Contents of this page:
Schizophrenia Basic Criteria Paranoid Disorganized Catatonic
Undifferentiated Residual Schizophreniform Disorder
Schizoaffective Disorder Delusional Disorder
Brief Psychotic Disorder Shared Psychotic Disorder
Psychotic Disorder Due to a General Medical Condition
Substance-Induced Psychotic Disorder
Symptoms. For a material part of at least one month (or
less, if effectively treated) the patient has had 2 or more of:*
-Delusions (only one symptom is required if a delusion is bizarre, such as
being abducted in a space ship from the sun)
-Hallucinations (only one symptom is required if hallucinations are of at
least two voices talking to one another or of a voice that keeps up a
running commentary on the patient's thoughts or actions)
-Speech that shows incoherence, derailment or other disorganization
-Severely disorganized or catatonic behavior
-Any negative symptom such as flat affect, reduced speech or lack of
volition
Duration. For at least 6 continuous months the patient has
shown some evidence of the disorder. At least one month must include the
symptoms of frank psychosis mentioned above. During the balance of this time
(either as a prodrome or residual of the illness), the patient must show
either or both
-Negative symptoms as mentioned above
-In attenuated form, at least 2 of the other symptoms mentioned above
(example: deteriorating personal hygiene plus an increasing suspicion that
people are talking behind one's back)
Dysfunction. For much of this time, the disorder has materially impaired the patient's ability to work, study, socialize or provide self-care.**
Mood exclusions. Mood and schizoaffective disorders have been ruled out, because the duration of any depressive or manic episodes that have occurred during the psychotic phase has been brief.
Other exclusions. This disorder is not directly caused by a general medical condition or the use of substances, including prescription medications.
Developmental Disorder exclusion. If the patient has a history of any Pervasive Developmental Disorder (such as Autistic Disorder), only diagnose Schizophrenia if prominent hallucinations or delusions are also present for a month or more (less, if treated).
After at least 1 year as passed since onset, classify the course of psychosis. Until a year has passed, you cannot assign any of these course specifiers.***
Continuous. There has been no remission of "A" symptoms (first bullet). If negative symptoms stand out, you can also add "With Prominent Negative Symptoms."
Episodic With Interepisode Residual Symptoms. During episodes, "A" criteria are met. Between episodes the patient has clinically important residual symptoms. If negative symptoms stand out, you can also add "With Prominent Negative Symptoms."
Episodic With No Interepisode Residual Symptoms. During episodes, "A" criteria are met. Between episodes the patient has remissions with no clinically important symptoms.
Single Episode in Partial Remission. There has been one episode during which "A" criteria are met. Now there are some clinically important residual symptoms. If negative symptoms stand out, you can also add "With Prominent Negative Symptoms."
Single Episode in Full Remission. No clinically important symptoms remain.
Other or Unspecified Pattern.
Coding Notes
*DSM-IV refers collectively to these five symptoms as the "A" criteria.
**If the illness begins in childhood or adolescence, the criteria for dysfunction require only that the patient fail to achieve the expected occupational, scholastic or social level.
***These longitudinal specifiers are listed last, following the term Schizophrenia and the subtype diagnosis (paranoid, disorganized, catatonic, undifferentiated, residual).
The patient meets the basic criteria for Schizophrenia (page 122).
The patient is preoccupied with delusions or frequent auditory hallucinations.
None of these symptoms is prominent:
Disorganized speech
Disorganized behavior
Inappropriate or flat affect
Catatonic behavior
The patient meets the basic criteria for Schizophrenia (page 122).
All of these symptoms are prominent:
disorganized behavior
disorganized speech
affect that is flat or inappropriate
The patient does not fulfill criteria for Catatonic Schizophrenia
The patient meets the basic criteria for Schizophrenia (page 122).
At least 2 catatonic symptoms predominate:
-Stupor or motor immobility (catalepsy or waxy flexibility)
-Hyperactivity that has no apparent purpose and is not influenced by
external stimuli
-Mutism or marked negativism
-Peculiar behavior such as posturing, stereotypies, mannerisms or grimacing
-Echolalia or echopraxia
Coding Notes
Negativism is demonstrated when the patient (1) refuses to follow all instructions without apparent motive or (2) maintains a rigid posture despite the examiner's physical attempts.
Mannerisms are unnecessary movements that are part of goal-directed behavior, such as a flourish of the pen when signing a document).
Stereotypies are behaviors that do not appear to be goal-directed, such as flashing a "Victory" sign with two upraised fingers every few seconds.
Posturing means that the patient spontaneously poses or assumes a posture that is bizarre or inappropriate.
The patient meets the basic criteria for Schizophrenia (page 122).
The patient does not meet criteria for Paranoid, Disorganized, or Catatonic types.
The patient at one time met criteria for Catatonic, Disorganized, Paranoid or Undifferentiated Schizophrenia.
The patient no longer has pronounced catatonic behavior, delusions, hallucinations or disorganized speech or behavior.
The patient is still ill, as indicated by either
-negative symptoms such as flattened affect, reduced speech output or lack
of volition, or
-an attenuated form of at least 2 characteristic symptoms of schizophrenia,
such as odd beliefs (related to delusions), distorted perceptions or
illusions (hallucinations), odd speech (disorganized speech) or
peculiarities of behavior (disorganized behavior).
For a material part of at least one month (or less, if
effectively treated) the patient has had 2 or more of:
-Delusions (only one symptom is required if a delusion is bizarre, such as
being abducted in a space ship from the sun)
-Hallucinations (only one symptom is required if hallucinations are of at
least two voices talking to one another or of a voice that keeps up a
running commentary on the patient's thoughts or actions)
-Speech that shows incoherence, derailment or other disorganization
-Severely disorganized or catatonic behavior
-Any negative symptom such as flat affect, muteness, lack of volition
Including prodromal, active and residual phases, an episode of the illness has lasted at least one month but not longer than 6 months.
Mood and schizoaffective disorders have been ruled out, because the duration of any depressive or manic episodes that have occurred during the psychotic phase has been brief.
This disorder is not the direct physiological result of a general medical condition or the use of substances, including prescription medications.
A statement of prognosis should be added to the diagnosis:
With Good Prognostic Features (2 or more of the following):
-Actual psychotic features begin within 4 weeks of the first noticeable
change in the patient's functioning or behavior.
-The patient is confused or perplexed when most psychotic.
-Premorbid social and job functioning are good.
-Affect is neither blunt nor flattened.
Without Good Prognostic Features (zero or 1 of the foregoing)
Coding Notes
If the diagnosis is made without waiting for recovery, which will often be the case, the term "(Provisional)" should be appended.
During a continuous period of illness, for a material part
of at least one month (or less, if effectively treated) the patient has had
2 or more of the following symptoms:*
-Delusions (only one symptom is required if a delusion is bizarre, such as
being abducted in a space ship from the sun)
-Hallucinations (only one symptom is required if hallucinations include at
least two voices are talking to one another or of a voice that keeps up a
running commentary on the patient's thoughts or actions)
-Speech that shows incoherence, derailment or other disorganization
-Severely disorganized or catatonic behavior
-Any negative symptom such as flat affect, muteness, lack of volition
During this same continuous period of illness the patient
has either
-A major depressive episode (page 162) that includes depressed mood, or
-A manic episode (page 167)
For at least 2 weeks of this period there have been delusions or hallucinations and no prominent mood symptoms.
The mood episode symptoms have been present during a substantial part of the active and residual portions of the illness
This disorder is not caused directly by a general medical condition or the use of substances, including prescription medications.
Specify whether:
Bipolar Type. The episode is either Manic, Mixed or Major Depressive with either Manic or Mixed.
Depressive Type. The episode is only Major Depressive.
Coding Notes
*These are the "A" criteria for schizophrenia.
For at least 1 month the patient has had delusions that are
nonbizarre (the content is something that could reasonably happen). These
may be:
Erotomanic Type. Someone (often of higher social station) is in love with
the patient.
Grandiose Type. The patient has exaggerated ideas of identity, knowledge,
power, self-worth, talent or special relationship to God or someone famous.
Jealous Type. The patient's spouse or lover has been unfaithful.
Persecutory Type. The patient (or a close associate) is in some way being
intentionally cheated, drugged, followed, slandered or otherwise mistreated.
Somatic Type. The patient notes physical sensations or bodily dysfunctions
(foul odors, insects crawling on or under skin) that imply a general medical
condition or physical defect.
Mixed Type. The patient has two or more of the above themes in about equal
portions.
Unspecified Type.
The patient has never met the "A" criterion for Schizophrenia, except that hallucinations of touch or smell may be present if they are related to the theme of the delusions.
Functioning and behavior are not markedly affected, apart from direct consequences of the delusions.
The duration of any mood symptoms accompanying delusions as been brief as compared to the duration of delusions.
This disorder is not directly caused by a general medical condition or the use of substances, including prescription medications.
Specify type, as listed in first bullet above.
The patient has at least one of the following that is not a
culturally sanctioned response:
-Delusions
-Hallucinations
-Speech that is markedly disorganized
Behavior that is markedly disorganized or catatonic
The patient has symptoms from 1 to 30 days and eventually recovers completely.
The symptoms are not due to a Mood Disorder, Schizophrenia, Schizoaffective Disorder.
This disorder is not directly caused by a general medical condition or the use of substances, including prescription medications.
Specify whether:
With Postpartum Onset. In a woman, the disorder begins within 4 weeks of having a baby.
With Marked Stressor(s). The stressors must appear to cause the symptoms, occur shortly before their onset and be severe enough that nearly anyone of that culture would feel markedly stressed.
Without marked stressor(s).
Coding Notes
If the diagnosis is made without waiting for recovery, the term "Provisional" should be appended.
Someone who is closely associated with a delusional person also develops a delusion.
The content of this new delusion is similar to that of the first person's delusion.
The disorder is not explained better by another psychotic disorder, such as Schizophrenia or Mood Disorder with Psychotic Features.
This disorder is not directly caused by a general medical condition or the use of substances, including prescription medications.
The patient has prominent delusions or hallucinations.
History, physical exam or laboratory findings suggest that a general medical condition has directly caused these symptoms.
The symptoms don't occur solely during a delirium.
No other mental disorder better accounts for these symptoms.
Code, based on the predominant symptoms:
.x1 With Delusions
.x2 With Hallucinations
Coding notes
Use the name of the medical disorder in the Axis I code, not "General Medical Condition."
On Axis III, also code the specific general medical condition that has caused the psychosis.
If the patient has a preexisting Dementia (Alzheimer's or Vascular) and then becomes psychotic, do not use code 293.8x. Instead, the Cognitive Disorder takes precedence, and you would code, for example, 290.42 Vascular Dementia, with delusions.
The patient has prominent hallucinations or delusions. Don't include hallucinations that the patient realizes are caused by substance use.
History, physical exam or laboratory data substantiate that
either:
-These symptoms have developed within a month of Substance Intoxication or
Withdrawal, or
-Medication use has caused the symptoms
Another, non-substance-induced psychotic disorder does not better account for the symptoms.*
The symptoms don't occur only in the context of a delirium.
The codes used for Substance-Induced Psychotic Disorder are somewhat arcane. Different numbers are used to describe a psychosis with delusions and with hallucinations, and the coding for alcohol-induced psychoses is different from all other substances. If delusions and hallucinations are both present, code the one that dominates the clinical picture. The numbers to use are:
With Delusions:
291.5 Alcohol
292.11 Amphetamine [or Amphetamine-Like Substance]; Cannabis; Cocaine; Hallucinogen; Inhalant; Opioid; Phencyclidine [or Phencyclidine-Like Substance]; Sedative, Hypnotic or Anxiolytic; Other [or Unknown] Substance
With Hallucinations:
291.3 Alcohol
292.12 Amphetamine [or Amphetamine-Like Substance]; Cannabis; Cocaine; Hallucinogen; Inhalant; Opioid; Phencyclidine [or Phencyclidine-Like Substance]; Sedative, Hypnotic or Anxiolytic; Other [or Unknown] Substance
When criteria are met for substance-specific intoxication or withdrawal (page 57), specify whether:
With Onset During Intoxication.
With Onset During Withdrawal
Coding Notes
* DSM-IV suggests several instances in which a disorder other than substance use could better explain the symptoms of psychosis. These include:
-Psychotic symptoms begin before the onset of the substance abuse.
-Psychotic symptoms persist long after (a month or more) the substance abuse stops.
-Psychotic symptoms are more severe than you would expect from the amount and extent of substance abuse.
-The patient has had previous psychotic episodes independent of substance use.
Use this diagnosis instead of Substance Intoxication or Substance Withdrawal only (1) when the symptoms exceed those you would expect from a syndrome of intoxication or withdrawal and (2) when they are serious enough by themselves to require clinical care.
Psychoses caused by most medications taken in therapeutic doses would be coded as, for example:
Axis I 292.11 Estrogen-Induced Psychotic Disorder, With Hallucinations, With Onset During Intoxication
Axis III E932.2 Ovarian hormones
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