SCHIZOPHRENIA SPECTRUM and OTHER PSYCHOTIC DISORDERS
Dr. Hakan Atalay
Yeditepe Üniversitesi Tip Fakültesi
Psikiyatri AD
Reference:


DSM-V. APA, 2013
Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Editors: Sadock,
Benjamin J.; Sadock, Virginia A. 8th Edition, Lippincott Williams & Wilkins,
2009
HISTORY
Written descriptions of symptoms commonly observed today in
patients with schizophrenia are found throughout recorded
history.
Early Greek physicians described delusions of grandeur, paranoia,
and deterioration in cognitive functions and personality.
However, since these symptoms are not necessarily unique to
schizophrenia, one cannot be certain whether these behaviors
were actually associated with what today would be called
schizophrenia.
Indeed, several scholars have argued that schizophrenia is of
relatively recent origin.
A major impediment to distinguishing schizophrenia from
other forms of psychoses was the existence of another
common type of insanity, general paresis.
The symptom manifestations of general paresis were quite
diverse and overlapped extensively with those of
schizophrenia.
The cause of syphilitic insanity was subsequently traced to
a spirochetal infestation, and antibiotics were eventually
found to be effective in treatment and prevention.
The identification of syphilitic insanity enabled Emil Kraepelin to
delineate the two other major patterns of insanity:
• manic-depressive psychosis and
• dementia praecox (or dementia of the young),
• and to group together under the diagnostic category of dementia
precox the previously disparate categories of insanity, such as
hebephrenia, paranoia, and catatonia.
In differentiating dementia precox from manic-depressive disorder,
Kraepelin emphasized what he believed to be the characteristic
poor long-term prognosis of dementia precox, as compared to the
relatively nondeteriorating course of manic-depressive illness.
In 1911 Eugen Bleuler, recognizing that dementia
was not a usual characteristic of dementia precox,
suggested the term schizophrenia (splitting of the
mind) for the disorder.
Bleuler introduced the concept of primary and
secondary schizophrenic symptoms; his four
primary symptoms (the four As) were abnormal
Associations, Autistic behavior and thinking,
Abnormal affect, and Ambivalence.
T
The major alternative etiopathophysiological model
conceptualizes schizophrenia as a clinical syndrome
rather than a single disease entity.
T
This view holds that although patients with
schizophrenia share a sufficient commonality of signs
and symptoms to validly differentiate them from
patients with other forms of psychosis (e.g., mood
disorder with psychotic features, substance-induced
psychotic disorder), more than one disease entity will
eventually be found within this syndrome.
EPIDEMIOLOGY
Schizophrenia affects just under 1 percent of the
world's population (approximately 0.85 percent).
The number of affected individuals increases if
schizophrenia spectrum disorders are included in
prevalence estimates.
The concept of schizophrenia spectrum disorders is
derived from observations of psychopathological
manifestations in the biological relatives of patients
with schizophrenia.
Diagnoses and approximate lifetime prevalence rates
(percentage of population) for spectrum disorders are:
• * schizoid personality disorder (fractional),
• * schizotypal personality disorder (1 to 4 percent),
• * schizoaffective psychosis (0.7 percent), and
• * atypical psychoses and delusional disorder (0.7 percent).
The relation of these disorders to schizophrenia in the general
population is unclear, but in family pedigree studies the
presence of a proband with schizophrenia significantly
increases the prevalence of these disorders among biological
relatives.
Schizophrenia is found in all societies and geographical areas.
Although comparable data are difficult to obtain, incidence and
lifetime prevalence rates are roughly equal worldwide.
The positive symptom component of the disorder usually
becomes manifest during late adolescence and early
adulthood, although there is a difference in onset associated
with gender.
In males, the incidence of the onset of positive symptoms peaks
during years 17 to 27, whereas in females the peak incidence
is a lengthy plateau between the years 17 to 37.
Rural and urban incidence figures are probably similar, but there
is a greater prevalence of schizophrenia among urban and
lower socioeconomic populations.
Deinstitutionalization has dramatically reduced the
number of beds in custodial facilities, but an overall
evaluation of the consequences of deinstitutionalization
is disheartening.
Many patients have simply been transferred to
alternative forms of custodial care (instead of to
treatment or rehabilitative services), including nursing
home care and poorly supervised shelter arrangements.
Others have been released to communities often unable
or unwilling to provide the minimal requirements for
clinical care or humane support.
For the more fortunate patients the burden of care has
shifted to the family, creating an extreme hardship for
large numbers of families in this country.
The less fortunate patient may either have no place to
live, be forced to live in circumstances of isolation
and hopelessness, or end up in jail.
Patients with a diagnosis of schizophrenia are reported
to account for 33 to 50 percent of homeless
Americans.
ETIOLOGY
Neurobiological Model
Psychoanalytical Model
Stress-Diathesis
Family, twin, and adoptive studies have long since
documented a robust contribution of genetic factors
to the etiology of schizophrenia, with genetic factors
established as relevant to some, perhaps all, cases.
However, it is not yet known which genes are
involved or how the proteins they produce
contribute to the pathophysiology of schizophrenia.
Genetics
Risk for development of sch in one of the children;
•when a parent has sch: % 10-14
•when both of parents have sch: % 40-50
•when one of siblings has sch: % 10-14
•when both a sibling and a parent have sch: % 20
•Concordance for sch in monozygotic twins: % 40-50
•in dizygotic twins: % 10-14
Sch prevalence is the same in children with a biological mother
who is sch and are adopted by “heathy” families as those who are
raised by “insane” mother: % 10
The rate is %1 both in healthy mothers and general population.
A central conceptual issue in the investigation of the etiology of
schizophrenia is whether schizophrenia is a neurodevelopmental
or a neurodegenerative disorder.
Is the cause of schizophrenia to be found in the failure of the
normal development of the brain, or is it to be found in a
disease process that alters a normally developed brain?
Both these options, or a combination of these options, may be true
because the schizophrenia syndrome probably represents more
than one disease process, or a developmental abnormality may
increase the risk for the subsequent occurrence of the disorder.
The explosion of information on the neurobiology of brain
development has led to considerable new knowledge on the
potential mechanisms of pathogenic influences. It is now
clear that subtle deviations in the development of the
brain could create dysfunctions associated with specific
behaviors.
Postmortem findings of abnormalities in neural plate
formation, which suggest a deviation in programmed cell
migration or reduced cell density, provide intriguing
support for the proposition that the developmental process
that establishes normal brain cytoarchitecture may have
gone awry in schizophrenia.
A
Another view is that the brain has established
extensive redundancy during the developing years,
and that the fine-tuning necessary for efficient
functioning involves eliminating certain nerve cells
and many of the synapses connecting cells.
A
A failure to adequately prune nerve cells and
synapses, or to err in selection for pruning could, in
theory, underlie dysfunctions that later lead to
schizophrenia symptoms.
T
The natural evolution of pathophysiological hypotheses of
schizophrenia is the development of comprehensive models that
integrate both neuroanatomical and biochemical hypotheses.
T
The superimposition of the neurotransmitters involved in the
connections among cortical, basal ganglia, and thalamic structures
that comprise the basal ganglia-thalamocortical neural circuits is a
prime example of this approach.
T
Through glutamate projections from the cortex to the basal
ganglia, the cerebral cortex facilitates the performance of selected
behaviors while inhibiting others.
The excitatory glutamatergic neurons terminate on GABAergic
and cholinergic neurons, which in turn suppress or excite
dopaminergic and other neurons. This regulatory activity can
enable the cortex to protect itself from overstimulation from
thalamocortical neurons.
The integrative models provide a framework for identifying
potential neurotransmitter targets for drug development, as
well as providing explanatory models for the observed effects
of pharmacological agents in patients with schizophrenia
(e.g., PCP-induced psychotic symptoms mediated through the
interactions of glutamate and other neurotransmitter systems
in the neocortex, basal ganglia, or limbic system structures).
DIAGNOSIS and CLASSIFICATION
Classification Systems
Post-Warld War II
* use of common language
* preventing chaos in decisions of disability
Veterans Administration Manual (1952)
DSM-II (1968)
DSM-III (1980) Development of diagnostic criteria
DSM-IV (2000) Simplification of criteria
* Agreement between clinicians
* Increase in reliability
* Progress in research
•Making easy for patients to obtain information
DSM-V (2013)
B. For a significant portion of the time since the onset of the disturbance,
level of functioning in one or more major areas, such as work, interpersonal
relations, or self-care, is markedly below the level achieved prior to the
onset (or when the onset is in childhood or adolescence, there is failure to
achieve expected level of interpersonal, academic, or occupational
functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6month period must include at least 1 month of symptoms (or less if
successfully treated) that meet criterion A (ie, active-phase symptoms) and
may include periods of prodromal or residual symptoms. During these
prodromal or residual periods, the signs of the disturbance may be
manifested by only negative symptoms or two or more symptoms listed in
criterion A present in an attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
• D. Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either: (1) no major
depressive or manic episodes have occurred concurrently with the
active-phase symptoms; or (2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.
• E. The disturbance is not due to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition.
• F. 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 a
month (or less if successfully treated).
Specify if:
•The following course specifiers are only to be used after a 1-year duration of the disorder and if
they are not in contradiction to the diagnostic course criteria.
•First episode, currently in acute episode: First manifestation of the disorder meeting the
defining diagnostic symptom and time criteria. An acute episode is a time period in which the
symptom criteria are fulfilled.
•First episode, currently in partial remission: Partial remission is a period of time during which
an improvement after a previous episode are only partially fulfilled.
•First episode, currently in full remission: Full remission is a period of time after a previous
episode during which no disorder-specific symptoms are present.
•Multiple episodes, currently acute episode: Multiple episodes may be determined after a
minimum of two episodes (i.e., after first episode, a remission and a minimum of one relapse).
•Multiple episodes, currently in partial remission
•Multiple episodes, currently in full remission
•Continous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining
fort he majority of the illness course, with subtreshold symptom periods being very brief relative to
the overall course.
•Unspecified
Specify if:
•With catatonia (refer to the catatonia associated with another mental
disorder).
Specify current severity:
•Severity is rated by a quantitative assessment of the primary symptoms
of psychosis, including delusions, hallucinations, disorganized speech,
abnormal psychomotor behavior, and negative symptoms. Each of these
symptoms may be rated for its current severity (most severe in the last 7
days) on a 5-point scale ranging from 0 (not present) to 4 (present and
severe).
Note: Diagnosis of schizophrenia can be made without using this
severity specifier.
TREATMENT
Treatment of Schizophrenia
The somatic treatment of schizophrenia has changed substantially
during the 1990s.
Until 1990 when clozapine (Clozaril) was introduced in the United
States, all available antipsychotic drugs had a similar range of
efficacy and were associated with neurological side effects that
seriously interfered with their effectiveness.
Clozapine was the first of a new generation of antipsychotics that are
associated with far fewer extrapyramidal side effects than older drugs
and perhaps have better efficacy.
Although clozapine's association with agranulocytosis has limited the
number of patients who receive it, this agent plays an important role
in the treatment of severe psychosis.
The introduction of risperidone (Risperdal) in 1994, olanzapine
(Zyprexa) in 1996, quetiapine (Seroquel) in 1997, and
ziprasidone (Zeldex) in 1998 have given clinicians new
alternatives for treating a large number of patients with
schizophrenia.
(The overall impact of these changes on the course of
schizophrenia remains to be seen.)
The Drug-Induced Extrapyramidal Syndromes (Acute)
Drug-induced parkinsonism
A generally mild parkinsonian syndrome that can recapitulate
virtually every aspect of the idiopathic form. The most common
manifestations are bradykinesia, an increase in muscular tone
(appendicular musculature affected more than axial), and a resting
tremor. Although the tremor is present less frequently than in the
idiopathic variety (about 10–25% of afflicted population), it is
indistinguishable from its idiopathic counterpart. It has a regular
frequency (3–6 cps), is usually suppressed during volitional action
of the involved body part, is exacerbated by stress and anxiety,
and classically involves alternating contractions of opposing
muscular groups (e.g., pronators and supinators of the forearm).
Sialorrhea, seborrhea, and altered righting reflexes also can be
present.
D
Dystonia
T
This is a sudden-onset, intense, sustained, and uncontrollable
muscular contraction.
T
The cephalic musculature is most often affected (jaw, tongue,
eyes, and neck) but other areas can be involved (upper
extremities and back).
I
It generally develops shortly after the initiation (or
reinitiation) of high-potency neuroleptics and occurs during
falling plasma neuroleptic levels (8–12 hours after oral
dosing).
A
Akathisia
T
This neuromotor syndrome consists of an unusual,
generally intense, and uniformly uncomfortable sense of
internal restlessness most commonly localized to the
lower half of the body coupled with pacing behaviors or
stereotyped restless movements. It is relieved somewhat
during ambulation and is made worse when the patient
lies down or is required to sit still. It can occur at any
time during neuroleptic treatment (minutes to years after
initiating treatment) and follows a waxing and waning
course.
L
Late (tardive)
T
Tardive dyskinesia
T
This is an irregular, choreiform movement disorder that can be
suppressed volitionally for variable periods by the patient, is
generally beyond their awareness, and is exacerbated during
distracting maneuvers (e.g., rapid alternating movements of the
upper extremities worsen the involuntary bucco-oral choreic
movements). Orobuccolingual structures and the distal upper
extremities are the most commonly affected, but virtually any
voluntary muscle group can be involved. Ninety-five percent of
subjects with some type of tardive syndrome will manifest a
choreic component.
T
Tardive dystonia
T
This is the second most common type of the tardive syndromes.
D
Dystonic movements are slow, variably sustained, and involuntary
and may affect the limbs, trunk, neck (e.g., torticollis, spasmodic
dysphonia) or face (e.g., Meige's syndrome).
U
Unlike the purely choreic form, tardive dystonia impairs function,
is less likely to remit even if the neuroleptics are discontinued
(90% still present several years after discontinuation), and can be
progressive.
Tardive akathisia
This tardive syndrome is objectively similar to the acute
form but exhibits a different treatment response profile
(e.g., may be made worse by anticholinergic agents) and is
less likely to be coupled with the intense internal sense of
restlessness.
Tardive tics
Multiple tic syndromes, ranging from simple invariant
motor tics to complex tics with involuntary
vocalizations (tardive Gilles de la Tourette's
syndrome), can develop after chronic neuroleptic
treatment.
Tardive myoclonus
These are brief, nonstereotyped, generally
asynchronous muscular jerks. This is the least
common of the tardive syndromes.
N
Neuroleptic malignant syndrome
T
This unusual but potentially fatal syndrome afflicts less than 1% of
subjects chronically treated with neuroleptics. Its protean features
are dense muscular rigidity (axial musculature affected more than
appendicular and not associated with a parkinsonian tremor), a
depressed sensorium, elevated temperature (sometimes to
malignant levels), elevated creatinine kinase, and myoglobinuria.
Early reports suggested that it had a mortality of 10% to 30%, but
with prompt neuroleptic withdrawal and proper supportive care
more than 95% now survive. Subsequent rechallenge with
neuroleptics is not contraindicated.
OTHER TYPES OF TREATMENT
PSYCHOSOCIAL TREATMENT
PSYCHOTHERAPIES:
INDIVIDUAL
- Supportive
- Dynamic
- Interpersonal
- CBT
FAMILY
GROUP
- Social skills training
REHABILITATION
ECT
OTHER PSYCHOSES
DSM-V DIAGNOSTIC CRITERIA FOR
SCHIZOAFFECTIVE DISORDER
A. An uninterrupted period of illness during which there is a major mood
episode (major depressive or manic) concurrent with Criterion A of
schizophrenia.
Note: The major depressive episode must include Criterion A: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major
mood episode (depressive or manic) during lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the
majority of the total duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of
abuse or a medication) or another medical condition.
Specify if:
•Bipolar subtype: This type applies if a manic episode is
a part of the presentation. Major depressive disorder may
also occur.
•Depressive subtype: This subtype applies if only major
depressive episodes are part of the presentation.
Specify if:
•With catatonia
Specify if:
•The following course specifiers are only to be used after a 1-year duration of the
disorder and if they are not in contradiction to the diagnostic course criteria.
•First episode, currently in acute episode: First manifestation of the disorder meeting
the defining diagnostic symptom and time criteria. An acute episode is a time period in
which the symptom criteria are fulfilled.
•First episode, currently in partial remission: Partial remission is a time period during
which an improvement after a previous episode is maintained and in which the defining
criteria of the disorder are only partially fulfilled.
•First episode, currently full remission: Full remission a period of time after a previous
episode during which no disorder-specific symptoms are present.
•Multiple episodes, currently in acute episode: Multiple episodes may be determined
after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of
one relapse).
•Multiple episodes, currently in partial remission
•Multiple episodes, currently in full remission
•Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subtreshold symptom periods being
very brief relative to the overall course.
•Unspecified
Specify current severity:
•Severity is rated by a quantitative assessment of the primary
symptoms of psychosis, including delusions, hallucinations,
disorganized speech, abnormal psychomotor behavior, and
negative symptoms. Each of these symptoms may be rated for
its current severity (most severe in 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe).
•Note: Diagnosis of schizoaffective disorder can be made
without using this severity specifier.
DSM-V DIAGNOSTIC CRITERIA FOR
SCHIZOPHRENIFORM DISORDER
A. Two (or more) of the following, each present for a significant portion of time
during a 1-month period (or less if successfully treated). At least one of these
must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. An episode of the disorder lasts at least 1 month but less
than 6 months. When the diagnosis must be made without
waiting for recovery, it should be qualified as "provisional".
C. Schizoaffective disorder and depressive or bipolar disorder
with psychotic features have been ruled out because either (1)
no major depressive or manic episode have occurred
concurrently with the active-phase symptoms, or (2) if mood
episodes have occurred during active-phase symptoms, they
have been present for a minority of the total duration of the
active and residual periods of the illness.
D. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, or a medication) or
another medical condition.
Specify if:
•With good prognostic features: This specifier requires the presence of at least
two of the following features: onset of prominent psychotic symptoms within 4
weeks of the first noticeable change in usual behavior or functioning; confusion
or perplexity; good premorbid social and occupational functioning; and absence
of blunted or flat affect
•Without good prognostic features: This specifier is applied if two or more of
the above features have not been present.
Specify if:
•With catatonia
Specify current severity:
Severity is rated by a quantitative assessment of the primary
symptoms of psychosis, including delusions, hallucinations,
disorganized speech, abnormal psychomotor behavior, and
negative symptoms. Each of these symptoms may be rated for
its current severity (most severe in 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe).
Note: Diagnosis of schizophreniform disorder can be made
without using this severity specifier.
DSM-V DIAGNOSTIC CRITERIA FOR
BRIEF PSYCHOTIC DISORDER
A. Presence of one (or more) of the following symptoms. At least one of these
symptoms must be (1), (2), or (3):
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
•Note: Do not include a symptom if it is a culturally sanctioned response.
• B. Duration of an episode of the disturbance is at
least 1 day but less than 1 month, with eventual full
return to premorbid level of functioning.
• C. The disturbance is not better explained for by
major depressive or bipolar disorder with psychotic
features or another psychotic disorder such as
schizophrenia or catatonia, and is not attributable to
the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical
condition.
Specify if:
•With marked stressor(s) (brief reactive psychosis): If symptoms occur in
response to events that, singly or together, would be markedly stressful to almost
anyone in similar circumstances in the individual’s culture.
•Without marked stressor(s): If symptoms do not occur in response to events
that, singly or together, would be markedly stressful to almost anyone in similar
circumstances in the individual’s culture
•With postpartum onset: If onset is during pregnancy or within 4 weeks
postpartum.
Specify if:
•With catatonia
Specify current severity:
•Severity is rated by a quantitative assessment of the
primary symptoms of psychosis, including delusions,
hallucinations, disorganized speech, abnormal psychomotor
behavior, and negative symptoms. Each of these symptoms
may be rated for its current severity (most severe in 7 days)
on a 5-point scale ranging from 0 (not present) to 4 (present
and severe).
Note: Diagnosis of brief psychotic disorder can be made
without using this severity specifier.
DSM-V DIAGNOSTIC CRITERIA FOR
DELUSIONAL DISORDER
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are related to the delusional
theme (e.g., the sensation of being infested with insects associated with delusions of
infestation).
C. Apart from the impact of the delusion(s), or its ramifications, functioning is not
markedly impaired and behavior is not obviously bizarre or odd.
D. If manic or depressive episodes have occurred, these have been brief relative to the
duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or a
another medical condition and is not better explained by another mental disorder, such as
body dysmorphic disorder or obsessive-compulsive disorder.
Specify whether:
Erotomanic type: This subtype applies when the central theme of delusion is that
another person is in love with the individual.
Grandiose type: This subtype applies when the central theme of delusion is the
conviction of having some great (but recognized) talent or insight or having made some
important discovery.
Jealous type: This subtype applies when the central theme of the individual’s delusion is
that his or her spouse or lover is unfaithful.
Persecutory type: This subtype applies when the central theme of the individual’s
delusion involves the individual’s belief that he or she is being conspired against, cheated,
spied on, followed, poisoned, or drugged, maliciously maligned, harassed, or obstructed
in the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme of the delusion involves
bodily functions and sensations.
Mixed type: This subtype applies when no one delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot be
clearly determined or is not described in the specific types (e.g., referential delusions
without a prominent persecutory or grandiose component.)
Specify if:
•With bizarre content: Delusions are deemed bizarre if
they are clearly implausible, not understandable, or are not
derived from ordinary life experiences (e.g., an individual’s
belief that a stranger has removed his or her internal
organs and replaced them with someone’s else’s organs
without any wounds or scars).
Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder.
•First episode, currently in acute episode: First manifestation of the disorder meeting
the defining diagnostic symptom and time criteria. An acute episode is a time period in
which the symptom criteria are fulfilled.
•First episode, currently in partial remission: Partial remission is a time period during
which an improvement after a previous episode is maintained and in which the defining
criteria of the disorder are only partially fulfilled.
•First episode, currently full remission: Full remission a period of time after a previous
episode during which no disorder-specific symptoms are present.
•Multiple episodes, currently in acute episode: Multiple episodes may be determined
after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of
one relapse).
•Multiple episodes, currently in partial remission
•Multiple episodes, currently in full remission
•Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subtreshold symptom periods being
very brief relative to the overall course.
•Unspecified
Specify current severity:
• Severity is rated by a quantitative assessment of the primary
symptoms of psychosis, including delusions, hallucinations,
disorganized speech, abnormal psychomotor behavior, and
negative symptoms. Each of these symptoms may be rated
for its current severity (most severe in 7 days) on a 5-point
scale ranging from 0 (not present) to 4 (present and severe).
Note: Diagnosis of delusional disorder can be made without
using this severity specifier.
DSM-V Diagnostic Criteria for Substance/Medication-Induced Psychotic
Disorder
A. Presence of one or both of the following symptoms:
•Delusions
•Hallucinations
B. There is evidence from the history, physical examination, or
laboratory findings of both (1) and (2):
•(1) The symptoms in Criterion A developed during or soon
after substance intoxication or withdrawal or after exposure to a
medication.
•(2) The involved substance/medication is capable of producing
the symptoms in Criterion A.
C. The disturbance is not better explained by a psychotic
disorder that is not substance/medication- induced. Such
evidence of an independent psychotic disorder could
include following:
D. The symptoms preceded the onset of the
substance/medication use; the symptoms persist for a
substantial period of time (e.g., about 1 month) after the
cessation of acute withdrawal or secere intoxication; or
there is evidence of an independent nonsubstance/medication-induced psychotic disorder (e.g., a
history of recurrent non-substance/medication-related
episodes).
D. The disturbance does not occur exclusively during the
course of a delirium.
Note: This diagnosis should be made instead of a
diagnosis of substance intoxication or substance
withdrawal only when the symptoms in Criterion
predominate A in the clinical picture and when they are
sufficiently severe to warrant clinical attention.
Specify if:
•With onset during intoxication: If the criteria are met for intoxication with the
substance and the symptoms develop during the intoxication.
•With onset during withdrawal: If criteria are met for withdrawal from the
substance and the symptoms develop during, or shortly after, withdrawal.
Specify current severity:
•Severity is rated by a quantitative assessment of the primary symptoms of
psychosis, including delusions, hallucinations, disorganized speech, abnormal
psychomotor behavior, and negative symptoms. Each of these symptoms may
be rated for its current severity (most severe in 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe).
•Note: Diagnosis of substance/medication-induced psychotic disorder can be
made without using this severity specifier.
DIAGNOSTIC CRITERIA FOR PSYCHOTIC
DISORDER DUE TO ANOTHER MEDICAL
CONDITION
A. Prominent hallucinations or delusions
B. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is the direct pathophysiological consequence
of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disorder does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Specify if:
•With delusions: If delusions are the predominant symptom.
•With hallucinations: If hallucinations are the predominant symptom.
Specify current severity:
•Severity is rated by a quantitative assessment of the primary symptoms
of psychosis, including delusions, hallucinations, disorganized speech,
abnormal psychomotor behavior, and negative symptoms. Each of these
symptoms may be rated for its current severity (most severe in 7 days) on
a 5-point scale ranging from 0 (not present) to 4 (present and severe).
Note: Diagnosis of psychotic disorder due to another medical condition
can be made without using this severity specifier.
CATATONIA ASSOCIATED WITH ANOTHER MENTAL DISORDER
(CATATONIA SPECIFIER)
The clinical picture is dominated by three (or more) of the following symptoms:
1.Stupor (i.e., no psychomotor activity; not actively relating to environment).
2.. Cataplexy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response (exclude if known aphasia)).
5.Negativism (i.e., opposition or no response to instructions or external stimuli).
6.Posturing (i.e., spontaneous and active maintenance of a posture against gravitiy).
7.Mannerism (i.e., odd, circumstantial caricature of normal actions).
8.Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9.Agitation, not influenced by external stimulation.
10.Grimacing.
11.Echolalia (i.e., mimicking another’s speech).
12.Echopraxia (i.e., mimicking another’s movements).
CATATONIC DISORDER DUE TO ANOTHER MEDICAL
CONDITION
A. The clinical picture is dominated by three (or more) of the following symptoms:
•1. Stupor (i.e., no psychomotor activity; not actively relating to environment)
•2. Cataplexy (i.e., passive induction of a posture held against gravity).
•3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner)
•4. Mutism (i.e., no, or very little, verbal response (exclude if known aphasia)).
•5. Negativism (i.e., opposition or no response to instructions or external stimuli).
•6. Posturing (i.e., spontaneous and active maintenance of a posture against gravitiy)
•7. Mannerism (i.e., odd, circumstantial caricature of normal actions)
•8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements)
•9. Agitation, not influenced by external stimulation
•10. Grimacing
•11. Echolalia (i.e., mimicking another’s speech)
•12. Echopraxia (i.e., mimicking another’s movements).
B. There is evidence from the history, physical
examination, or laboratory findings that the disturbance is
the direct pathophysiological consequence of another
medical condition.
C. The disturbance is not better explained by another
mental disorder (e.g., a manic episode).
D. The disturbance does not occur exclusively during the
course of a delirium.
E. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
UNSPECIFIED CATATONIA
This category applies to presentations in which
symptoms characteristic of catatonia cause clinically
significant distress of impairment in social,
occupational, or other important areas of functioning
but either the nature of the underlying mental disorder
or other medical condition is unclear, full criteria for
catatonia are not met, or there is insufficient
information to make a more specific diagnosis (e.g., in
emergency room settings).
OTHER SPECIFIED SCHIZOPHRENIA SPRECTRUM AND OTHER
PSYCHOTIC DISORDERS
1. Persistent auditory hallucinations occurring in the absence of any other
feature.
2. Delusions with significant overlapping mood episodes: This includes
persistent delusions with the periods of overlapping mood episodes that are
present for a substantial portion of the delusional disturbance (such that the
criterion stipulating only brief mood disturbance in delusional disorder is not
met).
3. Attenuated psychosis syndrome: This syndrome is characterized by
psychotic-like symptoms that are below a threshold for full psychosis (e.g., the
symptoms are less severe and more transient, and insight is relatively maintained.
4. Delusional symptoms in partner of individual with delusional disorder:
In the context of a relationship, the delusional material from the dominant
partner provides content for delusional belief by the individual who may not
otherwise entirely meet criteria for delusional disorder.
UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER
PSYCHOTIC DISORDER
This category applies to presentations in which symptoms characteristic of a
schizophrenia spectrum and other psychotic disorder that cause clinically
significant distress or impairment in social, occupational, or other important areas
of functioning predominate but do not meet the full criteria for any of the
disorders in the schizophrenia and other psychotic disorders diagnostic class. The
unspecified schizophrenia and other psychotic disorder category id 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).
DSM-IV Diagnostic Criteria for Shared Psychotic
Disorder
A. A delusion develops in an individual in the context of a
close relationship with another person(s), who has an
already-established delusion.
B. The delusion is similar in content to that of the person
who already has the established delusion.
C. The disturbance is not better accounted for by another
psychotic disorder (e.g., schizophrenia) or a mood
disorder with psychotic features and is not due to the
direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.