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What is new in DSM-5 for Schizophrenia
Spectrum & other Psychotic Disorders;
Bipolar & Related Disorders; Depressive
Disorders; and Personality Disorders?
David L. Fogelson, M.D.
Clinical Professor of Psychiatry
David Geffen School of Medicine at UCLA
And The Semel Institute for Neuroscience and Human Behavior at UCLA
Disclosures
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Grant Support from Genentech
 The grant is a naturalistic 5 year prospective study
of 3000 patients with Schizophrenia
 The grant speaks to current state of research in
Schizophrenia and the challenges in developing
DSM 5
 Why are we doing a naturalistic study in 2013?
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Lack fine grained information about heterogeneity of Sz
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e.g. developmental course, prognosis, functional consequences,
comorbidity, burden on family, caregivers, society
Need this information to cross correlate with genetic and
physiological measures
DSM 5 represents incremental change, not
transformational change
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The hope had been for a dimensional rather than
categorical approach to diagnosis
The construct was to apply genetic findings, neuroimaging, physiological markers, and neuro-cognitive
markers
They would be cross correlated with dimensional
environmental factors
• Nutritional, infectious disease, toxins, antigens,
and psychosocial adversity
Allowing for patient specific diagnoses rather than
the categorical diagnoses of DSM IV
The hope was not realized: here I review the
incremental change found in DSM 5
Schizophrenia Spectrum and Other Psychotic Disorders
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Schizophrenia, > 6 months, > 1 month active-phase
Schizotypal (Personality) Disorder
Delusional Disorder
Brief Psychotic Disorder, > 1day, < 1 month
Schizophreniform Disorder, > 1 month, < 6 months
Schizoaffective Disorder, some overlap of mood episodes (mood episodes
occur > 50% of lifetime duration of illness) with psychosis and > two weeks of
psychosis without overlap with mood at other times
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated with Another Mental Disorder (Catatonia Specifier)
Catatonic Disorder Due to Another Medical Condition
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
Unspecified Catatonia & Unspecified Schizophrenia Spectrum and Other
Psychotic Disorder
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Clinician’s choice and data may be insufficient
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Schizophrenia Spectrum and Other
Psychotic Disorders: Key Features
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Delusions
Hallucinations
Disorganized Thinking (Speech)
Grossly Disorganized or Abnormal Motor
Behavior, including Catatonia
Negative Symptoms (simplified to 2
domains)
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Diminished Emotional Expression
Avolition
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Schizophrenia
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Elimination of special treatment of bizarre
delusions and “special” hallucinations in Criterion
A (characteristic symptoms)
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Rationale: This was removed due to the poor reliability
in distinguishing bizarre from non-bizarre delusions.
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Schneiderian Delusions carry no special weight
At least one of two required symptoms to meet
Criterion A must be delusions, hallucinations, or
disorganized speech
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Rationale: This will improve reliability and prevent
individuals with only negative symptoms and catatonia
from being diagnosed with schizophrenia.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Schizophrenia (cont’d)
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Deletion of specific subtypes
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Rationale: DSM-IV’s subtypes were shown
to have very poor reliability and validity. They
also failed to differentiate from one another
based on treatment response and course.
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Eliminates:
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Paranoid Type
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Disorganized Type
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Catatonic Type (Catatonia becomes a specifier)
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Undifferentiated Type
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Residual Type
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Schizophrenia
295.90 (F20.9)
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A. Active phase, 1 month of two or more, must include one
* item
• Delusions*, hallucinations*, disorganized speech*,
grossly disorganized or catatonic behavior, negative
symptoms
 B. Deterioration and Impairment in work, interpersonal
relations, or self care
 C. Duration, 6 months of negative symptoms or 2 or more
Criterion A symptoms in attenuated form
 D. Rule out Schizoaffective and depressive/bipolar disorder
with psychotic features
 E. Not due to drug abuse, medication, medical illness
 If history of autism or communication disorder of childhood,
must meet criteria A – E.
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Catatonia Associated With Another Mental
Disorder (Catatonia Specifier)
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293.89 ( F06.1)
Now exists as a specifier for
neurodevelopmental, psychotic, mood and
other mental disorders; as well as for other
medical disorders (catatonia due to another medical
condition, e.g. cerebral folate deficiency, infections,
metabolic, neurologic, rare autoimmune and paraneoplastic
disorders)
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Rationale: As represented in DSM-IV, catatonia was
under-recognized, particularly in psychiatric
disorders other than schizophrenia and psychotic
mood disorders and in other medical disorders. It
was also apparent that inclusion of catatonia as a
specific condition that can apply more broadly
across the manual may help address gaps in the
treatment of catatonia.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Catatonia Associated with Another Mental Disorder
(Catatonia Specifier)
293.89 (F06.1)
 A.
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Three or more:
Stupor (no movement, unrelated to environment)
Catalepsy (passive induction of a posture held against gravity)
Waxy flexibility (slight, even resistance to positioning by examiner)
Mutism (exclude if known aphasia)
Negativisim (opposition or no response to instructions or external
stimuli)
Posturing (spontaneous maintenance of a posture against gravity)
Mannerism (odd, circumstantial caricature of normal actions)
Stereotypy (repetitive, abnormally frequent, non-goal-directed)
Agitation not influenced by external stimuli
Grimacing
Echolalia (mimicking another’s speech)
David L. Fogelson, M.D.,
Echopraxia (mimicking another’s movements) www.DavidFogelson.com, June 2013
Catatonic Disorder Due to Another Medical Condition
293.89 (F06.1)
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A. three or more symptoms of abnormal
movements, speech, or agitation (see prior
slide)
B. Evidence from Medical Examination due to
direct pathophysiological consequences of
another medical condition
C. Not better explained by another mental
disorder
D. Not due solely to a delirium
E. Distress or impairment in social,
occupational, or other important functions
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Schizoaffective Disorder
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Now based on the lifetime (rather than
episodic) duration of illness in which the mood
and psychotic symptoms described in Criterion
A occur
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Rationale: The criteria in DSM-IV have demonstrated
poor reliability and clinical utility, in part because the
language in DSM-IV regarding the duration of illness
is ambiguous. This revision is consistent with the
language in schizophrenia and in mood episodes,
which explicitly describe a longitudinal rather than
episodic course. Similarly applying a longitudinal
course to schizoaffective disorder will aid in its
differential diagnosis from these related disorders.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Schizoaffective Disorder
295.70 (F25.0) Bipolar Type
295.70 (F25.1) Depressive Type
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A. Uninterrupted period of major mood episode (MDD or
Bipolar) concurrent with Criterion A of Sz (overlap)
B. Delusions or hallucinations for 2 or more weeks in the
absence of a mood disorder during the lifetime duration
of the illness (non over-lap)
C. Major mood disorder present for > 50% of the active
and residual lifetime duration of the illness
D. Not due to medication, drug abuse, or medical illness
Specifiers
• Bipolar, MDD, Catatonia
• First episode, Multiple episodes, Continuous
• Acute, degree of remission
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Schizoaffective Disorder, research supports its
inclusion as a schizophrenia spectrum disorder
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Unclear if it differs from Sz in terms of structural or
functional brain abnormalities, cognitive deficits, or
genetic risk factors
Functioning and insight may not be impaired to the
same degree as in SZ
1/3 as common as Sz, lifetime prevalence is .3%
Prognosis somewhat better than Sz
An initial diagnosis of Schizoaffective Disorder may
change over time to Sz as the mood symptoms
longitudinally occupy < 50% of the lifetime duration
of the illness
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Diagnosis-Specific Severity Assessment:
Symptom Domains for Schizophrenia
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Hallucinations
Delusions
Disorganized Speech
Abnormal Psychomotor Beh
Negative Symptoms
(Restricted Emotional
Expression or Avolition)
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Impaired Cognition
 Depression
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0 = Not Present
1 = Equivocal
2 = Present, but mild
3 = Present and
moderate
4 = Present and
severe
Mania
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Attenuated Psychosis Syndrome
(categorized as a Condition for Further Study)
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May be a prodromal state; less severe and more transient than a
psychotic disorder
A. One of the following in attenuated form, with relatively intact
reality testing
• Delusions
• Hallucinations
• Disorganized Speech
B. Sxs present once per week for one month
C. Sxs began or worsened in past year vs. SPD which is a
relatively stable trait disorder of longstanding
D. Sxs are distressing/disabling requiring a consult
E. Not due to another condition or substance
F. Does not meet criteria for another psychotic disorder
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David L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Attenuated Psychosis Syndrome: Risk and
Prognostic Factors
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Temperamental prognostic factors associated with
poor outcome and progression to psychosis
• Negative symptoms
• Cognitive impairment
• Poor functioning
 Genetic and Physiological Factors associated with
poor outcome
• Family history of psychotic disorder(s)
• Structural, Functional, Neurochemical imaging
data
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Mania and Hypomania
(Bipolar and Related Disorders)
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Inclusion of increased energy/activity as a
Criterion A symptom of mania and
hypomania
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Rationale: This will make explicit the
requirement of increased energy/activity in
order to diagnose bipolar I or II disorder (which
is not required under DSM-IV) and will improve
the specificity of the diagnosis.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Mania and Hypomania
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“Mixed episode” is replaced with a “with
mixed features” specifier for manic,
hypomanic, and major depressive
episodes
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Rationale: DSM-IV criteria excluded from
diagnosis the sizeable population of
individuals with subthreshold mixed states
who did not meet full criteria for major
depression and mania, and thus were less
likely to receive treatment.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Mania and Hypomania
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“With anxious distress” also added as a
specifier for bipolar (and depressive)
disorders
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Rationale: The co-occurrence of anxiety with
depression is one of the most commonly seen
comorbidities in clinical populations. Addition
of this specifier will allow clinicians to indicate
the presence of anxiety symptoms that are not
reflected in the core criteria for depression
and mania but nonetheless may be
meaningful for treatment planning.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Bipolar I Disorder, Manic Episode
296.xx (F31.xx)
David
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L. Fogelson, M.D., www.DavidFogelson.com, June 2013
A. Abnormally and persistently elevated, expansive, or irritable mood
and persistently increased goal-directed activity or energy, 1 week, 4
days if hypomanic, or any duration if hospitalized
B. During episode three or more, four if mood only irritable:
• 1. inflated self-esteem or grandiosity
• 2. decreased sleep, e.g. 3 hours
• 3. more talkative or pressured speech
• 4. flight of ideas or subjective racing thoughts
• 5. Distractibility
• 6. increase in goal directed activity or psychomotor agitation
• 7. activities with painful consequences: buying sprees, promiscuity,
foolish investments
C. Marked impairment, hospitalization, psychotic features are present
D. Not due to drugs, medication, medical condition
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Mania induced by antidepressant, ECT, or other treatment that persists beyond the
physiological effect of the treatment is considered Mania and counts for a BPD Dx
Coding and Specifiers for Bipolar I Disorder
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Severity: mild, moderate, severe
Current or Recent episode manic or depressed
Are psychotic features present?
In partial or full remission
Specifiers
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Anxious distress
• Mixed features
• Rapid cycling
• Melancholic features
• Atypical features
• Mood-congruent psychotic features
• Mood-incongruent psychotic features
• Catatonia
• Peripartum onset
• Seasonal pattern
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Bipolar II Disorder, Hypomanic Episode,
Distinguishing Features
296.89 (F31.81)
4
days duration
 Change in functioning
 Not marked impairment
 Not psychotic
 Not hospitalized
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Coding and Specifiers for Bipolar II Disorder
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Severity: mild, moderate, severe
Current or Recent episode hypomanic or depressed
In partial or full remission
Specifiers
• Anxious distress
• Mixed features
• Rapid cycling
• Mood-congruent psychotic features in depression
• Mood-incongruent psychotic features in depression
• Catatonia
• Peri-partum onset
• Seasonal pattern
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Condition for further study: Depressive
Episodes
with Short-Duration Hypomania
 Meets
criteria for Major Depressive
Disorder at least once in lifetime
 Meets criteria for Hypomania at
least twice in lifetime except that
the duration of Hypomania is at
least 2 days and less than four
days
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Diagnosis-Specific Severity Assessment:
PHQ-9, symptoms in Major Depression
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Bereavement Exclusion
(Depressive Disorders)
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Eliminated from major depressive episode
(MDE)
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Rationale: In some individuals, major loss –
including but not limited to loss of a loved one –
can lead to MDE or exacerbate pre-existing
depression. Individuals experiencing both
conditions can benefit from treatment but are
excluded from diagnosis under DSM-IV. Further,
the 2-month timeframe required by DSM-IV
suggests an arbitrary time course to
bereavement that is inaccurate. Lifting the
exclusion alleviates both of these problems.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Bereavement Exclusion: expert clinical
judgment is required
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“Although some depressive symptoms
may be understandable or considered
appropriate to the loss, the presence of
a major depressive episode in addition
to the normal response to a significant
loss should be carefully considered.
This decision inevitably requires the
exercise of clinical judgment based on
the individual’s history and the cultural
norms for the expression of distress in
the context of loss.” DSM-5, page 161
David
L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Personality Disorders (PD)
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All 10 DSM-IV PDs remain intact in Section II. However,
Section III contains an alternate, trait-based approach to
assessing personality and PDs that includes specific PD
types (e.g., borderline, antisocial) but allows for the rating of
traits and facets, facilitating diagnosis in individuals who
meet core criteria for a PD but do not otherwise meet a
specific PD type.
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Rationale: A hybrid model with both dimensional and
categorical approaches is included in Section III. This
model calls for evaluation of impairments in personality
functioning and characterizes five broad areas of
pathological personality traits. It identifies six PD types,
each defined by both impairments in personality functioning
and a pattern of impairments in personality traits. We will
evaluate the strengths and weaknesses of the model,
leading to greater understanding of the causes and
treatments of PDs.
David L. Fogelson, M.D., www.DavidFogelson.com, June 2013; Copyright © 2013. American Psychiatric Association.
Alternative DSM-5 Model for Personality
Disorders: General Criteria
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A. Impairment in functioning in 2 or more areas as uniquely specified in 7 subtypes
• Self
• Identity
• Self-direction
• Interpersonal
• Empathy
• Intimacy
B. One or more pathological personality traits as uniquely specified in 7 subtypes
• Negative Affectivity vs. Emotional Stability
• Detachment vs. Extraversion
• Antagonism vs. Agreeableness
• Disinhibition vs. Conscientiousness
• Psychoticism vs. Lucidity
C. Impairment and Traits present across most personal and social situations
D. Impairment and Traits present since adolescence or early adulthood
E. Not better explained by another mental disorder
F. Not due to substance abuse, medication, or a medical condition
G. Not normal for cultural group or developmental age David L. Fogelson, M.D., www.DavidFogelson.com, June 2013
Specific Personality Disorders
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Antisocial
Avoidant
Borderline
Narcissistic
Obsessive-compulsive
Schizotypal
Personality Disorder-Trait Specified
• Made when a personality disorder is present but
criteria are not met for a specific disorder