Z: schizophrenia, unspecified
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Differences – Delusional disorder
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Differences – Delusional disorder
Slide information

In ICD-11, a six 4-point scale severity-graded symptom qualifiers can also be post-coordinated with the pre-coordinated cross-sectional status-based diagnostic category for all categories of the ‘Schizophrenia or other primary psychotic disorders‘ categories. DSM-5 in Section III ‘Emerging Measures and Models‘ (APA, 2013, pp 742-744) has also published 8 clinician-rated dimensions of psychosis-related symptom severity rated on a 5-point scale (hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, mania).

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Differences – Acute and transient psychotic disorders
Slide information

DSM-5 includes 2 types of psychotic disorders with required duration below the 6-months criterion for schizophrenia: Schizophreniform disorder (=/> 1 month, < 6 months) and (Brief psychotic disorder (=/> 1 day, < 1 month). Brief psychotic disorder resembles with its sudden onset and relative good acute prognosis the ICD-11 ATPD. ‘Schizophreniform disorder‘ would be diagnosed in ICD-11 either as ‘Schizophrenia‘ or ‘Other specified schizophrenia or other primary psychotic disorders‘ (6A2Y) or ‘Schizophrenia or other primary psychotic disorders, unspecified‘ (6A2Z). According to the changes made from ICD-10 to ICD-11 for ATPD, schizophrenia-like symptom manifestations below one month duration would go into one of the ‘Other primary psychotic disorders‘ instead of into ATPD. 

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Differences – Schizoaffective disorder
Slide information

Cross-sectional concept in ICD-11, longitudinal concept in DSM-5. In ICD-11, this requires simultaneously meeting requirements for schizophrenia and a mood episode (depressive, manic, or mixed) – starting roughly together and are present for at least 1 month. 

Not longitudinal or lifelong in nature, rather the diagnosis applies only to the current episode.

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Differences – Induced delusional disorder
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Differences – Unspecified psychosis
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Differences – Schizotypal disorder
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Summary
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Differences between DSM-IV and DSM-5
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Differences between 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 – Induced psychotic disorder – Due to another medical condition
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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: Updates from DSM-IV to DSM-5
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