Category: Observations

Categories
Education Observations Policy Reading

DSM-5: Schizophrenia.

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.]

(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The authors also comment that “individuals who had been socially active may become withdrawn from previous routines.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.

Categories
Education Medicine Observations Reading

Wanna join my DSM-5 e-mail list?

I’ve finally started to read DSM-5, the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders. I intend to summarize germane information for co-workers, though I also said:

I am also starting an e-mail list to share commentary and my opinions about DSM-5 that may not be entirely relevant to day-to-day work.

This accountability will help me get through the 900+ pages of the text.

I don’t know how much of my DSM-5 commentary will make it onto this blog, primarily because I worry that readers might find it boring and overly technical. (Perhaps I should let readers form their own opinions about that.) I hope to send out something about once a week.

If you’d like to join my DSM-5 e-mail list, you can do it one of four ways:

  1. Sign up here.
  2. Send me an e-mail and let me know.
  3. Send me a note and your e-mail address through Facebook.
  4. Send me a note and your e-mail through Twitter.

I’ll send you an invitation once I have your e-mail address.

Categories
Medicine Nonfiction Observations

I Remember.

I remember when we dragged ourselves to the large lecture hall every morning, backpacks slung over our shoulders and cups of coffee in our hands. Six to eight hours of lectures awaited us.

I remember where we all sat in that lecture hall. I remember the future ophthalmologist who sat behind me and made snarky comments while certain professors gave their lectures facing the chalkboard. I remember students sitting six rows behind me who told me after class, “We saw you falling asleep today. If you sit in the back, it won’t be as obvious.”

I remember the guys throwing around a fluorescent Nerf football between classes. Some of them would take off their shirts (and one would look around to see if women were watching) and relive their days of playing college sports.

I remember when we wore shorts, tee shirts, sandals, tattered jeans, dangling earrings, and tank tops.

I remember going to parties and watching people drink wine and beer out of those red plastic cups.

I remember when we received the short white coats. I remember how stiff they were, how awkward we looked in them, and how annoyed we were that we had to buy “nice clothes” in preparation of training in the hospitals.

I remember that we exchanged ideas of where to find “nice clothes” for “cheap”.

I remember how tired and haggard we looked after we took call. I remember when our scrubs were wrinkled, our hair was unkempt, and our hygiene was suboptimal.

I remember when we wondered how we would ever survive our intern year.

I remember when we contaminated sterile fields and didn’t know what size sterile gloves we needed. I remember certain nurses rolling their eyes and yelling at us for our ignorance. I remember when we would see each other in the hallways and stairwells, holding order sheets for signatures, carrying baskets filled with gauze and tape, and trailing behind the medical team that was into its third hour of rounding.

I remember when we tried not to cry when attending and resident physicians said unkind things. I remember when we shared strategies about how to manage certain doctors. I remember how much we said, “I don’t know.”

I now see current photos of my classmates from medical school and, to my surprise, they actually look like doctors. They have wrinkles around their eyes. The men wear white collared shirts, mild neckties, and dark business jackets. The women wear conservative jewelry and shirts with modest necklines. The long white coats fit their frames. Their smiles radiate confidence.

They look mature.

And old.

Which means I must look that way, too.

Categories
Medicine Observations

Reliability.

“There are images of my internal organs everywhere. Someone is collecting them.”

“How do you know that?”

“The sun produces radiation. It’s the same radiation that is used in X-rays. The sun shines, my body gets exposed to radiation, the X-rays go through me, and someone collects the images of my internal organs.”

“Doesn’t that happen to everybody, then? The sun shines on everyone.”

“No, I’m pretty sure it just happens to me. I’m going to die soon.”

“You’re going to die soon?”

“Isn’t this where they conduct executions? With the firing squad?”

“… no.”

“Oh.” He looked over his shoulder, his brow furrowed. He turned his head back. “I was wondering why they give me food every day. I guess I’ll never be normal.”

“Normal? What does ‘normal’ even mean?”

“What do I think a ‘normal’ person is like? A normal person is someone who is reliable. I’m not reliable because I do things like not take my medications and then I end up in situations like this. I can’t rely on me and if I can’t rely on me, no one else can rely on me. When I think about that, it makes me feel worthless. I’d be better off dead.”

He looked down, the furrow in his brow gone.

Categories
Nonfiction Observations

Contrast.

She was a petite woman. She thrust her shoulders back and her dark hair cascaded down in waves towards her slender waist. Her burgundy and white dress gently bounced with each step she took in her four-inch heels. Her arms and legs had the girths of tree saplings. A designer handbag swayed on her left shoulder and pearl-accented earrings dangled from her ears.

It was crowded at the buffet. With purpose she walked past the glistening hunks of prime rib, the pink slabs of baked salmon, the heaps of bacon, the blobs of scrambled eggs, the bowls of romaine lettuce and spinach, the rounded cubes of honeydew, pineapple, and cantaloupe, the bundles of fried egg rolls, the vats of noodles, the pot of egg drop soup, the bowl of quivering red jello, the trays of walnut brownies, lemon cake, and chocolate mousse pie, the racks of barbecue ribs, the oozing discs of pepperoni pizza, the rows of chocolate chip cookies, and the limp triangles of French toast.

She carried her plate with both hands, her fingers tightly gripping the edges. Her eyes scanned the buffet, but she was not looking at the food. The only item on her plate was one roasted red potato.