Decoding Schizophrenia: Understanding the 295.90 Diagnosis Code (DSM-5)

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Schizophrenia, classified under the DSM-5 as code 295.90 (F20.9), falls within the spectrum of Schizophrenia Spectrum and Other Psychotic Disorders. This categorization highlights a severe and chronic mental health condition that significantly impacts thought processes, potentially leading to disability if untreated (American Psychiatric Association, 2013). It’s recognized for its strong genetic component, typically manifesting in early adulthood, and characterized by fluctuating periods of symptom remission and relapse throughout an individual’s life. A significant factor contributing to relapses is often the discontinuation of prescribed medication, highlighting the complexities of long-term management (Battaglia, 2014; Masand, Roca, Turner, & Kane, 2009).

Unpacking the Symptoms of Schizophrenia (295.90)

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), outlines specific criteria for a 295.90 Schizophrenia diagnosis. This diagnosis requires individuals to exhibit significant disruptions in their perception of reality. To meet the diagnostic threshold, a person must experience at least two of the following symptoms for a minimum of one month – unless symptoms are effectively managed through treatment:

One of these symptoms must be from the group known as “positive symptoms”:

1. Delusions: These are firmly held false beliefs that are not based in reality and remain despite contradictory evidence. These beliefs can be bizarre and highly personal.
2. Hallucinations: These involve sensory experiences that occur without an external stimulus. Auditory hallucinations, or hearing voices, are the most common, but visual hallucinations can also occur.
3. Disorganized Speech: This refers to disruptions in thought processes that manifest as incoherent or nonsensical speech. It reflects an inability to think clearly and logically.
4. Disorganized or Catatonic Behavior: Disorganized behavior can range from unpredictable agitation to childlike silliness. Catatonic behavior is characterized by a marked decrease in reactivity to the environment, sometimes including rigid posture and resistance to movement, or conversely, excessive, purposeless motor activity.
5. Negative Symptoms: These symptoms represent a decrease or absence of normal functions. They include:
   • Flat affect: Reduced expression of emotions, appearing emotionally unresponsive.
   • A мотивация (Amotivation): Lack of motivation to engage in activities, including daily living tasks.
   • Anergia: Lack of energy.
   • Poor hygiene: Neglecting personal cleanliness. (American Psychiatric Association, 2013).

Furthermore, the DSM-5 295.90 Diagnosis Code requires the following criteria to be met:

1. Significant Functional Decline: There must be a marked decline in functioning in one or more major areas of life, such as work, social relationships, or self-care. For individuals with childhood or adolescent onset, this may manifest as a failure to achieve expected levels of academic, social, or interpersonal development.
2. Duration of Symptoms: Continuous signs of the disturbance must persist for at least six months. This period must include at least one month of active symptoms (meeting criterion A – including positive symptoms), and may include periods of prodromal (before active symptoms) or residual symptoms (after active symptoms subside). During these prodromal or residual phases, symptoms may be milder, such as negative symptoms or less intense positive symptoms like unusual beliefs or perceptual experiences.
3. Exclusion of Other Disorders: Schizoaffective disorder and mood disorders with psychotic features must be ruled out. This differentiation is crucial to ensure accurate diagnosis as these conditions share some symptoms with schizophrenia but have distinct diagnostic criteria.
4. Rule out Substance Use or Medical Condition: The psychotic symptoms must not be attributable to the direct physiological effects of a substance (like drug abuse or withdrawal) or another medical condition. This is essential to ensure the psychosis is primary and not secondary to another cause.
5. Consideration of Autism Spectrum Disorder or Communication Disorder: If the individual has a history of autism spectrum disorder or a childhood-onset communication disorder, a diagnosis of 295.90 schizophrenia is only made if prominent delusions or hallucinations, in addition to other schizophrenia symptoms, are present for at least one month (excluding periods of successful treatment). This criterion addresses the overlap in some symptoms and ensures schizophrenia is the primary diagnosis when warranted. (American Psychiatric Association, 2013).

When symptoms have been present for a year and other diagnostic criteria are consistently met, clinicians can further specify the course of the disorder using the 295.90 diagnosis code, such as:

1. First episode, currently in acute episode: Indicates the first time the disorder is manifesting with full symptom criteria being met.
2. First episode, currently in partial remission: The first episode, but with a period of improvement where symptoms are lessened but still present.
3. First episode, currently in full remission: Absence of noticeable symptoms following a first episode.
4. Multiple episodes, currently in acute episode: Indicates the person has experienced more than one episode, and is currently in an acute phase.
5. Multiple episodes, currently in partial remission: Recurrent episodes with the current episode showing partial symptom reduction.
6. Multiple episodes, currently in full remission: History of multiple episodes with the current period being symptom-free.
7. Continuous: Symptoms meet full diagnostic criteria for the majority of the time.
8. Unspecified: Used when criteria for any of the specific categories are not met.
9. With catatonia: Catatonia is present during the episode.
10. Current severity: Severity can be quantified using a rating scale for both positive and negative symptoms over the past week, typically using a five-point Likert scale (0 = absent, 4 = severe and present). (American Psychiatric Association, 2013).

Age of Onset and Progression of 295.90 Schizophrenia

Symptoms of schizophrenia, coded as 295.90, generally emerge between the ages of 18 and 35. Onset before adolescence is uncommon. The initial psychotic episode tends to occur in the early to mid-20s for males and in the late 20s and beyond for females. The onset can be sudden, appearing almost overnight, or gradual, developing over weeks or months. Depressive symptoms are also frequently observed, reported in approximately half of schizophrenia cases (American Psychiatric Association, 2013).

Prevalence of Schizophrenia (295.90)

Schizophrenia, identified by the 295.90 diagnosis code, affects about one percent of the global population (American Psychiatric Association, 2013).

Risk Factors Associated with Schizophrenia (295.90)

Research has identified several factors that may increase the risk of developing schizophrenia (295.90). Birth month is one such factor, with a higher incidence observed for those born in late winter and early spring, coinciding with flu season. Maternal influenza during the third trimester of pregnancy has been suggested as a potential contributing factor (Brown & Patterson, 2011). Urban environments and certain minority ethnic groups also show a higher prevalence.

Other factors that have been correlated with an increased risk include: pregnancy and birth complications involving hypoxia (oxygen deprivation), advanced paternal age, stress, infections, malnutrition, and maternal diabetes. It’s important to note that while these factors are correlated, the DSM-5 emphasizes that causality is not definitively established for many of these risk factors (American Psychiatric Association, 2013).

Comorbidity and Schizophrenia (295.90)

Individuals diagnosed with 295.90 schizophrenia frequently experience comorbid conditions. Substance use disorders are highly prevalent, as people with schizophrenia may attempt to self-medicate psychotic symptoms using substances like alcohol and illicit drugs. Tobacco use is also significantly higher in this population (Hanson, 2012). Anxiety disorders are another common comorbidity.

Personality disorders such as schizotypal or paranoid personality disorder sometimes precede a schizophrenia diagnosis. However, it is debated whether these are distinct pre-cursors or early, unrecognized manifestations of schizophrenia itself. Self-care is often compromised in individuals with schizophrenia, leading to neglect of medical and dental health. Consequently, the DSM-5 notes that lifespan is often reduced in people with schizophrenia due to comorbid medical conditions. Higher rates of obesity, type 2 diabetes, COPD (Chronic Obstructive Pulmonary Disease), emphysema, hypertension, CHD (Coronary Heart Disease), and dental problems are observed compared to the general population (American Psychiatric Association, 2013).

Treatment Strategies for Schizophrenia (295.90)

Managing schizophrenia (295.90) effectively requires a multifaceted approach. Social skills training (Diamond, 2012) and comprehensive case management, including instruction in Activities of Daily Living (ADLs), are essential to improve and sustain quality of life. These interventions are crucial complements to pharmacological treatments. Cognitive Behavioral Therapy (CBT) is also considered beneficial in some studies, although research in this area is ongoing (Morrison and Gillig, 2009).

Functional Impact of Schizophrenia (295.90)

Without appropriate intervention, schizophrenia (295.90) profoundly diminishes quality of life. Individuals often struggle to complete higher education, or even basic education in some instances (American Psychiatric Association, 2013). Maintaining stable employment is challenging, often resulting in a pattern of low-paying, menial jobs, or reliance on supported employment programs offered through mental health services (Diamond, 2012). Social isolation is common, and social networks may be limited to others facing similar mental health challenges.

Prognosis and Outcomes for 295.90 Schizophrenia

Most individuals with schizophrenia (295.90) require ongoing support throughout their lives. While some experience a fluctuating course of symptoms with periods of exacerbation and remission, others may face progressive deterioration. Positive psychotic symptoms tend to lessen with age, possibly linked to age-related changes in dopamine activity (American Psychiatric Association, 2013). Negative symptoms, however, are often more persistent, possibly due to the involvement of other neurotransmitter systems like adrenergic and GABA systems (Jagadeesh & Natarajan, 2013). With consistent support and treatment, the impact on functioning can be minimized, enabling individuals to achieve competitive employment and independent living, often through supported living arrangements where mental health professionals provide regular assistance.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Battaglia, J. (2014). Compliance with medication. Medscape multispeciality. Retrieved February 22, 2014, from: http://www.medscape.org/viewarticle/418612

Morrison, A.K., Gillig, P. M. (2009). Cognitive Behavior Therapy for People with Schizophrenia. 6(12): 32–39. PMCID: PMC2811142.

Brown, A.S., Patterson, P.H. (2011). Maternal Infection and Schizophrenia. Implications for Prevention. Schizophrenia Bulletin. 37(2):284-290.

Hanson, D. (2012). Smoking’s Ties to Schizophrenia. The Dana Foundation. Retrieved February 22, 2014, from: http://dana.org/News/Details.aspx?id=43220

Jagadeesh , S. J and Natarajan, S. . (2013). Schizophrenia: Interaction between Dopamine, Serotonin, Glutamate, GABA and Norepinephrine. Research Journal of Pharmaceutical, Biological and Chemical Sciences (4). 4. 267. Retrieved:February 22, 2014, http://www.rjpbcs.com/pdf/2013_4%284%29/%5B135%5D.pdf

Masand, P.S.,Roca,, M., Turner, M.S., and Kane, J.M. (2009). Partial Adherence to Antipsychotic Medication Impacts the Course of Illness in Patients With Schizophrenia: A Review Primary Care Companion Journal of Clinical Psychiatry. 11(4):147–154. doi: 10.4088/PCC.08r00612 PMCID: PMC2736032

NAMI. ( 2013). What is Schizophrenia. Retrieved February 22, 2014, from: http://www.nami.org/factsheets/schizophrenia_factsheet.pdf

Ronald J Diamond, R.J. (2012). Wisconsin Public Psychiatry Network Teleconference Social Skill Training for People with Schizophrenia. Retrieved February 22, 2014, from http://www.dhs.wisconsin.gov/mh_bcmh/docs/confandtraining/2012/9-27-12SkillTraining6SlidesPerPage.pdf