Category: Observations

This is another post from my DSM-5 e-mail list. If you find the information below useful or interesting, you are welcome to join.

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(747 words = 5 min read)

The essential feature of PTSD is the development of reactive symptoms following exposure to a traumatic event. The diagnosis of PTSD has notable changes in DSM-5.

One difference is that, according to DSM-5, a person no longer needs to experience emotional reactions (“intense fear, helplessness, or horror” described in DSM-IV) to the trauma.

The authors provide a long list to describe criterion A (“exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways”). Note that sexual violence is now included in the definition.

Criterion A also allows for the diagnosis of PTSD for individuals who have had only indirect exposure to the trauma, though the trauma must have occurred to “close relatives or friends”. There is also a clause for repeated and extreme exposures, such as what paramedics and other first responders witness. The events of September 11, 2001, have influenced this diagnosis.

Criterion B, previously the “re-experiencing” sphere, is now the “intrusion” sphere. These symptoms include memories, nightmares, dissociation, and distressing reactions to internal and external cues related to the trauma.

Criterion C remains the “avoidance” sphere (avoidance of both internal and external reminders), though patients only need to meet one of two criteria in DSM-5 (versus three of seven in DSM-IV).

Criterion D encompasses “negative alterations in cognitions and mood”, which includes memory problems, negative thoughts (think Beck’s cognitive theory of depression), and resulting distressing emotions. This criterion helps capture the “comorbidity” of depression seen in PTSD.

Criterion E is the “hyperarousal” sphere that describes the irritability, “jumpiness”, and paranoia often seen in PTSD.

The authors note that these symptoms must persist for at least one month and cause “clinically significant distress or impairment”. As usual, they ask that the reader ensure that these symptoms are not due to a medical problems or a substance use disorder. There are only two specifiers:

• with dissociative symptoms (depersonalization or derealization)
• with delayed expression (full criteria are not met until at least six months after the event… the authors state that there is “abundant evidence” to support the delay in symptom appearance, but do not offer any explanations as to why)

The authors also include PTSD criteria for children ages six and under (which I will not review here, since I only work with adults… child psychiatrists, I direct you to page 272).

The authors note “auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more voices”, as well as paranoid ideation, can be present in PTSD. I find this useful because, previously, I’d give a primary diagnosis of PTSD and a secondary diagnosis of “psychosis NOS”, though it was clear that these were not “organic” psychotic symptoms.

The authors also note that prolonged exposure to trauma can result in emotion dysregulation, problems with stable interpersonal relationships, and dissociative symptoms… which sounds a lot like borderline personality disorder.

DSM-5 states that the projected lifetime risk for PTSD is only about 9%. This speaks to the resilience people possess, as much more than 9% of the population experiences trauma described in criterion A. Complete recovery is within three months for about half of adults. This again is a testament to the resilience people have.

PTSD is also diagnosed much more in the US than in other Western countries. (Paul McHugh has written a lot about the amplification of PTSD in the US.) Women are more likely than men to receive a diagnosis of PTSD. Those at highest risk of developing PTSD include survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

The authors divide risk factors for PTSD into three groups:

1. pretraumatic factors (temperament; childhood adversity; racial minority; etc.)
2. peritraumatic factors (severity/dose of trauma; interpersonal violence; etc.)
3. posttraumatic factors (“negative appraisals”; exposure to upsetting reminders; etc.)

The differential diagnosis for PTSD is one of the largest in psychiatry; it includes other stress disorders, mood disorders, personality disorders, psychotic disorders, and neurocognitive disorders. PTSD also has many “comorbid” conditions as already noted above; DSM-5 states that 80% of people diagnosed with PTSD are likely to have symptoms that meet criteria for another mood, anxiety, or substance use disorder.

Anecdotally speaking, people wrestling with homelessness and poverty often have a significant history of trauma. We might assume that the homeless caused their own problems. When you start asking clarifying questions, however, you often learn that they had horrifying childhoods. Just some food for thought.

Next time: Probably bipolar disorder.

This post is directly from my DSM-5 e-mail list. If you find the information below useful or interesting, you are welcome to join. [Note: I have stopped updating this forum. Sorry.]

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(670 words = 5 min read)

The diagnosis of schizophrenia has expanded in DSM-5. Criterion A now includes five items:

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition)

At least two of the five symptoms must be present for at least one month. One of the two symptoms must be delusions, hallucinations, or disorganized speech. Negative symptoms, which impair function the most, are now official.

In discussing diagnostic features, the authors state that “no single symptom is pathognomonic of [schizophrenia]” and it is a “heterogeneous clinical syndrome”. This is what makes schizophrenia both fascinating and frustrating: I can diagnose two people with schizophrenia and they may look and behave nothing like each other.

Criterion B for schizophrenia gets more attention in DSM-5: “Level of functioning… is markedly below the level achieved prior to the onset”. This is not a criterion for schizoaffective disorder. (This is apparently unchanged from DSM-4.)

Furthermore, the authors note that if symptoms of schizophrenia begin in childhood or adolescence, “the expected level of function is not attained. Comparing the individual with unaffected siblings may be helpful.” This must only amplify sibling rivalry.

The authors also comment that “individuals who had been socially active may become withdrawn from previous routines. Such behaviors are often the first sign of a disorder.” In the past few years, some studies have argued for treating people with who are at high risk of developing schizophrenia, even though they have not yet met diagnostic criteria.

This is controversial because we cannot predict who will definitely develop schizophrenia. Some treatments, such as antipsychotic medication, are not benign. This statement seems to permit more assertive treatment of youths who present with “prodromal” symptoms of schizophrenia.

Criterion C discusses the six-month duration that distinguishes “schizophrenia” from “schizophreniform disorder” (one to six months) and “brief psychotic disorder” (one day to six months).

Criterion D makes the distinction between schizophrenia and schizoaffective disorder (primarily psychosis and limited mood symptoms in schizophrenia). This is repeated multiple times under the entry for schizoaffective disorder.

Criterion E asks the reader to please rule out psychosis due to drugs or a medical condition.

Criterion F makes the distinction between schizophrenia and an “autism spectrum disorder or a communication disorder”. That replaces “pervasive developmental disorder” in DSM-4.

The previous specifiers for schizophrenia (paranoid, disorganized, catatonic, etc.) have disappeared; now, specifiers are related to the illness course (“first episode” versus “multiple episodes”; state of remission; etc.). I am pleased to see that “currently in full remission” is a specifier. People can and do get better from schizophrenia. (DSM states that 20% of people with schizophrenia have a “favorable course”.)

The authors also explicitly comment about “decrements” in cognitive function in people with schizophrenia, which frames the condition as a brain disease. Similarly, there’s a note that “unawareness of [schizophrenia in the patient] is typically a symptom of schizophrenia itself rather than a coping strategy.” It’s not a psychodynamic defense mechanism of denial.

Kudos to the authors for their advocacy:

“It should be noted that the vast majority of persons with schizophrenia are not aggressive and are more frequently victimized than are individuals in the general population.”

The rest of the chapter discusses demographics, course of illness, etc. Here are some things I found noteworthy:

“Late-onset cases (i.e., onset after age 40 years) are overrepresented by females, who may have married.” Why is that last part there? Is this meant as a consolation prize to their husbands?

DSM-5 officially concedes that “some minority ethnic groups” are more likely to be diagnosed with schizophrenia.

Substance-related disorders are high (over 50% smoke cigarettes regularly). They are also more likely to experience weight gain, diabetes, metabolic syndrome, cardiovascular and pulmonary disease. People with schizophrenia at high risk for suicide: 5-6% die by suicide and 20% attempt suicide. The combination of these factors may explain why people with schizophrenia die early compared to the general population.

Next time: schizoaffective disorder.