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047 – Schizophrenia: Differential Diagnosis and DSM-5 Criteria
047 – Schizophrenia: Differential Diagnosis and DSM-5 Criteria
This episode features Dr. David Puder and Dr. Ariana Cunningham walking through the DSM-5 diagnostic criteria for schizophrenia and its common differential diagnoses. They explore how to differentiate schizophrenia from related psychotic, mood, and personality disorders, emphasizing the importance of timeline, symptom profile, and collateral history. Topics include schizophrenia vs. schizophreniform, schizoaffective disorder, bipolar disorder, substance-induced psychosis, and personality disorders like borderline and schizotypal. The episode highlights the dangers of premature diagnosis and encourages thoughtful assessment and exclusion of mimickers.
Training Year: PGY1-PGY2Duration: 42:00
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Podcast:: Psychiatry and Psychotherapy Podcast
Episode:: 047 – Schizophrenia: Differential Diagnosis and DSM-5 Criteria
Link:: Apple Podcast
Embed: Apple Podcast PublishDate:: 2020-05-06

✅ Pre-Lesson Quiz (Before You Listen)

1. How long must schizophrenia symptoms persist for a formal DSM-5 diagnosis?
A. 1 month
B. 3 months
C. 6 months
D. 12 months

2. Which of the following most clearly differentiates schizoaffective disorder from schizophrenia?
A. Delusions lasting >6 months
B. Mood symptoms that precede or co-occur with psychosis
C. Catatonia
D. Disorganized speech

3. Which substance is most commonly associated with acute, transient psychosis in the U.S.?
A. Alcohol
B. Methamphetamine
C. LSD
D. Nicotine

4. What is a distinguishing feature of borderline personality disorder when compared to schizophrenia?
A. Negative symptoms are more prominent
B. Delusions persist across time
C. Auditory hallucinations are prominent
D. Psychotic-like symptoms are transient and reactive

5. Which of the following best supports a diagnosis of delusional disorder?
A. Presence of auditory hallucinations
B. Functional impairment across all domains
C. Isolated fixed false belief without other core psychotic features
D. Presence of catatonia

🧠 Summary

This episode features Dr. David Puder and Dr. Ariana Cunningham walking through the DSM-5 diagnostic criteria for schizophrenia and its common differential diagnoses. They explore how to differentiate schizophrenia from related psychotic, mood, and personality disorders, emphasizing the importance of timeline, symptom profile, and collateral history. Topics include schizophrenia vs. schizophreniform, schizoaffective disorder, bipolar disorder, substance-induced psychosis, and personality disorders like borderline and schizotypal. The episode highlights the dangers of premature diagnosis and encourages thoughtful assessment and exclusion of mimickers.

⏱️ Timestamps & Highlights

  • 00:20 | Schizophrenia is a diagnosis of exclusion; no single pathognomonic sign.
  • 02:10 | DSM-5 criteria overview: 2+ symptoms for 1 month, 6 months of disturbance.
  • 04:05 | Schizophreniform = symptoms <6 months; schizophrenia = >6 months.
  • 06:30 | Must rule out substance use and medical causes.
  • 08:10 | Functioning typically declines abruptly in young adulthood.
  • 10:20 | Differential: Schizoaffective includes prominent mood symptoms.
  • 13:00 | Bipolar disorder usually ramps up before psychosis (e.g., mania with sleep loss).
  • 16:30 | Good history and collateral essential for accurate diagnosis.
  • 19:15 | Substance-induced psychosis: common, especially with methamphetamine.
  • 22:40 | THC and synthetic drugs can cause psychosis—watch for contamination.
  • 25:50 | Medical mimics: TBI, CVA, Wilson’s, syphilis, porphyria, steroids.
  • 30:00 | Delusional disorder = fixed delusion(s) without other symptoms.
  • 31:40 | Schizotypal vs. schizoid vs. schizophrenia – key traits and timelines.
  • 35:10 | Developmental disorders may look psychotic (e.g., autism), but differ by history.
  • 38:00 | Borderline PD: rapid onset quasi-psychosis, dissociation, voice-like thoughts.
  • 42:00 | Summary: diagnosis requires timeline, impairment, exclusion, and careful differentiation.

📝 Key Takeaways

  • Schizophrenia diagnosis requires 2+ core symptoms, 1 month active, 6 months total disturbance.
  • Always rule out substance use, medical conditions, mood disorders, and personality disorders.
  • Schizoaffective has mood symptoms plus psychosis; bipolar psychosis comes after mania.
  • Meth and THC, especially in youth, are common culprits for substance-induced psychosis.
  • Borderline personality disorder can mimic psychosis, but symptoms are reactive and transient.
  • Take time to gather collateral history and perform thorough diagnostics before labeling.

🔍 Quiz Answer Key & Explanations

  1. C. DSM-5 requires at least 6 months of symptoms (including at least 1 month of active-phase symptoms).
  2. B. Schizoaffective disorder includes a mood episode that is present for the majority of the illness duration.
  3. B. Methamphetamine is a leading cause of substance-induced psychosis, especially in certain U.S. regions.
  4. D. Borderline personality disorder may present with transient, stress-related quasi-psychosis.
  5. C. Delusional disorder is defined by the presence of one or more non-bizarre delusions without other schizophrenia criteria.

🧠 After-the-Episode Review

  • The DSM-5 requires 6 months of overall disturbance, with 1 month of active symptoms (hallucinations, delusions, disorganization, negative symptoms) to diagnose schizophrenia.
  • Schizophreniform is essentially the same presentation but less than 6 months in duration.
  • Schizoaffective disorder includes mood episodes that are present for a substantial portion of the illness, distinguishing it from pure schizophrenia.
  • Bipolar psychosis is typically preceded by mania with reduced sleep, elevated mood, and impulsivity.
  • Substance-induced psychosis often resolves after drug clearance but may result in permanent changes after repeated exposures.
  • Personality disorders like borderline may exhibit transient psychotic symptoms, often linked to emotional dysregulation or dissociation.
  • Always rule out medical mimics—TBI, CVA, neurosyphilis, porphyria, and steroid-induced states can present with psychosis.

📚 Further Reading & Resources

  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
  • Sadock, B. J., Sadock, V. A., & Ruiz, P. (2017). Kaplan and Sadock's Synopsis of Psychiatry (12th ed.).
  • Lieberman, J. A. et al. (2001). Practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry.
  • Tsuang, M. T., et al. (2000). Schizophrenia: The facts. Oxford University Press.
  • NIMH Schizophrenia Overview: https://www.nimh.nih.gov/health/topics/schizophrenia

🙏 Credits

Host: Dr. David Puder
Guest: Dr. Ariana Cunningham
Transcript processed using aTrain:
Armin Haberl, Jürgen Fleiß, Dominik Kowald, Stefan Thalmann (2024). Take the aTrain. Journal of Behavioral and Experimental Finance, 41, 100891. https://doi.org/10.1016/j.jbef.2024.100891