SCHIZOPHRENIA SPECTRUM AND OTHER

PSYCHOTIC DISORDERS
Adapted from DSM V

 Schizophrenia spectrum and other psychotic disorders include

a. Schizophrenia
b. other psychotic disorders
c. schizotypal (personality) disorder.
 They are defined by abnormalities in one or more of the following five domains:
a. Delusions
b. Hallucinations
c. Disorganized thinking (speech)
d. Grossly disorganized or abnormal motor behavior (including catatonia)
e. Negative symptoms.

Key Features That Define the Psychotic Disorders

Delusions
 Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Their
content may include a variety of themes (e.g., persecutory, referential, somatic, religious,
grandiose).
 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) and 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.
 Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture
peers and do not derive from ordinary life experiences. An example of a bizarre delusion is the belief
that an outside force has removed his or her internal organs and replaced them with someone else's
organs without leaving any wounds or scars. An example of a nonbizarre delusion is the belief that
one is under surveillance by the police, despite a lack of convincing evidence.
 Delusions that express a loss of control over mind or body are generally considered to be bizarre;
these include the belief that one's thoughts have been "removed" by some outside force {thought
withdrawal), that alien thoughts have been put into one's mind (thought insertion), or that one's
body or actions are being acted on or manipulated by some outside force (delusions of control).
 The distinction between a delusion and a strongly held idea is sometimes difficult to make and
depends in part on the degree of conviction with which the belief is held despite clear or reasonable
contradictory evidence regarding its veracity.

Hallucinations
 Hallucinations are perception-like experiences that occur without an external stimulus. They are
vivid and clear, with the full force and impact of normal perceptions, and not under voluntary
control.
 Hallucinations occur in any sensory modality, but auditory hallucinations are the most common in
schizophrenia and related disorders.
 Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are
perceived as distinct from the individual's own thoughts. The hallucinations must occur in the
context of a clear sensorium; those that occur while falling asleep (hypnagogic) or waking up
(hypnopompic) are considered to be within the range of normal experience. Hallucinations may be a
normal part of religious experience in certain cultural contexts.

Disorganized Thinking (Speech)

 Disorganized thinking (formal thought disorder) is typically inferred from the individual's speech.
The individual may switch from one topic to another {derailment or loose associations). Answers to
questions may be obliquely related or completely unrelated (tangentiality). Rarely, speech may be
so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its
linguistic disorganization {incoherence or "word salad").
 Because mildly disorganized speech is common and nonspecific, the symptom must be severe
enough to substantially impair effective communication. The severity of the impairment may be
difficult to evaluate if the person making the diagnosis comes from a different linguistic background
than that of the person being examined. Less severe disorganized thinking or speech may occur
during the prodromal and residual periods of schizophrenia.

Grossly Disorganized or Abnormal Motor Behavior (including Catatonia)

 Grossly disorganized or abnormal motor behavior may manifest itself in a variety of ways, ranging
from childlike "silliness" to unpredictable agitation. Problems may be noted in any form of goal-
directed behavior, leading to difficulties in performing activities of daily living. Catatonic behavior is
a marked decrease in reactivity to the environment. This ranges from resistance to instructions
{negativism); to maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal
and motor responses {mutism and stupor).
 It can also include purposeless and excessive motor activity without obvious cause {catatonic
excitement). Other features are repeated stereotyped movements, staring, grimacing, mutism, and
the echoing of speech. Although catatonia has historically been associated with schizophrenia,
catatonic symptoms are nonspecific and may occur in other mental disorders (e.g., bipolar or
depressive disorders with catatonia) and in medical conditions (catatonic disorder due to another
medical condition).

Negative Symptoms
 Negative symptoms account for a substantial portion of the morbidity associated with schizophrenia
but are less prominent in other psychotic disorders.
 Two negative symptoms are particularly prominent in schizophrenia: diminished emotional
expression and avolition.
 Diminished emotional expression includes reductions in the expression of emotions in the face, eye
contact, intonation of speech (prosody), and movements of the hand, head, and face that normally
give an emotional emphasis to speech.
 Avolition is a decrease in motivated self-initiated purposeful activities. The individual may sit for long
periods of time and show little interest in participating in work or social activities.
 Other negative symptoms include alogia, anhedonia, and asociality. Alogia is manifested by
diminished speech output. Anhedonia is the 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 interactions.

COMPARING SCHIZOPHRENIA WITH OTHER CONDITIONS

 Diagnosis of a schizophrenia spectrum disorder requires the exclusion of another condition that may
give rise to psychosis.
 Schizotypal personality disorder is considered within the schizophrenia spectrum, although its full
description is explained as a personality disorder. The diagnosis schizotypal personality disorder
captures a pervasive pattern of social and interpersonal deficits, including reduced capacity for close
relationships; cognitive or perceptual distortions; and eccentricities of behavior, usually beginning
by early adulthood but in some cases first becoming apparent in childhood and adolescence.
Abnormalities of beliefs, thinking, and perception are below the threshold for the diagnosis of a
psychotic disorder.
 Two conditions are defined by abnormalities limited to one domain of psychosis: delusions or
catatonia.
 Delusional disorder is characterized by at least 1 month of delusions but no other psychotic
symptoms.
 Brief psychotic disorder lasts more than 1 day and remits by 1 month.
 Schizophreniform disorder is characterized by a symptomatic presentation equivalent to that of
schizophrenia except for its duration (less than 6 months) and the absence of a requirement for a
decline in functioning.
 Schizophrenia lasts for at least 6 months and includes at least 1 month of active-phase symptoms.
 In schizoaffective disorder, a mood episode and the active-phase symptoms of schizophrenia occur
together and were preceded or are followed by at least 2 weeks of delusions or hallucinations
without prominent mood symptoms.
 Psychotic disorders may be induced by another condition . In substance/medication- induced
psychotic disorder, the psychotic symptoms are judged to be a physiological consequence of a drug
of abuse, a medication, or toxin exposure and cease after removal of the agent.
 In psychotic disorder due to another medical condition, the psychotic symptoms are judged to be a
direct physiological consequence of another medical condition.

Delusional Disorder
Diagnostic Criteria
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 major 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 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 the delusion is that another
person is in love with the individual.
 Grandiose type: This subtype applies when the central theme of the delusion is the conviction of
having some great (but unrecognized) 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 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
or 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).

Diagnostic Features
 The essential feature of delusional disorder is the presence of one or more delusions that persist for
at least 1 month (Criterion A).
 A diagnosis of delusional disorder is not given if the individual has ever had a symptom presentation
that met Criterion A for schizophrenia (Criterion B).
 Apart from the direct impact of the delusions, impairments in psychosocial functioning may be more
circumscribed than those seen in other psychotic disorders such as schizophrenia, and behavior is
not obviously bizarre or odd (Criterion C).
 If mood episodes occur concurrently with the delusions, the total duration of these mood episodes
is brief relative to the total duration of the delusional periods (Criterion D).
 The delusions are not attributable to the physiological effects of a substance (e.g., cocaine) or
another medical condition (e.g., Alzheimer's disease) and are not better explained by another
mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder (Criterion E).

Prevalence
 The lifetime prevalence of delusional disorder has been estimated at around 0.2%, and the most
frequent subtype is persecutory. Delusional disorder, jealous type, is probably more common in
males than in females, but there are no major gender differences in the overall frequency of
delusional disorder.

Development and Course

 On average, global function is generally better than that observed in schizophrenia. Although the
diagnosis is generally stable, a proportion of individuals go on to develop schizophrenia. Delusional
disorder has a significant familial relationship with both schizophrenia and schizotypal personality
disorder. Although it can occur in younger age groups, the condition may be more prevalent in older
individuals.
Culture-Related Diagnostic Issues
 An individual's cultural and religious background must be taken into account in evaluating the
possible presence of delusional disorder. The content of delusions also varies across cultural
contexts.

Functional Consequences of Delusional Disorder

The functional impairment is usually more circumscribed than that seen with other psychotic disorders,
although in some cases, the impairment may be substantial and include poor occupational functioning
and social isolation. When poor psychosocial functioning is present, delusional beliefs themselves often
play a significant role.
 A common characteristic of individuals with delusional disorder is the apparent normality of their
behavior and appearance when their delusional ideas are not being discussed or acted on.

Differential Diagnosis
 Delusional disorder can be distinguished from schizophrenia and schizophreniform disorder by the
absence of the other characteristic symptoms of the active phase of schizophrenia.
 If delusions occur exclusively during mood episodes, the diagnosis is depressive or bipolar disorder
with psychotic features.

Brief Psychotic Disorder

Diagnostic Criteria
A. Presence of one (or more) of the following symptoms. 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.
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 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.

Diagnostic Features
 The essential feature of brief psychotic disorder is a disturbance that involves the sudden onset of at
least one of the following positive psychotic symptoms: delusions, hallucinations, disorganized
speech (e.g., frequent derailment or incoherence), or grossly abnormal psychomotor behavior,
including catatonia (Criterion A).
 Sudden onset is defined as change from a nonpsychotic state to a clearly psychotic state within 2
weeks, usually without a prodrome.
 An episode of the disturbance lasts at least 1 day but less than 1 month, and the individual
eventually has a full return to the premorbid level of functioning (Criterion B).
 The disturbance is not better explained by a depressive or bipolar disorder with psychotic features,
by schizoaffective disorder, or by schizophrenia and is not attributable to the physiological effects of
a substance (e.g., a hallucinogen) or another medical condition (e.g., subdural hematoma) (Criterion
C).
 the assessment of cognition, depression, and mania symptom domains is vital for making critically
important distinctions between the various schizophrenia spectrum and other psychotic disorders.

Prevalence
 Brief psychotic disorder is twofold more common in females than in males.

Functional Consequences of Brief Psychotic Disorder

 Despite high rates of relapse, for most individuals, outcome is excellent in terms of social
functioning and symptomatology.

Schizophreniform Disorder
Diagnostic Criteria
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 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
D. The disturbance 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 good prognostic features:
 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: With catatonia (refer to the criteria for catatonia associated with
another mental disorder, pp. 119-120, for definition).
 catatonia associated with schizophreniform disorder to indicate the presence of the comorbid
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
the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-
Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”) Note:
Diagnosis of schizophreniform disorder can be made without using this severity specifier.
Note: For additional information on Associated Features Supporting Diagnosis, Development and Course
(age-related factors), Culture-Related Diagnostic Issues, Gender-Related Diagnostic Issues, Differential
Diagnosis, and Comorbidity, see the corresponding sections in schizophrenia.

Diagnostic Features
 The characteristic symptoms of schizophreniform disorder are identical to those of schizophrenia
(Criterion A). Schizophreniform disorder is distinguished by its difference in duration: the total
duration of the illness, including prodromal, active, and residual phases, is at least 1 month but less
than 6 months (Criterion B).
 The duration requirement for schizophreniform disorder is intermediate between that for brief
psychotic disorder, which lasts more than 1 day and remits by 1 month, and schizophrenia, which
lasts for at least 6 months.
 The diagnosis of schizophreniform disorder is made under two conditions. 1) when an episode of
illness lasts between 1 and 6 months and the individual has already recovered, and 2) when an
individual is symptomatic for less than the 6 months' duration required for the diagnosis of
schizophrenia but has not yet recovered. In this case, the diagnosis should be noted as
"schizophreniform disorder (provisional)" because it is uncertain if the individual will recover from
the disturbance within the 6-month period. If the disturbance persists beyond 6 months, the
diagnosis should be changed to schizophrenia.
 Another distinguishing feature of schizophreniform disorder is the lack of a criterion requiring
impaired social and occupational functioning. While such impairments may potentially be present,
they are not necessary for a diagnosis of schizophreniform disorder. In addition to the five symptom
domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and
mania symptom domains is vital for making critically important distinctions between the various
schizophrenia spectrum and other psychotic disorders.

Associated Features Supporting Diagnosis

 As with schizophrenia, currently there are no laboratory or psychometric tests for schizophreniform
disorder. There are multiple brain regions where neuroimaging, neuropathological, and
neurophysiological research has indicated abnormalities, but none are diagnostic.

Development and Course

 The development of schizophreniform disorder is similar to that of schizophrenia. About one-third
of individuals with an initial diagnosis of schizophreniform disorder (provisional) recover within the
6-month period and schizophreniform disorder is their final diagnosis. The majority of the remaining
two-thirds of individuals will eventually receive a diagnosis of schizophrenia or schizoaffective
disorder.

Risk and Prognostic Factors

Genetic and physiological.
 Relatives of individuals with schizophreniform disorder have an increased risk for schizophrenia.

Functional Consequences of Schizophreniform Disorder

For the majority of individuals with schizophreniform disorder who eventually receive a diagnosis of
schizophrenia or schizoaffective disorder, the functional consequences are similar to the consequences
of those disorders. Most individuals experience dysfunction in several areas of daily functioning, such as
school or work, interpersonal relationships, and self-care. Individuals who recover from
schizophreniform disorder have better functional outcomes.

Differential Diagnosis
Other mental disorders and medical conditions. A wide variety of mental and medical conditions can
manifest with psychotic symptoms that must be considered in the differential diagnosis of
schizophreniform disorder. These include psychotic disorder due to another medical condition or its
treatment; delirium or major neurocognitive disorder; substance/medication-induced psychotic disorder
or delirium; depressive or bipolar disorder with psychotic features; schizoaffective disorder; other
specified or unspecified bi polar and related disorder; depressive or bipolar disorder with catatonic
features; schizophrenia; brief psychotic disorder; delusional disorder; other specified or unspecified
schizophrenia spectrum and other psychotic disorder; schizotypal, schizoid, or paranoid personality
disorders; autism spectrum disorder; disorders presenting in childhood with disorganized speech;
attention-deficit/hyperactivity disorder; obsessive-compulsive dis order; posttraumatic stress disorder;
and traumatic brain injury. Since the diagnostic criteria for schizophreniform disorder and schizophrenia
differ primarily in duration of illness, the discussion of the differential diagnosis of schizophrenia also
applies to schizophreniform disorder. Brief psychotic disorder. Schizophreniform disorder differs in
duration from brief psychotic disorder, which has a duration of less than 1 month.

Schizophrenia
Diagnostic Criteria
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. 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 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 by 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 attributable 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 1 month (or less if
successfully treated).

Diagnostic Features
 The characteristic symptoms of schizophrenia involve a range of cognitive, behavioral, and
emotional dysfunctions, but no single symptom is pathognomonic of the disorder.
 The diagnosis involves the recognition of a constellation of signs and symptoms associated with
impaired occupational or social functioning.

Associated Features Supporting Diagnosis

 Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the absence of an
appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety, or anger; a
disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in
eating or food refusal.
 Depersonalization, derealization, and somatic concerns may occur and sometimes reach delusional
proportions.
 Anxiety and phobias are common.
 Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional
impairments. These deficits can include decrements in declarative memory, working memory,
language function, and other executive functions, as well as slower processing speed.
 Abnormalities in sensory processing and inhibitory capacity, as well as reductions in attention, are
also found. Some individuals with schizophrenia show social cognition deficits, including deficits in
the ability to infer the intentions of other people (theory of mind), and may attend to and then
interpret irrelevant events or stimuli as meaningful, perhaps leading to the generation of
explanatory delusions. These impairments frequently persist during symptomatic remission.
 Some individuals with psychosis may lack insight or awareness of their disorder (i.e., anosognosia).
 This lack of "'insight" includes unawareness of symptoms of schizophrenia and may be present
throughout the entire course of the illness. Unawareness of illness is typically a symptom of
schizophrenia itself rather than a coping strategy. It is comparable to the lack of awareness of
neurological deficits following brain damage, termed anosognosia. This symptom is the most
common predictor of non-adherence to treatment, and it predicts higher relapse rates, increased
number of involuntary treatments, poorer psychosocial functioning, aggression, and a poorer course
of illness.
 Hostility and aggression can be associated with schizophrenia, although spontaneous or random
assault is uncommon.
 Currently, there are no radiological, laboratory, or psychometric tests for the disorder. Differences
are evident in multiple brain regions between groups of healthy individuals

Prevalence
 there is reported variation by race/ethnicity, across countries, and by geographic origin for
immigrants and children of immigrants.
 The sex ratio differs across samples and populations: for example, an emphasis on negative
symptoms and longer duration of disorder (associated with poorer outcome) shows higher incidence
rates for males, whereas definitions allowing for the inclusion of more mood symptoms and brief
presentations (associated with better outcome) show equivalent risks for both sexes.
Development and Course
 The psychotic features of schizophrenia typically emerge between the late teens and the mid-30s;
onset prior to adolescence is rare.
 The peak age at onset for the first psychotic episode is in the early- to mid-20s for males and in the
late-20s for females.
 The onset may be abrupt or insidious, but the majority of individuals manifest a slow and gradual
development of a variety of clinically significant signs and symptoms. Half of these individuals
complain of depressive symptoms.
 Earlier age at onset has traditionally been seen as a predictor of worse prognosis .
 However, the effect of age at onset is likely related to gender, with males having worse premorbid
adjustment, lower educational achievement, more prominent negative symptoms and cognitive
impairment, and in general a worse out come. Impaired cognition is common, and alterations in
cognition are present during development and precede the emergence of psychosis, taking the form
of stable cognitive impairments during adulthood.
 Cognitive impairments may persist when other symptoms are in remission and contribute to the
disability of the disease.
 The predictors of course and outcome are largely unexplained, and course and outcome may not be
reliably predicted.
 The course appears to be favorable in about 20% of those with schizophrenia, and a small number of
individuals are reported to recover completely. However, most individuals with schizophrenia still
require formal or informal daily living supports, and many remain chronically ill, with exacerbations
and remissions of active symptoms, while others have a course of progressive deterioration.
 Psychotic symptoms tend to diminish over the life course, perhaps in association with normal age-
related declines in dopamine activity.
 Negative symptoms are more closely related to prognosis than are positive symptoms and tend to
be the most persistent. Further more, cognitive deficits associated with the illness may not improve
over the course of the illness. The essential features of schizophrenia are the same in childhood, but
it is more difficult to make the diagnosis. In children, delusions and hallucinations may be less
elaborate than in adults, and visual hallucinations are more common and should be distinguished
from normal fantasy play. Disorganized speech occurs in many disorders with childhood onset (e.g.,
autism spectrum disorder), as does disorganized behavior (e.g., attention-deficit/
hyperactivity disorder). These symptoms should not be attributed to schizophrenia with out due
consideration of the more common disorders of childhood. Childhood-onset cases tend to resemble
poor-outcome adult cases, with gradual onset and prominent negative symptoms. Children who later
receive the diagnosis of schizophrenia are more likely to have experienced nonspecific emotional-
behavioral disturbances and psychopathology, intellectual and language alterations, and subtle motor
delays. Late-onset cases (i.e., onset after age 40 years) are overrepresented by females, who may have
married. Often, the course is characterized by a predominance of psychotic symptoms with preservation
of affect and social functioning. Such late-onset cases can still meet the diagnostic criteria for
schizophrenia, but it is not yet clear whether this is the same condition as schizophrenia diagnosed prior
to mid-life (e.g., prior to age 55 years).

Risk and Prognostic Factors

Environmental.
 Season of birth has been linked to the incidence of schizophrenia, including late winter/early spring
in some locations and summer for the deficit form of the disease. The incidence of schizophrenia
 and related disorders is higher for children growing up in an urban environment and for some
minority ethnic groups.
Genetic and physiological.
 There is a strong contribution for genetic factors in determining risk for schizophrenia, although
most individuals who have been diagnosed with schizophrenia have no family history of psychosis.
 Pregnancy and birth complications with hypoxia and greater paternal age are associated with a
higher risk of schizophrenia for the developing fetus. In addition, other prenatal and perinatal
adversities, including stress, infection, malnutrition, maternal diabetes, and other medical
conditions, have been linked with schizophrenia. However, the vast majority of offspring with these
risk factors do not develop schizophrenia.

Culture-Related Diagnostic Issues

 Cultural and socioeconomic factors must be considered, particularly when the individual and the
clinician do not share the same cultural and socioeconomic background.

Gender-Related Diagnostic Issues

 general incidence of schizophrenia tends to be slightly lower in females, particularly among treated
cases. The age at onset is later in females
 Symptoms tend to be more affect-laden among females, and there are more psychotic symptoms,
as well as a greater propensity for psychotic symptoms to worsen in later life.
 social functioning tends to remain better preserved in females.

Suicide Risk
 Approximately 5%-6% of individuals with schizophrenia die by suicide, about 20% attempt suicide on
one or more occasions, and many more have significant suicidal ideation.

Functional Consequences of Schizophrenia

 Schizophrenia is associated with significant social and occupational dysfunction.

Differential Diagnosis
 If delusions or hallucinations occur exclusively during a major depressive or manic episode, the
diagnosis is depressive or bipolar disorder with psychotic features.
 A diagnosis of schizoaffective disorder requires that a major depressive or manic episode occur
concurrently with the active-phase symptoms and that the mood symptoms be present for a
majority of the total duration of the active periods.
 Schizophreniform disorder and brief psychotic disorder. These disorders are of shorter duration than
schizophrenia as specified in Criterion C, which requires 6 months of symptoms. In schizophreniform
disorder, the disturbance is present less than 6 months, and in brief psychotic disorder, symptoms
are present at least 1 day but less than 1 month.
 Delusional disorder can be distinguished from schizophrenia by the absence of the other symptoms
characteristic of schizophrenia (e.g., delusions, prominent auditory or visual hallucinations,
disorganized speech, grossly disorganized or catatonic behavior, negative symptoms).
 Schizotypal personality disorder may be distinguished from schizophrenia by subthreshold
symptoms that are associated with persistent personality features.
 Obsessive-compulsive disorder and body dysmorphic disorder. Individuals with obsessive-
compulsive disorder and body dysmorphic disorder may present with poor or absent insight, and
the preoccupations may reach delusional proportions. But these disorders are distinguished from
 schizophrenia by their prominent obsessions, compulsions, preoccupations with appearance or body
odor, hoarding, or body-focused repetitive behaviors.
 Posttraumatic stress disorder. Posttraumatic stress disorder may include flashbacks that have a
hallucinatory quality, and hypervigilance may reach paranoid proportions. But a traumatic event and
characteristic symptom features relating to reliving or reacting to the event are required to make
the diagnosis.
 Autism spectrum disorder or communication disorders. These disorders may also have symptoms
resembling a psychotic episode but are distinguished by their respective deficits in social interaction
with repetitive and restricted behaviors and other cognitive and communication deficits.

Schizoaffective Disorder
Diagnostic Criteria
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 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.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition.

Diagnostic Features
 The diagnosis of schizoaffective disorder is based on the assessment of an uninterrupted period of
illness during which the individual continues to display active or residual symptoms of psychotic
illness. The diagnosis is usually, but not necessarily, made during the period of psychotic illness. At
some time during the period. Criterion A for schizophrenia has to be met. Criteria B (social
dysfunction) and F (exclusion of autism spectrum disorder or other communication disorder of
childhood onset) for schizophrenia do not have to be met.
 In addition to meeting Criterion A for schizophrenia, there is a major mood episode (major
depressive or manic) (Criterion A for schizoaffective disorder).
 Because loss of interest or pleasure is common in schizophrenia, to meet Criterion A for
schizoaffective disorder, the major depressive episode must include pervasive depressed mood (i.e.,
the presence of markedly diminished interest or pleasure is not sufficient). Episodes of depression or
mania are present for the majority of the total duration of the illness (i.e., after Criterion A has been
met) (Criterion C for schizoaffective disorder).
 To separate schizoaffective disorder from a depressive or bipolar disorder with psychotic features,
delusions or hallucinations must be present for at least 2 weeks in the absence of a major mood
episode (depressive or manic) at some point during the lifetime duration of the illness
 symptoms must not be attributable to the effects of a substance or another medical condition
(Criterion D for schizoaffective disorder).
 Criterion C for schizoaffective disorder specifies that mood symptoms meeting criteria for a major
mood episode must be present for the majority of the total duration of the active and residual
portion of the illness.

Associated Features Supporting Diagnosis

 Occupational functioning is frequently impaired, but this is not a defining criterion (in contrast to
schizophrenia).
 Restricted social contact and difficulties with self-care are associated with schizoaffective disorder,
but negative symptoms may be less severe and less persistent than those seen in schizophrenia.
Anosognosia (i.e., poor insight) is also common in schizoaffective disorder, but the deficits in insight
may be less severe and pervasive than those in schizophrenia.
 There are no tests or biological measures that can assist in making the diagnosis of schizoaffective
disorder. Whether schizoaffective disorder differs from schizophrenia with regard to associated
features such as structural or functional brain abnormalities, cognitive deficits, or genetic risk factors
is not clear.

Prevalence
 Schizoaffective disorder appears to be about one-third as common as schizophrenia. Life time
prevalence of schizoaffective disorder is estimated to be 0.3%.
 The incidence of schizoaffective disorder is higher in females than in males, mainly due to an
increased incidence of the depressive type among females.

Development and Course

 The typical age at onset of schizoaffective disorder is early adulthood, although onset can occur
anywhere from adolescence to late in life.
 The prognosis for schizoaffective disorder is somewhat better than the prognosis for schizophrenia
but worse than the prognosis for mood disorders.
 Schizoaffective disorder may occur in a variety of temporal patterns. The following is a typical
pattern: An individual may have pronounced auditory hallucinations and persecutory delusions for 2
months before the onset of a prominent major depressive episode. The psychotic symptoms and the
full major depressive episode are then present for 3 months. Then, the individual recovers
completely from the major depressive episode, but the psychotic symptoms persist for another
month before they too disappear.

Risk and Prognostic Factors

Genetic and physiological.
 Among individuals with schizophrenia, there may be an increased risk for schizoaffective disorder in
first-degree relatives.
 The risk for schizoaffective disorder may be increased among individuals who have a first-degree
relative with schizophrenia, bipolar disorder, or schizoaffective disorder.

Culture-Related Diagnostic Issues

 Cultural and socioeconomic factors must be considered, particularly when the individual and the
clinician do not share the same cultural and economic background.

Suicide Risk
 The lifetime risk of suicide for schizophrenia and schizoaffective disorder is 5%, and the presence of
depressive symptoms is correlated with a higher risk for suicide.

Functional Consequences
 Schizoaffective disorder is associated with social and occupational dysfunction, but dysfunction is
not a diagnostic criterion (as it is for schizophrenia), and there is substantial variability between
individuals diagnosed with schizoaffective disorder.

Differential Diagnosis
 Distinguishing schizoaffective disorder from schizophrenia and from depressive and bipolar
disorders with psychotic features is often difficult.
 Criterion C is designed to separate schizoaffective disorder from schizophrenia
 Criterion B is designed to distinguish schizoaffective disorder from a depressive or bipolar disorder
with psychotic features.
 Schizoaffective disorder can be distinguished from a depressive or bipolar disorder with psychotic
features due to the presence of prominent delusions and/or hallucinations for at least 2 weeks in
the absence of a major mood episode. In contrast, in depressive or bipolar disorders with psychotic
features, the psychotic features primarily occur during the mood episode(s).

Substance/Medication-Induced Psychotic Disorder

Diagnostic Criteria
A. Presence of one or both of the following symptoms:
1. Delusions.
2. 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.

Diagnostic Features
 The essential features of substance/medication-induced psychotic disorder are prominent delusions
and/or hallucinations (Criterion A) that are judged to be due to the physiological effects of a
substance/medication (i.e., a drug of abuse, a medication, or a toxin exposure) (Criterion B).
 Hallucinations that the individual realizes are substance/medication- induced are not included here
and instead would be diagnosed as substance intoxication

Associated Features Supporting Diagnosis

 Psychotic disorders can occur in association with intoxication with the following classes of
substances: alcohol; cannabis; hallucinogens, including phencyclidine and related substances;
inhalants; sedatives, hypnotics, and anxiolytics; stimulants (including cocaine); and other (or
unknown) substances.

Development and Course

 The initiation of the disorder may vary considerably with the substance. For example, smoking a
high dose of cocaine may produce psychosis within minutes, whereas days or weeks of high-dose
alcohol or sedative use may be required to produce psychosis.
 Alcohol-induced psychotic disorder, with hallucinations, usually occurs only after prolonged, heavy
ingestion of alcohol in individuals who have moderate to severe alcohol use disorder, and the
hallucinations are generally auditory in nature.
 Psychotic disorders induced by amphetamine and cocaine share similar clinical features.
 Persecutory delusions may rapidly develop shortly after use of amphetamine or a similarly acting
sympathomimetic. The hallucination of bugs or vermin crawling in or under the skin (formication)
can lead to scratching and extensive skin excoriations. Cannabis- induced psychotic disorder may
develop shortly after high-dose cannabis use and usually involves persecutory delusions, marked
anxiety, emotional lability, and depersonalization. The disorder usually remits within a day but in
some cases may persist for a few days.
 Substance/medication-induced psychotic disorder may at times persist when the offending agent is
removed, such that it may be difficult initially to distinguish it from an independent psychotic
disorder. Agents such as amphetamines, phencyclidine, and cocaine have been reported to evoke
temporary psychotic states that can sometimes persist for weeks or longer despite removal of the
agent and treatment with neuroleptic medication. I
 Polypharmacy for medical conditions and exposure to medications for parkinsonism, cardiovascular
disease, and other medical disorders may be associated with a greater likelihood of psychosis
induced by prescription medications as opposed to substances of abuse.

Psychotic Disorder Due to Another Medical Condition

Diagnostic Criteria
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 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.