Schizophrenia Spectrum and Other belief that an outside force has removed his

Psychotic Disorders or her internal organs and replaced them

with someone else’s organs without leaving
Schizophrenia spectrum and other any wounds or scars. An example of a non
psychotic disorders include schizophrenia, bizarre delusion is the belief that one is
other psychotic disorders, and schizotypal under surveillance by the police, despite a
(personality) disorder. They are defined by lack of convincing evidence. Delusions that
abnormalities in one or more of the following express a loss of control over mind or body
five domains: delusions, hallucinations, are generally considered to be bizarre;
disorganized thinking (speech), grossly these include the belief that one’s thoughts
disorganized or abnormal motor behavior have been “removed” by some outside force
(including catatonia), and negative (thought withdrawal), that alien thoughts
symptoms. have been put into one’s mind (thought
insertion), or that one’s body or actions are
Key Features That Define the Psychotic being acted on or manipulated by some
Disorders outside force (delusions of control). The
distinction between a delusion and a
Delusions are fixed beliefs that are not strongly held idea is sometimes difficult to
amenable to change in light of conflicting determine and depends in part on the
evidence. Their content may include a degree of conviction with which the belief is
variety of themes (e.g., persecutory, held despite clear or reasonable
referential, somatic, religious, grandiose). contradictory evidence regarding its
Persecutory delusions (i.e., belief that one veracity. Assessing delusions in individuals
is going to be harmed, harassed, and so from a variety of cultural backgrounds can
forth by an individual, organization, or other be difficult. Some religious and supernatural
group) are most common. Referential beliefs (e.g., evil eye, causing illness
delusions (i.e., belief that certain gestures, through curses, influence of spirits) may be
comments, environmental cues, and so viewed as bizarre and possibly delusional in
forth are directed at oneself) are also some cultural contexts but be generally
common. Grandiose delusions (i.e., when accepted in others. However, elevated
an individual believes that he or she has religiosity can be a feature of many
exceptional abilities, wealth, or fame) and presentations of psychosis. Individuals who
erotomanic delusions (i.e., when an have experienced torture, political violence,
individual believes falsely that another or discrimination can report fears that may
person is in love with him or her) are also be misjudged as persecutory delusions;
seen. Nihilistic delusions involve the these may represent instead intense fears
conviction that a major catastrophe will of recurrence or posttraumatic symptoms. A
occur, and somatic delusions focus on careful evaluation of whether the person’s
preoccupations regarding health and organ fears are justified given the nature of the
function. Delusions are deemed bizarre if trauma can help to differentiate appropriate
they are clearly implausible and not fears from persecutory delusions.
understandable to same culture peers and
do not derive from ordinary life experiences. Hallucinations are perception-like
An example of a bizarre delusion is the experiences that occur without an external
stimulus. They are vivid and clear, with the identity). These phenomena are
full force and impact of normal perceptions, characterized by disorganized speech.
and not under voluntary control. They may These instances do not represent signs of
occur in any sensory modality, but auditory psychosis unless they are accompanied by
hallucinations are the most common in other clearly psychotic symptoms. Less
schizophrenia and related disorders. severe disorganized thinking or speech may
Auditory hallucinations are usually occur during the prodromal and residual
experienced as voices, whether familiar or periods of schizophrenia.
unfamiliar, that are perceived as distinct
from the individual’s own thoughts. The Grossly Disorganized or Abnormal Motor
hallucinations must occur in the context of a Behavior (Including Catatonia) may
clear sensorium; those that occur while manifest itself in a variety of ways, ranging
falling asleep (hypnagogic) or waking up from childlike “silliness” to unpredictable
(hypnopompic) are considered to be within agitation. Problems may be noted in any
the range of normal experience. form of goal-directed behavior, leading to
Hallucinations may be a normal part of difficulties in performing activities of daily
religious experience in certain cultural living. Catatonic behavior is a marked
contexts. decrease in reactivity to the environment.
This ranges from resistance to instructions
Disorganized Thinking (Speech) (formal (negativism); to maintaining a rigid,
thought disorder) is typically inferred from inappropriate or bizarre posture; to a
the individual’s speech. The individual may complete lack of verbal and motor
switch from one topic to another (derailment responses (mutism and stupor). It can
or loose associations). Answers to also include purposeless and excessive
questions may be obliquely related or motor activity without obvious cause
completely unrelated (tangentiality). Rarely, (catatonic excitement). Other features are
speech may be so severely disorganized repeated stereotyped movements, staring,
that it is nearly incomprehensible and grimacing, and the echoing of speech.
resembles receptive aphasia in its linguistic Although catatonia has historically been
disorganization (incoherence or “word associated with schizophrenia, catatonic
salad”). Because mildly disorganized symptoms are nonspecific and may occur in
speech is common and nonspecific, the other mental disorders (e.g., bipolar or
symptom must be severe enough to depressive disorders with catatonia) and in
substantially impair effective medical conditions (catatonic disorder due
communication. The severity of the to another medical condition).
impairment may be difficult to evaluate if the
person making the diagnosis comes from a Negative Symptoms account for a
different linguistic background than that of substantial portion of the morbidity
the person being examined. For example, associated with schizophrenia but are less
some religious groups engage in prominent in other psychotic disorders. Two
glossolalia (“speaking in tongues”); others negative symptoms are particularly
describe experiences of possession trance prominent in schizophrenia: diminished
(trance states in which personal identity is emotional expression and avolition.
replaced by an external possessing Diminished emotional expression
includes reductions in the expression of relationships; cognitive or perceptual
emotions in the face, eye contact, intonation distortions; and eccentricities of behavior,
of speech (prosody), and movements of the usually beginning by early adulthood but in
hand, head, and face that normally give an some cases first becoming apparent in
emotional emphasis to speech. Avolition is childhood and adolescence. Abnormalities
a decrease in motivated self initiated of beliefs, thinking, and perception are
purposeful activities. The individual may sit below the threshold for the diagnosis of a
for long periods of time and show little psychotic disorder. Two conditions are
interest in participating in work or social defined by abnormalities limited to one
activities. Other negative symptoms include domain of psychosis: delusions or catatonia.
alogia, anhedonia, and asociality. Alogia is Delusional disorder is characterized by at
manifested by diminished speech output. least 1 month of delusions but no other
Anhedonia is the decreased ability to psychotic symptoms. Catatonia is described
experience pleasure. Individuals with later in the chapter and further in this
schizophrenia can still enjoy a pleasurable discussion. Brief psychotic disorder lasts
activity in the moment and can recall it, but more than 1 day and remits by 1 month.
show a reduction in the frequency of Schizophreniform disorder is characterized
engaging in pleasurable activity. Asociality by a symptomatic presentation equivalent to
refers to the apparent lack of interest in that of schizophrenia except for its duration
social interactions and may be associated (less than 6 months) and the absence of a
with avolition, but it can also be a requirement for a decline in functioning.
manifestation of limited opportunities for Schizophrenia lasts for at least 6 months
social interactions. and includes at least 1 month of
active-phase symptoms. In schizoaffective
Disorders in This Chapter disorder, a mood episode and the
active-phase symptoms of schizophrenia
This chapter is organized along a gradient occur together and are preceded or are
of psychopathology. Clinicians should first followed by at least 2 weeks of delusions or
consider conditions that do not reach full hallucinations without prominent mood
criteria for a psychotic disorder or are symptoms. Psychotic disorders may be
limited to one domain of psychopathology. induced by substances, medications, toxins,
Then they should consider time-limited and other medical conditions. In
conditions. Finally, the diagnosis of a substance/medication-induced psychotic
schizophrenia spectrum disorder requires disorder, the psychotic symptoms are
the exclusion of another condition that may judged to be a direct physiological
give rise to psychosis. Schizotypal consequence of a drug of abuse, a
personality disorder is noted within this medication, or toxin exposure and cease
chapter as it is considered within the after removal of the agent. In psychotic
schizophrenia spectrum, although its full disorder due to another medical condition,
description is found in the chapter the psychotic symptoms are judged to be a
“Personality Disorders.” The diagnosis direct physiological consequence of another
schizotypal personality disorder captures a medical condition. Catatonia can occur in
pervasive pattern of social and interpersonal several disorders, including
deficits, including reduced capacity for close neurodevelopmental, psychotic, bipolar,
depressive, and other mental disorders. D. If manic or major depressive episodes
This chapter also includes the diagnosis of have occurred, these have been brief
catatonia associated with another mental relative to the duration of the delusional
disorder (catatonia specifier), catatonic periods.
disorder due to another medical condition,
and unspecified catatonia, and the E. The disturbance is not attributable to the
diagnostic criteria for all three conditions are physiological effects of a substance or
described together. Other specified and another medical condition and is not better
unspecified schizophrenia spectrum and explained by another mental disorder, such
other psychotic disorders are included for as body dysmorphic disorder or
classifying psychotic presentations that do obsessive-compulsive disorder.
not meet the criteria for any of the specific
psychotic disorders, or psychotic Specify whether:
symptomatology about which there is
inadequate or contradictory information. Erotomanic type: This subtype applies
when the central theme of the delusion is
Schizotypal (Personality) Disorder that another person is in love with the
individual.
Criteria and text for schizotypal personality Grandiose type: This subtype applies when
disorder can be found in the chapter the central theme of the delusion is the
“Personality Disorders.” Because this conviction of having some great (but
disorder is considered part of the unrecognized) talent or insight or having
schizophrenia spectrum of disorders, and is made some important discovery.
labeled in this section of ICD-10 as Jealous type: This subtype applies when
schizotypal disorder, it is listed in this the central theme of the individual’s
chapter and discussed in detail in the delusion is that his or her spouse or lover is
DSM-5 chapter “Personality Disorders.” unfaithful.
Persecutory type: This subtype applies
Diagnostic Criteria when the central theme of the delusion
involves the individual’s belief that he or she
A. The presence of one (or more) delusions is being conspired against, cheated, spied
with a duration of 1 month or longer. on, followed, poisoned or drugged,
maliciously maligned, harassed, or
B. Criterion A for schizophrenia has never obstructed in the pursuit of long-term goals.
been met. Note: Hallucinations, if present, Somatic type: This subtype applies when
are not prominent and are related to the the central theme of the delusion involves
delusional theme (e.g., the sensation of bodily functions or sensations.
being infested with insects associated with Mixed type: This subtype applies when no
delusions of infestation). one delusional theme predominates.
Unspecified type: This subtype applies
C. Apart from the impact of the delusion(s) when the dominant delusional belief cannot
or its ramifications, functioning is not be clearly determined or is not described in
markedly impaired, and behavior is not the specific types (e.g., referential delusions
obviously bizarre or odd.
without a prominent persecutory or Continuous: Symptoms fulfilling the
grandiose component). diagnostic symptom criteria of the disorder
are remaining for the majority of the illness
Specify if: course, with subthreshold symptom periods
being very brief relative to the overall
With bizarre content: Delusions are course.
deemed bizarre if they are clearly
implausible, not understandable, and not Unspecified
derived from ordinary life experiences (e.g.,
an individual’s belief that a stranger has Specify current severity: Severity is rated
removed his or her internal organs and by a quantitative assessment of the primary
replaced them with someone else’s organs symptoms of psychosis, including delusions,
without leaving any wounds or scars). hallucinations, disorganized speech,
abnormal psychomotor behavior, and
Specify if: negative symptoms. Each of these
symptoms may be rated for its current
The following course specifiers are only to severity (most severe in the last 7 days) on
be used after a 1-year duration of the a 5-point scale ranging from 0 (not present)
disorder: to 4 (present and severe). (See
Clinician-Rated Dimensions of Psychosis
First episode, currently in acute episode: Symptom Severity in the chapter
First manifestation of the disorder meeting “Assessment Measures”).
the defining diagnostic symptom and time
criteria. An acute episode is a time period in Note: Diagnosis of delusional disorder can
which the symptom criteria are fulfilled. be made without using this severity
specifier.
First episode, currently in partial
remission: Partial remission is a time Subtypes
period during which an improvement after a
previous episode is maintained and in which In erotomanic type, the central theme of
the defining criteria of the disorder are only the delusion is that another person is in love
partially fulfilled. with the individual. The person about whom
this conviction is held is usually of higher
First episode, currently in full remission: status (e.g., a famous individual or a
Full remission is a period of time after a superior at work) but can be a complete
previous episode during which no stranger. Efforts to contact the object of the
disorder-specific symptoms are present. delusion are common. In grandiose type,
the central theme of the delusion is the
● Multiple episodes, currently in conviction of having some great talent or
acute episode insight or of having made some important
● Multiple episodes, currently in discovery. Less commonly, the individual
partial remission may have the delusion of having a special
● Multiple episodes, currently in full relationship with a prominent individual or of
remission being a prominent person (in which case the
actual individual may be regarded as an may be more circumscribed than those
impostor). Grandiose delusions may have a seen in other psychotic disorders such as
religious content. In jealous type, the central schizophrenia, and behavior is not obviously
theme of the delusion is that of an unfaithful bizarre or odd (Criterion C). If mood
partner. This belief is arrived at without due episodes occur concurrently with the
cause and is based on incorrect inferences delusions, the total duration of these mood
supported by small bits of “evidence” (e.g., episodes is brief relative to the total duration
disarrayed clothing). The individual with the of the delusional periods (Criterion D). The
delusion usually confronts the spouse or delusions are not attributable to the
lover and attempts to intervene in the physiological effects of a substance (e.g.,
imagined infidelity. In persecutory type, the cocaine) or another medical condition (e.g.,
central theme of the delusion involves the Alzheimer’s disease) and are not better
individual’s belief of being conspired explained by another mental disorder, such
against, cheated, spied on, followed, as body dysmorphic disorder or
poisoned, maliciously maligned, harassed, obsessive-compulsive disorder (Criterion E).
or obstructed in the pursuit of long-term In addition to the delusions identified in the
goals. Small slights may be exaggerated diagnostic criteria, the assessment of
and become the focus of a delusional cognition, depression, and mania symptom
system. The affected individual may engage domains is vital for making critically
in repeated attempts to obtain satisfaction important distinctions between the various
by legal or legislative action. Individuals with schizophrenia spectrum and other psychotic
persecutory delusions are often resentful disorders. Whereas delusions are a sine
and angry and may resort to violence qua non of delusional disorder,
against those they believe are hurting them. hallucinations and negative symptoms are
In somatic type, the central theme of the uncommon and disorganization is rare. By
delusion involves bodily functions or definition, the presence of catatonia in
sensations. Somatic delusions can occur in conjunction with delusions rules out
several forms. Most common is the belief delusional disorder, because Criterion A for
that the individual emits a foul odor; that schizophrenia would be met. A subset of
there is an infestation of insects on or in the cases has prominent depressive symptoms,
skin; that there is an internal parasite; or but cognitive impairment and mania are
that parts of the body are not functioning. rarely demonstrated.

Diagnostic Features Associated Features

The essential feature of delusional disorder Social, marital, or work problems can result
is the presence of one or more delusions from the delusional beliefs of delusional
that persist for at least 1 month (Criterion disorder. Individuals with delusional disorder
A). A diagnosis of delusional disorder is not may be able to factually describe that others
given if the individual has ever had a view their beliefs as irrational but are unable
symptom presentation that met Criterion A to accept this themselves (i.e., there may be
for schizophrenia (Criterion B). Apart from “factual insight” but no true insight). Many
the direct impact of the delusions, individuals develop an irritable or dysphoric
impairments in psychosocial functioning mood, which can sometimes be understood
as a reaction to their delusional beliefs. Culture-Related Diagnostic Issues
Anger and violent behavior can occur with
persecutory, jealous, and erotomanic types. An individual’s cultural and religious
The individual may engage in litigious or background must be taken into account in
antagonistic behavior (e.g., sending evaluating the possible presence of
hundreds of letters of protest to the delusional disorder; in fact, some traditional
government). Legal difficulties can occur, beliefs unfamiliar to Western cultures may
particularly in jealous and erotomanic types. be wrongly labeled as delusional, so their
context must be carefully assessed. The
Prevalence nature and content of delusions also vary
among different cultural groups.
The lifetime prevalence of delusional
disorder has been estimated at around Functional Consequences of Delusional
0.2% in a Finnish sample, and the most Disorder
frequent subtype is persecutory. Delusional
disorder, jealous type, is probably more The functional impairment is usually more
common in men than in women, but there circumscribed than that seen with other
are no major sex or gender differences in psychotic disorders, although in some
the overall frequency of delusional disorder cases, the impairment may be substantial
or in the content of the delusions. and include poor occupational functioning
and social isolation. When poor
Development and Course psychosocial functioning is present,
delusional beliefs themselves often play a
On average, global functioning is generally significant role. A common characteristic of
better than that observed in schizophrenia. individuals with delusional disorder is the
Although the diagnosis is generally stable, a apparent normality of their behavior and
proportion of individuals go on to develop appearance when their delusional ideas are
schizophrenia. Whereas about a third of not being discussed or acted on. Men with
individuals with delusional disorder of 1–3 delusional disorder generally have more
months’ duration subsequently receive a severe symptoms and worse functional
diagnosis of schizophrenia, the diagnosis of outcomes compared with women.
delusional disorder is much less likely to
change if the duration of the disorder is Differential Diagnosis
greater than 6–12 months. Although
delusional disorder can occur in younger Obsessive-compulsive and related
age groups, it may be more prevalent in disorders: If an individual with
older individuals. obsessive-compulsive disorder is
completely convinced that his or her
Risk and Prognostic Factors obsessive-compulsive disorder beliefs are
true, then the diagnosis of
Genetic and Physiological: Delusional obsessive-compulsive disorder, with absent
disorder has a significant familial insight/delusional beliefs specifier, should
relationship with both schizophrenia and be given rather than a diagnosis of
schizotypal personality disorder. delusional disorder. Similarly, if an individual
with body dysmorphic disorder is completely involves various areas of the individual’s
convinced that his or her body dysmorphic life), and greater pressure (the degree to
disorder beliefs are true, then the diagnosis Depressive and bipolar disorders and
of body dysmorphic disorder, with absent schizoaffective disorder. F23 which the
insight/delusional beliefs specifier, should individual is preoccupied and concerned
be given rather than a diagnosis of with the expressed delusion).
delusional disorder.
Depressive and bipolar disorders and
Delirium, major neurocognitive disorder, schizoaffective disorder: These disorders
and psychotic disorder due to another may be distinguished from delusional
medical condition: Individuals with these disorder by the temporal relationship
disorders may present with symptoms that between the mood disturbance and the
suggest delusional disorder. For example, delusions and by the severity of the mood
simple persecutory delusions in the context symptoms. If delusions occur exclusively
of major neurocognitive disorder would be during mood episodes, the diagnosis is
diagnosed as major neurocognitive disorder, major depressive or bipolar disorder, with
with behavioral disturbance. psychotic features. Mood symptoms that
meet full criteria for a mood episode can be
Substance/medication-induced superimposed on delusional disorder.
psychotic disorder: A Delusional disorder can be diagnosed only if
substance/medication-induced psychotic the total duration of all mood episodes
disorder cross-sectionally may be identical remains brief relative to the total duration of
in symptomatology to delusional disorder the delusional disturbance. If not, then a
but can be distinguished by the diagnosis of other specified or unspecified
chronological relationship of substance use schizophrenia spectrum and other psychotic
to the onset and remission of the delusional disorder accompanied by other specified
beliefs. depressive disorder, unspecified depressive
disorder, other specified bipolar and related
Schizophrenia and schizophreniform disorder, or unspecified bipolar and related
disorder: Delusional disorder can be disorder is appropriate.
distinguished from schizophrenia and
schizophreniform disorder by the absence Brief Psychotic Disorder
of the other characteristic symptoms of the
active phase of schizophrenia. Furthermore, Diagnostic Criteria
the quality of delusions can help distinguish
between schizophrenia and delusional A. Presence of one (or more) of the
disorder. In schizophrenia, delusions show following symptoms. At least one of these
greater disorganization (the degree to which must be (1), (2), or (3):
delusions are internally consistent, logical,
and systematized), whereas in delusional 1. Delusions
disorder, they show greater conviction (the 2. Hallucinations
degree to which the individual is convinced 3. Disorganized speech (e.g., frequent
of the reality of the delusion), greater derailment or incoherence)
extension (the degree to which the delusion
4. Grossly disorganized or catatonic Coding note: Use additional code F06.1
behavior catatonia associated with brief psychotic
disorder to indicate the presence of the
Note: Do not include a symptom if it is a comorbid catatonia.
culturally sanctioned response.
Specify current severity:
B. Duration of an episode of the disturbance
is at least 1 day but less than 1 month, with Severity is rated by a quantitative
eventual full return to premorbid level of assessment of the primary symptoms of
functioning. psychosis, including delusions,
hallucinations, disorganized speech,
C.The disturbance is not better explained by abnormal psychomotor behavior, and
major depressive or bipolar disorder with negative symptoms. Each of these
psychotic features or another psychotic symptoms may be rated for its current
disorder such as schizophrenia or catatonia, severity (most severe in the last 7 days) on
and is not attributable to the physiological a 5-point scale ranging from 0 (not present)
effects of a substance (e.g., a drug of to 4 (present and severe). (See Clinician
abuse, a medication) or another medical Rated Dimensions of Psychosis Symptom
condition. Severity in the chapter “Assessment
Measures.”)
Specify if:
Note: Diagnosis of brief psychotic disorder
With marked stressor(s) (brief reactive can be made without using this severity
psychosis): If symptoms occur in response specifier.
to events that, singly or together, would be
markedly stressful to almost anyone in Diagnostic Features
similar circumstances in the individual’s
culture. The essential feature of brief psychotic
disorder is a disturbance that involves at
Without marked stressor(s): If symptoms least one of the following positive psychotic
do not occur in response to events that, symptoms: delusions, hallucinations,
singly or together, would be markedly disorganized speech (e.g., frequent
stressful to almost anyone in similar derailment or incoherence), or grossly
circumstances in the individual’s culture. abnormal psychomotor behavior, including
catatonia (Criterion A). An episode of the
With peripartum onset: If onset is during disturbance lasts at least 1 day but less
pregnancy or within 4 weeks postpartum. than 1 month, and the individual eventually
has a full return to the premorbid level of
Specify if: functioning (Criterion B). The disturbance is
not better explained by a depressive or
With catatonia (refer to the criteria for bipolar disorder with psychotic features, by
catatonia associated with another mental schizoaffective disorder, or by schizophrenia
disorder, p. 135, for definition). and is not attributable to the physiological
effects of a substance (e.g., a hallucinogen)
or another medical condition (e.g., subdural some individuals, the duration of psychotic
hematoma) (Criterion C). In addition to the symptoms may be quite brief (e.g., a few
four symptom domain areas identified in the days). Although brief psychotic disorder by
diagnostic criteria, the assessment of definition reaches a full remission within 1
cognition, depression, and mania symptom month, subsequently more than 50% of the
domains is vital for making critically individuals experience a relapse. Despite
important distinctions between the various the possibility of relapse, for most
schizophrenia spectrum and other psychotic individuals, outcome is favorable in terms of
disorders. social functioning and symptomatology. In
less than half of cases diagnosed with
Associated Features DSM-IV brief psychotic disorder or ICD-10
acute and transient psychotic disorder, the
Individuals with brief psychotic disorder diagnosis changes—more often to
typically experience emotional turmoil or schizophrenia spectrum disorders and less
overwhelming confusion. They may have often to affective disorders or to other
rapid shifts from one intense affect to psychotic disorders.
another. Although the disturbance is brief,
the level of impairment may be severe, and Culture-Related Diagnostic Issues
supervision may be required to ensure that
nutritional and hygienic needs are met and It is important to distinguish symptoms of
that the individual is protected from the brief psychotic disorder from culturally
consequences of poor judgment, cognitive sanctioned response patterns. For example,
impairment, or acting on the basis of in some religious ceremonies, an individual
delusions. There appears to be an may report hearing voices, but these do not
increased risk of suicidal behavior, generally persist and are not perceived as
particularly during the acute episode. abnormal by most members of the
individual’s community. In a wide range of
Prevalence cultural contexts, it would be common or
expected for bereaved relatives to hear,
Brief psychotic disorder may account for see, or interact with the spirit of a recently
2%–7% of cases of first-onset psychosis in deceased loved one without notable
several countries. pathological sequelae. In addition, cultural
and religious background must be taken into
Development and Course account when considering whether beliefs
are delusional.
Brief psychotic disorder may appear in
adolescence or early adulthood, and onset Differential Diagnosis
can occur across the lifespan, with the
average age at onset being the mid 30s. By Other medical conditions: A variety of
definition, a diagnosis of brief psychotic medical conditions can manifest with
disorder requires a full remission of all psychotic symptoms of short duration.
symptoms and an eventual full return to the Psychotic disorder due to another medical
premorbid level of functioning within 1 condition or a delirium is diagnosed when
month of the onset of the disturbance. In there is evidence from the history, physical
examination, or laboratory tests that the in the presentation. The differential
delusions or hallucinations are the direct diagnosis between brief psychotic disorder
physiological consequence of a specific and schizophreniform disorder is difficult
medical condition (e.g., Cushing’s when the psychotic symptoms have
syndrome, brain tumor) (see “Psychotic remitted before 1 month in response to
Disorder Due to Another Medical Condition” successful treatment with medication.
later in this chapter). Careful attention should be given to the
possibility that a recurrent disorder (e.g.,
Substance-related disorders: bipolar disorder, recurrent acute
Substance/medication-induced psychotic exacerbations of schizophrenia) may be
disorder, substance-induced delirium, and responsible for any recurrent psychotic
substance intoxication are distinguished episodes.
from brief psychotic disorder by the fact that
a substance (e.g., a drug of abuse, a Malingering and factitious disorders: An
medication, exposure to a toxin) is judged to episode of factitious disorder with
be etiologically related to the psychotic predominantly psychological signs and
symptoms (see symptoms may have the appearance of
“Substance/Medication-Induced Psychotic brief psychotic disorder, but in such cases
Disorder” later in this chapter). Laboratory there is evidence that the symptoms are
tests, such as a urine drug screen or a intentionally produced. When malingering
blood alcohol level, may be helpful in involves apparently psychotic symptoms,
making this determination, as may a careful there is usually evidence that the illness is
history of substance use with attention to being feigned for an understandable goal.
temporal relationships between substance
intake and onset of the symptoms and to Personality disorders: In certain
the nature of the substance being used. individuals with personality disorders,
psychosocial stressors may precipitate brief
Depressive and bipolar disorders: The periods of psychotic symptoms. These
diagnosis of brief psychotic disorder cannot symptoms are usually transient and do not
be made if the psychotic symptoms are warrant a separate diagnosis. If psychotic
better explained by a mood episode (i.e., symptoms persist for at least 1 day, an
the psychotic symptoms occur exclusively additional diagnosis of brief psychotic
during a full major depressive, manic, or disorder may be appropriate.
mixed episode).
Schizophreniform Disorder
Other psychotic disorders: If the
psychotic symptoms persist for 1 month or Diagnostic Criteria
longer, the diagnosis is either
schizophreniform disorder, delusional A. Two (or more) of the following, each
disorder, depressive disorder with psychotic present for a significant portion of time
features, bipolar disorder with psychotic during a 1-month period (or less if
features, or other specified or unspecified successfully treated). At least one of these
schizophrenia spectrum and other psychotic must be (1), (2), or (3):
disorder, depending on the other symptoms
1. Delusions Without good prognostic features: This
2. Hallucinations specifier is applied if two or more of the
3. Disorganized speech (e.g., frequent above features have not been present.
derailment or incoherence).
4. Grossly disorganized or catatonic Specify if:
behavior
5. Negative symptoms (i.e., diminished With catatonia (refer to the criteria for
emotional expression or avolition) catatonia associated with another mental
disorder, p. 135, for definition).
B. An episode of the disorder lasts at least 1
month but less than 6 months. When the Coding note: Use additional code F06.1
diagnosis must be made without waiting for catatonia associated with schizophreniform
recovery, it should be qualified as disorder to indicate the presence of the
“provisional.” comorbid catatonia.

C. Schizoaffective disorder and depressive Specify current severity:

or bipolar disorder with psychotic features
have been ruled out because either 1) no Severity is rated by a quantitative
major depressive or manic episodes have assessment of the primary symptoms of
occurred concurrently with the active-phase psychosis, including delusions,
symptoms, or 2) if mood episodes have hallucinations, disorganized speech,
occurred during active-phase symptoms, abnormal psychomotor behavior, and
they have been present for a minority of the negative symptoms. Each of these
total duration of the active and residual symptoms may be rated for its current
periods of the illness. severity (most severe in the last 7 days) on
a 5-point scale ranging from 0 (not present)
D. The disturbance is not attributable to the to 4 (present and severe). (See Clinician
physiological effects of a substance (e.g., a Rated Dimensions of Psychosis Symptom
drug of abuse, a medication) or another Severity in the chapter “Assessment
medical condition. Measures.”)

Specify if: Note: Diagnosis of schizophreniform

disorder can be made without using this
With good prognostic features: This severity specifier.
specifier requires the presence of at least
two of the following features: onset of Note: For additional information on
prominent psychotic symptoms within 4 Associated Features, Development and
weeks of the first noticeable change in usual Course (age-related factors),
behavior or functioning; confusion or Culture-Related Diagnostic Issues, Sex-
perplexity; good premorbid social and and Gender-Related Diagnostic Issues,
occupational functioning; and absence of Differential Diagnosis, and Comorbidity, see
blunted or flat affect. the corresponding sections in
Schizophrenia.
Prevalence speech; attention-deficit/hyperactivity
disorder; obsessive compulsive disorder;
Incidence of schizophreniform disorder posttraumatic stress disorder; and traumatic
across sociocultural settings is likely similar brain injury.
to that observed in schizophrenia. In the
United States and other high-income Brief psychotic disorder:
countries, the incidence is low, possibly Schizophreniform disorder differs in duration
fivefold less than that of schizophrenia. In from brief psychotic disorder, which has a
lower-income countries, the incidence may duration of less than 1 month.
be higher, especially for the specifier “with
good prognostic features”; in some of these Schizophrenia
settings schizophreniform disorder may be
as common as schizophrenia. Diagnostic Criteria

Risk and Prognostic Factors A. Two (or more) of the following, each
present for a significant portion of time
Genetic and physiological: Relatives of during a 1-month period (or less if
individuals with schizophreniform disorder successfully treated). At least one of these
have an increased risk for schizophrenia. must be (1), (2), or (3):

Differential Diagnosis 1. Delusions

2. Hallucinations
Other mental disorders and medical 3. Disorganized speech (e.g., frequent
conditions: A wide variety of mental derailment or incoherence)
disorders and medical conditions can 4. Grossly disorganized or catatonic
manifest with psychotic symptoms that must behavior
be considered in the differential diagnosis of 5. Negative symptoms (i.e., diminished
schizophreniform disorder. These include emotional expression or avolition)
psychotic disorder due to another medical
condition or its treatment; delirium or major B. For a significant portion of the time since
neurocognitive disorder; the onset of the disturbance, level of
substance/medication induced psychotic functioning in one or more major areas,
disorder or delirium; major depressive or such as work, interpersonal relations, or
bipolar disorder with psychotic features; self-care, is markedly below the level
schizoaffective disorder; other specified or achieved prior to the onset (or when the
unspecified bipolar and related disorder; onset is in childhood or adolescence, there
major depressive or bipolar disorder with is failure to achieve expected level of
catatonic features; schizophrenia; interpersonal, academic, or occupational
delusional disorder; other specified or functioning).
unspecified schizophrenia spectrum and
other psychotic disorder; schizotypal, C. Continuous signs of the disturbance
schizoid, or paranoid personality disorders; persist for at least 6 months. This 6-month
autism spectrum disorder; disorders period must include at least 1 month of
presenting in childhood with disorganized symptoms (or less if successfully treated)
that meet Criterion A (i.e., active-phase the defining diagnostic symptom and time
symptoms) and may include periods of criteria. An acute episode is a time period in
prodromal or residual symptoms. During which the symptom criteria are fulfilled.
these prodromal or residual periods, the
signs of the disturbance may be manifested First episode, currently in partial
by only negative symptoms or by two or remission: Partial remission is a period of
more symptoms listed in Criterion A present time during which an improvement after a
in an attenuated form (e.g., odd beliefs, previous episode is maintained and in which
unusual perceptual experiences). the defining criteria of the disorder are only
partially fulfilled.
D. Schizoaffective disorder and depressive
or bipolar disorder with psychotic features First episode, currently in full remission:
have been ruled out because either 1) no Full remission is a period of time after a
major depressive or manic episodes have previous episode during which no
occurred concurrently with the active-phase disorder-specific symptoms are present.
symptoms, or 2) if mood episodes have
occurred during active-phase symptoms, Multiple episodes, currently in acute
they have been present for a minority of the episode: Multiple episodes may be
total duration of the active and residual determined after a minimum of two
periods of the illness. episodes (i.e., after a first episode, a
remission and a minimum of one relapse).
E. The disturbance is not attributable to the
physiological effects of a substance (e.g., a Multiple episodes, currently in partial
drug of abuse, a medication) or another remission
medical condition.
Multiple episodes, currently in full
F. If there is a history of autism spectrum remission
disorder or a communication disorder of
childhood onset, the additional diagnosis of Continuous: Symptoms fulfilling the
schizophrenia is made only if prominent diagnostic symptom criteria of the disorder
delusions or hallucinations, in addition to the are remaining for the majority of the illness
other required symptoms of schizophrenia, course, with subthreshold symptom periods
are also present for at least 1 month (or less being very brief relative to the overall
if successfully treated). course.

Specify if: Unspecified

The following course specifiers are only to Specify if:

be used after a 1-year duration of the
disorder and if they are not in contradiction With catatonia (refer to the criteria for
to the diagnostic course criteria. catatonia associated with another mental
disorder, p. 135, for definition).
First episode, currently in acute episode:
First manifestation of the disorder meeting
Coding note: Use additional code F06.1 show higher incidence rates for men,
catatonia associated with schizophrenia to whereas definitions allowing for the
indicate the presence of the comorbid inclusion of more mood symptoms and brief
catatonia. presentations (associated with better
outcome) show equivalent risks for both
Specify current severity: sexes. A large worldwide study, which was
based on a range of definitions of
Severity is rated by a quantitative schizophrenia, found no difference in
assessment of the primary symptoms of prevalence between the sexes.
psychosis, including delusions,
hallucinations, disorganized speech, Risk and Prognostic Factors
abnormal psychomotor behavior, and
negative symptoms. Each of these Environmental: Season of birth has been
symptoms may be rated for its current linked to the incidence of schizophrenia,
severity (most severe in the last 7 days) on including late winter/early spring in some
a 5-point scale ranging from 0 (not present) locations and summer for the deficit form of
to 4 (present and severe). (See Clinician the disease. The incidence of schizophrenia
Rated Dimensions of Psychosis Symptom and related disorders may be higher for
Severity in the chapter “Assessment children growing up in an urban
Measures.”) environment, for refugees, for some migrant
groups, and for socially oppressed groups
Note: Diagnosis of schizophrenia can be facing discrimination. There is evidence that
made without using this severity specifier. social deprivation, social adversity, and
socioeconomic factors may be associated
Prevalence with increased rates of this disorder. Among
individuals with schizophrenia and other
The estimated lifetime prevalence of psychotic disorders, the severity of positive
schizophrenia is approximately 0.3%–0.7%, and negative symptoms appears to be
with variation over a fivefold range in correlated with the severity of adverse
meta-analyses of nationally representative childhood experiences, such as trauma and
surveys. Studies have shown increased neglect. Higher rates of schizophrenia for
prevalence and incidence of schizophrenia some ethnic and racialized groups have
for some groups based on migration and been documented when they live in areas
refugee status, urbanicity, and the economic with lower proportions of people from the
status and latitude of the country. It is same ethnicity or racialized group. The
important to note that the reported reasons for this are not completely clear but
prevalence and incidence of schizophrenia appear related to several factors, including
may be affected by the fact that some the following: 1) higher levels of
groups are more likely to be misdiagnosed discrimination or fear of discrimination; 2)
or overdiagnosed. The sex ratio differs less social support and more stigmatization
across samples and populations: for of those with schizophrenia; 3) higher social
example, presentations with prominent isolation; and 4) decreased availability of
negative symptoms and longer duration of and access to normalizing explanations of
disorder (associated with poorer outcome) perceptual experiences and abnormal
beliefs reported by individuals at high risk of illness, and older age at illness onset. A
for developing schizophrenia. systematic review and meta-analysis of
longitudinal studies found that the odds of
Genetic and physiological: There is a suicidal behavior during follow-up after
strong contribution for genetic factors in first-episode psychosis were higher among
determining risk for schizophrenia, although individuals with depressive symptoms
most individuals who have been diagnosed during first-episode psychosis compared
with schizophrenia have no family history of with those without. A meta-analysis of a
psychosis. Liability is conferred by a large number of studies of the relationship
spectrum of risk alleles, common and rare, of schizophrenia with suicidal behavior
with each allele contributing only a small found that alcohol, tobacco, and drug
fraction to the total population variance. The abuse; depression; number of
risk alleles identified to date are also hospitalizations; physical comorbidity; and
associated with other mental disorders, family history of depression and suicidal
including bipolar disorder, depression, and behavior increased the risk of suicide
autism spectrum disorder. Pregnancy and attempt. Risk factors for suicide included
birth complications with hypoxia and greater male sex, being younger, having a higher
paternal age are associated with a higher IQ, history of attempts, hopelessness, and
risk of schizophrenia for the developing poor adherence to treatment.
fetus. In addition, other prenatal and
perinatal adversities, including stress, Differential Diagnosis
infection, malnutrition, maternal diabetes,
and other medical conditions, have been Major depressive or bipolar disorder with
linked with schizophrenia. However, the vast psychotic or catatonic features: The
majority of offspring with these risk factors distinction between schizophrenia and
do not develop schizophrenia. major depressive or bipolar disorder with
psychotic features or with catatonia
Association With Suicidal Thoughts or depends on the temporal relationship
Behavior: Approximately 5%–6% of between the mood disturbance and the
individuals with schizophrenia die by psychosis, and on the severity of the
suicide, about 20% attempt suicide on one depressive or manic symptoms. If delusions
or more occasions, and many more have or hallucinations occur exclusively during a
significant suicidal ideation. Suicidal major depressive or manic episode, the
behavior is sometimes in response to diagnosis is depressive or bipolar disorder
command hallucinations to harm oneself or with psychotic features.
others. Suicide risk remains high over the
whole lifespan for men and women, Schizoaffective disorder: A diagnosis of
although it may be especially high for schizoaffective disorder requires that a
younger men with comorbid substance use. major depressive or manic episode occur
Other risk factors include depressive concurrently with the active-phase
symptoms, hopelessness, being symptoms and that the mood symptoms be
unemployed, the period after a psychotic present for a majority of the total duration of
episode or hospital discharge, number of the active periods.
psychiatric admissions, closeness to onset
Schizophreniform disorder and brief reliving or reacting to the event are required
psychotic disorder: These disorders are of to make the diagnosis of posttraumatic
shorter duration than schizophrenia as stress disorder.
specified in Criterion C, which requires 6
months of symptoms. In schizophreniform Autism spectrum disorder or
disorder, the disturbance is present less communication disorders: These
than 6 months, and in brief psychotic disorders may also have symptoms
disorder, symptoms are present at least 1 resembling a psychotic episode but are
day but less than 1 month. distinguished by their respective deficits in
social
Delusional disorder: Delusional disorder
can be distinguished from schizophrenia by Other mental disorders associated with a
the absence of the other symptoms psychotic episode: The diagnosis of
characteristic of schizophrenia (e.g., schizophrenia is made only when the
delusions, prominent auditory or visual psychotic episode is persistent and not
hallucinations, disorganized speech, grossly attributable to the physiological effects of a
disorganized or catatonic behavior, negative substance or another medical condition.
symptoms). Individuals with a delirium or major or minor
neurocognitive disorder may present with
Schizotypal personality disorder: psychotic symptoms, but these would have
Schizotypal personality disorder may be a temporal relationship to the onset of
distinguished from schizophrenia by cognitive changes consistent with those
subthreshold symptoms that are associated disorders.
with persistent personality features.
Substance/medication-induced
Obsessive-compulsive disorder and psychotic disorder: Individuals with
body dysmorphic disorder: Individuals substance/medication-induced psychotic
with obsessive compulsive disorder and disorder may present with symptoms
body dysmorphic disorder may present with characteristic of Criterion A for
poor or absent insight, and the schizophrenia, but the
preoccupations may reach delusional substance/medication-induced psychotic
proportions. But these disorders are disorder can usually be distinguished by the
distinguished from schizophrenia by their chronological relationship of substance use
prominent obsessions, compulsions, to the onset and remission of the psychosis
preoccupations with appearance or body in the absence of substance use.
odor, hoarding, or body-focused repetitive
behaviors. Comorbidity

Posttraumatic stress disorder: Rates of comorbidity with substance-related

Posttraumatic stress disorder may include disorders are high in schizophrenia. Over
flashbacks that have a hallucinatory quality, half of individuals with schizophrenia have
and hypervigilance may reach paranoid tobacco use disorder and smoke cigarettes
proportions. But a traumatic event and regularly. Comorbidity with anxiety disorders
characteristic symptom features relating to is increasingly recognized in schizophrenia.
Rates of obsessive-compulsive disorder and ★ a significant number of
panic disorder are elevated in individuals people with schizophrenia
with schizophrenia compared with the are not helped by the use of
general population. Schizotypal or paranoid dopamine antagonists
personality disorder may sometimes
precede the onset of schizophrenia. Life ★ although neuroleptics block
expectancy is reduced in individuals with the reception of dopamine
schizophrenia because of associated quite quickly, the relevant
medical conditions. Weight gain, diabetes, symptoms subside after
metabolic syndrome, and cardiovascular several days or weeks, more
and pulmonary disease are more common slowly than we expect
in schizophrenia than in the general
population. Poor engagement in health ★ these drugs are only partly
maintenance behaviors (e.g., cancer helpful in reducing the
screening, exercise) increases the risk of negative symptoms of
chronic disease, but other disorder factors, schizophrenia
including medications, lifestyle, cigarette
smoking, and diet, may also play a role. A VENTRICLE
shared vulnerability for psychosis and
medical conditions may explain some of the ● enlarged ventricle are observed
medical comorbidity of schizophrenia. more often in men that in women

ADDITIONAL INFORMATION ON ● seem to be in proportion to age and

SCHIZOPHRENIA duration of schizophrenia

DOPAMINE ● enlarged lateral and third ventricle

● believed that there is an over activity TREATMENT TO SCHIZOPHRENIA

of dopamine in the system of people
with schizophrenia ★ BIOLOGICAL INTERVENTION
★ PSYCHOSOCIAL INTERVENTIONS
● further supported by antipsychotic - BEHAVIORAL THERAPY - TOKEN
drugs often being dopamine ECONOMY - rewarding with meals
antagonists and small luxuries by behaving
appropriately.
● another support for this theory is ★ PSYCHOSOCIAL INTERVENTIONS
how psychotic symptoms often - COGNITIVE REMEDIATION - aimed
worsen with amphetamines which at improving cognitive processes
are known to activate dopamine (attention, executive functioning, and
memory).
● CONTRADICTIONS TO THE
DOPAMINE THEORY Schizoaffective Disorder

Diagnostic Criteria
A. An uninterrupted period of illness during The following course specifiers are only to
which there is a major mood episode (major be used after a 1-year duration of the
depressive or manic) concurrent with disorder and if they are not in contradiction
Criterion A of schizophrenia. to the diagnostic course criteria.

Note: The major depressive episode must First episode, currently in acute episode:
include Criterion A1: Depressed mood. First manifestation of the disorder meeting
the defining diagnostic symptom and time
B. Delusions or hallucinations for 2 or more criteria. An acute episode is a time period in
weeks in the absence of a major mood which the symptom criteria are fulfilled.
episode (depressive or manic) during the
lifetime duration of the illness. First episode, currently in partial
remission: Partial remission is a time
C. Symptoms that meet criteria for a major period during which an improvement after a
mood episode are present for the majority of previous episode is maintained and in which
the total duration of the active and residual the defining criteria of the disorder are only
portions of the illness. partially fulfilled.

D. The disturbance is not attributable to the First episode, currently in full remission:
effects of a substance (e.g., a drug of Full remission is a period of time after a
abuse, a medication) or another medical previous episode during which no
condition. disorder-specific symptoms are present.

Specify whether: Multiple episodes, currently in acute

episode: Multiple episodes may be
F25.0 Bipolar type: This subtype applies if determined after a minimum of two
a manic episode is part of the presentation. episodes (i.e., after a first episode, a
Major depressive episodes may also occur. remission and a minimum of one relapse).
F25.1 Depressive type: This subtype
applies if only major depressive episodes Multiple episodes, currently in partial
are part of the presentation. remission
Multiple episodes, currently in full
Specify if: remission

With catatonia (refer to the criteria for Continuous: Symptoms fulfilling the
catatonia associated with another mental diagnostic symptom criteria of the disorder
disorder, p. 135, for definition). are remaining for the majority of the illness
Coding note: Use additional code F06.1 course, with subthreshold symptom periods
catatonia associated with schizoaffective being very brief relative to the overall
disorder to indicate the presence of the course.
comorbid catatonia.
Unspecified
Specify if:
Specify current severity:
Severity is rated by a quantitative schizoaffective disorder itself. The
assessment of the primary symptoms of molecular genetic composite signatures
psychosis, including delusions, known as polygenic risk scores for
hallucinations, disorganized speech, schizophrenia, bipolar disorder, and major
abnormal psychomotor behavior, and depressive disorder may all be elevated in
negative symptoms. Each of these schizoaffective disorder.
symptoms may be rated for its current
severity (most severe in the last 7 days) on Association With Suicidal Thoughts or
a 5-point scale ranging from 0 (not present) Behavior
to 4 (present and severe). (See Clinician
Rated Dimensions of Psychosis Symptom The lifetime risk of suicide for schizophrenia
Severity in the chapter “Assessment and schizoaffective disorder is 5%, and the
Measures.”) presence of depressive symptoms is
correlated with a higher risk for suicide.
Note: Diagnosis of schizoaffective disorder There is evidence that suicide rates are
can be made without using this severity higher in North American populations than
specifier. in European, Eastern European, South
American, and Indian populations of
Prevalence individuals with schizophrenia or
schizoaffective disorder.
Schizoaffective disorder appears to be
about one-third as common as Differential Diagnosis
schizophrenia. Lifetime prevalence of
schizoaffective disorder was estimated to be Other mental disorders and medical
0.3% in a Finnish sample and is higher in conditions: A wide variety of psychiatric
women than in men when DSM-IV and medical conditions can manifest with
diagnostic criteria were used. This rate psychotic and mood symptoms and must be
would be expected to be lower because of considered in the differential diagnosis of
the more stringent requirement of DSM-5 schizoaffective disorder. These include
Criterion C (i.e., mood symptoms meeting delirium; major neurocognitive disorder;
criteria for a major mood episode must be substance/medication-induced psychotic
present for the majority of the total duration disorder or neurocognitive disorder; bipolar
of the active and residual portion of the disorders, with psychotic features; major
illness). depressive disorder, with psychotic features;
depressive or bipolar disorders, with
Risk and Prognostic Factors catatonic features; schizotypal, schizoid, or
paranoid personality disorder; brief
Genetic and Physiological: Among psychotic disorder; schizophreniform
individuals with schizophrenia, there may be disorder; schizophrenia; delusional disorder;
an increased risk for schizoaffective and other specified and unspecified
disorder in first-degree relatives. The risk for schizophrenia spectrum and other psychotic
schizoaffective disorder may also be disorders.
increased among individuals who have a
first-degree relative with bipolar disorder or
Psychotic disorder due to another require collateral information from medical
medical condition: Other medical records and from informants.
conditions and substance use can manifest
with a combination of psychotic and mood Comorbidity
symptoms, and thus psychotic disorder due
to another medical condition needs to be Many individuals diagnosed with
excluded. schizoaffective disorder are also diagnosed
with other mental disorders, especially
Schizophrenia, bipolar, and depressive substance use disorders and anxiety
disorders: Distinguishing schizoaffective disorders. Similarly, the incidence of
disorder from schizophrenia and from medical conditions, including metabolic
depressive and bipolar disorders with syndrome, is increased above the base rate
psychotic features is often difficult. Criterion for the general population and leads to
C is designed to separate schizoaffective decreased life expectancy.
disorder from schizophrenia, and Criterion B
is designed to distinguish schizoaffective Substance/Medication-Induced
disorder from a depressive or bipolar Psychotic Disorder
disorder with psychotic features. More
specifically, schizoaffective disorder can be Diagnostic Criteria
distinguished from a major depressive or
bipolar disorder with psychotic features A. Presence of one or both of the following
based on the presence of prominent symptoms:
delusions and/or hallucinations for at least 2
weeks in the absence of a major mood 1. Delusions
episode. In contrast, in depressive or bipolar 2. Hallucinations
disorder with psychotic features, the
psychotic features only occur during the B. There is evidence from the history,
mood episode(s). Because the relative physical examination, or laboratory findings
proportion of mood to psychotic symptoms of both (1) and (2):
may change over time, the appropriate
diagnosis may change from and to 1. The symptoms in Criterion A developed
schizoaffective disorder. (For example, a during or soon after substance intoxication
diagnosis of schizoaffective disorder for a or withdrawal or after exposure to or
severe and prominent major depressive withdrawal from a medication.
episode lasting 4 months during the first 6 2. The involved substance/medication is
months of a chronic psychotic illness would capable of producing the symptoms in
be changed to schizophrenia if active Criterion A.
psychotic or prominent residual symptoms
persist over several years without a C. The disturbance is not better explained
recurrence of another mood episode.) by a psychotic disorder that is not
Achieving greater clarity about the relative substance/medication-induced. Such
proportion of mood to psychotic symptoms evidence of an independent psychotic
over time and about their concurrence may disorder could include the following:
The symptoms preceded the onset of the moderate or severe substance use disorder
substance/medication use; the symptoms is comorbid with the substance-induced
persist for a substantial period of time (e.g., psychotic disorder, the 4th position
about 1 month) after the cessation of acute character is “2,” and the clinician should
withdrawal or severe intoxication; or there is record “moderate [substance] use disorder”
other evidence of an independent or “severe [substance] use disorder,”
non-substance/medication-induced depending on the severity of the comorbid
psychotic disorder (e.g., a history of substance use disorder. If there is no
recurrent non-substance/medication-related comorbid substance use disorder (e.g., after
episodes). a one-time heavy use of the substance),
then the 4th position character is “9,” and
D. The disturbance does not occur the clinician should record only the
exclusively during the course of a delirium. substance-induced psychotic disorder.

E. The disturbance causes clinically ★ Alcohol

significant distress or impairment in social, ★ Cannabis
occupational, or other important areas of ★ Phencyclidine
functioning. ★ Other hallucinogen
★ Inhalant
Note: This diagnosis should be made ★ Sedative, hypnotic, or anxiolytic
instead of a diagnosis of substance ★ Amphetamine-type substance (or
intoxication or substance withdrawal only other stimulant)
when the symptoms in Criterion A ★ Cocaine
predominate in the clinical picture and when ★ Other (or unknown) substance
they are sufficiently severe to warrant
clinical attention. With onset during intoxication: If criteria
are met for intoxication with the substance
Coding note: The ICD-10-CM codes for the and the symptoms develop during
[specific substance/medication]-induced intoxication.
psychotic disorders are indicated in the
table below. Note that the ICD-10-CM code With onset during withdrawal: If criteria
depends on whether or not there is a are met for withdrawal from the substance
comorbid substance use disorder present and the symptoms develop during, or
for the same class of substance. In any shortly after, withdrawal.
case, an additional separate diagnosis of a
substance use disorder is not given. If a With onset after medication use: If
mild substance use disorder is comorbid symptoms developed at initiation of
with the substance-induced psychotic medication, with a change in use of
disorder, the 4th position character is “1,” medication, or during withdrawal of
and the clinician should record “mild medication.
[substance] use disorder” before the
substance induced psychotic disorder (e.g., Prevalence
“mild cocaine use disorder with
cocaine-induced psychotic disorder”). If a
Prevalence of disorder is distinguished from an
substance/medication-induced psychotic independent psychotic disorder, such as
disorder in the general population is schizophrenia, schizoaffective disorder,
unknown. Between 7% and 25% of delusional disorder, brief psychotic disorder,
individuals presenting with a first episode of other specified schizophrenia spectrum and
psychosis in different settings are reported other psychotic disorder, or unspecified
to have substance/medication-induced schizophrenia spectrum and other psychotic
psychotic disorder. disorder, by the fact that a substance is
judged to be etiologically related to the
Differential Diagnosis Substance symptoms.
intoxication or substance withdrawal:
Individuals intoxicated with stimulants, Psychotic disorder due to another
cannabis, the opioid meperidine, or medical condition: A
phencyclidine, or those withdrawing from substance/medication-induced psychotic
alcohol or sedatives, may experience disorder due to a prescribed treatment for a
altered perceptions that they recognize as mental disorder or medical condition must
drug effects. If reality testing for these have its onset while the individual is
experiences remains intact (i.e., the receiving the medication (or during
individual recognizes that the perception is withdrawal, if there is a withdrawal
substance induced and neither believes in syndrome associated with the medication).
nor acts on it), the diagnosis is not Because individuals with medical conditions
substance/medication-induced psychotic often take medications for those conditions,
disorder. Instead, substance intoxication or the clinician must consider the possibility
substance withdrawal, with perceptual that the psychotic symptoms are caused by
disturbances, is diagnosed (e.g., cocaine the physiological consequences of the
intoxication, with perceptual disturbances). medical condition itself rather than the
“Flashback” hallucinations that can occur medication, in which case psychotic
long after the use of hallucinogens has disorder due to another medical condition is
stopped are diagnosed as hallucinogen diagnosed. History often provides the
persisting perception disorder. If primary basis for such a judgment. At times,
substance/medication-induced psychotic a change in the treatment for the medical
symptoms occur exclusively during the condition (e.g., medication substitution or
course of a delirium, as in severe forms of discontinuation) may be needed to
alcohol withdrawal, the psychotic symptoms determine empirically for that individual
are considered to be an associated feature whether the medication is the causative
of the delirium and are not diagnosed agent. If the clinician has ascertained that
separately. Delusions in the context of a the disturbance is attributable to both a
major or mild neurocognitive disorder would medical condition and substance/medication
be diagnosed as major or mild use, both diagnoses (i.e., psychotic disorder
neurocognitive disorder, with behavioral due to another medical condition and
disturbance. substance/medication-induced psychotic
disorder) may be given.
Independent psychotic disorder: A
substance/medication-induced psychotic
Other specified or unspecified Differential Diagnosis
schizophrenia spectrum and other
psychotic disorders: The psychotic Delirium and major or mild
symptoms included in the diagnosis of neurocognitive disorder: Hallucinations
substance/medication-induced psy-chotic and delusions commonly occur in the
disorder are limited to either delusions or context of a delirium; a separate diagnosis
hallucinations. Individuals with other of psychotic disorder due to during the
substance-induced psychotic symptoms course of a delirium. On the other hand, a
(e.g., disorganized or catatonic behavior; diagnosis of psychotic disorder due to
disorganized speech; incoherence or another medical condition may be given in
irrational content) should be classified in the addition to a diagnosis of major or mild
category of other specified or unspecified neurocognitive disorder if the delusions or
schizophrenia spectrum and other psychotic hallucinations are judged to be a
disorders. physiological consequence of the
pathological process causing the
Psychotic Disorder Due to Another neurocognitive disorder (e.g., psychotic
Medical Condition disorder due to Lewy body disease, with
delusions).
A. Prominent hallucinations or delusions.
Substance/medication-induced
B. There is evidence from the history, psychotic disorder: If there is evidence of
physical examination, or laboratory findings recent or prolonged substance use
that the disturbance is the direct (including medications with psychoactive
pathophysiological consequence of another effects), withdrawal from a substance or
medical condition. medication that can cause psychotic
symptoms on withdrawal, or exposure to a
C. The disturbance is not better explained toxin (e.g., LSD [lysergic acid diethylamide]
by another mental disorder. intoxication, alcohol withdrawal), a
substance/medication-induced psychotic
D. The disturbance does not occur disorder should be considered. Symptoms
exclusively during the course of a delirium. that occur during or shortly after (i.e., within
4 weeks) of substance intoxication or
E. The disturbance causes clinically withdrawal or after medication use may be
significant distress or impairment in social, especially indicative of a substance-induced
occupational, or other important areas of psychotic disorder, depending on the
functioning. character, duration, or amount of the
substance used. If the clinician has
Specify whether: ascertained that the disturbance is due to
Code based on predominant symptom: both a medical condition and substance
use, both diagnoses (i.e., psychotic disorder
F06.2 With delusions: If delusions are the due to another medical condition and
predominant symptom. substance/medication-induced psychotic
F06.0 With hallucinations: If hallucinations disorder) can be given.
are the predominant symptom.
Psychotic disorder: Psychotic disorder ★ FLUID OR ELECTROLYTE
due to another medical condition must be IMBALANCES
distinguished from a psychotic disorder that ★ HEPATIC OR RENAL DISEASES
is not due to another medical condition ★ AUTOIMMUNE DISORDERS WITH
(e.g., schizophrenia, delusional disorder, CENTRAL NERVOUS SYSTEM
schizoaffective disorder) or a major
depressive or bipolar disorder, with Prevalence
psychotic features. In psychotic disorders
and in depressive or bipolar disorders, with Prevalence rates for psychotic disorder due
psychotic features, no specific and direct to another medical condition are difficult to
causative physiological mechanisms estimate given the wide variety of
associated with a medical condition can be underlying medical etiologies. Lifetime
demonstrated. Late age at onset and the prevalence has been estimated to range
absence of a personal or family history of from 0.21% to 0.54% in studies in Sweden
schizophrenia or delusional disorder and Finland. When the prevalence findings
suggest the need for a thorough are stratified by age group, individuals older
assessment to rule out the diagnosis of than 65 years have a significantly greater
psychotic disorder due to another medical prevalence of 0.74% compared with those
condition. Auditory hallucinations that in younger age groups in Finland. Rates of
involve voices speaking complex sentences psychosis also vary according to the
are more characteristic of schizophrenia underlying medical condition; conditions
than of psychotic disorder due to a medical most commonly associated with psychosis
condition. While certain symptoms suggest include untreated endocrine and metabolic
a medical or toxic etiology (e.g., visual or disorders, autoimmune disorders (e.g.,
olfactory hallucinations, dreamlike quality of systemic lupus erythematosus, NMDA
delusions [individual as uninvolved receptor autoimmune encephalitis), or
observer]), there are no pathognomonic temporal lobe epilepsy. Psychosis
signs or symptoms that unequivocally point attributable to epilepsy
clinicians either way. Visual hallucinations
are not uncommon in schizophrenia or Risk and Prognostic Factors
bipolar disorder, and olfactory hallucinations
(e.g., unpleasant smells) are also consistent Course modifiers: Identification and
with a diagnosis of schizophrenia. Thus, treatment of the underlying medical
clinicians should not give undue weight to condition has the greatest impact on course,
any one particular hallucination alone when although preexisting central nervous system
deciding between a psychiatric and a injury may confer a worse course outcome
medical cause for psychopathology. (e.g., head trauma, cerebrovascular
disease).
★ TEMPORAL LOBE EPILEPSY
★ NEUROLOGICAL CONDITIONS Differential Diagnosis
★ ENDOCRINE CONDITIONS
★ METABOLIC CONDITIONS Delirium and major or mild
★ VITAMIN B12 DEFICIENCY neurocognitive disorder: Hallucinations
and delusions commonly occur in the
context of a delirium; a separate diagnosis is not due to another medical condition
of psychotic disorder due to another medical (e.g., schizophrenia, delusional disorder,
condition is not given if the delusions and/or schizoaffective disorder) or a major
hallucinations occur exclusively during the depressive or bipolar disorder, with
course of a delirium. On the other hand, a psychotic features. In psychotic disorders
diagnosis of psychotic disorder due to and in depressive or bipolar disorders, with
another medical condition may be given in psychotic features, no specific and direct
addition to a diagnosis of major or mild causative physiological mechanisms
neurocognitive disorder if the delusions or associated with a medical condition can be
hallucinations are judged to be a demonstrated. Late age at onset and the
physiological consequence of the absence of a personal or family history of
pathological process causing the schizophrenia or delusional disorder
neurocognitive disorder (e.g., psychotic suggest the need for a thorough
disorder due to Lewy body disease, with assessment to rule out the diagnosis of
delusions). psychotic disorder due to another medical
condition. Auditory hallucinations that
Substance/medication-induced involve voices speaking complex sentences
psychotic disorder: If there is evidence of are more characteristic of schizophrenia
recent or prolonged substance use than of psychotic disorder due to a medical
(including medications with psychoactive condition. While certain symptoms suggest
effects), withdrawal from a substance or a medical or toxic etiology (e.g., visual or
medication that can cause psychotic olfactory hallucinations, dreamlike quality of
symptoms on withdrawal, or exposure to a delusions [individual as uninvolved
toxin (e.g., LSD [lysergic acid diethylamide] observer]), there are no pathognomonic
intoxication, alcohol withdrawal), a signs or symptoms that unequivocally point
substance/medication-induced psychotic clinicians either way. Visual hallucinations
disorder should be considered. Symptoms are not uncommon in schizophrenia or
that occur during or shortly after (i.e., within bipolar disorder, and olfactory hallucinations
4 weeks) of substance intoxication or (e.g., unpleasant smells) are also consistent
withdrawal or after medication use may be with a diagnosis of schizophrenia. Thus,
especially indicative of a substance-induced clinicians should not give undue weight to
psychotic disorder, depending on the any one particular hallucination alone when
character, duration, or amount of the deciding between a psychiatric and a
substance used. If the clinician has medical cause for psychopathology.
ascertained that the disturbance is due to
both a medical condition and substance Comorbidity
use, both diagnoses (i.e., psychotic disorder
due to another medical condition and Psychotic disorder due to another medical
substance/medication-induced psychotic condition in individuals older than 80 years
disorder) can be given. is associated with concurrent major
neurocognitive disorder (dementia).
Psychotic disorder: Psychotic disorder Alzheimer’s disease is commonly
due to another medical condition must be accompanied by psychosis, and psychosis
distinguished from a psychotic disorder that is a defining feature in Lewy body disease.
Catatonia 10. Grimacing.
11. Echolalia (i.e., mimicking another’s
Catatonia can occur in the context of speech).
several disorders, including 12. Echopraxia (i.e., mimicking another’s
neurodevelopmental, psychotic, bipolar, and movements).
depressive disorders, and other medical
conditions (e.g., cerebral folate deficiency, Catatonic Disorder Due to Another
rare autoimmune and paraneoplastic Medical Condition
disorders). The manual does not treat
catatonia as an independent class but Diagnostic Criteria
recognizes a) catatonia associated with
another mental disorder (i.e., a A. The clinical picture is dominated by three
neurodevelopmental, psychotic disorder, a (or more) of the following symptoms:
bipolar disorder, a depressive disorder, or
other mental disorder), b) catatonic disorder 1. Stupor (i.e., no psychomotor activity; not
due to another medical condition, and c) actively relating to the environment).
unspecified catatonia. 2. Catalepsy (i.e., passive induction of a
posture held against gravity).
Catatonia Associated With Another 3. Waxy flexibility (i.e., slight, even
Mental Disorder (Catatonia Specifier) resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal
Diagnostic Criteria response [exclude if known aphasia]).
5. Negativism (i.e., opposition or no
A. The clinical picture is dominated by three response to instructions or external stimuli).
(or more) of the following symptoms: 6. Posturing (i.e., spontaneous and active
maintenance of a posture against gravity).
1. Stupor (i.e., no psychomotor activity; not 7. Mannerism (i.e., odd, circumstantial
actively relating to the environment). caricature of normal actions).
2. Catalepsy (i.e., passive induction of a 8. Stereotypy (i.e., repetitive, abnormally
posture held against gravity). frequent, non-goal-directed movements).
3. Waxy flexibility (i.e., slight, even 9. Agitation, not influenced by external
resistance to positioning by examiner). stimuli.
4. Mutism (i.e., no, or very little, verbal 10. Grimacing.
response [exclude if known aphasia]). 11. Echolalia (i.e., mimicking another’s
5. Negativism (i.e., opposition or no speech).
response to instructions or external stimuli). 12. Echopraxia (i.e., mimicking another’s
6. Posturing (i.e., spontaneous and active movements).
maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial B. There is evidence from the history,
caricature of normal actions). physical examination, or laboratory findings
8. Stereotypy (i.e., repetitive, abnormally that the disturbance is the direct
frequent, non-goal-directed movements). pathophysiological consequence of another
9. Agitation, not influenced by external medical condition.
stimuli.
C. The disturbance is not better explained occupational, or other important areas of
by another mental disorder (e.g., a manic functioning predominate but do not meet the
episode). full criteria for any of the disorders in the
schizophrenia spectrum and other psychotic
D. The disturbance does not occur disorders diagnostic class. The other
exclusively during the course of a delirium. specified schizophrenia spectrum and other
psychotic disorder category is used in
E. The disturbance causes clinically situations in which the clinician chooses to
significant distress or impairment in social, communicate the specific reason that the
occupational, or other important areas of presentation does not meet the criteria for
functioning. any specific schizophrenia spectrum and
other psychotic disorder. This is done by
Unspecified Catatonia recording “other specified schizophrenia
spectrum and other psychotic disorder”
Diagnostic Criteria followed by the specific reason (e.g.,
“persistent auditory hallucinations”).
This category applies to presentations in
which symptoms characteristic of catatonia Examples of presentations that can be
cause clinically significant distress or specified using the “other specified”
impairment in social, occupational, or other designation include the following:
important areas of functioning but either the
nature of the underlying mental disorder or 1. Persistent auditory hallucinations
other medical condition is unclear, full occurring in the absence of any other
criteria for catatonia are not met, or there is features.
insufficient information to make a more 2. Delusions with significant overlapping
specific diagnosis (e.g., in emergency room mood episodes: This includes persistent
settings). delusions with periods of overlapping mood
episodes that are present for a substantial
Coding note: Code first R29.818 other portion of the delusional disturbance (such
symptoms involving nervous and that the criterion stipulating only brief mood
musculoskeletal systems, followed by F06.1 disturbance in delusional disorder is not
unspecified catatonia. met).
3. Attenuated psychosis syndrome: This
Other Specified Schizophrenia syndrome is characterized by
Spectrum and Other Psychotic psychotic-like symptoms that are below a
threshold for full psychosis (e.g., the
Disorder
symptoms are less severe and more
transient, and insight is relatively
Diagnostic Criteria
maintained).
4. Delusional symptoms in the context of
This category applies to presentations in
relationship with an individual with
which symptoms characteristic of a
prominent delusions: In the context of a
schizophrenia spectrum and other psychotic
relationship, the delusional material from the
disorders that cause clinically significant
individual with a psychotic disorder provides
distress or impairment in social,
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

Diagnostic Criteria

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 areas 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. The unspecified
schizophrenia spectrum and other psychotic
disorder category is used in situations in
which the clinician chooses not to specify
the reason that the criteria are not met for a
specific schizophrenia spectrum and other
psychotic disorder and includes
presentations in which there is insufficient
information to make a more specific
diagnosis (e.g., in emergency room
settings).