Overview

The Schizophrenia Spectrum and Other Psychotic Disorders encompass conditions defined by significant disruptions in thinking, perception, behavior, and emotional responsiveness. This category includes schizophrenia, other psychotic disorders, and schizotypal (personality) disorder. These disorders are characterized by abnormalities in one or more of the following five key domains:

• Delusions
  Fixed, false beliefs resistant to contrary evidence. Common types include:
  • Persecutory delusions: Belief of being harmed or harassed.
  • Grandiose delusions: Belief in exceptional abilities, wealth, or fame.
  • Erotomanic delusions: Belief someone is in love with the individual.
  • Referential delusions: Belief that environmental cues or gestures are directed at oneself. Delusions are considered bizarre if they are implausible and culturally incongruent (e.g., believing one’s thoughts are controlled by an external force).
• Hallucinations: Sensory experiences without external stimuli. Auditory hallucinations (e.g., hearing voices) are the most common in schizophrenia. These experiences must occur in a clear mental state to be considered pathological.
• Disorganized Thinking (Speech): Reflected in speech patterns such as loose associations, tangentiality, or incoherence (“word salad”). The symptom must be severe enough to impair communication and should be differentiated from culturally or linguistically specific practices (e.g., speaking in tongues).
• Grossly Disorganized or Abnormal Motor Behavior (Including Catatonia): Behavior can range from unpredictable agitation to marked unresponsiveness. Catatonia includes rigid postures, mutism, excessive motor activity, or repetitive movements.
• Negative Symptoms: These involve diminished emotional expression and reduced motivation (avolition). Other symptoms include:
  • Alogia: Limited speech output.
  • Anhedonia: Reduced ability to experience pleasure.
  • Asociality: Lack of interest in social interactions.

While schizophrenia is the most well-known disorder in this spectrum, other psychotic disorders share overlapping features but differ in duration, severity, or associated conditions.

Diagnoses in this section of the DSM:

• Schizotypal (Personality) Disorder (detailed in the Personality Disorders section in the DSM)
• Delusional Disorder
• Brief Psychotic Disorder
• Schizophreniform Disorder
• Schizophrenia
• Schizoaffective Disorder
• Substance/Medication Induced Psychotic Disorder
• Catatonia
• Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
• Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Delusional disorder

Delusional disorder is a condition where one or more delusions persist for at least one month or longer, without schizophrenia criteria being met.

Key Diagnostic Criteria:

• Delusions: Fixed false beliefs, such as persecutory, grandiose, erotomanic, jealous, somatic, or mixed themes.
• Functioning: Relatively intact apart from the delusions; behavior is neither bizarre nor obviously odd.
• Hallucinations: If present, are minor and tied to the delusional theme.
• Mood Episodes: If manic or depressive episodes occur, they are brief relative to the delusional periods.
• Exclusion: Not caused by substances, medical conditions, or better explained by another mental disorder.

Specify Subtypes of Delusional Disorder:

1. Erotomanic: Belief that someone is in love with the individual.
2. Grandiose: Belief in possessing exceptional talent, insight, or accomplishments.
3. Jealous: Belief that a partner is unfaithful.
4. Persecutory: Belief of being conspired against, spied on, or harassed.
5. Somatic: Belief centered on bodily sensations or health concerns.
6. Mixed: No single delusional theme predominates.
7. Unspecified: Delusional theme cannot be clearly determined.

Also, specify is with bizarre content (e.g., delusions that are ‘clearly implausible’).

Additional specifiers:

• First episode (acute, partial, or full remission).
• Multiple episodes (acute, partial, or full remission).
• Continuous or unspecified

brief psychotic disorder

Brief psychotic disorder involves a sudden onset of psychotic symptoms that last at least one day but less than one month, followed by a full return to the individual’s previous level of functioning before the onset of symptoms.

At least one of the following key symptoms:

• Delusions
• Hallucinations
• Disorganized speech (e.g., incoherence or derailment).
• Grossly disorganized or catatonic behavior.
• Symptoms cannot be attributed to cultural practices, another mental disorder, substance use, or a medical condition.

Duration:

• Duration: Symptoms persist for 1 day to less than 1 month (Criterion B).

Exclusions:

• The condition is not better explained by another psychotic disorder, mood disorder with psychotic features, substance use, or a medical condition (Criterion C).

Schizophreniform disorder

Schizophreniform disorder shares the same core symptoms as schizophrenia but differs in its duration and functional criteria. The disorder lasts at least one month but less than six months, with a possibility of full recovery within that period. This diagnosis represents a potentially transitional or time-limited condition within the schizophrenia spectrum, highlighting the importance of duration and functional impact in diagnosis.

Diagnostic Criteria:

A. Diagnosis requires two or more of the following symptoms, present for a significant portion of a 1-month period (or less if successfully treated). At least one must be (1), (2), or (3):

1. 1. Delusions
   2. Hallucinations
   3. Disorganized speech
   4. Grossly disorganized or catatonic behavior
   5. Negative symptoms (e.g., diminished emotional expression or avolition).

Additional criteria include:

• Duration: Symptoms last one to six months (Criterion B). If the duration is unclear, the diagnosis is noted as “provisional.”
• Exclusions: The disorder is not explained by another psychotic, mood, or medical condition (Criterion C, D).

Specifiers:

• With good prognostic features: Requires at least two of the following:
  • Rapid onset of symptoms (within 4 weeks of noticeable behavioral changes).
  • Confusion or perplexity.
  • Good premorbid functioning.
  • Absence of flat or blunted affect.
• Without good prognostic features: Fewer than two of the above features are present.
• With catatonia: Presence of catatonic symptoms (coded separately as F06.1).
• Severity: Symptoms can be rated on a 5-point scale for delusions, hallucinations, disorganized speech, motor behavior, and negative symptoms.

Distinguishing Features:

• The duration of illness is intermediate: longer than brief psychotic disorder (>1 day, <1 month) but shorter than schizophrenia (≥6 months).
• Social or occupational impairment is not required for diagnosis, unlike schizophrenia.

Note:

• If symptoms persist beyond six months, the diagnosis transitions to schizophrenia.

Schizophrenia

Schizophrenia is a chronic and severe mental disorder characterized by disruptions in thinking, perception, emotions, and behavior, leading to significant impairment in functioning. Symptoms must persist for at least six months, including one month of active-phase symptoms. Functional impairment is a required criterion, unlike in schizophreniform disorder.

A diagnosis requires two or more of the following symptoms, present for a significant portion of a one month period. At least one must be (1), (2), or (3):

1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., incoherence, derailment)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (e.g., diminished emotional expression or avolition)

Additional criteria include:

• Functional impairment: Marked decline in work, relationships, or self-care (Criterion B).
• Duration: Symptoms persist for at least six months, including prodromal, active, and residual phases (Criterion C).
• Exclusions: The condition is not better explained by schizoaffective disorder, mood disorders, substance use, or medical conditions (Criterion D, E).
• Autism considerations: If autism spectrum disorder or a childhood communication disorder is present, schizophrenia is diagnosed only if prominent delusions or hallucinations last at least one month.

Specifiers:

•  Used after one year of symptoms:
  • First episode (acute, partial, or full remission)
  • Multiple episodes (acute, partial, or full remission)
  • Continuous symptoms
  • Unspecified
• With Catatonia: Presence of catatonic features (coded separately as F06.1).
• Severity: Primary symptoms (e.g., delusions, hallucinations) rated on a 5-point scale based on the last seven days.

schizoaffective disorder

Schizoaffective disorder is characterized by an uninterrupted period of illness where psychotic symptoms (meeting Criterion A for schizophrenia) co-occur with a major mood episode (depressive or manic). Psychotic symptoms must also be present for at least two weeks in the absence of a major mood episode at some point during the illness.

Diagnostic Criteria:

• A: Concurrent symptoms of schizophrenia (Criterion A) and a major mood episode (depressive or manic). A depressive episode must include depressed mood (not just loss of interest or pleasure).
• B: Delusions or hallucinations for two+ weeks without a mood episode during the illness.
• C: Symptoms of the major mood episode are present for the majority of the illness’s active and residual phases.
• D: Symptoms are not caused by a substance or another medical condition.

Specifiers

• Type:
  • Bipolar type: Manic episodes (with or without depressive episodes).
  • Depressive type: Only depressive episodes.
• With Catatonia: Indicates the presence of catatonic symptoms (coded separately).
• Course Specifiers (used after one year):
  • First episode (acute, partial, or full remission).
  • Multiple episodes (acute, partial, or full remission).
  • Continuous symptoms.
  • Unspecified.
• Severity: Symptoms are rated on a 5-point scale (0 = not present, 4 = severe) for delusions, hallucinations, disorganized speech, motor behavior, and negative symptoms.

Distinguishing Features:

• Schizophrenia: If mood symptoms are only brief, schizophrenia is diagnosed instead.
• Mood Disorders with Psychosis: If psychotic symptoms only occur during mood episodes, a mood disorder with psychotic features is diagnosed instead.

substance/medication-induced psychotic disorder

Substance/medication-induced psychotic disorder involves the presence of delusions or hallucinations caused by substance use, intoxication, withdrawal, or exposure to a medication. Symptoms must be severe enough to require clinical attention and cause significant distress or impairment. This disorder highlights the importance of evaluating the timing and context of symptoms in relation to substance use or medication exposure.

Key Features

• Psychotic symptoms (delusions/hallucinations) are temporally linked to substance use or medication changes.
• Symptoms resolve after the substance/medication clears the system unless there is evidence of a preexisting psychotic disorder.
• This diagnosis emphasizes the role of substances/medications rather than intrinsic psychotic disorders.

Diagnostic Criteria:

• A. One or both of the following symptoms:

1. 1. Delusions
   2. Hallucinations

• B. Evidence from history, examination, or lab findings that:

1. 1. Symptoms developed during or shortly after substance use, intoxication, withdrawal, or medication exposure.
   2. The substance or medication is known to cause such symptoms.

• C. Symptoms are not better explained by an independent psychotic disorder. Indicators of an independent psychotic disorder include:
  • Symptoms preceding substance/medication use.
  • Symptoms persisting for an extended period (e.g., one month) after withdrawal or intoxication.
  • A history of non-substance-related psychotic episodes.
• D. The disturbance does not occur exclusively during delirium.
• E. Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.

Specifiers:

• With onset during intoxication: Symptoms arise while intoxicated.
• With onset during withdrawal: Symptoms occur during or shortly after withdrawal.
• With onset after medication use: Symptoms develop when starting, changing, or withdrawing from a medication.

Severity:

• Symptoms are rated on a 5-point scale for psychotic features (0 = not present, 4 = severe) based on the last 7 days.
• Severity assessment is optional for diagnosis.

psychotic disorder due to another medical condition

This disorder involves prominent hallucinations or delusions directly caused by the physiological effects of a medical condition. Symptoms must cause significant distress or functional impairment and cannot be better explained by another mental disorder or substance use.

Diagnostic Criteria:

• A. Presence of hallucinations or delusions.
• B. Evidence from history, exam, or labs that the symptoms are a direct result of a medical condition.
• C. Symptoms are not better explained by another mental disorder.
• D. Symptoms do not occur exclusively during delirium.
• E. The symptoms cause significant distress or impairment in functioning.

Specifiers:

• With delusions (F06.2): Delusions are the primary symptom.
• With hallucinations (F06.0): Hallucinations are the primary symptom.
• Severity: Symptoms are rated on a 5-point scale for psychotic features (0 = not present, 4 = severe).

Diagnostic Features:

• Hallucinations: May involve any sensory modality (e.g., visual, olfactory, auditory) and often reflect the underlying medical condition.
  • Example: Olfactory hallucinations may indicate temporal lobe epilepsy.
• Delusions: Themes may include somatic, persecutory, grandiose, or religious ideas.
• Symptoms are often atypical for primary psychotic disorders, such as:
  • Atypical age of onset.
  • Specific sensory hallucinations (e.g., visual or olfactory).
• Reality testing is often intact, with patients recognizing the symptoms as related to their medical condition.

Key Diagnostic Considerations:

1. Biological Plausibility: The medical condition has a known mechanism capable of causing psychotic symptoms (e.g., temporal lobe epilepsy, lupus).
2. Temporality: Psychotic symptoms are temporally associated with the onset, worsening, or resolution of the medical condition.
3. Typicality: Symptoms are atypical for an independent psychotic disorder (e.g., hallucination type or age at onset).
4. Exclusions: Rule out substance-induced psychotic disorder or psychosis due to treatments (e.g., steroids).

catatonia

Catatonia is a psychomotor disturbance involving abnormalities in movement, speech, or responsiveness. It can occur alongside various condiCatatonia ranges from immobility and unresponsiveness (e.g., stupor, mutism) to excessive motor activity (e.g., agitation, stereotypy). Symptoms can fluctuate, with some individuals alternating between extremes.tions, including psychotic, bipolar, depressive, neurodevelopmental disorders, or medical conditions (e.g., cerebral folate deficiency, autoimmune disorders).

Catatonia is not a standalone diagnosis but classified as:

• Catatonia associated with another mental disorder.
• Catatonic disorder due to another medical condition.
• Unspecified catatonia.

Severe catatonia can lead to complications such as:

• Malnutrition.
• Pressure ulcers.
• Muscle contractions.
• Exhaustion.
• Hyperpyrexia (extreme fever).
• Thromboembolism.
• Self-injury or harm to others.

Catatonia Associated with Another Medical Disorder

Catatonia can occur during the course of various mental disorders, including psychotic, bipolar, depressive, or neurodevelopmental disorders. It involves marked psychomotor disturbances and requires at least 3 of 12 specified symptoms for diagnosis.

Associated Mental Disorders

• Catatonia can occur in the context of schizophrenia (up to 35% of cases), as well as bipolar, depressive, or neurodevelopmental disorders.
• A majority of cases involve individuals with depressive or bipolar disorders.

Key Considerations:

1. Rule Out Medical Conditions: Other causes, such as neurological, infectious, or metabolic disorders, must be excluded before diagnosis.
2. Medication Side Effects: Catatonia may result from medications, such as neuroleptic malignant syndrome.
3. Setting: Diagnosis typically occurs in inpatient settings.

Catatonic Disorder Due to Another Medical Condition

Catatonic disorder due to another medical condition is characterized by catatonia caused by the physiological effects of a medical condition. Diagnosis requires at least 3 of 12 specific catatonic symptoms and evidence linking the symptoms to an underlying medical condition.

Catatonia can result from various neurological or metabolic conditions, such as:

• Neurological: Brain tumors, head trauma, cerebrovascular disease, encephalitis.
• Metabolic: Hypercalcemia, hepatic encephalopathy, diabetic ketoacidosis, homocystinuria.

other specified schizophrenia spectrum and other psychotic disorder

This diagnosis applies when a person exhibits symptoms of schizophrenia spectrum and other psychotic disorders that cause significant distress or impairment but do not fully meet the criteria for any specific psychotic disorder.

• The specific reason why full criteria are not met is documented (e.g., “persistent auditory hallucinations”).
• Examples of presentations:
  1. Persistent auditory hallucinations without other psychotic features.
  2. Delusions with significant mood episodes, where mood symptoms are too prominent to meet delusional disorder criteria.
  3. Attenuated psychosis syndrome, involving mild, transient psychotic-like symptoms with maintained insight.
  4. Shared delusional symptoms, where delusional content is influenced by a relationship with someone who has a psychotic disorder.

unspecified schizophrenia spectrum and other psychotic disorder

This diagnosis is used when a person presents with symptoms of schizophrenia spectrum and other psychotic disorders that cause distress or impairment, but the clinician:

• Does not specify the reason full criteria are unmet.
• Lacks sufficient information to make a more specific diagnosis (e.g., in emergency settings).

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