DSM-5 in Action

Sophia F. Dziegielewski

• Publisher: Wiley
• Year: 2014
• ISBN:
  9781118760666
• Edition: 3
• Topic: Psicologia
• Subtopic: Psicopatologia

Full exploitation of the DSM-5 allows for more comprehensive care

By demystifying the DSM-5, author Sophia Dziegielewski goes beyond the traditional diagnostic assessment and suggests both treatment plans and practice strategy. She covers the changes in criteria to the DSM-5 and what those changes mean for mental health professionals. This resource has been updated to include:

• New and updated treatment plans
• All treatment plans, interventions strategies, applications, and practice implications are evidence based
• Instructions on doing diagnostic assessments and differential diagnosis using the DSM-5
• Changes to coding and billing using the DSM-5 and ICD-10

The book includes robust tools for students, instructors, and new graduates seeking licensure. DSM-5 in Action makes the DSM-5 accessible to all practitioners, allowing for more accurate, comprehensive care.

Section II
Diagnostic and Treatment Applications

Chapter 5
Schizophrenia Spectrum and the Other Psychotic Disorders

Sophia F. Dziegielewski

Introduction

This chapter provides information on children, adolescents, and adults suffering from the disorders that constitute schizophrenia spectrum and the other psychotic disorders. A brief overview of each disorder is provided, along with a case example that includes specific treatment planning and an intervention-related application. Although the definitions of what constitutes schizophrenia and the other spectrum related disorders continue to shift (Wong, 2013), these devastating illnesses can have far-reaching effects that go beyond the client. They can touch the very core of the individual, affecting the development of close relationships, talents, family relations, and economic independence. Further complicating the conditions, now referred to as the schizophrenia spectrum disorders, is that even with the best treatments known, repeated episodes of the illness will occur throughout a client's life (Menezes, Arenovich, & Zipursky, 2006). Also, the symptoms can vary so much among individuals that no single treatment can be considered the intervention of choice. This varied and unpredictable course of the illness and the label placed can affect those seeking and receiving treatment (Rusch et al., 2013).

Because the psychotic disorders involve some level of psychosis that results in distorted perceptions and affects the way an individual perceives reality (Walker, Mitial, Tessner, & Trotman, 2008), when experiencing these incorrect impressions, individuals often cannot function as others do. They can become lost in a world where they cannot communicate their basic needs. These types of communications are so basic to daily functioning and survival, and the variability of response and accomplishment has left many family members to question how this could happen. This lack of understanding of the symptoms related to the disease and the impaired communication further disturb family relationships and thereby alienate support systems critical to enhanced functioning (Dziegielewski, 2007).

This chapter highlights the guidelines for using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association [APA], 2013) to better understand and assess these conditions. It is beyond the purpose of this chapter to explore in depth all of the diagnoses that constitute schizophrenia spectrum and the other psychotic disorders and the treatment options specific to each. Rather, the purpose of this chapter is to introduce the primary disorders as listed in DSM-5: schizotypal personality disorder (listed in this chapter but described in the chapter on personality disorders), delusional disorder, brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, substance/medication-induced psychotic disorder, and psychotic disorder due to another medical condition. Of all the psychotic disorders, schizophrenia is the most common (Walker et al., 2008). Although this chapter presents a brief overview of this spectrum of disorders, the diagnosis and treatment of schizophrenia is the central focus.

The application section of this chapter provides a case example of an individual suffering from schizophrenia with specific recommendations for completing the diagnostic assessment and the subsequent treatment plan. The extent, importance, and the early predictors of problem behaviors and symptoms are explored. The various aspects of the disorder are presented with a case application that highlights the diagnostic assessment, treatment planning, and evidence-based treatment strategy. In addition, the latest practice methods and newest research and findings are highlighted to further the understanding of these often-devastating illnesses.

Toward a Basic Understanding of the Conditions

Reading about diverse ancient cultures (e.g., Egypt, India, Greece, and China), makes it clear that strange and bizarre behavior, often referred to as madness or lunacy, has existed for thousands of years (Woo & Keatinge, 2008, p. 470). The term demence precoce, or early dementia (dementia praecox), was the general term for what we today call schizophrenia. Within the psychotic disorders, schizophrenia historically has always been the most clearly defined. Several subtypes that can occur within schizophrenia were identified and described by Kraepelin in 1899. Emil Kraepelin (1856–1926), using the earlier work of Morel, developed a formal diagnostic category in which he divided dementia praecox into different subtypes: disorganized type (previously known as hebephrenia), paranoid, and catatonic. This classification system lasted for many years. Not until a new generation of researchers voiced concerns with the consistency and uniformity of these earlier classification schemes was the DSM definition most similar to what we utilize today developed (Walker et al., 2008). In DSM-5, limited diagnostic stability and problems with reliability and validity were the primary reasons for dropping the five subtypes, resulting in the definition we use today (Tandon, 2012).

Over the years, many theories about the causes of these mental health conditions evolved (Lehmann & Ban, 1997). Some of the more current theories of causation are oxygen deficiency, biological causes related to its similarity to epilepsy, and an imbalance of natural neurochemicals within the brain, such as serotonin or dopamine disturbance or both (Hong, Lee, Sim, & Hwu, 1997; Lehmann & Ban, 1997). One reason defining the disorder may be so difficult is that when most researchers think of the psychotic disorders, they immediately think of schizophrenia; to complicate the matter further, many professionals agree that schizophrenia is an illness with a complex and heterogeneous nature (Glick, 2005; National Institute of Mental Health [NIMH], 2009c). Based on recent research, the conceptual definition of schizophrenia has broadened to include awareness that it is not one singular disease (Walker et al., 2008). Walker et al. (2008) acknowledge this research and agree that trying to make schizophrenia one disorder might confuse and complicate the diagnostic assessment process. Rather, it might be easier to classify the disorder as a group or cluster of disorders that lack a single cause. According to DSM-5, what this complex group of psychotic disorders share is at least some symptoms such as hallucinations, delusions, disorganized or abnormal motor behavior, and a cadre of negative symptoms.

Understanding Individuals Who Suffer from the Psychotic Disorders

Receiving a diagnosis of schizophrenia or one of the psychotic disorders can be one of the most devastating experiences for an individual and his or her family. Unfortunately, no known prevention or cure exists for these disorders (Woo & Keatinge, 2008). The behaviors and coping styles characteristic of psychotic disorders such as schizophrenia, which include symptoms such as hallucinations, delusions, and disorganized or grossly disorganized, bizarre, or inappropriate behavior, can be problematic. The word psychotic can easily be misinterpreted. In the psychotic disorders, individual criteria must be met, and the definition and meaning of what constitutes a psychotic symptom can change, based on the diagnosis being considered. Further, the disorders in this category do not always stem from a common etiology. What diagnoses in this category share are problems with performing daily tasks, particularly those that involve interpersonal relationships. Symptoms related to the psychotic disorders often appear as a thought disorder, with poor reality testing, social isolation, poor self-image, problems in relating with family, and problems at work (Woo & Keatinge, 2008).

The individual who suffers from one of these disorders can experience states of terror that prevent daily interactions and create difficulty in distinguishing fantasy from reality. This resulting separation from reality makes the symptoms that an individual client suffers extend far beyond personal discomfort. These symptoms also affect the support system and all of the people who come into contact with him or her. This disorder has far-reaching effects; not only does it disrupt the life of the individual but also it can tear apart support systems and alienate the client from daily contacts with family and friends. These disorders are not static in symptomatology and presentation, and having a client misinterpret the signs and symptoms may frustrate family and friends (Wong, 2013). A further complication is not knowing the actual cause of psychotic disorders. This category of mental disorders, especially schizophrenia, has been documented as a leading worldwide public health problem.

The often-negative reaction by lay individuals, peers, family, and professionals toward individuals who suffer from schizophrenia and other psychotic disorders is extreme in comparison to what might be experienced by those who suffer from depression. Once diagnosed, clients with these disorders often need extensive monitoring and support that most primary care physicians and other practitioners are not able to provide or are not interested in providing (Dziegielewski, 2008). Furthermore, although they might not openly admit it, few professionals except in a mental health setting seek out this type of client to work with. Many professionals simply prefer not to work with clients suffering from a psychotic disorder because of the monitoring problems and the unpredictability of client responses, which makes it difficult to provide the support and supervision required in a nonspecialized treatment environment. On the more optimistic side, it appears that practitioner views toward this population are changing somewhat, although the process is slow. In psychopharmacology, however, new medications have brought relief for many clients who have this chronic and debilitating condition (Dziegielewski, 2010).

In summary, since fi...