DSM-5 Choosing Diagnosis
Phase 1 (prodromal), when they start to show up
Phase 2 (the active stage), your symptoms are most noticeable.
Phase 3 (residual phase) starting to recover, but still have some symptoms.
PDF 1 Schizophrenia Spectrum and Other Psychotic Disorders
1. Schizophrenia Spectrum - Split from Reality (Delusions / Hallucinations (false
perceptions)/ Disorganized thought & speech (incoherent/word salad)/Grossly Disorganized
or Abnormal Motor Behaviour (Includes catatonia) / Negative Symptoms(normative
behaviours are missing (laugh at non-humorous / no longer finding joy/ reduced sense of
will/ decrease in social activities))
1.
2.
3.
4.
5.
6.
Schizotypal (Personality) Disorder 310.22 (F21) PDF 13: page 11
Delusional Disorder (F22) page 4
Brief Psychotic Disorder 298.8 (F23) page 8
Schizophreniform Disorder 295.40 (F20.81) page 10
Schizophrenia 295.90 (F20.9) page 13
Schizoaffective Disorder page 19
Specify whether:
+ Bipolar type (F25.0): if a manic episode is part of the presentation. Major
depressive episodes may also occur.
+ Depressive type: (F25.1) if only major depressive present.
Specify if:
+ With catatonia (F06.1)
Catatonia is a marked psychomotor disturbance that may involve decreased motor activity,
decreased engagement during interview or physical examination, or excessive and peculiar
motor activity. The clinical presentation of catatonia can be puzzling, as the psychomotor
disturbance may range from marked unresponsiveness to marked agitation. Motoric
immobility may be severe (stupor) or moderate (catalepsy and waxy flexibility). Similarly,
decreased engagement may be severe (mutism) or moderate (negativism). Excessive and
peculiar motor behaviours can be complex (e.g., stereotypy) or simple (agitation) and may
include echolalia and echopraxia. In extreme cases, the same individual may wax and wane
between decreased and excessive motor activity. During severe stages of catatonia, the
individual may need careful supervision to avoid self-harm or harming others. There are
potential risks from malnutrition, exhaustion, hyperpyrexia and self-inflicted injury.
Delusions: fixed beliefs that are not amenable to change with conflicting evidence
- bizarre / non-bizarre – thought withdrawal/ thought insertion / delusions of control
Persecutory delusions (i.e., belief that one is going to be harmed, harassed, and so forth by
an individual, organization, or other group) are most common.
Referential delusions (i.e., belief that certain gestures, comments, environmental cues, and
so forth are directed at oneself) are also common.
Grandiose delusions (i.e., when an individual believes that he or she has exceptional
abilities, wealth, or fame)
Erotomanic delusions (i.e., when an individual believes falsely that another person is in love
with him or her) are also seen.
Nihilistic delusions involve the conviction that a major catastrophe will occur, and somatic
delusions focus on preoccupations regarding health and organ function.
Hallucinations: perception-like experiences
- No external stimulus
- Vivd + clear
- Appear completely real to patient (full force of normal perceptions)
- Involuntary
- Any sensory modality (schizophrenia related disorders – mostly auditory)
- Distinct from own thoughts
- Must occur in clear sensorium context, not when waking up (hypnopompic) or falling
asleep (hypnagogic).
Disorganized Thought / speech
Disorganized thinking (formal thought disorder)
- (derailment or loose associations)
- Tangentially – answers to questions not really relatable
- Incoherence / world salad (very severe) resembling receptive aphasia
- Symptoms must be severe enough to effect function
Grossly Disorganized or Abnormal Motor Behaviour
- Childlike silliness – unpredictable agitation ( symptoms lead to function difficulty)
- Catatonia (marked decrease in reactivity to environment)
o ranges from resistance to instructions to maintaining bizarre posture, to lack
of motor (stupor) or verbal responses (mutism)
o nonspecific to schizophrenia
Negative Symptoms
- morbidity (mostly schizophrenia disorder)
- Avolition – decrease in motivated self-initiated purposeful activities (sit for long
periods / little interest in activities / social events)
- Diminished emotional expression – reduction in expression of emotions in the face /
eye contact / intonation of speech (prosody) / hand/head/face movements that
show emotion.
- Alogia – diminished speech output
- Anhedonia - decreased ability to experience pleasure from positive stimuli or a
degradation in the recollection of pleasure previously experienced.
- Asociality - refers to the apparent lack of interest in social interactions and may be
associated with avolition, but it can also be a manifestation of limited opportunities
for social interaction.
1. Schizotypal (Personality) Disorder 310.22 (F21) PDF 13: page 11
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Pervasive pattern of social/interpersonal deficits marked by acute discomfort and
reduced capacity for close relationships + cognitive / perceptual distortions and
eccentricities of behaviour – start early adulthood – indicated by 5 or more
factors…
Differential Diagnosis:
- Paranoid / Schizoid personality disorder: (also show detachment and restricted
affect, but Schizotypal P shows presence of cognitive/perceptual distortions and
marked eccentricity or oddness.
- Avoidant personality disorder: Limited close-relationships - Schizotypal - lack of
desire in creating relationships / avoidant personality disorder has active desire to
form relationships but fear of rejection gets in the way.
- Borderline personality disorder:
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Transient, psychotic-like symptoms (related to affective shifts in response to stress, anxiety /
more dissociative – derealisation / depersonalization) / SchizoPD- enduring psychotic
symptoms that worsen under stress.
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social isolation (secondary due to angry outburst – there is desire to connect)
Impulsive and manipulative / schizotypal not.
Narcissistic PD: suspiciousness, social withdrawal, or alienation – Narcissistic PD – fear of
having imperfections revealed
Example:
F21 Schizotypal personality disorder (premorbid);
F20.9 Schizophrenia (primary);
2. Delusional Disorder (F22) page 4
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Presence of one or more delusions for a month or longer in a person who,
except for the delusions and their behavioural ramifications, does not appear
odd and is not functionally impaired. Prominent hallucinations and other
psychotic or marked mood symptoms are absent. Non-prominent
hallucinations and odd behaviours related to the delusional theme may be
present.
Look at types / specifiers / severity
3. Brief Psychotic Disorder 298.8 (F23) page 8
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Presence of 1 or more of following, at least 1 must be in top 3.
1. Delusions, 2. Hallucinations, 3. Disorganized Speech, 4. Grossly disorganized /
catatonic behaviour
At least 1 day – less than 1 month – full return to premorbid functioning
Not better explained by Major Depressive Disorder / bipolar with psychotic features
/ schizophrenia / catatonia.
Look at specifiers / severity
4. Schizophreniform Disorder 295.40 (F20.81) page 10
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Two (or more) of the following, each present for a significant portion of time during a 1month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1.
Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or
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incoherence). 4. Grossly disorganized or catatonic behaviour. 5. Negative symptoms (i.e.,
diminished emotional expression or avolition).
lasts at least 1 month but less than 6 months
Schizoaffective disorder and depressive or bipolar disorder with psychotic features have
been ruled out 1) no major depressive or manic episodes occurred + if they have occurred
(minor)
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Specifiers
5. Schizophrenia 295.90 (F20.9) page 13
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2 positive symptoms – at least one symptom must be from 1, 2 or 3 (1. Delusions. 2.
Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly
disorganized or catatonic behaviour. 5. Negative symptoms (i.e., diminished emotional
expression or avolition)
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Persist for at least 6 months (1 month within these 6 month worth of symptoms)
Schizoaffective disorder and depressive or bipolar disorder with psychotic features have
been ruled out 1) no major depressive or manic episodes occurred + if they have occurred
(minor)
If there is a history of autism spectrum disorder or a communication disorder of childhood
onset, the additional diagnosis of schizophrenia is made only if prominent delusions or
hallucinations, in addition to the other required symptoms of schizophrenia, are also present
for at least 1 month
Specifiers
Patients lack awareness of their symptoms
Deficit in executive functioning/ memory/attention
Psychosis – losing contact with reality
Rarely violent or aggressive – more likely to inflict harm on self or be victim of
violence
6. Schizoaffective Disorder page 19
Specify whether:
+ Bipolar type (F25.0): if a manic episode is part of the presentation. Major
depressive episodes may also occur.
+ Depressive type: (F25.1) if only major depressive present.
Specify if:
+ With catatonia (F06.1)
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An uninterrupted period of illness during which there is a major mood episode
(major depressive or manic)
AT some time during this period – schizophrenia criterion A must be met.
No social dysfunction
No exclusion of Autism or Communication D of childhood onset
The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood
episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority
of the total duration of the active and residual portions of the illness.
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If the mood symptoms are present for only a relatively brief period, the diagnosis is
schizophrenia, not schizoaffective disorder.
In bipolar disorder, you have mood swings that include depression and mania. If you have
schizoaffective disorder, you can have these bipolar symptoms. But separate from those,
you also get psychotic symptoms similar to schizophrenia for at least 2 weeks at a time.