In the DSM-IV, the patient had to meet specified criteria for a diagnosis e.g. delusions or hallucinations. If not, then we couldn't make the diagnosis of any Schizophrenia. But the DSM5 proposes different thinking in-between.
Example
J is a 40+ year-old business woman with her own company. Regularly, friends/colleagues have noticed some bizarre behaviors - on many occasions they’ve overheard J talking in an agitated voice, sometimes laughing out loud, even though there is no one nearby; and other times simply chatting to or scolding herself. In addition, she tends to neglect her personal appearance at times and prefers time spent alone. Her children – 2 teenage daughters who also struggles with various problems - complains that J is increasingly also exhibiting a-social behaviour (I refrain from using the term anti-social as it also has different applications).
However, they also later on, admitted to their mother talking aloud as long as they can remember.
Diagnosis: Unspecified Schizophrenia Spectrum Disorder (according to DSM5)
DSM Controversies
DSM-5 introduces a new diagnosis namely "Unspecified Schizophrenia Spectrum Disorder." The only required criterion is that you have some distress from unspecified symptoms, but you do not meet the full criteria for any of the other schizophrenias spectrum or other psychotic disorders diagnostic classes.
(J has not reported any distress, only from friends and family).
For the DSM5 diagnosis, you don't have to have delusions or hallucinations. In fact if you do, then you in all likelihood don't qualify for the diagnosis.
In the DSM-IV at least, the diagnosis of “Undifferentiated Schizophrenia” required the presence of delusions. In fact, no delusions – no schizophrenia at all. And now -
“This category applies to presentations in which symptoms characteristic off a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominates but does not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class.”
In other words, this means a lack of criteria: the patient does not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class.
If J actually did experience delusions and hallucinations for the past month, then she would probably meet criteria for Schizophrenia and therefore would not meet the criteria for unspecified Schizophrenia Spectrum Disorder. But she didn’t and doesn’t.
And then the criteria does not state what “symptoms characteristic” must be present, or for how long– a month, a week, a day, an hour, a minute? If one minute of incoherence caused “significant distress” to family members would than then qualify the patient for the diagnosis? No required criterion for duration is mentioned in the new DSM-5 diagnosis of "Unspecified Schizophrenia Spectrum Disorder"; on the contrary, only the absence of criteria.
Previously, fuzziness was associated with teddy bears and fluffy toys
Previously, in the DSM-IV, a very brief, transient psychotic episode/ break-down would have been considered as a “psychotic disorder not otherwise specified.” And interventions very likely, would be different.
And what about the label...? A schizophrenia diagnosis carries lifelong disability and implications, while a brief psychotic episode does n’t. At least the DSM-IV at times provide “provisional diagnosis” with the specification to add information, and adjust the diagnosis later on. DSM5 seldom does, if at all.
And what about the term “spectrum/continuum”? Does this mean Schizophrenia comes in “degrees”?
Well, as Dr David Kupfer stated in the April 24 Journal of the American Medical Association, there is really no cut-off line between high, normal or low blood pressure, rather a continuum of normality. So, such a continuum should also be applicable to mental health*.
So, does this new DSM diagnosis hold implications for interventions?
Apparently not. “Results of clinical trials in patients with pre-DSM-5 schizophrenia also apply to patients diagnosed with DSM-5 schizophrenia. Omission of the classic subtypes is justified as they are not predictive of response to treatment. The DSM-5 C-RDPSS scale adds valuable information to the categorical diagnosis of schizophrenia, which is relevant for antipsychotic response.”
Just a shame research in this regard is so limited and “new” (aimed at development of the DSM5). And, research only focused on possible medical interventions?
Impact on families
A diagnosis of schizophrenia always have impact on the family. Whether as caregiver, as sibling, or as offspring.
Firstly, there is always the genetic component to consider. Will I inherit schizophrenia?
Children furthermore, will not always have their basic needs met. The parent might not be up as role model, to teach appropriate social, emotional or other life/coping skills. Children may develop attachment issues, guilt issues, and have difficulty trusting other people. It can also be very confusing for children to understand the difference between delusions and reality, since the parent self cannot always tell the difference. Some children of schizophrenic parents go on to develop post-traumatic stress disorder as a result of their childhood experiences.
As with any child whose parent struggles with any mental disorder, or traumas; they face more challenges and risks than “normal” parents (The concept of "normal" parents, I continuously struggle with, but this is a topic for another Blogging)
Often these children develop mental disorders themselves, such as e.g. mood disorders; which is complicated if there is also e.g. possible learning or other problems present.
Typical behavior might vary from disruptive to destructive behaviors. This does not make it any different from living with any parent, with any “mental” disorder (Or from many teenagers, tongue in the cheek).
Proposed interventions
In J’s case, I would, still, give a provisional diagnosis. Here I would rather, still, work according the DSM-IV for interventions. But then I am not a Psychiatrist, so please take my comments as it is – a simple “Blogging “.
Family therapy and assertive community treatment have clear effects on the prevention of psychotic relapse and re-hospitalization.
Personal Therapy and CBT (Cognitive Behavioral Therapy) - designed to help patients with schizophrenia recognise and respond appropriately to arousing stimuli improves function and reduces relapse.
Personal therapy, as it is called, aims to create a therapeutic umbrella to protect the patients from undue personal stress. Recent studies have suggested that over the long haul, individual psychotherapy tailored to strengthen interpersonal skills and control social stress markedly helps many people suffering from the disorder.
As for the family members?
Children might need to undergo social and life skills training. In addition, the care giver (partner) might have to learn to take care of him/herself. We so regularly forget, that partners, also require support….
I would tread very lightly.
Summary
The DSM5 makes it a bit difficult at times, to exactly define “what’s what”.
According to this DSM edition, everybody's a little bit crazy, it just depends where you find yourself on any particular continuum*.
Great. But while I tend to agree with this statement (and happily trying to score myself on the continuum LoL; knowing I would probably fulfill many criteria from so many categories) It does make diagnostic guidelines rather fuzzy at times for newly qualified practitioners. And I don’t mean warm, accommodating or hug-able (If I want fuzzy and warm, I will play with my dogs or the teddy bears in my office).
What I and most other practitioners want (I presume) is firm and definite diagnostic guidelines. We are rather concerned, that the new DSM’s might increasingly become more fuzzy.
Above links to another concern - those who did not know/were trained/grew up with the DSM-III or DSM-IV and therefore have limited understanding where it all “comes from”, or at least have an inkling how to adjust and know what else to look out for; might have no idea how to handle the DSM5.
And as I say, the one concern is how to train new mental health workers in this regard. As it is, a growing concern, is that the DSM5 might support increasing mental diagnosis (This is a topic I will still write on, it requires various more bloggings. Amongst others, for example, the diagnosis for ADHD has risen considerably since publication of the DSM5.
Lastly…..and Personal.....
I have nothing against the DSM5. I have been waiting for this edition, since 1995 already. I need to read through all the several thousands of pages and integrate all the adjusted categories. But I do have several questions of course (I read and learn per category so forgive me for addressing them as such).
And then as to J.... personally, I also have a habit of talking to myself on a regular basis.
It breaks the silence. It also assists me with solving problems. I also talk to my animals and ‘imagine’ answers….
In general - I need to see, write, and hear the issue at hand. This is a habit I taught myself years+ ago, in an attempt to memorise study materials due to my own learning disabilities as child (I do, however, refrain from answering myself aloud… OK, at times..).
I also think, sometimes, the pets and animals in my garden is trying to tell me things. Such as diving/flying at my head when there is a mamba in the garden, and me instinctively understanding this.
Does this mean I need to be diagnosed with Unspecified Schizophrenia, DSM5?
References
http://www.amhc.org/1418-dsm-5/article/51960-the-new-dsm-5-schizophrenia-spectrum-and-other-psychotic-disorders
https://www.psychologytoday.com/blog/sax-sex/201306/now-you-too-can-be-diagnosed-schizophrenia
http://www.psych.uic.edu/docassist/changes-from-dsm-iv-tr--to-dsm-51.pdf
http://schizophreniabulletin.oxfordjournals.org/content/early/2014/12/19/schbul.sbu172.abstract
http://www.amhc.org/1418-dsm-5/article/51960-the-new-dsm-5-schizophrenia-spectrum-and-other-psychotic-disorders
http://www.psychiatrictimes.com/schizophrenia/abcs-cognitive-behavioral-therapy-schizophrenia
http://www.slideshare.net/reebasarakoshy/a-case-study-on-schizophrenia
http://www.schizophrenia.com/family/perstherapy.relapse.htm
http://schizophreniabulletin.oxfordjournals.org/content/early/2014/12/19/schbul.sbu172.abstract
https://jama.jamanetwork.com/article.aspx?articleid=1656312
Example
J is a 40+ year-old business woman with her own company. Regularly, friends/colleagues have noticed some bizarre behaviors - on many occasions they’ve overheard J talking in an agitated voice, sometimes laughing out loud, even though there is no one nearby; and other times simply chatting to or scolding herself. In addition, she tends to neglect her personal appearance at times and prefers time spent alone. Her children – 2 teenage daughters who also struggles with various problems - complains that J is increasingly also exhibiting a-social behaviour (I refrain from using the term anti-social as it also has different applications).
However, they also later on, admitted to their mother talking aloud as long as they can remember.
Diagnosis: Unspecified Schizophrenia Spectrum Disorder (according to DSM5)
DSM Controversies
DSM-5 introduces a new diagnosis namely "Unspecified Schizophrenia Spectrum Disorder." The only required criterion is that you have some distress from unspecified symptoms, but you do not meet the full criteria for any of the other schizophrenias spectrum or other psychotic disorders diagnostic classes.
(J has not reported any distress, only from friends and family).
For the DSM5 diagnosis, you don't have to have delusions or hallucinations. In fact if you do, then you in all likelihood don't qualify for the diagnosis.
In the DSM-IV at least, the diagnosis of “Undifferentiated Schizophrenia” required the presence of delusions. In fact, no delusions – no schizophrenia at all. And now -
“This category applies to presentations in which symptoms characteristic off a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominates but does not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class.”
In other words, this means a lack of criteria: the patient does not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class.
If J actually did experience delusions and hallucinations for the past month, then she would probably meet criteria for Schizophrenia and therefore would not meet the criteria for unspecified Schizophrenia Spectrum Disorder. But she didn’t and doesn’t.
And then the criteria does not state what “symptoms characteristic” must be present, or for how long– a month, a week, a day, an hour, a minute? If one minute of incoherence caused “significant distress” to family members would than then qualify the patient for the diagnosis? No required criterion for duration is mentioned in the new DSM-5 diagnosis of "Unspecified Schizophrenia Spectrum Disorder"; on the contrary, only the absence of criteria.
Previously, fuzziness was associated with teddy bears and fluffy toys
Previously, in the DSM-IV, a very brief, transient psychotic episode/ break-down would have been considered as a “psychotic disorder not otherwise specified.” And interventions very likely, would be different.
And what about the label...? A schizophrenia diagnosis carries lifelong disability and implications, while a brief psychotic episode does n’t. At least the DSM-IV at times provide “provisional diagnosis” with the specification to add information, and adjust the diagnosis later on. DSM5 seldom does, if at all.
And what about the term “spectrum/continuum”? Does this mean Schizophrenia comes in “degrees”?
Well, as Dr David Kupfer stated in the April 24 Journal of the American Medical Association, there is really no cut-off line between high, normal or low blood pressure, rather a continuum of normality. So, such a continuum should also be applicable to mental health*.
So, does this new DSM diagnosis hold implications for interventions?
Apparently not. “Results of clinical trials in patients with pre-DSM-5 schizophrenia also apply to patients diagnosed with DSM-5 schizophrenia. Omission of the classic subtypes is justified as they are not predictive of response to treatment. The DSM-5 C-RDPSS scale adds valuable information to the categorical diagnosis of schizophrenia, which is relevant for antipsychotic response.”
Just a shame research in this regard is so limited and “new” (aimed at development of the DSM5). And, research only focused on possible medical interventions?
Impact on families
A diagnosis of schizophrenia always have impact on the family. Whether as caregiver, as sibling, or as offspring.
Firstly, there is always the genetic component to consider. Will I inherit schizophrenia?
Children furthermore, will not always have their basic needs met. The parent might not be up as role model, to teach appropriate social, emotional or other life/coping skills. Children may develop attachment issues, guilt issues, and have difficulty trusting other people. It can also be very confusing for children to understand the difference between delusions and reality, since the parent self cannot always tell the difference. Some children of schizophrenic parents go on to develop post-traumatic stress disorder as a result of their childhood experiences.
As with any child whose parent struggles with any mental disorder, or traumas; they face more challenges and risks than “normal” parents (The concept of "normal" parents, I continuously struggle with, but this is a topic for another Blogging)
Often these children develop mental disorders themselves, such as e.g. mood disorders; which is complicated if there is also e.g. possible learning or other problems present.
Typical behavior might vary from disruptive to destructive behaviors. This does not make it any different from living with any parent, with any “mental” disorder (Or from many teenagers, tongue in the cheek).
Proposed interventions
In J’s case, I would, still, give a provisional diagnosis. Here I would rather, still, work according the DSM-IV for interventions. But then I am not a Psychiatrist, so please take my comments as it is – a simple “Blogging “.
Family therapy and assertive community treatment have clear effects on the prevention of psychotic relapse and re-hospitalization.
Personal Therapy and CBT (Cognitive Behavioral Therapy) - designed to help patients with schizophrenia recognise and respond appropriately to arousing stimuli improves function and reduces relapse.
Personal therapy, as it is called, aims to create a therapeutic umbrella to protect the patients from undue personal stress. Recent studies have suggested that over the long haul, individual psychotherapy tailored to strengthen interpersonal skills and control social stress markedly helps many people suffering from the disorder.
As for the family members?
Children might need to undergo social and life skills training. In addition, the care giver (partner) might have to learn to take care of him/herself. We so regularly forget, that partners, also require support….
I would tread very lightly.
Summary
The DSM5 makes it a bit difficult at times, to exactly define “what’s what”.
According to this DSM edition, everybody's a little bit crazy, it just depends where you find yourself on any particular continuum*.
Great. But while I tend to agree with this statement (and happily trying to score myself on the continuum LoL; knowing I would probably fulfill many criteria from so many categories) It does make diagnostic guidelines rather fuzzy at times for newly qualified practitioners. And I don’t mean warm, accommodating or hug-able (If I want fuzzy and warm, I will play with my dogs or the teddy bears in my office).
What I and most other practitioners want (I presume) is firm and definite diagnostic guidelines. We are rather concerned, that the new DSM’s might increasingly become more fuzzy.
Above links to another concern - those who did not know/were trained/grew up with the DSM-III or DSM-IV and therefore have limited understanding where it all “comes from”, or at least have an inkling how to adjust and know what else to look out for; might have no idea how to handle the DSM5.
And as I say, the one concern is how to train new mental health workers in this regard. As it is, a growing concern, is that the DSM5 might support increasing mental diagnosis (This is a topic I will still write on, it requires various more bloggings. Amongst others, for example, the diagnosis for ADHD has risen considerably since publication of the DSM5.
Lastly…..and Personal.....
I have nothing against the DSM5. I have been waiting for this edition, since 1995 already. I need to read through all the several thousands of pages and integrate all the adjusted categories. But I do have several questions of course (I read and learn per category so forgive me for addressing them as such).
And then as to J.... personally, I also have a habit of talking to myself on a regular basis.
It breaks the silence. It also assists me with solving problems. I also talk to my animals and ‘imagine’ answers….
In general - I need to see, write, and hear the issue at hand. This is a habit I taught myself years+ ago, in an attempt to memorise study materials due to my own learning disabilities as child (I do, however, refrain from answering myself aloud… OK, at times..).
I also think, sometimes, the pets and animals in my garden is trying to tell me things. Such as diving/flying at my head when there is a mamba in the garden, and me instinctively understanding this.
Does this mean I need to be diagnosed with Unspecified Schizophrenia, DSM5?
References
http://www.amhc.org/1418-dsm-5/article/51960-the-new-dsm-5-schizophrenia-spectrum-and-other-psychotic-disorders
https://www.psychologytoday.com/blog/sax-sex/201306/now-you-too-can-be-diagnosed-schizophrenia
http://www.psych.uic.edu/docassist/changes-from-dsm-iv-tr--to-dsm-51.pdf
http://schizophreniabulletin.oxfordjournals.org/content/early/2014/12/19/schbul.sbu172.abstract
http://www.amhc.org/1418-dsm-5/article/51960-the-new-dsm-5-schizophrenia-spectrum-and-other-psychotic-disorders
http://www.psychiatrictimes.com/schizophrenia/abcs-cognitive-behavioral-therapy-schizophrenia
http://www.slideshare.net/reebasarakoshy/a-case-study-on-schizophrenia
http://www.schizophrenia.com/family/perstherapy.relapse.htm
http://schizophreniabulletin.oxfordjournals.org/content/early/2014/12/19/schbul.sbu172.abstract
https://jama.jamanetwork.com/article.aspx?articleid=1656312
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