Schizophrenia
Updated May-17-2010
Schizophrenia
A. Characteristic symptoms: 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 should include 1-3
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Catatonia
5. Negative symptoms, i.e., restricted affect or avolition/asociality
B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., 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 and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the activephase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).
Schizophrenia Subtypes
The work group is recommending that these subtypes not be included in DSM-5.
Classification of Longitudinal Course for Schizophrenia
The course specifiers are to be worked on and potential change is not reflected in the current documents
Since the publication of DSM-IV in 1994, additional data about the relationship between different symptoms of schizophrenia have been generated and dimensions of schizophrenic psychopathology have been further clarified. These data are briefly considered in the context of the diagnostic criteria for schizophrenia, but are described in greater detail in a related document on dimensions. The boundaries with schizoaffective disorder are better defined with a revision of the criteria for that condition and this is discussed in a related document on schizoaffective disorder. In view of the minimal utility and diagnostic stability of schizophrenia subtypes, a recommendation to eliminate these subtypes and instead utilize dimensions is made, as discussed in another document. A recommendation to better delineate variations in course of schizophrenia is made as discussed in a related summary. With regard to the 6 diagnostic criteria for schizophrenia, no changes in criteria B-F are recommended and minor changes in criterion A (characteristic symptoms) are suggested. Before considering criterion A, we summarize principal considerations and our rationale for not recommending changes in criteria B-F.
- Criterion B (social and occupational dysfunction). We considered recommending elimination of this criterion in an effort to delink criteria for diagnosing a condition in an individual from aspects of its impact on the life of the person and to achieve concordance with the ICD criteria. We decided against doing so because of the absence of compelling data to make such a change.
- Criterion C (duration). We considered suggesting a reduction in the minimum required duration from 6 months to 1 month and to achieve concordance with the ICD criteria but decided against doing so because of the greater diagnostic stability if one uses the 6-month criterion and the absence of compelling data to make such a change.
- Criterion D (schizoaffective disorder and mood disorder exclusion). We suggest retaining this exclusion but have recommended revisions in the criteria for schizoaffective disorder in an effort to better demarcate that condition from schizophrenia with prominent mood symptoms.
- Criterion E (substance/general medical disorder exclusion). We recommend no changes in this criterion but will make text revisions to better clarify this exclusion.
- Criterion F (relationship to pervasive developmental disorder). We considered recommending elimination of this criterion in an effort to achieve concordance with ICD criteria, but decided against doing so because of the absence of compelling data to make such a change.
With reference to criterion A, we suggest retaining five characteristic symptoms of schizophrenia with some revisions and recommend requiring the presence of two or more of these symptoms for a significant portion of time during a 1-month period (as in DSM-IV) with at least one of these symptoms to include delusions, hallucinations, or disorganized speech. The rationale for recommending these four changes in criterion A for schizophrenia and other major considerations are briefly summarized:
1. Removal of disorganized behavior from grossly disorganized and catatonic behavior
Disorganized speech and behavior cluster together in the psychopathological domain of disorganization whereas catatonia is part of the psychomotor domain schizophrenic psychopathology. Consequently, disorganized behavior was separated from catatonia. Although we considered adding it to the domain of disorganization as disorganized speech or behavior, we decided against doing so because of the low reliability of “disorganized behavior” in contrast to disorganized speech
2. Clarification of negative symptoms
Restricted affect better describes the range of abnormalities in affective experience and expression in schizophrenia than flat affect. Avolition/asociality and restricted affect are two distinguishable dimensions of negative symptoms and are therefore so described.
3. Elimination of requirement that only 1 characteristic symptom need be present if that is a bizarre delusion or a Schneiderian first-rank symptom hallucination.
No unique diagnostic specificity for these characteristic symptoms in comparison to others has been identified and consequently there is no basis for treating these symptoms as being pathognomonic.
4. Requirement that at least one of the characterisic symptoms be delusions, hallucinations, or disorganized speech.
Schizophrenia is a psychotic disorder and psychosis is defined by reality distortion (delusions and hallucinations) and severe disorganization (disorganized speech).
We considered adding cognitive impairment as a characteristic symptom, but recommended against doing so because of its lack of diagnostic specificity and limited information about the impact of such a change. It was considered a key aspect of schizophrenic psychopathology, however, and is recommended as one key dimension to be measured across patients with a psychotic disorder.
References
Barch D.M., Braver T.S., Carter C.S., et al. Context-processing deficits in schizophrenia: diagnostic specificity, 4-week course, and relationships to clinical symptoms. J.
Bell R.C., Dudgeon P., McGorry P.D., Jackson H.J. The dimensionality of schizophrenia concepts in first-episode psychosis. Acta Psychiatr. Scand.,1998;97:334-342.
Carpenter W.T., Strauss J.S., Muleh S. Are there pathognomonic symptoms in schizophrenia? An empiric investigation of Schneider’s first-rank symptoms. Arch. Gen. Psychiatry,1973;28:847-852.
Cermolacce M, Sass L, Parnas J. What is bizarre about bizarre delusions. Schizophr Bull, In press.
Daban C., Martinez-Aran A., Torrent C., et al. Specificity of cognitive deficits in bipolar disorder versus schizophrenia. Psychother. Psychosom.,2006;75:72-84.
Deister A., Marneros A. Long-term stability of subtypes in schizophrenia disorders: a comparison of four diagnostic systems. Eur. Arch. Psychiatry Clin. Neurosci.,1992;242:184-190.
Fiedorowicz J.G., Epping E.A., Flaum M. Toward defining schizophrenia as a more useful clinical construct. Curr. Psychiatry Rep.,2008;10:344-351.
Grube B.S., Bilder R.M., Goldman R.S. Meta-analysis of symptom factors in schizophrenia. Schizophr. Res.,1998;31:113-120.
Heinrichs RW, Ammari N, Vaz SM, Miles AA. Are schizophrenia and schizoaffective disorder neuropsychologically distinguishable? Schizophr Res,2008;99:149-154.
Kitamura T, Okazaki Y, Fujinawa A, et al. Symptoms of psychoses: A factor-analytic study. Br J Psychiatry,1995;166:236-240.
Klingberg S, Wittorf A, Wiedemann G. Disorganization and cognitive impairment in schizophrenia: independent symptom dimensions. Eur Arch Psychiatry Clin Neurosci,2006;256:532-540.
Lenzenweger MF, Dworkin RH. The dimensions of schizophrenic phenomenology. Br J Psychiatry,1996;168:432-440.
Lykouras L, Oulis P, Psarros K, et al. Five-factor model of schizophrenic psychopathology: how valid is it? Eur Arch Psychiatr Clin Neurosci,2000;250:93-100.
Morrens M., Hulstijn W., Lewi P.J., et al. Stereotypy in schizophrenia. Schizophr Res,2006;84:397-404.
Murray V., McKee I., Miller P.M., et al. Dimensions and classes of psychosis in a population cohort. Psychol Med,2005;35:499-510.
Nakaya M., Suwa H., Ohmori K. Latent structures underlying schizophrenic symptoms: a five-dimensional model. Schizophr Res,1999;39:39-50.
Peralta V., Cuesta M.J. How many and which are the psychopathological dimensions of schizophrenia? Issues influencing their ascertainment. Schizophr Res,2001;49:269-285.
Ratakonda S., Gorman J.M., Yale S.A., et al. Characterization of psychotic disorders. Arch Gen Psychiatry,1998;55:75-81.
Regier D.A. Time for a fresh start? Rethinking psychosis in DSM-V. Schizophr Bull,2007;33:843-845.
Rietkirk T., Boks M.P.M., Sommer I.E., et al. The genetics of symptom dimensions of schizophrenia: Review and meta-analysis. Schizophr Res,2008;102:197-205.
Rossler A.R., Rossler W. The course of schizophrenic psychoses: what do we really know? A selective review from the epidemiological perspective. Eur. Arch. Psychiatry Clin.
Salokangas RKR, Honkonen T, Stengard E, Koivisto A-M. Symptom associations and their association with outcome and treatment setting in long-term schizophrenia. Nord J Psychiatry,2002;56:319-327.
Suvisaari J., Perala J., Saarni S.I., et al. The epidemiology and descriptive and predictive validity of DSM-IV delusional disorder and subtypes of schizophrenia. Clin. Schizophr. Related Psychoses,2009;2:289-297.
Tandon R, Nasrallah HA, Keshavan MS. Schizophrenia, ”Just the Facts”. IV. Clinical features and conceptualization. Schizophr Res, 2009;110:1-23.
Tirupati SN, Padmavati R, Thara R, McCreadie RG. Psychopathology in never-treated schizophrenia. Compr. Psychiatry 2006; 47:1-6.
Dimensions will be assessed on a 0-4 scale cross-sectionally, with severity assessment based on past month. There are distinct psychopathological domains in psychotic illnesses (most clearly noted in schizophrenia) with distinctive patterns of treatment-response, prognostic implications, and course. The relative severity of symptoms across these domains varies across the course of illness and among patients. This is a major change that will potentially be of great clinical value and will also be of additional research utility.
|
|
Hallucinations |
Delusions |
Disorganization |
Abnormal Psychomotor Behavior |
Restricted Emotional Expression |
Avolition |
Impaired Cognition |
Depression |
Mania |
|
0 |
Not Present |
Not Present |
Not Present |
Not Present |
Not Present |
Not Present |
Not Present |
Not Present |
Not Present |
|
1 |
Equivocal (severity or duration not sufficient to be considered psychosis) |
Equivocal (severity or duration not sufficient to be considered psychosis) |
Equivocal (severity or duration not sufficient to be considered disorganization) |
Equivocal (severity or duration not sufficient to be considered abnormal psychomotor behavior) |
Equivocal decrease in facial expressivity, prosody, or gestures |
Equivocal decrease in self-initiated behavior |
Equivocal (cognitive function not clearly outside the range expected for age or SES, i.e., within 1 SD of mean) |
Equivocal (some depressed mood, but insufficient symptoms, duration or severity to meet diagnostic criteria) |
Equivocal (some inflated or irritable mood, but insufficient symptoms, duration, or severity to meet diagnostic criteria) |
|
2 |
Present, but mild (little pressure to act upon voices, not very bothered by voices)
|
Present, but mild (delusions are not bizarre, or little pressure to act upon delusional beliefs, not very bothered by beliefs) |
Present, but mild (some difficulty following speech and/or occasional bizarre behavior) |
Present, but mild (occasional abnormal motor behavior) |
Present, but mild decrease in facial expressivity, prosody, or gestures |
Present, but mild in self-initiated behavior |
Present, but mild (some reduction in cognitive function below expected for age and SES, b/w 1 and 2 SD from mean) |
Present, but mild (meets criteria for Major Depression, with minimum number of symptoms, duration, and severity) |
Present, but mild (meets criteria for Mania with minimum number of symptoms, duration, and severity) |
|
3 |
Present and moderate (some pressure to respond to voices, or is somewhat bothered by voices) |
Present and moderate (some pressure to act upon beliefs, or is somewhat bothered by beliefs)
|
Present and moderate (speech often difficult to follow and/or frequent bizarre behavior) |
Present and moderate (frequent abnormal motor behavior) |
Present and moderate decrease in facial expressivity, prosody, or gestures |
Present and moderate in self-initiated behavior |
Present and moderate (clear reduction in cognitive function below expected for age and SES, b/w 2 and 3 SD from mean) |
Present and moderate (meets criteria for Major Depression with somewhat more than the minimum number of symptoms, duration, and/or severity |
Present and moderate (meets criteria for Mania with somewhat more than the minimum number of symptoms duration, and/or severity) |
|
4 |
Present and severe (severe pressure to respond to voices, or is very bothered by voices)
|
Present and severe (severe pressure to act upon beliefs, or is very bothered by beliefs) |
Present and severe (speech almost impossible to follow and/or behavior almost always bizarre) |
Present and severe (abnormal motor behavior almost constant) |
Present and severe decrease in facial expressivity, prosody, or gestures |
Present and severe in self-initiated behavior |
Present and severe (severe reduction in cognitive function below expected for age and SES, > 3SD from mean) |
Present and severe (meets criteria for Major Depression with many more than the minimum number of symptoms and/or severity) |
Present and severe (meets criteria for Mania with many more than the minimum umber of symptoms and/or severity) |
Logic and Justification for Dimensional Assessment of Symptoms and
Related Clinical Phenomena in Psychosis.
Work on the causes and treatment of schizophrenia and other psychotic disorders has long recognized the heterogeneity of the symptoms that can be displayed by individuals with psychosis. In addition, researchers have increasingly emphasized the ways in which the severity of different symptoms of this illness can vary across individuals, and have provided evidence that the severity of such symptoms can predict other important aspects of the illness, such as the degree of cognitive and/or neurobiological deficits (e.g., Barch et al. 2003; Barch et al. 2004; Delawalla et al. 2006; Kerns and Berenbaum 2002; Perlstein et al. 2003; Strauss et al. 1993). Further, research has increasingly emphasized that the boundaries between nosological entities may not be as categorical as suggested by individuals such as Kraepelin (Kraepelin 1971), and putative comorbidity of various disorders may reflect impairments in common dimensions of genetic variation, human behavior and neurobiological function (Owen et al. 2007). As such, it is important to explicitly include dimensional assessments of the core symptoms of psychotic disorders to help us identify this important variability. Thus, we propose to include dimensional assessments of all of the symptoms included as diagnostic indicators in Criterion A of the diagnostic criteria for schizophrenia. This includes hallucinations, delusions, disorganization, abnormal motor behavior, restricted emotional expression, and avolition. Each of these symptoms will be rated for their current severity (most severe in the past month) on a five-point scale ranging from 0 (Not Present) to 5 (Present and Severe). A score of 2 or higher will be considered sufficient severity to fulfill a Criterion A diagnostic Indicator for Schizophrenia. We believe that including these dimensional assessments will help diagnosticians make reliable decisions about the presence or absence of diagnostic phenomena and that it will help clinicians attend to the clinically meaningful variation in the severity of these symptoms, which will help with treatment planning, prognostic decision making, and research on pathophysiological mechanisms.
Hallucinations and Delusions
One might question whether we could collapse some of the symptoms in to a single dimension. For example, both hallucinations and delusions are considered to be evidence of impaired reality testing, and in theory we could collapse these into a single dimension of reality testing. However, a number of treatment approaches, such as cognitive behavioral therapy, focus on the treatment of hallucinations and delusions in somewhat different ways, and thus we feel it is important for clinicians to have a means by which to separately assess the severity of such symptoms separately and to be able to track change in each domain of symptom individually(Addington and Mancuso 2009; Gleeson et al. 2009; Velligan 2009).
Restricted Emotional Expression and Avolition
In addition, we felt it important to distinguish between two different domains of negative symptoms: 1) restricted emotional expression; and 2) avolition. Exploratory and confirmatory factor analyses of symptom assessment scales such as the Schedule for the Assessments of Negative Symptoms (SANS) at the item level have overwhelmingly supported separate negative symptom factors for Flat Affect/Diminished Expression and Avolition/Asociality/Anhedonia.39, 90-97 Factor analytic studies of the SDS have also supported two separate factors of Diminished Emotional Expression and Avolition.99, 100 Additional support for a two-factor model of negative symptoms comes from replication of the finding across heterogeneous samples. Separate factors for Flat Affect/Diminished Expression and Avolition/Asociality/Anhedonia have been identified in heterogeneous groups of patients with any psychotic disorder93, 95, 97 as well as schizophrenia spectrum patients34, 39, 90-92, 94, 96 and deficit syndrome patients.99, 100 Furthermore, these factors were found in patients on34, 94, 96, 99 and off medication39 and in first-episode92 and chronic91 patients. Separate factors for affective flattening and avolition appear to hold up cross-culturally. Factor analyses of data collected from patients in the United States,34, 39, 91, 94, 96, 99 Canada,92 Spain,95 South Africa,90 Australia,93 and Japan,100 all supported Flat Affect/Diminished Expression and Avolition/Asociality/Anhedonia as separate factors, providing further evidence for recognizing deficits in affect and volition as two distinct symptom domains in schizophrenia.
A primary reason for asking clinicians to rate each of these types of negative symptoms separately is evidence that they may differentially predict factors such as clinical presentation(Strauss et al. in submission), functional outcome(Strauss et al. in submission; Tattan and Creed 2001), cognitive deficits (Gur et al. 2006; Malaspina and Coleman 2003; Suslow et al. 1998), emotional deficits(Gur et al. 2006; Henry et al. 2007), and neurobiological impairments(Dichter et al. 2009; Dowd and Barch in press; Fahim et al. 2005; Gur et al. 2007; Waltz et al. 2009).
Cognitive Function
In addition to including dimensional assessments of the criterial symptoms of psychosis, we feel it is also important to include dimensional assessments of other important clinical phenomena that are relevant to treatment planning and prognosis. First, we propose to include a dimensional assessment of cognitive impairment. There is ample evidence that a large percentage of individuals with schizophrenia and other psychotic disorders suffer from impairments in a range of cognitive domains (e.g., Reichenberg et al. 2008), and growing evidence that the level of cognitive impairment predicts functional abilities (social, occupational, living status) (e.g., Cervellione et al. 2007; Green et al. 2004; Heinrichs et al. 2008b; McClure et al. 2007).
Despite the importance of cognition to understanding function in schizophrenia and other psychotic disorders, we do not propose to include cognitive deficits as a Criterion A symptom of schizophrenia or any other psychotic disorder. This is because cognition may not be useful as differential diagnosis tool. The profile of cognitive impairments in similar across the non-affective and affective psychosis (Depp et al. 2007; Hill et al. 2004; Reichenberg et al. 2008; Schretlen et al. 2007; Smith et al. 2009), though the level of impairment may be greater in non-affective psychoses (Depp et al. 2007; Hill et al. 2004; Krabbendam et al. 2005; Schretlen et al. 2007). Perhaps one of the clearest examples of such a result was recently provided by Reichenberg and colleagues (Reichenberg et al. 2008). These researchers compared individuals with consensus research diagnoses of schizophrenia, schizoaffective disorder, major depressive disorder with affective features and bipolar disorder with psychotic features. The individuals with schizophrenia and schizoaffective disorder were overall more impaired than the individuals with psychotic mood disorders, and the prevalence of cognitive impairment was higher in schizophrenia and schizoaffective disorder by definitions that they examined. However, the individuals within all four groups showed the same relative pattern of impairment across cognitive domains, with the greatest impairment in verbal memory, and the least impairment in visual processing general verbal ability. Depp et al provided another compelling example in their studying comparing individuals with schizophrenia, bipolar disorder and healthy controls (Depp et al. 2007). Unlike, Reichenberg et al., Depp found that the bipolar patients were as impaired as the schizophrenia patients on many of the tests. Further, the profile of impairment was very similar across groups, with the most impairment in information processing speed for both groups, and the least impairment in crystallized IQ. In addition, there is evidence that the factor structure of cognition is very similar across schizophrenia and bipolar disorder (Czobor et al. 2007). There are of course some exceptions to these results, and some studies that have shown differences across psychotic disorders in the pattern or severity of cognitive impairment (Heinrichs et al. 2008a). However, the wealth of data suggest that this separation is not sufficient to justify inclusion of cognition as a Criterion A symptom of schizophrenia.
Nonetheless, it remains clear that cognitive function is important for understanding functional status in schizophrenia (Bowie et al. 2008; Green et al. 2000; Green et al. 2004), as well as other psychotic disorders, including bipolar disorder (Gruber et al. 2008; Jaeger et al. 2007; Martinez-Aran et al. 2004; Tabares-Seisdedos et al. 2008), and that cognitive deficits are not well treated by current antipsychotic medications (e.g., Keefe et al. 2007). Thus, we have included a dimensional assessment of cognition because it is important to highlight the potential need for additional treatments specifically targeting cognitive remediation in schizophrenia and other psychotic disorders (e.g., Marder 2006; Marder and Fenton 2004). We will be recommending that it is optimal to obtain a formal neuropsychological assessment in individuals with psychosis to fully understand the nature and severity of their cognitive impairments. However, should this not be possible, we will be recommending that at minimum, clinicians conduct a brief and easy to validity administer assessment of cognition such as one of the many variations of the Digit Symbol Substitution Test. These measures are very brief (under 5 minutes), are highly reliable, and are strong predictors of the severity of cognitive impairments shown by individuals with schizophrenia on large batteries of cognitive tests (Dickinson 2008; Dickinson et al. 2008; Dickinson et al. 2007). The growing research on other methods for assessing cognitive function (e.g., self-report, clinician interview) suggests that these methods do not provide valid assessments of objective cognition impairment or functional outcome in psychosis(Green et al. 2008) and thus these are not sufficient as a basis for assessing cognitive impairment in schizophrenia.
Depression and Mania
We also propose to include dimensional assessments of depression and mania for all psychotic disorders. There is growing evidence that schizoaffective disorder does not represent a distinct nosological category separate form schizophrenia (e.g., Malhi et al. 2008; Owen et al. 2007; Peralta and Cuesta 2009). However, at the same time there is good evidence that the severity of the mood pathology present in individuals with schizophrenia indicates important information about prognosis and outcome (Bowie et al. 2006; Crumlish et al. 2005), and the need for treatments specifically targeting these mood symptoms (e.g., Addington et al. 1998; Peralta and Cuesta 2009). Thus, dimensional assessments of depression and mania for all psychotic disorders will serve to alert clinicians to look for the presence of mood pathology and treat it were appropriate.
References
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Barch, D.M.; Mitropoulou, V.; Harvey, P.D.; New, A.S.; Silverman, J.M.; and Siever, L.J. Context-processing deficits in schizotypal personality disorder. Journal of Abnormal Psychology, 113(4):556-68, 2004.
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Cervellione, K.L.; Burdick, K.E.; Cottone, J.G.; Rhinewine, J.P.; and Kumra, S. Neurocognitive deficits in adolescents with schizophrenia: longitudinal stability and predictive utility for short-term functional outcome. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7):867-78, 2007.
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Czobor, P.; Jaeger, J.; Berns, S.M.; Gonzalez, C.; and Loftus, S. Neuropsychological symptom dimensions in bipolar disorder and schizophrenia. Bipolar Disord, 9(1-2):71-92, 2007.
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Depp, C.A.; Moore, D.J.; Sitzer, D.; Palmer, B.W.; Eyler, L.T.; Roesch, S.; Lebowitz, B.D.; and Jeste, D.V. Neurocognitive impairment in middle-aged and older adults with bipolar disorder: comparison to schizophrenia and normal comparison subjects. J Affect Disord, 101(1-3):201-9, 2007.
Dichter, G.S.; Bellion, C.; Casp, M.; and Belger, A. Impaired Modulation of Attention and Emotion in Schizophrenia. Schizophr Bull, 2009.
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Dickinson, D.; Ramsey, M.E.; and Gold, J.M. Overlooking the obvious: a meta-analytic comparison of digit symbol coding tasks and other cognitive measures in schizophrenia. Archives of General Psychiatry, 64(5):532-42, 2007.
Dowd, E., and Barch, D.M. Subjective emotional experience in schizophrenia: Neural and behavioral markers. Biological Psychiatry, in press.
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A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., 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 and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the activephase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).
Schizophrenia Subtypes
The subtypes of Schizophrenia are defined by the predominant symptomatology at the time of evaluation.
295.30 Paranoid Type
A type of Schizophrenia in which the following criteria are met:
A. Preoccupation with one or more delusions or frequent auditory hallucinations.
B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
295.10 Disorganized Type
A type of Schizophrenia in which the following criteria are met:
A. All of the following are prominent:
(1) disorganized speech
(2) disorganized behavior
(3) flat or inappropriate affect
B. The criteria are not met for Catatonic Type.
295.20 Catatonic Type
A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:
(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor
(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli)
(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism
(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing
(5) echolalia or echopraxia
295.90 Undifferentiated Type
A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.
295.60 Residual Type
A type of Schizophrenia in which the following criteria are met:
A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.
B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
Classification of Longitudinal Course for Schizophrenia
These specifiers can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms:
Episodic With Interepisode Residual Symptoms. This specifier applies when the course is characterized by episodes in which Criterion A for Schizophrenia is met and there are clinically significant residual symptoms betweenthe episodes. With Prominent Negative Symptoms can be added if prominent negative symptoms are present during these residual periods.
Episodic With No Interepisode Residual Symptoms.
This specifier applies when the course is characterized by episodes in which Criterion A for Schizophrenia is met and there are no clinically significant residual symptoms between the episodes.
Continuous. This specifier applies when characteristic symptoms of Criterion A are met throughout all (or most) of the course. With Prominent Negative Symptoms can be added if prominent negative symptoms are also present.
Single Episode In Partial Remission. This specifier applies when there has been a single episode in which Criterion A for Schizophrenia is met and some clinically significant residual symptoms remain. With Prominent Negative Symptoms can be added if these residual symptoms include prominent negative symptoms.
Single Episode In Full Remission. This specifier applies when there has been a single episode in which Criterion A for Schizophrenia has been met and no clinically significant residual symptoms remain.
Other or Unspecified Pattern. This specifier is used if another or an unspecified course pattern has been present. |
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