condition), abnormal psychomotor behavior, and negative symptoms, as well as dimen-
sional assessments of depression and mania. Th e severity of mood symptoms in psychosis
has prognostic value  and guides treatment. There is growing evidence that schizoaffective


90 Schizophrenia Spectrum and Other Psychotic Disorders
disorder is not a distinct nosological catego ry. Thus, dimensional assessments of depres-
sion and mania for all psychotic disorders alert clinicians to mood pathology and the need
to treat where appropriate. The Section III sc ale also includes a dimensional assessment of
cognitive impairment. Many individuals with psychotic disorders have impairments in a
range of cognitive domains that predict functi onal status. Clinical neuropsychological as-
sessment can help guide diagnosis and treatm ent, but brief assessments without formal
neuropsychological assessment can provide us eful information that can be sufficient for
diagnostic purposes. Formal neuropsychological  testing, when conducted, should be ad-
ministered and scored by personnel trained in  the use of testing instruments. If a formal
neuropsychological assessment is not conducted, the clinician should use the best avail-
able information to make a judgment. Furthe r research on these assessments is necessary
in order to determine their c linical utility; thus, the assessments available in Section III
should serve as a prototype to  stimulate such research.
Schizotypal (Personality) Disorder
Criteria and text for schizotypal personality disorder can be found in the chapter “Person-
ality Disorders.” Because this disorder is cons idered part of the schizophrenia spectrum of
disorders, and is labeled in this section of ICD-9 and ICD-10 as schizotypal disorder, it is
listed in this chapter and disc ussed in detail in the DSM-5 chapter “Personality Disorders.”
Delusional Disorder
Diagnostic Criteria 297.1 (F22)
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.


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 an-
other medical condition and is not better ex plained 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 in-
volves 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.


Delusional Disorder 91
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 delu-
sions without a prominent persecutory or grandiose component).
Specify if:
With bizarre content:  Delusions are deemed bizarre if they are clearly implausible, not
understandable, and not derived from ordinary li fe experiences (e.g., an individual’s be-
lief that a stranger has removed his or her internal organs and replaced them with some-
one else’s organs without leaving 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, currentl y in acute episode:  First manifestation of the disorder meet-
ing the defining diagnostic symptom and time criteria. An acute episode is a time pe-
riod in which the symptom criteria are fulfilled.
First episode, currently in partial remission:  Partial remission  is a time period dur-
ing which an improvement after a previous episode is maintained and in which the de-
fining criteria of the disorder 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, curr ently in acute episode
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 subthreshold symptom periods be-
ing very brief relative to the overall course.
Unspecified
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,


Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor be-
havior, 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 delusional disorder can be made without using this severity specifier.
Subtypes
In erotomanic type,  the central theme of the delusion is that another person is in love with
the individual. The person about whom this conviction is held is usually of higher status
(e.g., a famous individual or a superior at work) but can be a complete stranger. Efforts to
contact the object of the delusion are common. In grandiose type, the central theme of the de-
lusion is the conviction of having some great talent or insight or of having made some im-
portant discovery. Less commo nly, the individual may have  the delusion of having a
special relationship with a prominent individu al or of being a prominent person (in which
case the actual individual may be regarded as an impostor). Grandiose delusions may
have a religious content. In jealous type,  the central theme of the delusion is that of an un-
faithful partner. This belief is arrived at with out due cause and is based on incorrect infer-
ences supported by small bits of “evidence”  (e.g., disarrayed clothing). The individual
with the delusion usually conf ronts the spouse or lover and at tempts to intervene in the


imagined infidelity. In persecutory type,  the central theme of the delusion involves the in-


92 Schizophrenia Spectrum and Other Psychotic Disorders
dividual’s belief of being conspired against,  cheated, spied on, followed, poisoned, mali-
ciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small slights
may be exaggerated and become the focus of a delusional system. The affected individual
may engage in repeated attempts to obtain sat isfaction by legal or legislative action. Indi-
viduals with persecutory delusions are often resentful and angry and may resort to vio-
lence against those they believe are hurting them. In somatic type,  the central theme of the
delusion involves bodily functi ons or sensations. Somatic de lusions can occur in several
forms. Most common is the belief that the indi vidual emits a foul odor ; that there is an in-
festation of insects on or in the skin; that ther e is an internal parasite; that certain parts of
the body are misshapen or ugly; or that parts of the body are not functioning.
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 presen tation that met Criterion A for schizophre-
nia (Criterion B). Apart from the direct impact  of the delusions, impairments in psychoso-
cial functioning may be more circumscribed th an 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 su bstance (e.g., cocaine) or another
medical condition (e.g., Alzheimer’s disease) and are not better explained by another men-
tal disorder, such as body dy smorphic disorder or obsessive- compulsive disorder (Crite-
rion E).
In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mani a symptom domains is vital for making crit-
ically important distinctions between the va rious schizophrenia spectrum and other psy-
chotic disorders.
Associated Features Supporting Diagnosis
Social, marital, or work problems can result from the delusional beliefs of delusional dis-
order. Individuals with delusional disorder ma y be able to factually describe that others
view their beliefs as irrational  but are unable to accept this themselves (i.e., there may be
“factual insight” but no true  insight). Many individuals de velop irritable or dysphoric
mood, which can usually be understood as a re action to their delusional beliefs. Anger and
violent behavior can occur with persecutory, jealous, and erotomanic types. The individ-
ual may engage in litigious or antagonistic behavior (e.g., sending hundreds of letters of
protest to the government). Legal difficulties can occur, particularly in jealous and eroto-
manic types.
Prevalence
The lifetime prevalence of delusional disorder has been estimated at around 0.2%, and the
most frequent subtype is persecutory. Delu sional disorder, jealous type, is probably more
common in males than in females, but there ar e no major gender differences in the overall
frequency of delu sional disorder.
Development and Course
On average, global function is generally better than that observed in schizophrenia. Al-


On average, global function is generally better than that observed in schizophrenia. Al-
though the diagnosis is generally stable, a pr oportion of individuals go on to develop


Delusional Disorder 93
schizophrenia. Delusional disorder has a significant familial relationship with both
schizophrenia and schizotypal personality diso rder. 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 backgr ound must be taken into  account in evaluat-
ing the possible presence of delusional di sorder. The content of delusions also varies
across cultural contexts.
Functional Consequences of Delusional Disorder
The functional impairment is usually more ci rcumscribed than that seen with other psy-
chotic disorders, although in some cases, the impairment may be substantial and include
poor occupational functioning and social isola tion. When poor psychosocial functioning is
present, delusional beliefs themselves ofte n play a significant role. A common character-
istic of individuals with delusional disorder is the apparent normality of their behavior
and appearance when their delusional idea s are not being discussed or acted on.
Differential Diagnosis
Obsessive-compulsive and related disorders. If an individual wi th obsessive-compul-
sive disorder is completely convinced that his or her obsessive-comp ulsive disorder beliefs
are true, then the diagnosis of obsessive-compulsive disorder, with absent insight/delu-
sional beliefs specifier, should be given rath er than a diagnosis of delusional disorder.
Similarly, if an individual with body dysm orphic disorder is completely convinced that
his or her body dysmorphic disorder beliefs are true, then the diagnosis of body dysmor-
phic disorder, with absent insight/delusional beliefs specifier, should be given rather than
a diagnosis of delusional disorder.
Delirium, major neurocognitive disorder, psychotic disorder due to another medical con-


Delirium, major neurocognitive disorder, psychotic disorder due to another medical con-
dition, and substance/medicati on-induced psychotic disorder. Individuals with these
disorders may present with symptoms that su ggest delusional disorder. For example, sim-
ple persecutory delusions in the context of major neurocognitive di sorder would be di-
agnosed as major neurocognitive  disorder, with behavioral  disturbance. A substance/
medication-induced psychotic disorder cross-sectionally may be identical in symptom-
atology to delusional disorder but can be di stinguished by the chronological relationship
of substance use to the onset and remission of the delusional beliefs.
Schizophrenia and schizophreniform disorder. Delusional disorder can be distinguished
from schizophrenia and schizophreniform disord er by the absence of the other character-
istic symptoms of the active phase of schizophrenia.
Depressive and bipolar disorders and schizoaffective disorder. These disorders may
be distinguished from delusional disorder by  the temporal relationship between the mood
disturbance and the delusions and by the severi ty of the mood symptoms. If delusions oc-
cur exclusively during mood episodes, the diag nosis is depressive or  bipolar disorder with
psychotic features. Mood sympto ms that meet full criteria for a mood episode can be su-
perimposed on delusional disorder. Delusional di sorder can be diagnose d only if the total
duration of all mood episodes remains brief rela tive to the total duration of the delusional
disturbance. If not, then a diagnosis of othe r specified or unspecified schizophrenia spec-
trum and other psychotic diso rder accompanied by other sp ecified depressi ve disorder,
unspecified depressive disorder, other specif ied bipolar and related disorder, or unspeci-


fied bipolar and related disorder is appropriate.


94 Schizophrenia Spectrum and Other Psychotic Disorders
Brief Psychotic Disorder
Diagnostic Criteria 298.8 (F23)
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.
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 circum-
stances in the individual’s culture.
With postpartum onset:  If onset is during pregnancy or within 4 weeks postpartum.
Specify if:
With catatonia  (refer to the criteria for catatonia associated with another mental dis-
order, pp. 119–120, for definition)
Coding note: Use additional code 293.89 (F06.1) catatonia associated with brief


psychotic 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 be-
havior, 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 brief psychotic disorder can be made without using this severity
specifier.
Diagnostic Features
The essential feature of brief psychotic disorder is a disturba nce that involves the sudden
onset of at least one of the following positive psychotic symptoms: delusions, hallucina-
tions, disorganized speech (e.g., frequent de railment or incoherence), or grossly abnormal
psychomotor behavior, includin g catatonia (Criterion A). Sudden onset  is defined as
change from a nonpsychotic state to a clearly psychotic state within 2 weeks, usually with-
out 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 (Cri-


Brief Psychotic Disorder 95
terion B). The disturbance is not better explai ned 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 condi-
tion (e.g., subdural hematoma) (Criterion C).
In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mani a symptom domains is vital for making crit-
ically important distinctions between the va rious schizophrenia spectrum and other psy-
chotic disorders.
Associated Features Supporting Diagnosis
Individuals with brief psychoti c disorder typically experience  emotional turmoil or over-
whelming confusion. They may have rapid sh ifts from one intense affect to another.
Although the disturbance is brief, the level of  impairment may be severe, and supervision
may be required to ensure that nutritional and hygienic needs are met and that the indi-
vidual is protected from the consequences of poor judgment, cognitive impairment, or act-
ing on the basis of delusions. There appears to  be an increased risk of suicidal behavior,
particularly during the acute episode.
Prevalence
In the United States, brief psychotic disorder  may account for 9% of cases of first-onset
psychosis. Psychotic disturbances that meet Crit eria A and C, but not Criterion B, for brief
psychotic disorder (i.e., duration of active symptoms is 1–6 months  as opposed to remis-
sion within 1 month) are more common in developing countries than in developed coun-
tries. Brief psychotic diso rder is twofold more common in females than in males.
Development and Course
Brief psychotic disorder may appear in adolescence or early adulthood, and onset can oc-


Brief psychotic disorder may appear in adolescence or early adulthood, and onset can oc-
cur across the lifespan, with the average age at onset being the mid 30s. By definition, a
diagnosis of brief psychotic disorder requir es a full remission of all symptoms and an
eventual full return to the premorbid level of functioning within 1 mont h of the onset of the
disturbance. In some individuals, the duration of psychotic symptoms may be quite brief
(e.g., a few days).
Risk and Prognostic Factors
Temperamental.  Preexisting personality disorders an d traits (e.g., schizotypal person-
ality disorder; borderline personality disorder; or traits in the psychoticism domain, such
as perceptual dysregulation, and the negative affectivity domain, such as suspiciousness)
may predispose the individual to the development of the disorder.
Culture-Related Diagnostic Issues
It is important to distinguish symptoms of br ief psychotic disorder from culturally sanc-
tioned response patterns. For example, in so me religious ceremonies, an individual may
report hearing voices, but these do not genera lly persist and are not perceived as abnormal
by most members of the indivi dual’s community. In addition , cultural and religious back-
ground must be taken into account when considering whether be liefs are delusional.
Functional Consequences of  Brief Psychotic Disorder
Despite high rates of relapse, for most indivi duals, outcome is excellent in terms of social
functioning and symptomatology.


96 Schizophrenia Spectrum and Other Psychotic Disorders
Differential Diagnosis
Other medical conditions. A variety of medical disorders can manifest with psychotic
symptoms of short duration. Psychotic disorder  due to another medica l condition or a de-
lirium is diagnosed when there is evidence from  the history, physical examination, or lab-
oratory tests that the delusions or hallucinati ons are the direct physiological consequence
of a specific medical condition (e.g., Cushing’s syndrome, brain tumor) (see “Psychotic
Disorder Due to Another Medical Co ndition” later in this chapter).
Substance-related disorders. Substance/medication-induced psychotic disorder, sub-
stance-induced delirium, and substance intoxication are distinguished from brief psychotic
disorder by the fact that a substance (e.g., a drug of abuse, a medication, exposure to a toxin)
is judged to be etiologically related to the psychotic symp toms (see “Substance/Medication-
Induced Psychotic Disorder” later in this chapte r). Laboratory tests, such as a urine drug
screen or a blood alcohol level, may be helpful in making this determination, as may a care-
ful history of substance use with attention to  temporal relationships between substance in-
take and onset of the symp toms and to the nature of the substance being used.
Depressive and bipolar disorders. The diagnosis of brief psychotic disorder cannot be
made if the psychotic symptoms are better explained by a mood episode (i.e., the psychotic
symptoms occur exclusively during a full major depressive, manic, or mixed episode).
Other psychotic disorders. If the psychotic symptoms pers ist for 1 month or longer, the
diagnosis is either schizophr eniform disorder, delusional disorder, depressive disorder
with psychotic features, bipolar disorder with psychotic fe atures, or other specified or un-


with psychotic features, bipolar disorder with psychotic fe atures, or other specified or un-
specified schizophrenia spectrum and other psychotic disorder, depending on the other
symptoms in the presentation. The differentia l diagnosis between brief psychotic disorder
and schizophreniform disorder is difficult wh en the psychotic symptoms have remitted be-
fore 1 month in response to successful trea tment with medication. Careful attention should
be given to the possibility that a recurrent diso rder (e.g., bipolar disorder, recurrent acute ex-
acerbations of schizophrenia) may be respon sible for any recurring  psychotic episodes.
Malingering and factitious disorders. An episode of factitious disorder, with predomi-
nantly psychological signs and symptoms, may have the appearance of brief psychotic
disorder, but in such cases there is evidence that the symptoms are intentionally produced.
When malingering involves apparently psyc hotic symptoms, there is usually evidence
that the illness is being feigned for an understandable goal.
Personality disorders. In certain individual s with personality disorders, psychosocial
stressors may precipitate brief periods of psychotic symptoms. These symptoms are usu-
ally transient and do not warrant a separate diagnosis. If psychotic symptoms persist for at
least 1 day, an additional diagnosis of br ief psychotic disorder  may be appropriate.
Schizophreniform Disorder
Diagnostic Criteria 295.40 (F20.81)
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.


4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).


Schizophreniform Disorder 97
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 “provi-
sional.”
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 dur-
ing 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:  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 f unctioning; 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  (refer to the criteria for catatonia associated with another mental disor-
der, pp. 119–120, for definition).
Coding note:  Use additional code 293.89 (F06.1) catatonia associated with schizo-
phreniform 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 be-


including delusions, hallucinations, disorganized speech, abnormal psychomotor be-
havior, 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 Supp orting Diagnosis, Develop-
ment and Course (age-related factors), Culture-Related Diag nostic Issues, Gender-Related
Diagnostic Issues, Differential Diagnosis, and Comorbidity, see the corresponding sec-
tions in schizophrenia.
Diagnostic Features
The characteristic symptoms of  schizophreniform disorder are identical to those of schizo-
phrenia (Criterion A). Schizophreniform disorder is distinguish ed by its difference in du-
ration: the total duration of the illness, includ ing prodromal, active, and residual phases, is
at least 1 month but less than 6 months (Crite rion B). The duration requirement for schizo-
phreniform disorder is intermediate between th at 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 ep-
isode 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


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 indi-
vidual will recover from the disturbance within  the 6-month period. If the disturbance per-
sists beyond 6 months, the diagnosis should be changed to schizophrenia.


98 Schizophrenia Spectrum and Other Psychotic Disorders
Another distinguishing feature of schizophren iform disorder is the lack of a criterion
requiring impaired social and occupational functioning. While such  impairments may po-
tentially 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 mani a symptom domains is vital for making crit-
ically important distinctions between the va rious schizophrenia spectrum and other psy-
chotic disorders.
Associated Features Supporting Diagnosis
As with schizophrenia, currently there are no laboratory or psychometric tests for schizo-
phreniform disorder. There are multiple brain regions where ne uroimaging, neuropa-
thological, and neurophy siological research has indicated abnormalities, but none are
diagnostic.
Prevalence
Incidence of schizophreniform disorder across sociocultural settings is likely similar to
that observed in schizophrenia. In the United States and other developed countries, the in-
cidence is low, possibly fivefold less than th at of schizophrenia. In developing countries,
the incidence may be higher, especially for th e specifier “with good prognostic features”;
in some of these settings schizophreniform disorder may be as common as schizophrenia.
Development and Course
The development of schizophreniform disorder  is similar to that of schizophrenia. About
one-third of individuals with an initial di agnosis of schizophreniform disorder (provi-
sional) recover within the 6-mo nth period and schizophreniform disorder is their final di-
agnosis. The majority of the remaining two-th irds 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


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 schizo phreniform disorder who eventually receive a
diagnosis of schizophrenia or schizoaffective disorder, the functional consequences are
similar to the consequences of those disorder s. Most individuals ex perience dysfunction in
several areas of daily functioning, such as sc hool or work, interperso nal relationships, and
self-care. Individuals who recover from schi zophreniform disorder ha ve better functional
outcomes.
Differential Diagnosis
Other mental disorders and medical conditions. A wide variety of mental and medical
conditions can manifest with psychotic sympto ms that must be considered in the differ-
ential diagnosis of schizophreniform disord er. These include psychotic disorder due to
another medical condition or its treatment; delirium or major neurocognitive disorder;
substance/medication-induced psychotic diso rder or delirium; depressive or bipolar
disorder with psychotic features; schizoaffectiv e disorder; other specified or unspecified bi-
polar and related disorder; depressive or bipola r disorder with catatonic features; schizophre-


Schizophrenia 99
nia; brief psychotic disorder; delusional diso rder; other specified or  unspecified schizo-
phrenia spectrum and other psychotic diso rder; schizotypal, schizoid, or paranoid
personality disorders; autism spectrum disorder; disorders presenting in childhood with
disorganized speech; attention-deficit/hype ractivity disorder; ob sessive-compulsive dis-
order; posttraumatic stress diso rder; 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 schizophre-
nia also applies to schizophreniform disorder.
Brief psychotic disorder. Schizophreniform disorder differs  in duration from brief psy-
chotic disorder, which has a duration of less than 1 month.
Schizophrenia
Diagnostic Criteria 295.90 (F20.9)
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 function-
ing 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).


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 Cri-
terion 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-phas e 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 child-
hood onset, the additional diagnosis of schizophrenia is made only if prominent delu-
sions or hallucinations, in addition to the other required symptoms of schizophrenia,
are also present for at least 1 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, currentl y in acute episode:  First manifestation of the disorder meet-
ing the defining diagnostic symptom and time criteria. An acute episode is a time pe-
riod in which the symptom criteria are fulfilled.


100 Schizophrenia Spectrum and Other Psychotic Disorders
First episode, currently in partial remission:  Partial remission  is a period of time
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 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 in acute episode:  Multiple episodes may be deter-
mined 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 subthreshold symptom periods be-
ing very brief relative to the overall course.
Unspecified
Specify if:
With catatonia  (refer to the criteria for catatonia associated with another mental disorder,
pp. 119–120, for definition).
Coding note:  Use additional code 293.89 (F06.1) catatonia associated with
schizophrenia 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 be-
havior, 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.”)


Severity in the chapter “Assessment Measures.”)
Note:  Diagnosis of schizophrenia can be made without using this severity specifier.
Diagnostic Features
The characteristic symptoms of schizophrenia involve a range of cogn itive, behavioral, and
emotional dysfunctions, but no single sympto m is pathognomonic of the disorder. The di-
agnosis involves the recognition of a constellation of sign s and symptoms associated with
impaired occupational or social functioning. Individuals with the disorder will vary sub-
stantially on most features, as schizophrenia is a heterogeneous clinical syndrome.
At least two Criterion A symptoms must be  present for a significant portion of time
during a 1-month period or longer. At least one of these symptoms must be the clear pres-
ence of delusions (Criterion A1), hallucinati ons (Criterion A2), or disorganized speech
(Criterion A3). Grossly disorganized or ca tatonic behavior (Criterion A4) and negative
symptoms (Criterion A5) may also be present.  In those situations in which the active-
phase symptoms remit within a mo nth in response to treatment, Criterion A is still met if the
clinician estimates that they would have persisted in the absence of treatment.
Schizophrenia involves impairment in one or more major areas of functioning (Crite-
rion B). If the disturbance begins in childhood or adolescence,  the expected level of func-
tion is not attained. Co mparing the individual with unaffected siblings may be helpful. The
dysfunction persists for a substantial period du ring the course of the disorder and does not
appear to be a direct result of any single feature. Avolition (i.e., reduced drive to pursue
goal-directed behavior; Criterion A5) is linked to the social dysfunction described under
Criterion B. There is also strong evidence for a relationship betw een cognitive impairment


Criterion B. There is also strong evidence for a relationship betw een cognitive impairment
(see the section “Associated Features Supporting Diagnosis” for this disorder) and func-
tional impairment in individuals with schizophrenia.


Schizophrenia 101
Some signs of the disturbance must persist for a continuous period of at least 6 months
(Criterion C). Prodromal symptoms often prec ede the active phase,  and residual symp-
toms may follow it, characterized by mild or subthreshold forms of hallucinations or
delusions. Individuals may express a variety of unusual or odd beliefs that are not of de-
lusional proportions (e.g., ideas of reference or  magical thinking); they may have unusual
perceptual experiences (e.g., sensing the pres ence of an unseen person); their speech may
be generally understandable but vague; and their behavior may be unusual but not grossly
disorganized (e.g., mumbling in public). Negative symptoms are common in the pro-
dromal and residual phases and can be seve re. Individuals who had been socially active
may become withdrawn from previous routines . Such behaviors are often the first sign of
a disorder.
Mood symptoms and full mood episodes ar e common in schizophrenia and may be con-
current with active-phase symptomatology. However, as distinct from a psychotic mood dis-
order, a schizophrenia diagnosis requires the presence of delusions or hallucinations in the
absence of mood episodes. In addition, mood ep isodes, taken in total,  should be present for
only a minority of the total duration of th e active and residual periods of the illness.
In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mani a symptom domains is vital for making crit-
ically important distinctions between the va rious schizophrenia spectrum and other psy-
chotic disorders.
Associated Features Supporting Diagnosis
Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the ab-
sence 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 refu sal. Depersonalization, derealization, and so-
matic concerns may occur and sometimes reac h delusional proportions. Anxiety and pho-
bias are common. Cognitive deficits in schi zophrenia are common and are strongly linked
to vocational and functional impairments. Thes e deficits can include decrements in declar-
ative memory, working memory, language function, and other executive functions, as well
as slower processing speed. Ab normalities 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 th e generation of explanatory delusions. These
impairments frequently persist during symptomatic remission.
Some individuals with psychosis may lack insi ght 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 cour se of the illness. Unawareness of illness is
typically a symptom of schizophrenia itself rath er than a coping strategy. It is comparable
to the lack of awareness of neurological  deficits following brain damage, termed anoso-
gnosia.  This symptom is the most common predicto r of non-adherence to treatment, and it
predicts higher relapse rates, increased numb er of involuntary trea tments, poorer psycho-
social functioning, aggression, and a poorer course of illness.
Hostility and aggression can be associated  with schizophrenia, although spontaneous


Hostility and aggression can be associated  with schizophrenia, although spontaneous
or random assault is uncommon. Aggression is more frequent for younger males and for
individuals with a past history of violence, non-adherenc e with treatment, substance
abuse, and impulsivity. It should be noted that the vast majority of persons with schizo-


individuals with a past history of violence, non-adherenc e with treatment, substance
abuse, and impulsivity. It should be noted that the vast majority of persons with schizo-
phrenia are not aggressive and are more frequently victimized than are individuals in the
general population.
Currently, there are no radiological, laborato ry, or psychometric tests for the disorder.
Differences are evident in multiple brain regions between groups of healthy individuals


102 Schizophrenia Spectrum and Other Psychotic Disorders
and persons with schizophrenia, including ev idence from neuroimaging, neuropatholog-
ical, and neurophysiological studies. Differences  are also evident in cellular architecture,
white matter connectivity, and gray matter volume in a vari ety of regions such as the pre-
frontal and temporal cortices. Reduced overall brain volume has been observed, as well as
increased brain volume reduction with age. Brain volume reductions with age are more
pronounced in individuals with schizophrenia than in healthy individuals. Finally, indi-
viduals with schizophrenia appear to differ from individuals withou t the disorder in eye-
tracking and electrophysiological indices.
Neurological soft signs common in individuals with schizophrenia include impairments
in motor coordination, sensory integration, and motor sequencing of complex movements;
left-right confusion; and disinhibition of associated mo vements. In addition, minor phys-
ical anomalies of the face and limbs may occur.
Prevalence
The lifetime prevalence of schizophrenia appears to be approximately 0.3%–0.7%, al-
though there is reported variation by race/ethnicity, across countries, and by geographic
origin for immigrants and children of immigr ants. The sex ratio differs across samples and
populations: for example, an emphasis on nega tive symptoms and longer duration of dis-
order (associated with poorer outcome) show s 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 ep-


isode 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 develop-
ment 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 pre-
dictor 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 cognitiv e impairment, and in general a worse out-
come. Impaired cognition is common, and altera tions in cognition are present during de-
velopment and precede the emergence of psycho sis, 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 la rgely 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 indi viduals 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 re-
lated 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 th e same in childhood, but it is more diffi-


The essential features of schizophrenia are th e same in childhood, but it is more diffi-
cult to make the diagnosis. In children, delu sions and hallucinations may be less elaborate
than in adults, and visual hallucinations are more common and should be distinguished


cult to make the diagnosis. In children, delu sions and hallucinations may be less elaborate
than in adults, and visual hallucinations are more common and should be distinguished
from normal fantasy play. Disorganized speec h occurs in many disorders with childhood
onset (e.g., autism spectrum disorder), as does  disorganized behavior (e.g., attention-deficit/


Schizophrenia 103
hyperactivity disord er). 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 diag nosis of schizophrenia are more likely to
have experienced nonspecific emotional-behavioral distur bances and psychopathology,
intellectual and language alterati ons, and subtle motor delays.
Late-onset cases (i.e., onset after age 40 ye ars) are overrepresent ed by females, who
may have married. Often, the course is ch aracterized by a predom inance of psychotic
symptoms with preservation of affect and soci al functioning. Such late-onset cases can still
meet the diagnostic crit eria for schizophrenia, but it is not yet clear whether this is the
same condition as schizophrenia diagnosed prio r 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, in-
cluding late winter/early spring in some locations and summer for the deficit form of the
disease. The incidence of schizophrenia and related disorders is high er for children grow-
ing up in an urban environment an d for some minority ethnic groups.
Genetic and physiological. There is a strong contribution  for genetic factors in deter-
mining risk for schizophrenia, although most individuals who have been diagnosed with
schizophrenia have no family history of psyc hosis. Liability is conferred by a spectrum of
risk alleles, common and rare, with each allele contributing only a small fraction to the to-
tal population variance. The risk alleles identi fied to date are also associated with other
mental disorders, including bipolar disorder, depression, an d autism spectrum disorder.


mental disorders, including bipolar disorder, depression, an d autism spectrum disorder.
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, in fection, malnutrition, maternal diabetes, and
other medical conditions, have been linked wi th schizophrenia. However, the vast major-
ity of offspring with these risk factors do not deve lop schizophrenia.
Culture-Related Diagnostic Issues
Cultural and socioeconomic factors must be considered, particularly  when the individual
and the clinician do not share the same cult ural and socioeconomic background. Ideas that
appear to be delusional in one culture (e.g.,  witchcraft) may be commonly held in another.
In some cultures, visual or auditory halluci nations with a religious  content (e.g., hearing
God’s voice) are a normal part of religious experience. In addition, the assessment of dis-
organized speech may be made difficult by lin guistic variation in narrative styles across
cultures. The assessment of affect requires sens itivity to differences in  styles of emotional
expression, eye contact, and body language, wh ich vary across cultures. If the assessment
is conducted in a language that is differen t from the individual’s  primary language, care
must be taken to ensure that alogia is not rela ted to linguistic barriers. In certain cultures,
distress may take the form of hallucinations or pseudo -hallucinations and overvalued
ideas that may present clinically similar to true psychosis but are normative to the pa-
tient’s subgroup.
Gender-Related Diagnostic Issues
A number of features distinguish the clinical expression of schizophrenia in females and
males. The general incidence of schizophrenia tends to be slightly lower in females, par-


males. The general incidence of schizophrenia tends to be slightly lower in females, par-
ticularly among treated cases. The age at onset is later in females, with a second mid-life
peak as described earlier (see the section “D evelopment and Course” for this disorder).
Symptoms tend to be more affect-laden am ong females, and there are more psychotic


peak as described earlier (see the section “D evelopment and Course” for this disorder).
Symptoms tend to be more affect-laden am ong females, and there are more psychotic
symptoms, as well as a greater propensity for psychotic symptoms to worsen in later life.


104 Schizophrenia Spectrum and Other Psychotic Disorders
Other symptom differences include less freque nt negative symptoms and disorganization.
Finally, social functioning tends to remain better preserved in females. There are, how-
ever, frequent exceptions to these general caveats.
Suicide Risk
Approximately 5%–6% of individuals with schizophrenia die by suicide, about 20% attempt
suicide on one or more occasions, and many mo re have significant suicidal ideation. Suicidal
behavior is sometimes in response to command  hallucinations to harm oneself or others.
Suicide risk remains high over the whole lifespan for males an d females, although it may be
especially high for younger males with comorb id substance use. Other risk factors include
having depressive symptoms or feelings of hopelessness and being unemployed, and the
risk is higher, also, in the period after a psychotic episode or hospital discharge.
Functional Consequences of Schizophrenia
Schizophrenia is associated with significant social and occupational dysfunction. Making
educational progress and maintaining employment are frequently impaired by avolition
or other disorder manifestatio ns, even when the cognitive sk ills are sufficient for the tasks
at hand. Most individuals are employed at a lower level than their parents, and most, par-
ticularly men, do not marry or have limited social contacts outside of their family.
Differential Diagnosis
Major depressive or bipolar disorder with psychotic or catatonic features. The distinc-
tion between schizophrenia and major depre ssive or bipolar disorder with psychotic
features or with catatonia depends on the te mporal relationship between the mood distur-
bance and the psychosis, and on the severity of the depressive or manic symptoms. If de-
lusions or hallucinations occur exclusively during a major depressive or manic episode,
the diagnosis is depressive or bipolar disorder with ps ychotic features.


the diagnosis is depressive or bipolar disorder with ps ychotic features.
Schizoaffective disorder. 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 an d brief psychotic disorder. These disorders are of shorter
duration than schizophrenia as specified in Cr iterion C, which requires 6 months of symp-
toms. In schizophreniform disorder, the disturbance is present less than 6 months, and in
brief psychotic disorder, symp toms are present at least 1 day but less than 1 month.
Delusional disorder. Delusional disorder can be distinguished from schizophrenia by
the absence of the other symptoms characteristic of schizophrenia (e.g., delusions, prom-
inent auditory or visual halluc inations, disorganized speech, grossly disorganized or cata-
tonic behavior, negative symptoms).
Schizotypal personality disorder. Schizotypal personality disorder may be distinguished
from schizophrenia by subthres hold symptoms that are associ ated with persistent person-
ality 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 schizophren ia by their prominent obsessions, compul-
sions, preoccupations with appearance or bo dy odor, hoarding, or body-focused repeti-
tive behaviors.
Posttraumatic stress disorder. Posttraumatic stress disorder  may include flashbacks that
have a hallucinatory quality, and hypervigilanc e may reach paranoid proportions. But a trau-


Schizoaffective Disorder 105
matic 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 defi-
cits in social interaction with repetitive an d restricted behaviors and other cognitive and
communication deficits. An individual with autism spectrum disord er or communication
disorder must have symptoms that meet fu ll criteria for schizophrenia, with prominent
hallucinations or delusions for at least 1 mont h, in order to be diagnosed with schizophre-
nia as a comorbid condition.
Other mental disorders associated with a psychotic episode. The diagnosis of schizo-
phrenia is made only when the psychotic episode  is persistent and not attributable to the
physiological effects of a subs tance or another medical condit ion. Individuals with a de-
lirium or major or minor neurocognitive disorder may present with psychotic symptoms,
but these would have a temporal relationship to the onset of cognit ive changes consistent
with those disorders. Individuals with subs tance/medication-induced psychotic disorder
may present with symptoms char acteristic of Criterion A for schizophrenia, but the sub-
stance/medication-induced psyc hotic disorder can usually be distinguished by the chron-
ological relationship of subs tance use to the onset and remi ssion of the psychosis in the
absence of substance use.
Comorbidity
Rates of comorbidity with substance-relate d disorders are high in schizophrenia. Over
half of individuals with schizophrenia have  tobacco use disorder and smoke cigarettes
regularly. Comorbidity with anxiety disorder s is increasingly recognized in schizophre-
nia. Rates of obsessive-compulsive disorder and panic disorder are elevated in individuals


nia. Rates of obsessive-compulsive disorder and panic disorder are elevated in individuals
with schizophrenia compared with the general population. Schizotypal or paranoid per-
sonality disorder may sometimes pr ecede the onset of schizophrenia.
Life expectancy is reduced in individual s with schizophrenia because of associated
medical conditions. Weight gain, diabetes, metabolic syndrome, and cardiovascular and
pulmonary disease are more common in schi zophrenia than in the general population.
Poor engagement in health maintenance behavi ors (e.g., cancer screening, exercise) in-
creases the risk of chronic disease, but other disorder factors, including medications, life-
style, cigarette smoking, and diet, may also  play a role. A shared vulnerability for
psychosis and medical disorders may explain so me of the medical comorbidity of schizo-
phrenia.
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 epi-
sode (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.


106 Schizophrenia Spectrum and Other Psychotic Disorders
Specify whether:
295.70 (F25.0)  Bipolar type:  This subtype applies if a manic episode is part of the pre-
sentation. Major depressive episodes may also occur.
295.70 (F25.1)  Depressive type:  This subtype applies if only major depressive epi-
sodes are part of the presentation.
Specify if:
With catatonia  (refer to the criteria for catatonia associated with another mental disorder,
pp. 119–120, for definition).
Coding note:  Use additional code 293.89 (F06.1) catatonia associated with
schizoaffective disorder to indicate the presence of the comorbid 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, currentl y in acute episode:  First manifestation of the disorder meet-
ing the defining diagnostic symptom and time criteria. An acute episode  is a time pe-
riod in which the symptom criteria are fulfilled.
First episode, currently in partial remission:  Partial remission  is a time period dur-
ing which an improvement after a previous episode is maintained and in which the de-
fining criteria of the disorder 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 in acute episode:  Multiple episodes may be deter-
mined 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


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 subthreshold symptom periods be-
ing 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 be-
havior, 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 schizoaffective disorder can be made without using this severity
specifier.
Note:  For additional information on Developmen t and Course (age-related factors), Risk
and Prognostic Factors (environmental risk factors), Culture-Related Diagnostic Issues,
and Gender-Related Diagnostic Issues, see th e corresponding sections in schizophrenia,
bipolar I and II disorders, an d major depressive disorder in their respective chapters.
Diagnostic Features
The diagnosis of schizoaffective disorder is based on the assessment of an uninterrupted
period of illness during which the individual co ntinues to display active or residual symp-
toms 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


Schizoaffective Disorder 107
has to be met. Criteria B (soc ial dysfunction) and F (exclusion  of autism sp ectrum 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 in-
terest or pleasure is common in schizophrenia,  to meet Criterion A for schizoaffective dis-
order, the major depressive episode must in clude pervasive depressed mood (i.e., the
presence of markedly diminished interest or pleasure is not sufficie nt). Episodes of de-
pression 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 schi zoaffective disorder). To separate schizoaf-
fective disorder from a depressive or bipola r disorder with psychotic features, delusions
or hallucinations must be present for at least  2 weeks in the absence of a major mood epi-
sode (depressive or manic) at some point duri ng the lifetime duration  of the illness (Cri-
terion B for schizoaffective disorder). The symptoms must not be attributable to the effects
of a substance or another medical condition (Criterion D for schi zoaffective disorder).
Criterion C for schizoaf fective disorder specifies that mood symptoms meeting criteria
for a major mood episode must be present for the majority of the total duration of the ac-
tive and residual portion of the illness. Criter ion C requires the asses sment of mood symp-
toms for the entire course of a psychotic illnes s, which differs from th e criterion in DSM-IV,


which required only an assessment of the curr ent period of illness. If the mood symptoms
are present for only a relative ly brief period, the diagnosis is schizophrenia, not schizoaf-
fective disorder. When deciding whether an individual’s presentation meets Criterion C,
the clinician should review the total duration of psychotic illness (i.e., both active and re-
sidual symptoms) and determine when significa nt mood symptoms (untreated or in need
of treatment with antidepressant and/or mo od-stabilizing medication) accompanied the
psychotic symptoms. This determination requir es sufficient histor ical information and
clinical judgment. For example, an individual with a 4-year history of active and residual
symptoms of schizophrenia develops depressi ve and manic episodes that, taken together,
do not occupy more than 1 year during the 4- year history of psycho tic illness. This presen-
tation would not meet Criterion C.
In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mani a symptom domains is vital for making crit-
ically important distinctions between the va rious schizophrenia spectrum and other psy-
chotic disorders.
Associated Features Supporting Diagnosis
Occupational functioning is frequently impair ed, but this is not a defining criterion (in
contrast to schizophrenia). Restricted social contact and difficulties with self-care are as-
sociated 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 com-
mon in schizoaffective disorder, but the deficits in insight may be less severe and perva-
sive than those in schizophrenia. Individual s with schizoaffective disorder may be at
increased risk for later developing episodes of  major depressive disorder or bipolar disor-


increased risk for later developing episodes of  major depressive disorder or bipolar disor-
der if mood symptoms contin ue following the remission of symptoms meeting Criterion A
for schizophrenia. There may be associated al cohol and other substance-related disorders.
There are no tests or biological measures that can assist in making the diagnosis of
schizoaffective disorder. Whether schizoaffe ctive disorder differs from schizophrenia


There are no tests or biological measures that can assist in making the diagnosis of
schizoaffective disorder. Whether schizoaffe ctive disorder differs from schizophrenia
with regard to associated features such as structural or function al brain abnormalities,
cognitive deficits, or geneti c risk factors is not clear.
Prevalence
Schizoaffective disorder appe ars to be about one-third as common as schizophrenia. Life-
time prevalence of schizoaffective disorder  is estimated to be 0.3%. The incidence of


108 Schizophrenia Spectrum and Other Psychotic Disorders
schizoaffective disorder is higher  in females than in males, mainly due to an increased in-
cidence of the depressive type among females.
Development and Course
The typical age at onset of schizoaffective di sorder is early adulthood, although onset can
occur anywhere from adolescence to late in lif e. A significant number of individuals diag-
nosed with another psychotic illness initially will receive the diagnosis schizoaffective dis-
order later when the pattern of mood epis odes has become more apparent. With the
current diagnostic Criterion C, it is expected  that the diagnosis for some individuals will
convert from schizoaffective d isorder to another disorder as mood symptoms become less
prominent. The prognosis for schizoaffective di sorder is somewhat better than the prog-
nosis 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 per-
secutory delusions for 2 months  before the onset of a prom inent major depressive episode.
The psychotic symptoms and the full major depr essive episode are then present for 3 months.
Then, the individual recovers completely fr om the major depressive episode, but the psy-
chotic symptoms persist for another month be fore they too disappear. During this period
of illness, the individual’s symptoms concurre ntly met criteria for a major depressive ep-
isode and Criterion A for schizophrenia, and during this same period of illness, auditory
hallucinations and delusions were present both before and after the depressive phase. The
total period of illness lasted for about 6 mo nths, with psychotic sy mptoms alone present
during the initial 2 months, both depressive  and psychotic symptoms present during the


during the initial 2 months, both depressive  and psychotic symptoms present during the
next 3 months, and psychotic symptoms alone pr esent during the last month. In this in-
stance, the duration of the depressive episode was not brief relative to the total duration of
the psychotic disturbance, and thus the presen tation qualifies for a diagnosis of schizoaf-
fective disorder.
The expression of psychotic symptoms across the lifespan is variable. Depressive or
manic symptoms can occur before the onset of psychosis, during acute psychotic episodes,
during residual periods, and after cessation of psychosis. For example, an individual
might present with prominent mood symptoms  during the prodromal stage of schizo-
phrenia. This pattern is not necessarily indicative  of schizoaffective disorder, since it is the
co-occurrence of psychotic and mood symptoms  that is diagnostic. For an individual with
symptoms that clearly meet the criteria for sc hizoaffective disorder but who on further fol-
low-up only presents with residual psychoti c symptoms (such as subthreshold psychosis
and/or prominent negative symptoms), the diagnosis may be changed to schizophrenia,
as the total proportion of psychotic illness compared with mood symptoms becomes more
prominent. Schizoaffective diso rder, bipolar type, may be more common in young adults,
whereas schizoaffective disorder, depressive type, may be more common in older adults.
Risk and Prognostic Factors
Genetic and physiological. Among individuals with schizophrenia, there may be an in-
creased risk for schizoaffective disorder in first-degree relatives. The risk for schizoaffec-
tive disorder may be increased among indivi duals who have a first- degree relative with
schizophrenia, bipolar disorder, or schizoaffective disorder.
Culture-Related Diagnostic Issues


Culture-Related Diagnostic Issues
Cultural and socioeconomic factors must be considered, particularly  when the individual
and the clinician do not share the same cultur al and economic backgr ound. Ideas that ap-
pear to be delusional in one culture (e.g., witchcraft) may be commonly held in another.


and the clinician do not share the same cultur al and economic backgr ound. Ideas that ap-
pear to be delusional in one culture (e.g., witchcraft) may be commonly held in another.
There is also some evidence in the literature for the overdiagnosis of schizophrenia com-


Schizoaffective Disorder 109
pared with schizoaffective disorder in Afri can American and Hispanic populations, so
care must be taken to ensure a culturally appropri ate evaluation that includes both psy-
chotic and affective symptoms.
Suicide Risk
The lifetime risk of suicide for schizophreni a and schizoaffective disorder is 5%, and the
presence of depressive symptoms is correlated with a higher risk for suicide. There is ev-
idence that suicide rates are higher in North American populations than in European,
Eastern European, South American, and Indian  populations of individuals with schizo-
phrenia or schizoaffective disorder.
Functional Consequences of  Schizoaffective Disorder
Schizoaffective disorder is associated with social and occupational dysfunction, but dys-
function is not a diagnostic criterion (as it is for schizophrenia), an d there is substantial
variability between individuals diagno sed with schizoaffective disorder.
Differential Diagnosis
Other mental disorders and medical conditions. A wide variety of psychiatric and med-
ical conditions can manifest with psychotic and mood symptoms that must be considered
in the differential diagnosis of  schizoaffective disorder. Th ese include psychotic disorder
due to another medical condition; delirium; major neurocognitive disorder; substance/
medication-induced psychotic disorder or neurocognitive disorder; bipolar disorders
with psychotic features; major depressive diso rder with psychotic features; depressive or
bipolar disorders with catatonic features; schi zotypal, schizoid, or paranoid personality
disorder; brief psychotic disorder; schizophre niform disorder; schizophrenia; delusional
disorder; and other specified and unspecified schizophrenia spectrum and other psychotic
disorders. Medical conditions and substance use can present with a combination of psy-
chotic and mood symptoms, and thus psychoti c disorder due to another medical condition


chotic and mood symptoms, and thus psychoti c disorder due to another medical condition
needs to be excluded. Distinguishing schizoaffective disorder from schizophrenia and
from depressive and bipolar diso rders with psychotic features  is often difficult. Criterion
C is designed to separate schizoaffective di sorder from schizophrenia, and Criterion B is
designed to distinguish schizoaffective diso rder from a depressive or bipolar disorder
with psychotic features. More specifically, schizoaffective disorder can be distinguished
from a depressive or bipolar disorder with psyc hotic features due to the presence of prom-
inent delusions and/or hallucinations for at least 2 weeks in the absence of a major mood
episode. In contrast, in depressive or bipo lar disorders with psychotic features, the psy-
chotic features primarily occur during the mo od episode(s). Because the relative propor-
tion of mood to psychotic symptoms may ch ange over time, the appropriate diagnosis
may change from and to schizoaffective disord er (e.g., a diagnosis of schizoaffective dis-
order for a severe and prominent major depre ssive episode lasting 3 months during the
first 6 months of a persistent psychotic illnes s would be changed to schizophrenia if active
psychotic or prominent residual symptoms pe rsist over several years without a recurrence
of another mood episode).
Psychotic disorder due to another medical condition. Other medical conditions and
substance use can manifest with a combinat ion of psychotic and mood symptoms, and
thus psychotic disorder due to another medical condition needs to be excluded.
Schizophrenia, bipolar, and depressive disorders. Distinguishing schizoaffective dis-
order from schizophrenia and from depressiv e and bipolar disorders with psychotic fea-
tures is often difficult. Criterion C is design ed to separate schizoaffective disorder from


tures is often difficult. Criterion C is design ed to separate schizoaffective disorder from
schizophrenia, and Criterion B is  designed to distinguish schi zoaffective disorder from a


110 Schizophrenia Spectrum and Other Psychotic Disorders
depressive or bipolar disorder with psychoti c features. More specifically, schizoaffective
disorder can be distinguished from a depressive or bipolar disorder with psychotic features
based on the presence of prom inent delusions and/or hallucinations for at least 2 weeks in
the absence of a major mood episode. In cont rast, in depressive or bipolar disorder with
psychotic features, the psychoti c features primarily occur duri ng the mood episode(s). Be-
cause the relative proportion of mood to ps ychotic symptoms may change over time, the
appropriate diagnosis may change from and to  schizoaffective disorder. (For example, a
diagnosis of schizoaffective disorder for a se vere and prominent major depressive episode
lasting 3 months during the first 6 months of  a chronic psychotic illness would be changed
to schizophrenia if active ps ychotic or prominent residual symptoms persist over several
years without a recurrence of another mood episode.)
Comorbidity
Many individuals diagnosed with schizoaffect ive disorder are also diagnosed with other
mental disorders, especially substance use d isorders and anxiety disorders. Similarly, the
incidence of medical conditions is increase d above base rate for the general population
and leads to decre ased life expectancy.
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 Crite-
rion A.


rion 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 in-
clude the following:
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 severe intoxication; or there is other evidence of an indepen-
dent non-substance/medication-induced psychotic disorder (e.g., a history of recur-
rent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and when they are sufficiently severe to warrant clinical attention.


Substance/Medication-Induced Psychotic Disorder 111
Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced psychotic disorders are indicated in the table below. Note that the ICD-10-
CM code depends on whether or not there is a comorbid substance use disorder present
for the same class of substance. If a mild substance use disorder is comorbid with the sub-
stance-induced psychotic disorder, the 4th position character is “1,” and the clinician should
record “mild [substance] use disorder” before the substance-induced psychotic disorder
(e.g., “mild cocaine use diso rder with cocaine-induced ps ychotic disorder”). If a m oderate or
severe substance use disorder is comorbid with the substance-induced psychotic disor-
der, the 4th position character is “2,” and the clinician should record “moderate [substance]
use disorder” or “severe [substance] use disorder,” depending on the severity of the co-
morbid substance use disorder. If there is no comorbid substance use disorder (e.g., after
a one-time heavy use of the substance), then the 4th position character is “9,” and the cli-
nician should record only the substance-induced psychotic disorder.
Specify  if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for diag-
noses associated with substance class):
With onset during intoxication:  If the criteria are met for intoxication with the sub-
stance and the symptoms develop during intoxication.
With onset during withdrawal:  If the criteria are met for withdrawal from the sub-
stance and the symptoms develop during, or shortly after, withdrawal.
Specify current severity:


stance 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, 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 chap-
ter “Assessment Measures.”)
Note:  Diagnosis of substance/medication-induced psychotic disorder can be made
without using this severity specifier.ICD-10-CM
ICD-9-CMWith use
disorder,
mildWith use
disorder,
moderate
or severeWithout
use
disorder
Alcohol 291.9 F10.159 F10.259 F10.959
Cannabis 292.9 F12.159 F12.259 F12.959
Phencyclidine 292.9 F16.159 F16.259 F16.959
Other hallucinogen 292.9 F16.159 F16.259 F16.959
Inhalant 292.9 F18.159 F18.259 F18.959
Sedative, hypnotic, or
anxiolytic292.9 F13.159 F13.259 F13.959
Amphetamine (or other
stimulant)292.9 F15.159 F15.259 F15.959
Cocaine 292.9 F14.159 F14.259 F14.959
Other (or unknown) substance 292.9 F19.159 F19.259 F19.959


112 Schizophrenia Spectrum and Other Psychotic Disorders
Recording Procedures
ICD-9-CM. The name of the substance/medication -induced psychotic disorder begins
with the specific substance (e.g., cocaine, de xamethasone) that is presumed to be causing
the delusions or hallucinations. The diagnostic code is selected from the table included in
the criteria set, which is based on the drug clas s. For substances that do not fit into any of
the classes (e.g., dexamethasone), the code for “other substance” should be used; and in
cases in which a substance is judged to be an etiological factor but the specific class of sub-
stance is unknown, the category “u nknown substance” should be used.
The name of the disorder is followed by the sp ecification of onset (i.e., onset during in-
toxication, onset during with drawal). Unlike the recording procedures for ICD-10-CM,
which combine the substance-induced disorder and substance use disorder into a single
code, for ICD-9-CM a separate diagnostic code  is given for the substance use disorder. For
example, in the case of delusio ns occurring during intoxication in a man with a severe co-
caine use disorder, the diagnosis is 292.9 cocaine-induced psychotic disorder, with onset
during intoxication. An additional diagnosis of 304.20 severe cocaine use disorder is also
given. When more than one subs tance is judged to play a significant role in the development
of psychotic symptoms, each should be listed separately (e.g., 292.9 cannabis-induced psy-
chotic disorder with onset during intoxicati on, with severe cannabis use disorder; 292.9
phencyclidine-induced psychotic disorder, wi th onset during intoxication, with mild
phencyclidine use disorder).


phencyclidine use disorder).
ICD-10-CM. The name of the substance/medication-induced psychotic disorder begins
with the specific substance (e.g., cocaine, de xamethasone) that is presumed to be causing
the delusions or hallucinations. The diagnostic code is selected from the table included in
the criteria set, which is based on the drug  class and presence or absence of a comorbid
substance use disorder. For substances that do not fit into an y of the classes (e.g., dexa-
methasone), the code for “other substance” with no comorbid substance use should be
used; and in cases in which a substance is judged  to be an etiological factor but the specific
class of substance is unknown, the category “unknown substance” wi th no comorbid sub-
stance use should be used.
When recording the name of the disorder, th e comorbid substance use disorder (if any)
is listed first, followed by the word “with,” followed by the name of the substance-induced
psychotic disorder, followed by  the specification of onset (i .e., onset during intoxication,
onset during withdrawal). For example, in the case of delusions occurring during intoxi-
cation in a man with a severe cocaine use d isorder, the diagnosis is F14.259 severe cocaine
use disorder with cocaine-induced psychotic disorder, with onset during intoxication. A
separate diagnosis of the comorbid severe co caine use disorder is not given. If the sub-
stance-induced psychotic disorder occurs without a comorbid substance use disorder
(e.g., after a one-time heavy use of the substance), no accompanying substance use disor-
der is noted (e.g., F16.959 phencyclidine-induce d psychotic disorder, with onset during in-


toxication). When more than one substance is  judged to play a significant role in the
development of psychotic symptoms, each should be listed separately (e.g., F12.259 severe
cannabis use disorder with cannabis-induced ps ychotic disorder, with onset during intox-
ication; F16.159 mild phencyclidine use diso rder with phencyclidine-induced psychotic
disorder, with onset during intoxication).
Diagnostic Features
The essential features of substance/medicati on-induced psychotic disorder are prominent
delusions and/or hallucinations (Criterion A) that are judged to be due to the physiolog-


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


Substance/Medication-Induced Psychotic Disorder 113
or substance withdrawal with the accompanyi ng specifier “with perceptual disturbances”
(applies to alcohol withdrawal; cannabis into xication; sedative, hypnotic, or anxiolytic
withdrawal; and stimulant intoxication).
A substance/medication-induced psychotic di sorder is distinguished from a primary
psychotic disorder by considering the onset, course, and other factors. For drugs of abuse,
there must be evidence from the history, physical examination, or laboratory findings of
substance use, intoxication, or withdrawal . Substance/medication-induced psychotic
disorders arise during or soon after exposure to a medication or after substance intoxica-
tion or withdrawal but can persist for week s, whereas primary psychotic disorders may
precede the onset of substance/ medication use or may occur during times of sustained ab-
stinence. Once initiated, the psychotic symp toms may continue as long as the substance/
medication use continues. Anothe r consideration is the presence  of features that are atyp-
ical of a primary psychotic disord er (e.g., atypical age at onse t or course). For example, the
appearance of delusions de novo in a person older than 35 years without a known history
of a primary psychotic disorder should sugge st the possibility of a substance/medication-
induced psychotic disorder. Even  a prior history of a primary psychotic disorder does not
rule out the possibility of a substance/medicati on-induced psychotic disorder. In contrast,
factors that suggest that the psychotic symp toms are better accounted for by a primary
psychotic disorder include persistence of ps ychotic symptoms for a substantial period of
time (i.e., a month or more) after the end of substance intoxication or acute substance with-


drawal or after cessation of medication use;  or a history of prior recurrent primary psy-
chotic disorders. Other causes of psychoti c symptoms must be considered even in an
individual with substance into xication or withdrawal, because substance use problems are
not uncommon among individuals with non- substance/medication-induced psychotic
disorders.
In addition to the four symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mani a symptom domains is vital for making crit-
ically important distinctions between the va rious schizophrenia spectrum and other psy-
chotic disorders.
Associated Features Supporting Diagnosis
Psychotic disorders can occur in association wi th intoxication with the following classes of
substances: alcohol; cannabis; hallucinoge ns, including phencyclidine and related sub-
stances; inhalants; sedatives, hypnotics, and anxiolytics; stimulants (including cocaine);
and other (or unknown) substances. Psychotic disorders can occur in association with with-
drawal from the following classes of substanc es: alcohol; sedatives, hypnotics, and anxio-
lytics; and other (or unknown) substances.
Some of the medications reported to evoke psychotic symptoms include anesthetics
and analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive
and cardiovascular medications, antimicrobial medications, antiparkinsonian medica-
tions, chemotherapeutic agents (e.g., cyclosporine, procarbazine), corticosteroids, gastro-
intestinal medications, muscle relaxants, nonsteroidal anti-inf lammatory medications,
other over-the-counter medicati ons (e.g., phenylephrine, ps eudoephedrine), antidepres-


sant medication, and disulfiram . Toxins reported to induce  psychotic symptoms include
anticholinesterase, organophosphate insectic ides, sarin and other nerve gases, carbon
monoxide, carbon dioxide,  and volatile substances such as fuel or paint.
Prevalence
Prevalence of substance/medi cation-induced psychotic disorder in the general popula-
tion is unknown. Between 7% and 25% of in dividuals presenting with a first episode of


Prevalence
Prevalence of substance/medi cation-induced psychotic disorder in the general popula-
tion is unknown. Between 7% and 25% of in dividuals presenting with a first episode of
psychosis in different settings are reported  to have substance/medication-induced psy-
chotic disorder.


114 Schizophrenia Spectrum and Other Psychotic Disorders
Development and Course
The initiation of the disorder may vary co nsiderably 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 ma y be required to produce psychosis. Alco-
hol-induced psychotic disorder, with hallucina tions, 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 fea-
tures. Persecutory delusions may rapidly develop shortly af ter use of amphetamine or a
similarly acting sympathomimetic. The hallucination of bugs or vermin crawling in or un-
der the skin (formication) can lead to scratchi ng and extensive skin excoriations. Cannabis-
induced psychotic disorder may develop shortl y after high-dose cannabis use and usually
involves persecutory delusions, marked anxiety, emotional lability, and depersonalization.
The disorder usually remits within a day bu t in some cases may persist for a few days.
Substance/medication-induced psychotic disord er may at times persist when the offend-
ing agent is removed, such that it may be difficult initially to distinguish it from an indepen-
dent psychotic disorder. Agents such as amph etamines, phencyclidine, and cocaine have been
reported to evoke temporary ps ychotic states that can someti mes persist for weeks or longer
despite removal of the agent and treatment with  neuroleptic medication. In later life, poly-
pharmacy for medical conditions and exposure to medications for parkinsonism, cardiovas-
cular disease, and other medi cal disorders may be associated  with a greater likelihood of


cular disease, and other medi cal disorders may be associated  with a greater likelihood of
psychosis induced by prescription medicati ons as opposed to substances of abuse.
Diagnostic Markers
With substances for which relevant blood le vels are available (e.g., blood alcohol level,
other quantifiable blood levels su ch as digoxin), the presence of a level consistent with tox-
icity may increase diagnostic certainty.
Functional Consequences of
Substance/Medication-Indu ced Psychotic Disorder
Substance/medication-induced psychotic diso rder is typically severely disabling and
consequently is observed most frequently in  emergency rooms, as individuals are often
brought to the acute-care setting when it occu rs. However, the disability is typically self-
limited and resolves upon removal of the offending agent.
Differential Diagnosis
Substance intoxication or substance withdrawal. Individuals intoxicated with stimu-
lants, cannabis, the opioid meperidine, or phe ncyclidine, or those withdrawing from alco-
hol or sedatives, may experience altered percep tions that they recognize as drug effects. If
reality testing for these experiences remains inta ct (i.e., the individual recognizes that the
perception is substance induced and neither believe s in nor acts on it), the diagnosis is not
substance/medication-induced psychotic disorder. Instead, substance intoxication or
substance withdrawal, with perceptual disturbances, is diagnosed (e.g., cocaine intoxica-
tion, with perceptual disturba nces). “Flashback” hallucinations that can occur long after
the use of hallucinogens has stopped are diag nosed as hallucinogen persisting perception
disorder. If substance/medication-induced psychotic symptoms oc cur exclusively during
the course of a delirium, as in severe forms of alcohol withdrawal, the psychotic symptoms


the course of a delirium, as in severe forms of alcohol withdrawal, the psychotic symptoms
are considered to be an associated feature of the delirium and are not diagnosed sepa-
rately. Delusions in the context of a major or  mild neurocognitive disorder would be di-
agnosed as major or mild neurocognitive disorder, with behavioral disturbance.


Psychotic Disorder Due to Another Medical Condition 115
Primary psychotic disorder. A substance/medication-induc ed psychotic disorder is
distinguished from a primary psychotic disord er, such as schizophrenia, schizoaffective
disorder, delusional disorder, brief psychotic disorder, other specified schizophrenia
spectrum and other psychotic disorder, or un specified schizophrenia spectrum and other
psychotic disorder, by the fact that a substance is judged to be etiologically related to the
symptoms.
Psychotic disorder due to another medical condition. A substance/medication-induced
psychotic disorder due to a prescribed trea tment for a mental or medical condition must
have its onset while the individual is receiv ing the medication (or during withdrawal, if
there is a withdrawal syndrome associated with the medication). Because individuals with
medical conditions often take medications fo r those conditions, the clinician must con-
sider the possibility that the psychotic symptoms are caused by the physiological conse-
quences of the medical condition rather than  the medication, in which case psychotic
disorder due to another medical condition is  diagnosed. The hist ory often provides the
primary basis for such a judgme nt. At times, a change in the treatment for the medical con-
dition (e.g., medication substitution or disc ontinuation) may be needed to determine em-
pirically for that individual whether the medica tion is the causative agent. If the clinician
has ascertained that the distur bance is attributable to both  a medical condition and sub-
stance/medication use, both diagnoses (i.e., psychotic disorder due to another medical
condition and substance/medication-induced psychotic disorder) may be given.
Psychotic Disorder
 Due to Another Medical Condition
Diagnostic Criteria
A. Prominent hallucinations or delusions.


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 condi-
tion.
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, occupa-
tional, or other important areas of functioning.
Specify whether:
Code based on predominant symptom:
293.81 (F06.2)  With delusions:  If delusions are the predominant symptom.
293.82 (F06.0)  With hallucinations:  If hallucinations are the predominant symptom.
Coding note: Include the name of the other medical condition in the name of the mental
disorder (e.g., 293.81 [F06.2] psychotic disorder due to malignant lung neoplasm, with de-
lusions). The other medical condition should be coded and listed separately immediately
before the psychotic disorder due to the medical condition (e.g., 162.9 [C34.90] malignant
lung neoplasm; 293.81 [F06.2] psychotic disorder due to malignant lung neoplasm, with
delusions).
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, 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


116 Schizophrenia Spectrum and Other Psychotic Disorders
severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chap-
ter “Assessment Measures.”)
Note:  Diagnosis of psychotic disorder due to another medical condition can be made
without using this severity specifier.
Specifiers
In addition to the symptom domain areas identified in the diagnostic criteria, the assess-
ment of cognition, depressio n, and mania symptom domains is vital for making critically
important distinctions between the various schizophrenia spectrum and other psychotic
disorders.
Diagnostic Features
The essential features of psychotic disorder  due to another medical condition are promi-
nent delusions or hallucinations that are judged  to be attributable to the physiological ef-
fects of another medical condition and are not better explained by another mental disorder
(e.g., the symptoms are not a psychologically mediated response to a severe medical con-
dition, in which case a diagnosis of brief psychotic disorder, with ma rked stressor, would
be appropriate).
Hallucinations can occur in any sensory modalit y (i.e., visual, olfactory, gustatory, tac-
tile, or auditory), but certai n etiological factors are likely to evoke specific hallucinatory
phenomena. Olfactory hallucinations are suggest ive of temporal lobe  epilepsy. Hallucina-
tions may vary from simple and unformed to highly comp lex and organized, depending
on etiological and environmental factors. Ps ychotic disorder due to another medical con-
dition is generally not diagnosed if the individual maintains reality testing for the hallu-
cinations and appreciates that they result from the medical conditio n. Delusions may have
a variety of themes, including somatic, gran diose, religious, and, most commonly, perse-