Psychiatry & Psychotherapy Podcast - Schizophrenia Differential Diagnosis & DSM5

Episode Date: June 6, 2019

Schizophrenia is a diagnosis of exclusion. Doctors and therapists need to be able to rule everything else out before they can land on schizophrenia as an official diagnosis. There are specific symptoms are known as "first-rank symptoms," which we will cover later in the article, that will help with diagnosing patients (Schneider, 1959). Eighty-five percent of people with schizophrenia endorse these symptoms, but be wary of jumping to conclusions because they are not specific to schizophrenia and, in some studies, are also endorsed by bipolar manic patients (Andreasen, 1991). DSM5 (Diagnostic and Statistical Manual of Mental Disorders 5th ed.) Schizophrenia is a clinical diagnosis made through observation of the patient and the patient's history. There must be 2 or more of the characteristic symptoms below (Criterion A) with at least one symptom being items 1, 2 or 3. These symptoms must be present for a significant portion of time during a 1 month period (or less, if successfully treated). The patient must have continuous, persistent signs of disturbance for at least 6 months, which includes the 1 month period of symptoms (or less, if successfully treated) and may include prodromal or residual periods. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset. If the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational achievement. Criterion A: A. Positive symptoms (presence of abnormal behavior) 1. Delusions 2. Hallucinations 3. Disorganized speech (eg, frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior B. Negative symptoms (absence or disruption of normal behavior) 5. Negative symptoms include affective flattening, alogia, avolition, anhedonia, asociality. By listening to this episode, you can earn 0.5 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel

Hello and welcome to the psychiatry and psychotherapy podcast, with over 32,000 mental health professionals listening every episode. Why? Because we need to stick together to survive the mental health field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. All right. So this is the subsequent episode, episode three of our schizophrenia series. And I'm here with Dr. Arianna Cunningham. Hello. And today we're going to go through the DSM-5 diagnostic criteria for schizophrenia, and we're going to hit the differential diagnosis for schizophrenia like other things that cause psychotic

symptoms. And we'll see if we have time to get into medications. Awesome. Yeah, let's get started. Okay, let's get started. So I think to kind of open things up, first off, it's important to note that schizophrenia in itself as a diagnosis is a diagnosis of exclusion. there's nothing directly pathognomic for this.

It's something that we really need to rule everything out that on the differential diagnosis list before we can firmly say this is schizophrenia, but we do have, thankfully, like a list of what we consider to be like the actual diagnostic criteria that we'll go over. Yeah, so let's go through the diagnostic criteria and then we'll launch into the differential diagnosis. Yeah. So to start off, this is. is when we go towards making the diagnosis, we kind of want to separate some components of the

diagnosis itself. This is a clinical diagnosis, meaning we don't take a blood test. We don't have at this point in time with our tools available, like a genetic test we can do off the bat. We do this through observation and good history taking. So it's going to be comprised of the symptoms, which we talked about in more detail in previous episodes, but those include delusions, hallucinations, disorganization in speech or behavior, along with negative symptoms, plus some type of dysfunction in their life that you might see, let's say, on an occupational or social level. So how long do the symptoms have to be going on?

So that's a good question. When we talk about the symptom presentation, in a one-month time period, we'd expect those to be present for the majority of the time. but before we can call it schizophrenia, we need to see the dysfunction for about six months. And we'll get into that a little bit more before, if you have a patient who's first presenting with some of these things, and it hasn't gone on for six months yet, let's say there's been one month or two months of this behavior, and you've ruled out the rest of the differential. We would actually have a different name that we would tack on to this before they hit the

six-month mark, and at which time we would say schizophrenia as a major diagnosis. So what is the name of that? schizophrenia form. Yeah, so schizophrenia form, what is it, less than six months? Yeah. And then after six months, on the boards, it's called schizophrenia. Yes. So that's a good, I think it's important to hold on to those specific time markers for board

examinations and even in practical life as a practitioner so that you know when you can take, because it is a bit of a step forward to put on such a serious diagnosis as schizophrenia onto someone. Okay, so you have to have two or more of criterion A symptoms. Let's go through that list. Yeah, delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms. Right. And for disorganized behavior, it can also be catatonic behavior. Yeah.

And for the negative symptoms, you can have affect of blunting, eulogia, evolution, Yeah, and that's something in the last episode that we did, we kind of went more deeply into the specifics of that. Right. But it's important to remember that catatonia and negative symptoms may not look like your stereotypical thought. So we have links to even like the Bush-Francis rating scale for catatonia that will list up on the blog. Yeah, just to help you out so you have a tool to turn to when you have someone that you're kind of trying to sift through what they're presenting with. Cool. at psychiatrypodcast.com.

Okay, so then anything else on the DSM diagnosis you want to add in? I think we kind of already outlined the emphasis on the time duration, but just for those taking board exams, six months is our cutoff for saying this is full-blown schizophrenia, and it has to include at least one month where the symptoms are really present for the predominant part of that time. this can't be like intermittent disorganized behavior one day out of a month. This really needs to be something that's been present in their life consistently.

Yeah, and for a significant portion of the time, since they have the onset of the disturbance, they usually have one or more major area of, you know, issues of functioning, such as, you know, at work, interpersonal relationships, self-care. and it'll be markedly lower than what they were doing before. Yeah. The onset. Yeah. So, you know, all of a sudden, a patient will stop showering.

All of a sudden, the patient will be neglectful of his friendships, be neglectful of his relationships. All of a sudden, at work, they'll show up very differently. Yeah. And I think it's helpful to realize that the typical age of onset being, for like in young adulthood, you'd really see this in a time period where otherwise they might be fairly high functioning, let's say, in higher education classes. And for the majority of patients, we found to be about around 80% of the people who will have this disease manifest, it's an

abrupt onset. So like you were saying, this will be kind of like a pretty quick turnaround where you see a rapid decrease in functioning. And then another thing, and we'll get more into this when we go through the differential diagnosis for the disease. is that part of the diagnostic criteria is that it can't be explained by a substance or a physiological effect of a medical condition outside of schizophrenia. So you really have to go through, like we said, it's a diagnosis of exclusion. Okay. Yeah. And let's go through the differential now. Yeah. So differential diagnosis, I think this is maybe one of the most important parts, practically speaking, for the people who are listening, is to talk about what other things we

need to make sure this isn't before we call it schizophrenia. So for the list to start off with schizophreniform, we already talked about it. This is exactly what schizophrenia looks like, but for a shorter time duration, less than six months. So this is, I guess you could kind of say that transitional zone into a diagnosis of schizophrenia. The only thing differentiating is just timeline. Yeah, and I think it's partially because, you know, schizophrenia is a, a very significant diagnosis to make. And so we don't want to be making this diagnosis unless we're pretty sure this is what's going on. So I think that six-month period of time lets us know, you know, oh, is this just because of drugs or something else that's going on?

And as a practitioner, you know, once you get into the realm of putting in, making up problem lists for the patient's charts, putting things into the charts, sometimes once something's entered, it's much harder to get it. removed than it is to add it on. So we really need to have some understanding of what time frame really constitutes schizophrenia versus anything else. Yeah. Okay. The next one. The next one is schizoaffective disorder and this can basically be differentiated from schizophrenia in the sense that there's a prominent mood component to the patient's presentation. Right. So they're either very depressed and usually the depression precedes the psychosis or they're manic and the mania precedes the psychosis. So it's very rare that you'll have a major depression that starts with psychosis. It'll be significant like months of depression and really, really bad, progressive suicidality

and then they get psychotic almost after the suicidality. So it's like for them to get psychotic, it usually is progressive for several months, at least, is what I've seen in clinical practice. So that would be the major depression with psychotic features. And for this, it's really important to get a strong timeline and you really might need collateral information from family members to say which of the symptoms that we see, if you have a mixed picture of both psychosis and mood,

which of the symptoms started first, which one stays present when the other one goes away, just to get an understanding of what's what. some cool visuals that I'm going to try to put in the blog that some of the attendings have mapped out for us as residents and training that have been really helpful in conceptualizing the differences between these. Cool. And then bipolar, you know, bipolar, once again, they're going to be ramping up for weeks. They're going to have a loss of sleep. They're going to have elevated mood or irritable, angry mood. And they're going to be talking faster. They're going to be grandiose. So they're

going to be on a special mission, a special purpose. They're going to be doing more impulsive, high-risk behaviors that's not in their character, and then they'll get psychotic. So the psychosis is one of the later things that I see in the bipolar sort of progression. And by the time they're psychotic and paranoid, they have been manic for at least a week where they haven't been sleeping almost at all. That's what I've seen. I don't know if you have anything to add to that. No, I think that's really true. And also just for a moment of like connection and sympathy or empathy with other providers is that sometimes it's really hard to get a good history on these presentations or, you know, if it's an edy kind of presentation and maybe you don't have any

collateral access at all. And yeah, sometimes when I'm trying to figure out if someone had a bipolar episode in the past, I'll ask about previous, like, admissions. And usually the admissions were for longer than three to four days. Like, you cannot be manic and be hospitalized and be cured in three or four days. It just doesn't happen. And so what I've seen a couple times is they have a manic episode, they get better. And they don't remember very much from that manic episode. Like, they're very poor historians. But the family, will remember. And this is where, like, looking back through medical records can be really important. So, you know, do you dig a little bit? Do you go with your gut? You know, it takes a little bit of

time to get a good diagnosis. Absolutely. I think the patients that come through our psych hospital, because our residents take a lot of time and our attendings are really good, I really trust the diagnoses on the discharge summary. And it's been very, very rare because I mostly do outpatient. I cover inpatient on the weekend sometimes, but I mostly do outpatient. And I see a lot of the patients that get discharged. And it's a rarity that I'll change the diagnosis later on. So I appreciate that about you guys. Yeah, especially if someone comes in and they're on inpatient for one or two weeks, then you've had time to really dig into as much collateral as exists. And yeah, a good, A good history, I think, is absolutely key to the diagnosis of schizophrenia.

And we in our psych hospital will utilize social workers and support staff to really help us get that history as well. And they're so helpful in digging in and we really value what they learn from the family. And it's just like putting those little pieces together. I think it's really important. Yeah. And I think it's also something, a bit of a gift that I've heard reflected from family members when we get a thorough history. because there's a lot of fear of being misdiagnosed and overmedicated and all these things, whereas if you're able to perhaps take a little bit more time with the family and explain why you're asking the questions you are,

I think that in and of itself can be therapeutic as well. Okay, and so let's go on to the next one. Substance induced, psychotic disorder? So this is probably one of the, I guess, most practical things for me as a resident who works in the emergency room is you have someone who comes in presenting with strong psychosis, hallucinations, delusions, paranoia, disorganization, et cetera. And once again, a good history makes all the difference and timeline once they're admitted for treatment.

And a good urine drug screen. Yeah. Absolutely. So luckily, you know, most of the time, most of the patients have been in our system in and out of the ER so you can quickly scan back and look at their drug screens and get an idea. and sometimes I'll even like ask questions like oh you know when was the last time you did any drugs what drugs do you do you know and people will be very guarded but if you kind of like have like a very non-judgmental like yeah just need to know to be able to know how to treat you the best to know which

medications are going to work the best often they'll tell you if not on day one subsequent days And once they know that you do a urine drug screen, there's almost a sense of like, hey, if you don't tell me and it comes up, I'll just come back and ask you again. But we could do this here and now, make it a little bit easier. So methamphetamines is, you know, we live here in Loma Linda next to the meth capital of the world, the high desert, San Bernardino. I think it's the meth capital of the world. It's one of the top cities. It's not, it's surely, it's surely pretty high on our list of what we treat and who we see and how often we do have repeat methamphetamine users. I would say, out of the 30 or 40 patients in the units that we have, I would say about maybe five to 10.

Absolutely. Our previous meth users or current meth users. Yeah. And, you know, so these people, when you see them on the day after admission, they're sleeping. Absolutely. And they do not want to get up. and they're very irritable. So they're crashing.

So the first couple days of their admission, they're immediately crashing. So they're not manic because the manic patients, it takes them a couple days to get to sleep. Yeah, they wouldn't be crashing there. And the schizophrenic patients will usually get up and talk with you, but someone who's been using meth and coming acutely off of meth, they really don't want to talk to you.

Yeah. And I think that's something important is that the symptoms of methamphetamine use that mimic some of the presentations that look like schizophrenia are, happening when they're actively on the substance and that should kind of go away as they crash off of it. Although there are some cases really long-term chronic users of meth and THC where some of those symptoms may become persistent even outside of active use. You know, interesting I was talking to Dr. Cummings about Dr. Cummings is one of my mentors. He's on a bunch of episodes with me.

And we were talking about marijuana. Yeah. And he said usually people who get psychotic on marijuana get psychotic earlier on. than later. Yeah. And so if you've been using it for like 40 years, you're probably not going to get acutely psychotic from using marijuana because there are genetic differences

that they found in people that have the tendency to get psychotic on marijuana. And so that was an interesting new thing to me. Yeah. Because if you've smoked marijuana and it increases your anxiety acutely, don't do it again. That would be one of the big takeaways. Yeah, if you have a bad trip,

this is something definitely to avoid for your longevity of health. Mental health. Because you do not want to get a psychotic illness. No. Okay, so there are psychotic illnesses caused by drugs. Sometimes the psychosis continues, but most of the time it dies off. Yeah, yeah, which is encouraging for the majority of people that I've seen on inpatient. You know, they come in, they might be, like, loosely termed, like, hyacite, really psychotic,

looking a lot like someone with active schizophrenia, but then you give them a couple days, they sleep it off, they crash off, they come back. But each time there may be some permanent damage and you increase the risk of permanent psychosis. And that to me is pretty scary. Yeah. I once had a patient come in

who felt like bugs were crawling all over the skin. And I got a big history from him and finally it came out that he was using meth occasionally. And I told him, I think that's the big issue. I think if you get off meth, you'll have a resolution of these symptoms. Yeah. And there's nothing that I can do long term. As helpful as just.

As helpful as getting off. Yeah. And we talked to, you know, I mean, you could give a little bit of Risperdoll or whatnot. But for him, he was actually so scared of these bugs crawling over him that he was willing to give up meth. Wow. That does sound like. just torture. I get a little preached out with a single bug, so I can't imagine

being in that experience. That would be awful. Okay, so the next is psychosis due to a medical condition? Yeah, and I think anytime you have anything that's affecting, especially the brain itself when you think of traumatic brain injuries,

Wilson's disease, syphilis infection, porphyria in different presentations, all of these sorts of things could in some ways, mimic. And granted, these are these are just things to have your eye out for. Like if you have an acute change in mentation,

oftentimes imaging of the brain is one of the first places you'll go as a provider. Yeah. Traumatic brain injury, CVA, porphyria, syphilis. And, you know, I think it's good as providers to keep

medical things on our radar. Yes. Because we are physicians first, and so we really want to be to rule out any other sort of things that might be causing the issue. Yeah. One thing that comes to my mind is medications as well. So steroids can cause any mental illness is an easy way to remember what steroids can cause. So steroids can cause mania.

They can cause psychosis. They can cause depression. Have your eye out for different dietary supplements. I've been on inpatients where we've had a few patients who presented acute psychosis onset and then through history taking and finding out things that they didn't think to report in their medication review of some dietary supplements are not regulated by the FDA and for that case can contain different just elements that really throw your body for a loop bath salts mushrooms these are going back to the drugs but those are always on my radar and unfortunately

it could be their first experience of the thing so you know were they at a rave what was their setting of the onset of psychosis. Even with THC, I know this is something we touched on briefly, is that there are new synthetic versions of a majority of the drugs that are in existence and these newer synthetic versions are sometimes not, like what we kind of call like dirty drugs or mixed or laced with other components. And sometimes even if you've tolerated one form of the same drug in the past, you may be getting a different form or different forms.

or a different chemical version of it. Right. So a good example of that is ecstasy. They found that people who thought they were only taking ecstasy also got methamphetamines, also got some bath salts occasionally. So there was a really interesting study looking at all the different substances that were mixed into just various doses of street drugs. So you really don't know what you're getting. And so the other substances could be part of the bigger. picture. And some of the things like bath salts, like we, we don't, that's not going to be positive

in your urine drug screen. Yeah, that's actually a really good, that might be a good fodder for a future podcast is just what our typical screening things pick up and what they don't, because that's definitely a very practical issue in emergency room settings and inpatient settings, you name it. Yeah. Okay, so the next one is delusional disorder. Yeah, so this one is kind of, is like one symptom of schizophrenia in isolation from the other symptoms of schizophrenia. So you might have someone who holds a delusion and it's consistent, but none of the other presentations or none of the other core symptoms are present. So they don't have the negative symptoms.

Yeah. And they don't have the auditory hallucinations. They just have the delusion. Yes. And I often wonder, like, okay, is this. person believing this delusion in isolation? Or does their family believe this delusion? If there's a community of people, even if it's like 12 or more people, I'm forgetting what that specific cutoff was, it's no longer considered a delusion if it's a belief held commonly enough

by at least some subset of the community that they exist in. So just something to keep in mind. Also, the timing if you have someone who holds a strong delusion at the age of 45, once again, line up the factors of risks that you'd expect to see in someone typical of a schizophrenia presentation being like younger aged more likely. Just those sorts of things to kind of bear in mind. Then there's a schizo-tipple personality, which is a longstanding pattern of odd or eccentric beliefs. Or they may have some perceptual disturbances that don't rise to the level of delusions or hallucinations. Yeah, and it's helpful because I think anytime we have SCH-I-Z like SCI-Z, like Schitz or Schizzo, in the name of any disease state, I think our mind's kind of automatically referenced to schizophrenia. So Schizophrenia-Tipal personality disorder and schizoid personality disorder are separate from schizophrenia. And then side by side, because I remember when I was a student in medical school, trying to make sure I could differentiate these. Schizophrenia-tipple has the T and we associate it with magical thinking. versus schizoid personality has the D, and we think of that as distant because this one is a longstanding pattern of little interest in social relationships or intimacy.

So they're a distant personality, relationally speaking. That's good. Yeah. Just if anyone out there is a visual learner, that's definitely how I got by. And then pervasive developmental disorders. So these ones may present with psychosis or negative symptoms, which definitely overlaps with a problem. presentation of schizophrenia. But you really want to make sure when you're approaching someone that you're considering, does this person have schizophrenia or not, that you're able to look

at their developmental pattern? And finally, does this person have, let's say, autism? Do they have any in the history taking abnormalities in childhood or development that might offer a better explanation for some of how they're presenting or any social dysfunction? Because remember, social or occupational dysfunction is a component of the diagnosis of schizophrenia, but we need to make sure it's not due to something else. Yeah, and I think, you know, you have to think about how old this person is in their mind. So like, when you hear this person's vocabulary, when you hear them speak, what age would you put them at? would you put them at three years old or four years old if they're a three or four year old

and how they speak they might have an imaginary best friend like a three or four year old might yeah and so in that case you shouldn't call it a visual hallucination because that's a normative part of development for that age range and then the question is is this

something that they enjoy is this a way that they cope with the world and if that's case like please don't medicate you know like something that's like yeah just something you would expect in someone with a developmental disorder no absolutely that's a really good point i think just to reemphasize the reason why we're going through this differential diagnosis in such detail is because on a practical level and even on a legal level you really want to make sure that you aren't calling something schizophrenia when it's not and that you aren't treating incorrectly because you

could do harm with the medications that you prescribe if the benefits don't outweigh the risk. Yeah. Yeah. So I would like to add one to this list you have here of a borderline personality disorder. Oh, yes. Because they often have quasi-psychotic symptoms. they can hear voices that are persecutory, that are congruent to their affect. But unlike chronic depression, when they get the psychotic symptoms, it's rapid onset.

So they have a breakup with a significant other. And then immediately they can get these quasi-psychotic symptoms, like you're worthless, you're horrible. and it's the negative internal voice, but it's like really loud, so it sounds like they're hearing voices. And sometimes they are sort of inculturated in mental health to say that they're voices, although they're not. Or they may have voices like,

you should kill yourself or hurt yourself. And unlike schizophrenia, they don't have the negative symptoms in the same way. They may have negative symptoms occasionally, like a blunted affect that is sort of similar to dissociation where they feel distant, they feel depersonalization, where they don't feel themselves, they don't feel in their body, or de-realization the world is sort of a fog, is separate from them. So they may have those dissociative types of symptoms, but they can snap out of it and they can put on a social veneer. Whereas someone with schizophrenia cannot put on the social veneer like a person with borderline personality disorder. So when you interact with someone with borderline personality disorder and you're an authority figure, they may put on, they may pull themselves together to interact with you. And if they can't do that, then they may be in sort of an acute episode of their distress and dissociation.

and they may be stuck in the dissociative types of symptoms. And those might seem psychotic, but they're not psychotic in the way that schizophrenia is, and they're not psychotic in the way that you would see depression progress over months. And they're not psychotic in the way that someone would be in a manic episode because they haven't ramped up without sleep slowly over a couple weeks. So I think that's really important to talk about. No, absolutely.

Yeah, and once again, just making sure you have a really good timeline, like you said, of when this started and the timeline of the individual symptoms, not just the psychosis itself. I think also with borderline personality disorder, they're not going to have the delusions in the same way that someone with schizophrenia would. They won't have the prodrome where they are sort of aloof and disconnected and no religiously. relationships. They won't have that sort of for years before the onset of the schizophrenic episode. Much to the opposite. They'll have like a strong pursuit of relationships, a strong desire for a connection. They'll have a strong desire for connection and a very, very strong desire for attachments and relationships. And a lot of their distress will center around not feeling connected, disconnection, breakups. And so it's so important to not get confused with, okay, is this person psychotic or is this person, you know, suffering from a lot of the constellation of chronic trauma, you know, or chronic disconnection early on in their life.

Yeah. With having a sensitive temperament on top of it, which is how I think a borderline personality disorder. Yeah. So you have someone who is a sensitive person who. person, often empathic, and they go through a series of traumatic events or just lack of mirroring of the primary caregiver, and then they can end up in adolescence with chronic suicidality. And then they can have these sort of quasi-psychotic episodes in the midst of that, which often come on fast and leave fast. And so within that, you may get confused if you just

read the symptoms like, okay, is this schizophrenia? is it's bipolar, but it's often the sequela of trauma. Anything else on that you'd like to add? No, I think that's a really good point is just not to jump the gun based on what we see as the most stereotypical or prototypic presentation, which is psychosis, that that is something that's presented and manifested in like a lot of other situations. Yeah. So in this episode, we went through the DSM criteria for schizophrenia, and we went through the differential diagnosis.

Yeah. And on the blog, we will put all of this information for your consumption. And if you have any thoughts, feel free to send me a direct message on Instagram. That's probably where I'm the most active. Or you could tweet at me or follow the show notes to any of the different. different places to interact. And I actually got, you know, I get a couple messages a day and I really enjoy it. So if you're out there, I got one from Australia just yesterday, some person in a sort of a, you know, a small town who's found this and found it helpful. And that, that's exciting because that's,

that's what I'm hoping that people can take away from this is, or people can, people can gain knowledge and empathy all across the world. tools to equip for you to deal with this subject matter in a professional or personal context. Yeah. Yeah. So next episode, we're going to really launch into the treatment. And then I'm also going to have, I think the very next episode after maybe Dr. Cummings, we're going to talk about clausero, clozapine, and all of the, it's going to be a deep dive into that medication in particular and why it's important for schizophrenia.

So, yeah, I hope this was helpful. and have a great day. Thank you.