Schizophrenia Spectrum and Other Psychotic Disorders

What is a delusion?

Fixed beliefs that are not amenable to change in light of conflicting evidence

What are the different types of delusions?

Persecutory, referential, grandiose, erotomanic, nihilistic, and somatic

What is a persecutory delusion?

Belief that one is going to be harmed, harassed, and so forth by an individual, organization, or another group

What is a referential delusion?

Belief that certain gestures, comments, environmental cues, or events have strong personal significance

What is a grandiose delusion?

When an individual believes that he or she has exceptional abilities, wealth, or fame

What is an erotomanic delusion?

When an individual believes falsely that another person is in love with him or her

What is a somatic delusion?

Focus on preoccupations regarding health and organ function

What is a nihilistic delusion?

Involves the conviction that a major catastrophe will occur

When are delusions deemed bizarre?

If they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences

What is a hallucination?

Perception-like experiences that occur without an external stimulus

What is disorganized thinking?

The individual may switch from one topic or another. Answers to questions may be so severely disorganized that it is nearly incomprehensible

What is grossly disorganized or abnormal motor behavior?

May manifest itself in a variety of ways, ranging from childlike "silliness" to unpredictable agitation

What is catatonic behavior?

Marked decrease in reactivity to the environment. This ranges from resistance to instructions (negativism); to maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and motor responses (mutism and stupor). It can also include purposeless and excessive motor activity without obvious cause (catatonic excitement)

What are negative symptoms?

Absence of a behavior, ability, or characteristic. Account for a substantial portion of the morbidity associated with schizophrenia but are less prominent in other psychotic disorders

Delusional Disorder

A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for Schizophrenia has never been met.
- Hallucinations, if present, are not prominent and are related to the delusional theme
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dystrophin disorder or obsessive-compulsive disorder

Delusional Disorder Specifiers

Specify whether:
- Erotomanic type - This subtype applies when the central theme of the delusion is that another person is in love with the individual.
- Grandiose type - This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight of having made some important discovery.
- Jealous type - This subtype applies when the central theme of the individual's delusion is that his or her spouse or lover is unfaithful
- Persecutory type - This subtype applies when the central theme of the delusion involves the individual's belief that he or she is being conspired against, cheated, spied on, follower, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
- Somatic type - This subtype applies when the central theme of the delusion involves bodily functions or sensations
- Mixed type - This subtype applies when no one delusional theme predominates.
- Unspecified type - This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types
Specify if:
- With bizarre content - Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences
Specify if:
The following course specifiers are only to used after a 1-year duration of the disorder:
- First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
- First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the definition criteria of the disorder are only partially fulfilled
- First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present
- Multiple episodes, currently in acute episodes
- Multiple episodes, currently in partial remission
- Multiple episodes, currently in full remission
- Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining

Brief Psychotic Disorder

A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), (3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance

Brief Psychotic Disorder Specifiers

Specify if:
- With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to events that, singly or together, would be markedly stressful to almost anyone in a similar circumstance in the individual's culture
- Without marked stressor(s): If symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual's culture
- With peripartum onset: If onset is during pregnancy or within 4 weeks postpartum.
Specify if:
- With catatonia
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms.

Schizophreniform Disorder

A) Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). *At least one of these must be (1), (2), or (3):
1) Delusions.
2) Hallucinations.
3) Disorganized speech (e.g., frequent derailment or incoherence).
4) Grossly disorganized or catatonic behavior.
5) Negative symptoms (i.e., diminished emotional expression or avolition).
B) An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as "provisional."
C) Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
D) The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Schizophreniform Disorder Specifiers

Specify if:
- With good prognostic features: This specifier requires the presence of at least two of the following features:
onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity; good premorbid social and occupational functioning; and absence of blunted or flat affect
- Without good prognostic features: This specifier is applied if two or more of the above features have not been present
Specify if:
- With catatonia
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. 5 point scale

Schizophrenia

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. For a significant portion of the time since the of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
F. If there is a history of ASD or a communication disorder of a childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Schizophrenia Specifiers

Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.
- First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria and fulfilled.
- First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
- First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
- Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes
- Multiple episodes, currently in partial remission
- Multiple episodes, currently in full remission
- Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the remaining the majority of the illness course, with sub threshold symptom periods being very brief relative to the overall course.
- Unspecified
Specify if:
- With catatonia
Specify current severity:
- Severity is rated by quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. 5 point scale

Schizoaffective Disorder

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Schizoaffective Disorder Specifiers

Specify whether:
- Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur.
- Depressive type: This subtype applies if only major depressive episodes are part of the presentations.
Specify if:
- With catatonia
Specify if:
- The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.
- First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
- First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
- First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
- Multiple episodes, currently in acute episode: Multiple episodes may be determined after a maximum of two episodes
- Multiple episodes, currently in partial remission
- Multiple episodes, currently in full remission
- Continuous: Symptoms fulfilling the diagnostic criteria of the disorder are remaining for the majority of the illness course, with sub threshold symptom period being very brief relative to the overall course.
- Unspecified
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. On a 5 point scale

Substance/Medication-Induced Psychotic Disorder

A. Presence of one or both of the following symptoms:
1. Delusions
2. Hallucinations
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication.
2. The involved substance/medication is capable of producing the symptoms in Criteria A
C. The disturbance is not better explained by a psychotic disorder that is not substance/medication-induced. Such evidence of an independent psychotic disorder could include the following:
The symptoms preceded the onset of the substance/medication use; the symptoms persist for a substantial period of time after the cessation of acute withdrawal or severe intoxication; or there is other evidence of an independent non-substance/medication-induced psychotic disorder
D. The disturbance does not occur exclusively during the course of delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Substance/Medication-Induced Psychotic Disorder Specifiers

Specify:
- With onset during intoxication: If criteria are met for intoxication with the substance and the symptoms develop during intoxication.
- With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal
- With onset after medication use: If symptoms developed at initiation of medication, with a change in use of medication, or during withdrawal of medication.
Specify current severity:
- Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. On a 5 point scale

Psychotic Disorder Due to Another Medical Condition

A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Psychotic Disorder Due to Another Medical Condition Specifiers

Specify whether:
- With delusions: If the delusions are the predominant symptom.
- With hallucinations: If hallucinations are the predominant symptom.
Specify current severity:
- Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. On a 5 point scale

Catatonia Associated with Another Mental Disorder (Catatonia Specifier)

A. The clinical picture is dominated by three (or more) of the following symptoms:
1. Stupor (no psychomotor activity; not entirely relating to environment)
2. Catalepsy (passive induction of a posture held against gravity)
3. Waxy flexibility (Slight, even resistance to positioning by examiner)
4. Mutism (No, or very little, verbal response)
5. Negativism (Opposition or no response to instructions or external stimuli
6. Posturing (Spontaneous and active maintenance of a posture against gravity)
7. Mannerism (Odd, circumstantial caricature of normal actions)
8. Stereotypy (Repetitive, abnormally frequent, non-goal, direct movements)
9. Agitation, not influenced by external stimuli
10. Grimacing
11. Echolalia (Mimicking another's speech)
12. Echopraxia (Mimicking another's movements)

Catatonia Disorder Due to Another Medical Condition

A. The clinical picture is dominated by three (or more) of the following symptoms:
1. Stupor (no psychomotor activity; not entirely relating to environment)
2. Catalepsy (passive induction of a posture held against gravity)
3. Waxy flexibility (Slight, even resistance to positioning by examiner)
4. Mutism (No, or very little, verbal response)
5. Negativism (Opposition or no response to instructions or external stimuli
6. Posturing (Spontaneous and active maintenance of a posture against gravity)
7. Mannerism (Odd, circumstantial caricature of normal actions)
8. Stereotypy (Repetitive, abnormally frequent, non-goal, direct movements)
9. Agitation, not influenced by external stimuli
10. Grimacing
11. Echolalia (Mimicking another's speech)
12. Echopraxia (Mimicking another's movements)
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant or impairment in social, occupational, or other important areas of functioning.

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

- This category applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important area of functioning predominate but do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class.
- Used when the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific schizophrenia spectrum and other psychotic disorder. This is done by recording "other specified schizophrenia spectrum and other psychotic disorder" followed by the specific reason.
- Examples of presentations that can be specified using the "other specified" designation include the following:
1. Persistent auditory hallucinations occurring in the absence of any other features.
2. Delusions with significant overlapping mood episodes: This includes persistent delusions with periods of overlapping mood episodes that are resent for a substantial portion of the delusional disturbance
3. Attenuated psychosis syndrome: This syndrome is characterized by psychotic-like symptoms that are below a threshold for full psychosis
4. Delusional symptoms in the context of relationship with an individual with prominent delusions: In the context of a relationships, the delusional material from the individual with a psychotic disorder provides content for the same delusions held by the other person who may not otherwise have symptoms that meet criteria for a psychotic disorder.

Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

- This category applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important area of functioning predominate but do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class.
- Used when the clinician chooses not to communicate the specific reason that the presentation does not meet the criteria for any specific schizophrenia spectrum and other psychotic disorder and includes presentations in which there is insufficient information to make a specific diagnosis.