The Psychotic Disorders in the Real World

[JackD]

Just a quick question, for the first time this week, i read through the DSM IV's section on psychotic disorders. Of course I have read about these disorders in other text books but this is the first time in the DSM. The impression I got, pretty much right away, is that the DSM's conceptualization of these disorders, especially schizophrenia, schizophreniform, and schizoaffective, is just total garbage. Like it needs to be completely redone. It seems like in the real world, the DSM's information on these disorders would be useless because it is just so convoluted and redundant. Is that an accurate interpretation of that section of the DSM.

And I am aware of how flawed the DSM in general but it seems like the psychotic disorders are especially flawed. No?

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[erg923]

It all depends on what you even mean by this statement. Are you talking about reliabilty of the diagnoses over time, interrater reliability, actual validty of them as disease entities?

DSM-V will rework some problematic issues im sure, but dont expect too much overhaul. The biggest and most obvious problematic issue, as you may have noticed, is schizoaffective disorder. Most of us with any considerble clinical experience with severe populations will agree that the presentation (and usually the course) of chronically psychotic folks vs chronically psychotic folks with prominent chronic mood symptoms is pretty different. The present different and they have they have a differnt feel to them, so to speak. Well duh, right? But does that really mean that they have a seperate disease. I dont think so, IMHO. The existence of Schizoaffective disorder is a direct consequence of the "Kraeplinain dichtomy" (if your not sure what that is, I would advise reading up on it). Evidence from both genetic and epidemiological studies clearly shows that this dictotomy does not exist. Unfortunately, our current nosology and classification systerm is so entreched in this model, its hard to break. There are no easy answers or soluations to the flaws in the system at the present time.

Im not sure if this what you were thinking or complaining about. If not, what were you getting at? Some of the stuff in the DSM wont make much sense until you see it in the clinic or on the psych floor. So its a prertty normal feeling for new grad students, dont worry.

 

[cara susanna]

In my psychopathology class, a lot of people are really having trouble with the differences between bipolar and schizophrenia. Schizoaffective disorder just confuses it even more.

 

[erg923]

Although severe mania can resemble or turn into a florid psychosis, especially if the person is extemely grandiose, im not sure I understand the confusion between bipolar and schizophrenia. The criteria are quite different, as one requires experiencing distinct mood episodes and the other only requires psychotic symtoms (ie., delusions and hallucinations) for a month long period. Like I said, bipolar and schiz can look alike clinically if the person is in the midst of a severe manic phase, but otherwise, they are very different presentations when you are in the room with them.

Now.....teasing apart a chronic schizophrenia with occasional depressive episodes from a schizoaffective disorder is the tough one. To qualify for schizoaffective disorder, not only do you have to demonstrate psychotic symptoms in the absence of prominent mood symptoms, you also have to be able to establish that the mood sympotms have been present for a substantial portion of the entire ilness. This is not easy, and may be quite the arbirtary distinction, but thats just me...😎

 

[cara susanna]

Well, I mean clinically. They're afraid that during an interview they will mistake one for the other.

 

[JackD]

Well I am not exactly confused by these disorders. I did take a little longer to read that section on schizophrenia but I think I got it down. Let me try to clear up what i was attempting to say. There is something about me trying to talk about psychology late at night that just never works.

1. It seems as if some of the ways that schizophrenia is conceptualized in the DSM is very unrealistic, particularity with the subtypes. For example, it seems like you would never see someone with pure disorganized schizophrenia. However, it think that is a common criticism.

2. It looks like their current view of schizophrenia is too broad, almost as if schizophrenia is several disorders just lumped into one. If certain symptoms do indeed go together, whether it is the paranoid, disorganized, catatonic, etc or one of the other grouping systems out there, it seems like there are going to be situations where people with widely different problems have the same label. This is the problem of the categorical system, i know, but it seems to be really severe with schizophrenia. How can someone with disorganized schizophrenia have the same disorder as someone with paranoid schizophrenia? The presentation, the subjective feelings, the dysfunction, the prognosis, the response to treatment are all different. It seems like in that respect, the disorder should be broken up into their own disorders.

3. Schizophreniform and brief psychotic disorder both seem unnecessary. If most people with these disorders go on to have full blown schizophrenia, shouldn't it just be assumed that everyone with these disorders have schizophrenia and some people just make a full recovery, rather quickly?

4. Schizoaffective disorder just seems like b.s.. It sounds like someone with it would just have schizophrenia with mood problems or less likely, mood problems with psychotic features that start early and last for awhile. I am not sure it is should be its own entity.

I guess overall what I am trying to say is that the system feels backward. It feels like they are making distinctions that they shouldn't be, such as with the duration of the symptoms, and that they aren't making distinctions that they should be, such as making schizophrenia a catch all with too many possible symptom combinations.

But who knows?

 

[erg923]

from wikipedia:
In April 2009, the DSM-V Psychotic Disorders Work Group headed by psychiatrist William T. Carpenter of the University of Maryland, College Park School of Medicine, reported that they will be "developing new criteria for schizoaffective disorder to improve reliability and face validity," and that they will be "determining whether the dimensional assessment of mood will justify a recommendation to drop schizoaffective disorder as a diagnostic category."[7] Speaking at the May 2009 annual conference of the American Psychiatric Association, Carpenter said, "We had hoped to get rid of schizoaffective [disorder] as a diagnostic category because we don't think it's valid and we don't think it's reliable. On the other hand, we think it's absolutely indispensable to clinical practice."[13]

Im not really ur what the last sentence means though. Its not that hard to communicate that a patient also has prominent mood symptoms in addition to his/her psychosis. Not sure what you have to have a seperate diagnostic entity in order to communicate that to other health care providers?

 

[erg923]

=JackD;8681009]
4. Schizoaffective disorder just seems like b.s.. It sounds like someone with it would just have schizophrenia with mood problems or less likely, mood problems with psychotic features that start early and last for awhile. I am not sure it is should be its own entity.

Well yes, exactly, However, there are some good arguments on why this really does represent a seperate disease process. They are too much to go into here, but alot has to do with differences in progosis and course between the 2 conditions. Although there are also many arguments for they are not different disorders too. I big part of getting to understand the disorders is to understand that they have multiple purposes and functions. They are not just names of diseases. They are descriptor labels that allow us to communciate information to one another, both clinically and for research purposes. I hate schizoaffective disorder, but really think of it as a descriptor of the nature of the pathology/distrurbance for the medical record, rather than as a seperate disease entity itself.

Yes, the subtypes are pretty useless, and people are almost always a blend. But yes, I have seen very pure "disorganzied types" and very pure "paranoid types" Yes, you are correct, these may represent different pathophysiological disease processes. Schizophrenia probably is many many different pathophisological processes and dysfunctions, not a unified disease entity. Most all of psychiatry accpepts this and has for sometime. There is just now way to change a diagnostic classification to the system to reflect this that wont reak havoc with both practice and research.

 

[KillerDiller]

3. Schizophreniform and brief psychotic disorder both seem unnecessary. If most people with these disorders go on to have full blown schizophrenia, shouldn't it just be assumed that everyone with these disorders have schizophrenia and some people just make a full recovery, rather quickly?

Clinically speaking, I think these diagnoses are useful because not everyone who suffers one psychotic episode has subsequent episodes. I'm not sure what the percentages here are, but I do know I've seen several cases where the psychosis seemed fairly confined to one time period in the person's life. Usually, the person went on to develop a different sort of disorder, like MDD or OCD. But, aside from that, the label of "schizophrenia" is a pretty heavy one that is laden with all kinds of assumptions and stigma. Thus, it is sometimes less harmful for a patient to receive a "less severe" diagnosis. Just a practical consideration.

I personally would like to see the DSM clarify a prodromal state of schizophrenia. We had a fascinating presentation on what this tends to look like in my pathology class.