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Dysfuncitonal (or Dissociative) Symptoms

Some of the least understood and most stigmatized disorders in the DSM-5 are those that fall under the categories of depersonalization, dissociative, and psychotic disorders. To better understand what these disorders entail, we'll go over some definitions:

Psychosis - a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality. This can include the following:
  • Hallucinations - sensations that appear to be real but are created within the mind.

  • Delusions - beliefs that conflict with reality.

  • Depersonalization - a state in which one's thoughts and feelings seem unreal or not to belong to oneself, or in which one loses all sense of identity.

  • Dissociation - a mental process of disconnecting from one's thoughts, feelings, memories or sense of identity.

  • Derealization - an alteration in the perception or experience of the external world so that it seems unreal.

Delusional Disorder F22

  • Onset – common in elderly

  • Duration – 1month or more

  • Symptoms:

    • Criteria for Schizophrenia are not met.

    • If Hallucinations are present, they are related to the delusion.

    • Functioning is not markedly impaired.

    • Any mood episodes are brief in comparison to delusional symptoms.

  • Types:

    • Erotomanic

    • Grandiose

    • Jealous

    • Persecutory

    • Somatic

    • Mixed

    • Unspecified

  • Differential:

    • Schizophrenia/Schizophreniform Disorder – (absence of other characteristic symptoms)

    • Depressive/Bipolar/Schizoaffective Disorders – (mood disturbance related to delusions)

    • Delirium – (neurological in nature)

    • Obsessive-Compulsive and Related Disorders – (delusion caused by obsession/compulsion)

    • Major Neurocognitive Disorder – (neurological in nature)

  • Treatment:

    • Cognitive therapy

    • Psychoeducation

Brief Psychotic Disorder F23

  • Onset – average mid-30s

  • Duration – at least 1 day <1 month

  • Differential:

    • Other Psychotic Disorders – (not brief, meets other criteria)

    • Depressive and Bipolar Disorders – (caused by mood episode)

    • Malingering – (gains something by faking psychosis)

    • Factitious Disorder – (gains nothing by faking psychosis)

    • Personality Disorders – (not brief, virtually life-long)

  • Treatment:

    • Psychoeducational approach

    • Cognitive-behavioral therapy

Schizophreniform Disorder F20.81

  • Duration: 1-6 months

  • Symptoms:

    • Same as Schizophrenia but with different duration. May not include impaired social functioning.

  • Differential:

    • Delirium or Major Neurocognitive Disorder – (not delirious/neurologically caused)

    • Depressive or Bipolar Disorder with Psychotic Features (coincides with mood disorder symptoms)

    • Schizotypal, Schizoid, or Paranoid Personality Disorders – (duration is >6 months)

    • Autism Spectrum Disorder – (repetitive/ritualistic/social issues)

    • Attention-Deficit/Hyperactivity Disorder – (attention/hyperactivity)

    • Obsessive-Compulsive Disorder – (caused by compulsion/obsession)

    • Post-Tramatic Stress Disorder – (caused by trauma)

    • Traumatic Brain Injury – (caused by brain injury)

Schizophrenia F20.9

  • Duration: 6 months

  • Onset: 90% are 15-45yo

  • Symptoms - 2 or more symptoms such as:

    • delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (i.e. abolition, monosyllabic speech, lack of motivation, flat affect)

  • Etiology:

    • Genetics

    • Complications in Pregnancy

    • Viral factors

    • Stress

    • Dysfunctional Family

    • Brain structure

  • Differential:

    • Delusional Disorder – (more symptoms than just delusions)

    • Schizoaffective Disorder (major mood episode involved)

    • Brief Psychotic Disorder – (<1 month vs >6 months)

    • Schizophreniform Disorder (<6months vs >6 months)

    • Schizotypal Personality Disorder (lifelong)

    • Autism Spectrum Disorder or Communication Disorders (ritualistic/social issues without psychosis)

    • Major Depressive Disorder with Psychotic Features or with Catatonia (psychosis that happens mainly during mood episode is NOT schizophrenia)

    • Bipolar Disorder with Psychotic Features or with Catatonia (psychosis that happens mainly during mood episode is NOT schizophrenia)

    • Post-Tramatic Stress Disorder – (trauma is cause)

Schizoaffective Disorder

  • Duration: The presence of both of the following during the course of the illness:

    • 2 weeks of psychotic symptoms without the presence of a major mood episode

    • A major mood episode concurrent with active phase symptoms of Schizophrenia

  • Symptoms:

    • Major depressive episode or manic episode present for the majority of active and residual Criterion A of Schizophrenia. Schizophrenic symptoms for at least 2 weeks absent a mood episode. Symptoms not better attributed to a substance or medication or another physical/mental illness.

  • Diagnostic Coding:

    • Bipolar Type F25.0

    • Depressive Type F25.1

  • Differential:

    • Schizophrenia – (symptoms of major mood episode are present for the majority of total duration of active/residual portions of the illness)

    • Bipolar I/MDD with Psychotic Features – (delusions or hallucinations for 2+ weeks in absence of major mood episode)

Dissociative Identity Disorder F44.81

  • Symptoms:

    • Presence of 2 or more distinct identities/personality states who recurrently take control of the person's behavior. Person has an inability to recall important personal information.

  • Differential:

    • Major Depressive Disorder – (can coincide, dissociation)

    • PTSD – (trauma caused/criteria)

    • Psychotic Disorders – (other types of psychosis)

    • Factitious Disorder and Malingering (Faking for gain or not)

    • Bipolar Disorders – (manic episodes/depressive episodes)

    • Personality Disorders – (ongoing traits/characteristics)

    • Conversion Disorder – (absence of identity disruption)

    • Seizure Disorders – (actual seizures/physical symptoms)

Dissociative Amnesia F44.0

  • Duration – minutes to decades

  • Symptoms:

    • Inability to recall important personal information, usually of traumatic or stressful nature

  • Types:

    • With dissociative fugue F44.1

  • Differential:

    • Dissociative Identity Disorder – (Identity disruption)

    • Post-Tramatic Stress Disorder – (trauma caused)

    • Factitious Disorder or Malingering –(faking for gain or not)

    • Neurocognitive Disorders (neurologically caused)

    • Seizure Disorders – (physical seizures)

Depersonalization/Derealization Disorder F48.1

  • Onset – adolescence or early adulthood

  • Duration – varies (brief – years)

  • Symptoms:

    • Persistent or recurrent experiences of feeling detached from, and as if one is an observer of one's mental processes or body (like in a dream).

    • Reality testing is intact.

  • Differential:

    • Illness Anxiety Disorder – (presence of depersonalization/derealization absence of IAD criteria)

    • Obsessive-Compulsive Disorder – (criteria not met-may have obsession/repetition)

    • Psychotic Disorders – (other psychosis)

    • Major Depressive Disorder – (not full depersonalization/derealization)

    • Anxiety Disorders – (symptoms of panic attack – must be ongoing not brief)

Unspecified Dissociative Disorder F44.9

Other Specified Dissociative Disorder F44.89

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