13 - Contrasting DSM IV and ICD 10

Contrasting DSM-IV and ICD-10

© SPMM Course florid symptoms such as delusions and hallucinations have been minimal or substantially reduced and absence of organic brain disease or disorder”. Post schizophrenic depression is classed under F20s. Some schizophrenic symptoms (mostly negative) must be present though not dominating the picture. The most recent episode of relapse must not be more than 12 months ago. If no current schizophrenic symptoms at all then depressive disorder can be diagnosed. If florid schizophrenia symptoms with minor affective disturbances noted, then relapse must be suspected. Contrasting DSM-IV and ICD-10

ICD 10 DSM IV Characteristic symptoms

At least one of:

1. Thought echo, thought insertion/withdrawal/broadcast
2. Passivity, delusional perception
3. Third person auditory hallucination, running commentary
4. Persistent bizarre delusions

OR two or more of:

1. Persistent hallucinations
2. Thought disorder
3. Catatonic behaviour
4. Negative symptoms
5. Significant  behaviour  change At least one of:
6. Bizarre delusions
7. Third person auditory hallucinations
8. Running commentary

OR two or more of:

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized behaviour
5. Negative symptoms Duration More than 1 month 1 month of characteristic symptoms With 6 months of social/occupational dysfunction Subtypes Paranoid Catatonic Hebephrenic Residual Undifferentiated Simple Postschizophrenic depression Paranoid Catatonic Disorganized Residual Undifferentiated Chapters • F20 Schizophrenia • F21 Schizotypal disorder • F22 Persistent delusional disorder • F23 Acute and transient psychotic disorders • F24 Induced delusional disorders • F25 Schizoaffective disorder • F28 Other non-organic psychotic disorders • F29  Unspecified  non-organic psychosis

• 295.x Schizophrenia • 295.4 Schizophreniform disorder • 295.7 Schizoaffective disorder • 297.1 Delusional disorder • 297.3 Shared psychotic disorder • 298.8 Brief psychotic disorder • 298.9 Psychotic disorder NOS

© SPMM Course Other ‘schizophrenias’ in ICD-10 In acute and transient psychotic disorders (ICD-10), onset within two weeks is described as acute while the onset within 48 hours is called abrupt. Complete recovery within 2 to 3 months is the rule. It can be of polymorphic form or schizophrenia-like in it is presentation. In acute polymorphic psychosis, several hallucination and delusions changing in both type and intensity from day to day or even same day is noted. Schizotypal disorder is diagnosed in patients with eccentric manners, social withdrawal, magical thinking, suspiciousness, and obsessive ruminations but without resistance. The ruminations may have dysmorphophobic contents too. At least a 2-year history with schizophrenia being never diagnosed in the past is necessary for diagnosing schizotypal disorder. Schizotypal disorder includes older descriptions such as borderline schizophrenia, pseudo neurotic schizophrenia, etc. Is classified along with schizophrenia and related disorders in ICD-10 but along with Cluster A personality disorders in DSM-4. Schizotypy is more common in the other first-degree relatives of schizophrenic subjects than in the general population and the relatives of schizotypal subjects have an increased risk of schizophrenia. Persistent delusional disorders are characterised by a persistent, often life-long, typically  ‘non-bizarre’ delusion or a set of related delusions arising insidiously in mid-life or later. Transient auditory hallucinations may occur, but clear and persistent auditory hallucinations (voices), schizophrenic symptoms such as delusions of control and marked blunting of affect, and definite evidence of brain disease are incompatible with this diagnosis. However, the presence of occasional or transitory auditory hallucinations, particularly in elderly patients, does not rule out this diagnosis. The delusions need not be strictly monothematic though this is mostly the case. Affect, thought and behaviour are globally normal, but  patients’  attitudes   Schizophrenia Delusional Disorder Bizarre delusions are common Non-bizarre delusions (cannot be bizarre by ICD-10 definition) Daily functioning is significantly impaired Daily functioning is not significantly impaired Apart from delusions may have one or more of the following: x Hallucinations x Disorganized speech x Disorganized behaviour x Negative symptoms

These symptoms are almost always absent (tactile or olfactory hallucinations if at all present, are entangled in the content of a delusional complex) DSM-5 AND SCHIZOPHRENIA Presence of bizarre delusions or hallucinations is no longer sufficient as a sole criterion A for diagnosing schizophrenia. 2  of  5  ‘criterion-A’  symptoms  required  for  a   diagnosis with at-least one being a core positive symptom (delusions, hallucinations or disorganized speech) Schizophrenia subtypes (paranoid, disorganized, catatonic, undifferentiated, and residual types) have been removed. A dimensional method of rating severity for the core symptoms of schizophrenia is included. This proposes 8 dimensions (delusions, hallucinations, depression, mania, abnormal cognition, abnormal psychomotor behavior, disorganized speech and negative symptoms)

© SPMM Course and actions in response to these delusions are appropriate and may lead to dangerousness in some cases. Symptoms should have been present for at least 1 month (DSM-IV). ICD-10 specifies at least 3 months for delusional disorder. According to DSM-IV delusional disorder – ‘Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour  is  not  obviously  odd  or  bizarre’.  This   criterion is not explicit in ICD-10.

DSM-IV subtypes of delusional disorders Type Description Erotomania (de Clerambault syndrome) An erotic conviction that a person with higher status is secretly in love with the patient Seen most often in women though forensic samples are mostly males; may be associated with stalking or assaultive behaviour Grandiosity Patients believe they fill some special role, have some special relationship, or possess some special abilities. They may be involved with social or religious organisations Jealousy (Othello syndrome) Characterised by a delusion of infidelity. Patients possess the fixed belief that their spouse or partner has been unfaithful. Often patients try to collect evidence and/or attempt to restrict their partner's activities. Contributes to both wife battering and homicide. Persecutory Most common form of the delusional disorder. Patients are often convinced that others are attempting to hurt or harm them. This leads to them trying to obtain legal recourse, and sometimes turning violent. Somatic Varying presentations including patients who have repeated medical consultations requesting several treatment to those that show delusional concerns about a bodily infestation, deformity (delusional dysmorphophobia) or odour.

Mixed and unspecified types Please refer to delusional misidentification syndromes in Descriptive Psychopathology notes

Induced delusional disorders are accepted as a distinct diagnostic category and coded as F24 in ICD-10. This is a rare delusional disorder characterised by sharing of delusions between usually 2 or occasionally more persons who often have tightly knit emotional bonds. Only one person has genuine delusions due to underlying psychiatric disorder, most often schizophrenia or delusional disorder. On separation, the dependent individual may give up his or her delusions and the patient with the genuine delusions should be treated appropriately. In induced delusional disorders, induced hallucinations can be present, and this DSM-5 AND DELUSIONAL DISORDERS There is no requirement for delusions to be non-bizarre anymore Delusional symptoms must not be better explained by conditions such as obsessivecompulsive or body dysmorphic disorder with absent insight/delusional beliefs. Shared delusional disorder is no longer a separate diagnosis.