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Psychotic disorders in DSM-5 and ICD-11

Falko Biedermann and W. Wolfgang Fleischhacker

CNS Spectrums / FirstView Article / July 2016, pp 1 - 6

DOI: 10.1017/S1092852916000316, Published online: 15 July 2016

Link to this article: http://journals.cambridge.org/abstract_S1092852916000316

How to cite this article:

Falko Biedermann and W. Wolfgang Fleischhacker Psychotic disorders in DSM-5 and ICD-11. CNS Spectrums, Available
on CJO 2016 doi:10.1017/S1092852916000316

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 CNS Spectrums, page 1 of 6. © Cambridge University Press 2016
doi:10.1017/S1092852916000316

REVIEW ARTICLE

Psychotic disorders in DSM-5 and ICD-11

Falko Biedermann and W. Wolfgang Fleischhacker*

Department of Psychiatry and Psychotherapy, Medical University of Innsbruck, Innsbruck, Austria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was published by the American
Psychiatric Association (APA) in 2013, and the Work Group on the Classification of Psychotic disorders (WGPD),
installed by the World Health Organization (WHO), is expected to publish the new chapter about schizophrenia and
other primary psychotic disorders in 2017. We reviewed the available literature to summarize the major changes,
innovations, and developments of both manuals. If available and possible, we outline the theoretical background
behind these changes. Due to the fact that the development of ICD-11 has not yet been completed, the details about
ICD-11 are still proposals under ongoing revision. In this ongoing process, they may be revised and therefore have to be
seen as proposals. DSM-5 has eliminated schizophrenia subtypes and replaced them with a dimensional approach based
on symptom assessments. ICD-11 will most likely go in a similar direction, as both manuals are planned to be more
harmonized, although some differences will remain in details and the conceptual orientation. Next to these
modifications, ICD-11 will provide a transsectional diagnostic criterion for schizoaffective disorders and a
reorganization of acute and transient psychotic and delusional disorders. In this manuscript, we will compare the
2 classification systems.

Received 7 October 2015; Accepted 23 March 2016

Key words: Diagnostic criteria, DSM-5, ICD-11, psychotic disorder, schizophrenia.

Introduction
In June 2013, the Fifth Edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5),
published by the American Psychiatric Association
(APA), became available. Its development was a 14-year
process, involving and coordinating the work of
hundreds of people.1 Not only were the leading experts
engaged, but the development process was also open to
the public. A simultaneous publication of the Eleventh
Edition of the International Statistical Classification of
Diseases and Related Health Problems (ICD-11),
developed by the World Health Organization (WHO),
was not possible given the laborious evaluation and
review efforts of both organizations. The release of
ICD-11 is expected in 2017.2 Nevertheless, certain
trends and details already have been published. We will
outline and discuss the main changes regarding
psychotic disorders in both manuals.
* Address for correspondence: W. Wolfgang Fleischhacker, Department
of Psychiatry, Psychotherapy and Psychosomatics, Medical University
Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
(Email: wolfgang.fleischhacker@i-med.ac.at)
DSM-5
One of the main changes is related neither to form nor
content, but to the development process itself. This
undertaking started in 1999, and for 14 years, hundreds
of experts worldwide cooperated to create the new
manual. In 2008, after the pre-planning phase, the
DSM-5 Tasks Force announced the members of the 13
Work Groups who started to revise the diagnostic criteria
of the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV). A special focus was
put on recent data in the fields of human genetics and
neuroimaging. In addition, the Work Groups were
charged with implementing several innovations. All
chapters had to be reorganized in order to credit
individual developmental aspects of subjects and the
phenomenological similarity of disorders, and also
reflect the course of the disease across the lifespan. The
multiaxial system of DSM-IV was given up, and dimen-
sional aspects of diseases had to be specified instead.
More consistent, more precise, and more understandable
definitions of diagnostic criteria were the target. In
addition, a more systematic and wider discussion of
differential diagnostic criteria, as well as the deletion or
addition of respectively obsolete or newly observed

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 2 F. BIEDERMANN AND W. W. FLEISCHHACKER

phenomena, were part of the goal. The drafts of the Work Delusional disorder
Groups were frequently made available for public
The requirement for non-bizarre delusion for this
annotation. Critique and amendments were integrated
diagnosis was eliminated. A clearer discrimination of
in the development of DSM-5, if they were considered
delusional disorders and psychotic variants of obsessive
relevant. Next to this, all diagnoses were marked with the
compulsive disorders or body dysmorphic disorders
best suitable ICD-10-CM code. This phase was followed
was introduced by the following exclusion criterion:
by field trials from 2010 to 2012. Simultaneously the
Symptoms must not be better explained by conditions
revision process was pushed forward, and the reviewers
like obsessive-compulsive disorders or body dysmorphic
were asked to integrate the findings of the field trials.
disorders. Shared delusional disorders were subsumed in
Finally, after the approval of the APA Board of Trustees,
this chapter.3
DSM-5 was released in May 2013 at the APA 2013 Annual
Meeting in San Francisco.1,3
Brief psychotic disorder

DSM-5 innovations No major changes were implemented.

In the following section, we will illustrate the main

changes of the chapter entitled “Schizophrenia Spec-
trum and Other Psychotic Disorders.” As DSM-IV was
felt to be clinically useful with high reliability and fair
validity, the changes in DSM-5 are modest with the aim of
simplification and incorporation of the latest research.4
The new organization of the chapter follows the general
DSM-5 concept to include developmental aspects of the
respective disorders. Therefore, DSM-5 diagnostic chap-
ters are arranged with respect to their appearance across
the developmental course of life and the severity of the
disease, earliest onset first.1 Diagnoses will be briefly
reviewed here as they appear in the manual (see Table 1).
Schizotypal personality disorder
Schizotypal personality is classified in the chapter
“Personality Disorders” and is only mentioned here due
to its relationship to the ICD-10 diagnosis schizotypal
disorder, which is described in the “Schizophrenia and
Other Psychotic Disorders” chapter in ICD-10.
Schizophreniform disorder
As long as the criteria changes for schizophrenia are
considered, no major changes were made for this diagnosis.
Schizophrenia
To diagnose schizophrenia in DSM-5, at least 2 of 5
characteristic symptoms are mandatory (delusions,
hallucinations, disorganized speech, grossly dis-
organized/catatonic behavior, or negative symptoms),
and these must have persisted for a minimum of 1 month.
One of them must be delusions, hallucinations, or
disorganized speech. Continuous signs of the distur-
bance have to be present for 6 months.1
DSM-5 has eliminated the diagnostic relevance of
bizarre delusions for schizophrenia due to the difficult
differentiation between bizarre and not bizarre.5 Because
of their unspecificity and questionable value for the
diagnostic process, Schneiderian first rank symptoms,
especially auditory hallucinations, lost their importance.6,7

TABLE 1. Organization of the chapters regarding psychotic disorders in ICD-10/11 and DSM-IV/5

ICD-10: Schizophrenia, Schizotypal and ICD-11: Schizophrenia Spectrum and Other DSM-IV: Schizophrenia and Other DSM-5: Schizophrenia Spectrum and Other
Delusional Disorders Primary Psychotic Disorders Psychotic Disorders Psychotic Disorders

Schizophrenia Schizophrenia Schizophrenia Schizotypal personality disorder

Schizotypal
Persistent delusion
Acute transient psychotic disorder
Induced delusional disorder
Schizoaffective disorder
Other nonorganic disorder
Unspecific nonorganic psychosis
Schizoaffective disorder
Acute transient psychotic disorder
Schizotypal disorder
Delusional disorder
Other primary psychotic disorder
Unspecific primary psychotic disorder
Attenuated psychosis syndrome
More research needed
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared psychotic disorder
Psychotic disorder due to another
medical condition
Substance-induced psychotic
disorder
Psychotic Disorder NOS
Delusional disorder
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia
Schizoaffective disorder
Substance-induced psychotic disorder
Psychotic disorder due to another medical
condition
Section III: Attenuated psychosis syndrome
More research needed

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The heterogeneity and variety of schizophrenia, as
well as the low lifetime stability of the symptoms, were
given tribute by eliminating the subtypes described in
DSM-IV. Subtypes were found to be of little to no clinical
and scientific utility and did not show differences
regarding sociodemographic parameters or cognitive
outcome.8 They were of no prognostic use, and in several
cluster analyses a classification on the basis of symptoms
was not possible.9–11
Two negative symptoms have demonstrated increas-
ing evidence as typical for schizophrenia and are there-
fore highlighted in DSM-5: avolition and diminished
emotional expression.12,13
In addition to the well-established symptoms of
schizophrenia, cognitive impairment is newly implemen-
ted as a dimension. To describe the different phenotypes
and the symptom switches over the course of schizo-
phrenia, DSM-5 introduces a Scale to Assess the Severity
of Symptom Dimensions (C-RDPSS) in Section 3.
Clinicians can now rate 8 dimensions of schizophrenia
(hallucinations, delusions, disorganized speech,
abnormal psychomotor behavior, negative symptoms,
impaired cognition, depression, mania) on a 5-level
rating scale from 0 (not present) to 4 (severe). This
individual assessment adds information that is relevant
for clinical evaluation, prognostic considerations, treat-
ment planning, and functional outcome.14 Additionally,
treatment response can be described more precisely.
Schizoaffective disorder
Due to the low reliability and validity of DSM-IV
schizoaffective disorder, DSM-5 criteria were
modified.15 DSM-5 requires that a major mood episode
has to be present for a majority of the disorder’s total
duration when criterion A (psychotic symptoms) of
schizophrenia has been met. This should allow for a
better differentiation between schizophrenia with mood
symptoms and schizoaffective disorder.16 Schizoaffective
disorders are seen as a longitudinal diagnosis, such as
schizophrenia or bipolar disorders, and not as a
cross-sectional phenomenon. With these changes, the
Psychosis Work Group expects a higher diagnostic
stability of this disorder.16
Substance-induced psychotic disorder
An additional criterion was introduced. Symptoms must
induce clinically relevant suffering or influence func-
tional outcome negatively. Apart from this, no changes
were implemented.
Psychotic disorder due to another medical condition
The same change was established as for substance-
induced psychotic disorders.
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CLASSIFICATION OF PSYCHOSIS 3
Catatonia
In DSM-5, catatonia becomes an additional code, which
can now be described independently of underlying
disorders such as schizophrenia, mood disorders, or
general medical conditions. If 3 or more of the 12
symptom clusters (DSM-5), instead of 2 out of 5
(DSM-IV), are present, catatonia can be coded.
Unspecific catatonia is used in the case of uncertainty
regarding the underlying disorder or as a transient
diagnosis if more information about the pathogenesis is
needed.
Attenuated psychosis syndrome (APS)
APS is characterized by a clinical and functional relevant
but alleviated experience of delusion, hallucination, or
disorganized speech. Time criteria and symptom severity
do not reach the intensity of another psychotic disorder.
Due to its importance for the development of preventive
strategies and early treatment, this entity was included
into Section 3 and is regarded as an issue required for
further study.
ICD-11
The planning process for the development of ICD-11
started in 2003. A series of 13 international conferences
were held to obtain information and data, which were
critically reviewed with respect to potential global utility.17
Of special interest were biological markers and functional
impairments.2 ICD is a classification system developed for
worldwide clinical use and public health questions, such as
statistics and health policy, but also for research. There-
fore it is required to be easy and practical, needs clear
language, and must be useful for clinical decision making.
So the aim of a new version is to incorporate diagnostic
implications of the most recent research and to improve
clinical utility without sacrificing validity and availability.2
As stated in our introduction, ICD-11 is still in the
development stage, therefore all proposed changes, which
have so far been published or presented at meetings, have
to be seen as a work in progress.
ICD-11 innovations
The chapter name will be changed from “Schizophrenia,
Schizotypal and Delusional Disorders” to “Schizophre-
nia Spectrum and Other Primary Psychotic Disorders.”
Non-primary psychotic disorders are coded in the
context of other mental diseases, such as mood or
personality disorders; secondary psychotic disorders
due to substance abuse or somatic illness will be
described in the respective chapters.18 All diagnoses will
be specified by category name, relationship to ICD-10,
definition, diagnostic guidelines, functional properties,
IP address: 132.239.1.231
 4 F. BIEDERMANN AND W. W. FLEISCHHACKER
code qualifiers (specifiers), and assessment issues.19 The
following paragraphs will outline the major changes
regarding the diagnoses in this chapter.18
Schizophrenia
Symptoms and criteria will be revised in the following
way: At least 2 symptoms have been present for 1 month,
and 1 of them must be a core symptom. Core symptoms
will be persistent delusions of any kind, persistent
hallucinations of any kind, thought disorders, and
distortion of self-experience. Negative symptoms, dis-
organized behavior, and psychomotor disorders are
defined as additional symptoms. As discussed in the
section “Changes in DSM-5,” subtypes will be taken out
of ICD-11 as well. Instead, schizophrenia should be
specified by 6 symptoms: positive, negative, depressive,
manic, psychomotor, and cognitive deficits. The latter
was introduced because of its importance in terms of
clinical and functional outcome.20,21 A course specifier,
similar to DSM-5, will also be implemented. Following
WHO practice, the Work Group for Psychotic Disorders
does not recommend incorporating functional outcome
as a diagnostic criterion for schizophrenia or any other
mental disease.18
Schizoaffective disorder
As long the diagnostic criteria changes in the schizo-
phrenia and mood disorder chapters are respected, the
diagnostic parameters for schizoaffective disorder only
change minimally. Noteworthy is a new time criterion
that requires 4 weeks of simultaneous diagnoses of both
schizophrenia and at least 1 moderate mood disorder. As
lifetime symptoms can hardly be assessed reliably in
schizoaffective patients, ICD-11 will conflict with DSM-5
and give up the longitudinal aspects of this disorder, in
order to make the diagnostic process easier and to
underline the cross-sectional approach.17
Acute and transient psychotic and delusional disorders (ATPD)
Based on the ICD-10/F23 diagnosis “Acute Polymorphic
Psychotic Disorder,” the ATPD chapter in ICD-11 will be
completely reorganized. Diagnostic criteria, such as
acute onset, brief duration, and clinical appearance, will
stay the same, whereas the differentiation between
schizophrenic and delusional aspects will be eliminated
and the delusional subtype (ICD-10/F23.3) will be
incorporated into the chapter “Delusional Disorders.”
“Acute Psychotic Polymorphic Disorder” (APPD), with-
out symptoms of schizophrenia, seems to have better
outcome and to convert into a mood disorder more
often.22 Therefore, the distinction between with and
without symptoms of schizophrenia could be of prog-
nostic value and will be kept in ICD-11. “ATPD with
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Symptoms of Schizophrenia and Acute Schizophrenia-
Like Psychotic Disorder,” lasting less than 4 weeks, will
be summarized as “Unspecific Primary Psychotic
Disorders.” Schizophreniform disorder should no longer
be diagnosed.
Schizotypal disorder
No changes are expected in this chapter
Delusional disorder
For simplification, 3 diagnoses with delusional aspects
will be merged in this chapter: ICD-10/ F22 “Delusional
Disorder,” F32.3 “Other Predominantly Delusional
Disorder,” and F24 “Induced Delusional Disorder.”
Other primary and unspecific primary psychotic disorders
There will be no changes in these chapters. Unspecific
psychotic disorders will be coded if there is not enough
information or as an interim diagnosis until the
diagnostic process is completed.
Catatonia
As subtypes of schizophrenia will be eliminated, catato-
nia is currently suggested to be described among the
clinical psychomotor specifiers.
Attenuated psychosis syndrome (APS)
There will be no such chapter in ICD-11, but research in
this field is important and required. Therefore APS,
similar to DSM-5, will be placed in the category Mental
Health States Requiring Further Study.18
Code qualifiers
Code qualifiers will be mainly used for schizophrenia and
schizoaffective disorder but can also be used in other
psychotic disorders and may be appropriate for other
illnesses of the Mental and Behavioural Disorder chapter.
They include qualifiers for symptoms, course of illness,
and cognitive and functional outcome.18
Differences and Similarities Between DSM-5 and
ICD-11
DSM and ICD are different in terms of intention,
function, and purpose. ICD is a nomenclature that is
used internationally, not only by specialists but also by
other health workers and organizations. Therefore, it is
more compact and easy to use, and characterizes
disorders in a less detailed manner. DSM on the
other hand focuses on scientific and teaching
challenges, mainly targeting mental health professionals.
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Descriptions, etiological information, and comments, as
well as diagnostic assessments and recommendations,
are therefore more comprehensive.
As both work groups tried to harmonize the 2 systems
as much as possible, the differences are fairly small in the
respective psychotic disorder chapters. The new meta-
structure of the chapters in DSM-5 catches the eye first.
The background of this new order is the idea to give credit
to developmental aspects of the disorders. Diagnoses with
early onsets are dealt with first. Additional information
about development, course, and symptomatic lifetime
changes of the disorder are given in the text.
Specific differences most commonly deal with time and
duration criteria. This can for instance be seen in the cases
of the DSM-5 diagnosis Brief Psychotic Disorder and the
ICD-11 counterpart Acute and Transient Psychotic and
Delusional Disorder. ICD-11 has a time criterion for
schizophrenia of 1 month, whereas DSM-5 requires
6 months. So ICD-11 ATPD with symptoms of schizo-
phrenia has to stay within this 1-month period, while
DSM-5 splits this syndrome into 1 month of brief Psychotic
Disorder and up to 6 months of Schizophreniform Disorder.
Regarding schizoaffective disorder, the longitudinal
aspect will be taken out of ICD-11 in order to simplify the
diagnostic process and to underline the transsectional
approach. DSM-5 holds on to a more longitudinal
approach, which makes necessary time-consuming
history-taking with questionable value of information.
The characterization of patients with both mood and
psychotic disorders remains a clinical challenge.
The role of functional outcome remains a hotly debated
issue. On the one hand, deficits are found consistently in
schizophrenia. On the other hand, some patients with a
considerable degree of typical symptoms may show a high
level of functioning and would therefore not be eligible for
healthcare benefits if they do not meet diagnostic criteria
for a disorder. WHO has a separate classification system
for functional impairment and disability.23
In spite of these discrepancies, it is important not to
lose sight of similarities between the 2 systems. Both
eliminate the subcategories of schizophrenia, both
underscore the relevance of dimensional aspects with
symptom specifier/assessment, and both diminish the
role of first rank symptoms and include cognitive
impairments. Attenuated psychosis syndrome is consid-
ered highly important for further scientific investigation,
even though it is not yet included as a diagnostic entity.
Conclusion
The changes in DSM-5 and ICD-11 represent no
paradigmatic shift. Many specialists would have wished
that the diagnostic process could be based more on a
neurobiological fundamental. Although huge efforts are
made in this direction, the exact neurophysiological
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CLASSIFICATION OF PSYCHOSIS 5
underpinnings of schizophrenia remain elusive.7 For the
time being, the available evidence does not allow for the
introduction of biological markers to aid the individual
diagnostic process.24 To outperform well-introduced and
validated diagnostic manuals in terms of higher
reliability and validity is an ambitious challenge and not
easy to reach. As the review process and the field trials
for ICD-11 are not yet completed predictions regarding
clinical utility, reliability, and validity seem premature.
We do not expect major surprises regarding these
parameters due to the modest changes so far discussed
for ICD-11. The fact that 99.5% of DSM-IV schizo-
phrenia patients meet DSM-5 criteria supports this
conjecture.14 One of the goals for DSM-5 and ICD-11
was to create more practical manuals. In this respect, the
clinical utility of ICD-11 in terms of psychotic disorders
may be improved because of the reduced count of
diagnoses and the consolidation of disorders with
delusional aspects. On the other hand, the dimensional
approach implemented in both systems calls for time-
consuming assessments and may therefore impede the
clinical usability.18 Having said this, we strongly feel that
the dimensional approach is justified by the considerable
heterogeneity of symptoms and the course of illness of
schizophrenia and other psychotic disorders.
Both systems so far ignore pre-psychotic prodromal
syndromes. As a lot of research is done in this important
field, so it would appear desirable to include these into
the chapter for syndromes requiring further study.
Another issue of ongoing discussion is the role of
functional outcome. In DSM-5, an impaired functional
outcome is a mandatory criterion for schizophrenia,
while the WHO argues against this.25 Functional deficits
do not occur in all schizophrenia patients and are far
from specific for this diagnosis.26 This problem remains
an unsolved issue, and further studies will hopefully shed
more light on it.17
On a related note, the role of cognitive impairment
was carefully considered by both working groups. Due to
the lack of specificity for schizophrenia, the role of
cognitive impairment is not part of the core diagnostic
criteria, but is given attention as a symptom specifier/
assessment.4,27
Some have questioned whether the modest innovations
of the new diagnostic manuals justify the enormous
consumption of financial and human resources. The
diagnostic process remains an everyday challenge and
depends greatly on the one who performs it. As we tend to
find what we are looking for, it is important to critically
reconsider familiar diagnostic practice from time to time
and to systematically put it into context with the latest
research. This assures the enhancement of diagnostic
accuracy and the development of new research fields, in
the interest of training clinicians better in the best
interest of the patients for whom we care.
IP address: 132.239.1.231
 6 F. BIEDERMANN AND W. W. FLEISCHHACKER
Disclosures
Falko Biedermann does not have anything to disclose.
W. Wolfgang Fleischhacker has the following disclosures:
Otsuka, consultant, principal investigator, research
grant; Lundbeck, consultant, principal investigator,
research grant; Janssen, consultant, research grant;
Boehringer Ingelheim, consultant, research grant;
Dainippon Sumitomo, consultant, honoraria; Teva,
consultant, honoraria.
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