DIAGNOSIS OF SCHIZOPHRENIA

DSM-IV diagnostic criteria for schizophrenia

In DSM-IV, the diagnosis of schizophrenia depends upon the presence of characteristic

symptoms, a minimum duration of those symptoms, a minimum duration of the disorder, the
presence of social/occupational dysfunction, and adifferentiation from mood, schizoaffective,
other psychotic disorders, general medical conditions, substance-induced disorders and pervasive
developmental disorder

According to DSM-IV, there are no strictly pathognomonic symptomsof schizophrenia.

Characteristic symptoms are conceptualized as falling into two broad categories: positive and
negative. There are four groups of positive symptoms—delusions, hallucinations, disorganized
speech, and grossly disorganized or catatonic behaviour—and one group of negative symptoms,
which includes affective flattening, alogia avolition.

A. Characteristic Symptoms

Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated);
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g. frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, that is, affective flattening, alogia, or avolition.
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist
of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or
more voices conversing with each other.

B. Social/occupational dysfunction

For a significant portion of the time since the onset of the disturbance, one or more major areas
of functioning such as work, interpersonal relations, or self-care are markedly below the level
achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve
expected level of interpersonal academic, or occupational achievement).

C. Duration

Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.
active phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be manifested by only
negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form
(e.g. odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion

Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out
because either (1) no Major Depressive, Manic or Mixed Episodes have occurred concurrently
with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase
symptoms, their total duration has been brief relative to the duration of the active and residual
periods.
 E. Substance/general medical condition exclusion

The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse,
a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder

If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the

additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month (or less if successfully treated).

The DSM-IV diagnostic criteria for schizophrenia require the presence of symptoms from at
least two of the groups listed above. Symptoms from only one group are required if delusions are
bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s
behaviour or thoughts, or two or more voices conversing with each other. Each of the symptoms
must be present for a significant portion of time during a one-month period (or less if
successfully treated).

According to DSM-IV, schizophrenia is accompanied by marked social or occupational

dysfunction for a significant portion of the time since the onset of the disturbance. The
dysfunction must be present in at least one major area such as work, interpersonal relations or
self-care.

DSM-IV requires that continuous signs of the disturbance persist for at least 6 months. This 6-
month period may include periods when only negative or less severe symptoms are present. Such
periods are referred to as prodromal or residual, depending on whether they precede or follow the
one-month period of characteristic symptoms described above. Classification of course can be
applied only after at least one year has elapsed since the initial onset of active-phase symptoms.
According to DSMIV, the course of schizophrenia is variable. The manual lists the following
course specifiers: episodic with inter-episode residual symptoms; episodic with no inter-episode
residual symptoms; continuous; single episode in partial remission; single episode in full
remission; other or unspecified pattern.

Concerning differential diagnosis, DSM-IV emphasizes the distinction between schizophrenia

and mood disorders. If psychotic symptoms occur exclusively during periods of mood
disturbance, the diagnosis is mood disorder with psychotic features. If mood episodes have
occurred during active-phase symptoms, and if their total duration has been brief relative to the
duration of active and residual periods, the diagnosis is schizophrenia. If a mood episode is
concurrent with the active-phase symptoms of schizophrenia, and if mood symptoms have been
present for a substantial portion of the total duration of the disturbance, and if delusions or
hallucinations have been present for at least 2 weeks in the absence of prominent mood
symptoms, the diagnosis is schizoaffective disorder.

The differentiation between schizophrenia, brief psychotic disorder and schizophreniform

disorder rests upon a criterion of duration: less than one month for brief psychotic disorder; more
than one month but less than 6 months for schizophreniform disorder; at least 6 months for
schizophrenia. The differential diagnosis between schizophrenia and delusional disorder rests on
the nature of the delusions (in delusional disorder they are nonbizarre) and the absence of other
characteristic symptoms of schizophrenia such as hallucinations, disorganized speech and
behaviour, or prominent negative symptoms.

Schizophrenia and pervasive developmental disorder are distinguished by a number of criteria,

including in particular the presence of prominent delusions and hallucinations in the former but
not in the latter.
Finally, the diagnosis is not made if the disturbance is due to the direct physiological effects of a
substance or a general medical condition.

DSM-IV describes five subtypes of schizophrenia: paranoid, disorganized, catatonic,

undifferentiated and residual. Post-psychotic depressive disorder of schizophrenia and simple
deteriorative disorder or simple schizophrenia is described in Appendix B, among conditions
requiring further study. In both the ICD-10 and the DSM-IV there is a distinction between
positive and negative characteristic symptoms of schizophrenia. According to the definition
provided in DSM-IV, ‘‘the positive symptoms appear to reflect an excess or distortion of normal
functions, whereas the negative symptoms appear to reflect a diminution or loss in normal
functions’’.

In both ICD-10 and DSM-IV, positive symptoms include hallucinations and delusions,
disorganized thought and speech, as well as disorganized and catatonic behaviour. In both
systems, negative symptoms include affective flattening or blunting of emotional responses,
alogia or paucity of speech, and apathy or avolition.

The reliability and validity of psychiatric diagnoses that are based on explicit diagnostic criteria
have been investigated in a number of studies during recent decades. According to Kendell
[106], psychiatric diagnoses are now as reliable as the clinical judgements made in other
branches of medicine. High reliability does not, however, by itself predict high validity.