The DSM-5 modified the guidelines for diagnosing schizophrenia. This has helped mental health professionals provide a more reliable diagnosis.
Schizophrenia changes how people think, feel, and behave. It causes them to see reality differently than others.
It’s a serious mental illness that affects approximately 3.2 million Americans. Still, with proper treatment, a person with schizophrenia can be successful in school and work and enjoy a fulfilling personal life.
In 2013, the way schizophrenia is diagnosed changed, and its formal name was revised from just “schizophrenia” to “schizophrenia spectrum disorder.” This allows healthcare professionals to diagnose the condition based on the severity of symptoms.
These changes were created by the American Psychiatric Association (APA) and published in the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5).
The changes didn’t affect people who were already diagnosed with the condition. In fact, since that time, researchers have shown that over
Instead, these changes involved creating a new set of guidelines for mental health professionals. They were created to guarantee a more reliable diagnosis.
When it comes to symptoms and other criteria for diagnosis, most differences between the fourth edition (DSM-4) and fifth edition (DSM-5) of the Diagnostic and Statistical Manual of Mental Health Disorders are minor changes in wording.
The five key symptoms of schizophrenia remained the same:
- disorganized speech
- disorganized or catatonic behavior
- negative symptoms (not expressing any feelings or emotions)
However, the number of symptoms needed for diagnosis was changed. This is one of the biggest revisions from the DSM-4 to the DSM-5.
Previously, you needed to have at least two of the above symptoms to receive a diagnosis. But, your doctor could also diagnose schizophrenia if you had only one symptom and also experienced either “bizarre” delusions or hallucinations that included “a running commentary on a person’s thoughts/behavior, and/or two or more voices conversing.”
The DSM-5 removed the second criteria because experts decided that it wasn’t very specific. Also, it’s difficult to determine what is and isn’t considered “bizarre.”
Now, for a doctor to diagnose schizophrenia, an individual must have at least two symptoms, and at least one of those symptoms must be one of the first three:
- disorganized speech
In the DSM-4, the condition’s full name was “Schizophrenia and Other Psychotic Disorders.” Under this condition, there were five subtypes of schizophrenia.
When a healthcare professional diagnosed schizophrenia, the person receiving the diagnosis was placed into one of the following subtypes.
People with this subtype must have at least two of these symptoms:
- They don’t move much or at all.
- They experience a lot of unusual movements that don’t seem to have a purpose.
- They refuse to do things or speak.
- They choose to put themselves in strange positions or show stereotypical movements, very noticeable gestures, or very noticeable grimacing.
- They experience echolalia (repeating what others say) or echopraxia (repeating how others move).
People with this subtype must:
- have disorganized speech
- have disorganized behavior
- express no feelings or emotions
People with this subtype must have:
- one or more delusional thoughts that they think about regularly, or sounds they hear regularly that don’t exist
- no symptoms of “catatonic” or “disorganized” type
People with this subtype don’t have the very noticeable symptoms of the other types, but evidence suggests that they have schizophrenia because they have negative symptoms or two more symptoms of schizophrenia that are not as strong, such as odd beliefs or strange experiences.
People with this subtype don’t have symptoms that meet the criteria of the other types, but do have the main symptoms that meet the criteria for schizophrenia.
Why the subtypes were removed
With the release of the DSM-5, these subtypes were removed for
- They weren’t very reliable descriptions.
- People living with schizophrenia didn’t always experience the same symptoms or subtype.
- There was no difference in brain functioning between the subtypes.
- The subtypes didn’t help predict how the condition would play out over time.
- Some people couldn’t be assigned a subtype based on their symptoms.
- They didn’t help with treatment decisions.
- Scientists had stopped using the subtypes in their reports.
Instead, the APA believed it was more accurate to describe the symptoms of schizophrenia as a spectrum.
This means that people with schizophrenia may experience different symptoms at different times. It also means that not everyone with a schizophrenia diagnosis experiences the same symptoms.
This is why the condition is now called “Schizophrenia Spectrum and Other Disorders” in the DSM-5, compared with just “Schizophrenia and Other Disorders” in the DSM-4.
Due to the change from “schizophrenia” to “schizophrenia spectrum disorder,” a person’s condition is now described based on how severe their symptoms are.
The symptom ratings are not required to diagnose schizophrenia. But, doctors use them to clearly identify what the person is experiencing and what treatment should work best.
The symptoms that are rated include:
- reality distortion (having delusions or hallucinations)
- negative symptoms (for example, whether the person doesn’t express as much emotion or lacks any motivation to do things)
- cognitive impairment (trouble remembering or learning new things, can’t concentrate, has a hard time making decisions)
- motor symptoms (doesn’t move in a normal way)
- mood symptoms (experiences episodes of depression or mania)
Since these symptoms can now be rated, there is also a new rating scale in the DSM-5. The ratings are based on how severe the symptom has been during the last 7 days and range from 0 (no symptoms) to 4 (severe symptoms).
Because a person with schizophrenia may have different episodes, their symptoms and the ratings can change over time.
|Disorder class||Schizophrenia and Other Psychotic Disorders||Schizophrenia Spectrum and Other Psychotic Disorders|
|A. Characteristic symptoms||Two (or more) of the symptoms below. Each symptom must appear for a considerable amount of time over one month. The symptoms can appear for less time if they are being treated successfully.||stayed mostly the same, but it has been specified that at least one of the symptoms must be number 1, 2, or 3|
|1. delusions||stayed the same|
|2. hallucinations||stayed the same|
|3. disorganized speech||stayed the same|
|4. grossly disorganized or catatonic behavior||stayed the same|
|5. negative symptoms (i.e., affective flattening, alogia, or avolition)||stayed the same, but the description in parentheses was revised to “i.e., diminished emotional expression or avolition“|
|Note: A diagnosis can also be given if a person has only one of the symptoms above, but also has either bizarre delusions or hallucinations that included “a running commentary on a person’s thoughts/behavior, and/or two or more voices conversing.”||REMOVED|
|B. Social/occupational dysfunction||Since symptoms first appeared, they aren’t doing as well in at least one of the following areas: |
• interpersonal relations
Or, if they are a child or teen, they aren’t doing as well as expected:
• in school
• with managing daily life
|stayed mostly the same with a slight change in wording|
|C. Duration||• Regular symptoms have occurred for at least 6 months. |
• Within that time, there must be at least one month of symptoms (or less if successfully treated) that meet the criteria in A.
• There may be periods when the symptoms are just starting to show (called prodromal) or are decreasing because of successful treatment (called residual symptoms).
• During these times, there might only be negative symptoms or two or more symptoms from A that are not as intense (for example, odd beliefs or strange experiences).
|stayed the same|
|D. Schizoaffective and Mood Disorder exclusion||Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either: |
1. no major episodes of depression, mania or both happened at the same time as active symptoms of schizophrenia
2. if an episode did occur during active-phase symptoms, the amount of time was brief compared to the active and recovery periods of schizophrenia
|“Schizoaffective disorder and mood disorder with psychotic features” was replaced with “Schizoaffective disorder and depressive or bipolar disorder with psychotic features” — The rest stayed mostly the same with a slight change in wording|
|E. Substance/general medical condition exclusion:||The symptoms aren’t because of:|
• a reaction to a medication
• drug abuse
• a medical condition
|stayed mostly the same with a slight change in wording|
|F. Relationship to a Pervasive Developmental Disorder||If there is a history of autistic disorder or another pervasive developmental disorder, schizophrenia is only diagnosed if major delusions or hallucinations occur for least a month (or less if successfully treated).||stayed mostly the same with a slight change in wording|
|Classifications after 1 year since the beginning of active symptoms||• Episodic with interepisode residual symptoms (episodes mean that major symptoms return); also specify if: with prominent negative symptoms|
• Episodic with no interepisode residual symptoms
• Continuous (major symptoms continue); also specify if: with prominent negative symptoms
• Single episode in partial remission; also specify if: with prominent negative symptoms
• Single episode in full remission
• Other or unspecified pattern
• First episode, currently in acute episode. First episode that meets the criteria for diagnosis. An acute episode is the time period where there are symptoms.
• First episode, currently in partial remission. Partial remission means there is improvement after a previous episode. Now, the criteria are only partially fulfilled.
• First episode, currently in full remission. There are no symptoms present.
• Multiple episodes, currently in acute episode. There have been at least two episodes.
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous. Symptoms remain throughout the period of time. If they decrease, it’s for a very short period of time, compared to the overall amount of time.
Specify if: with catatonia (another mental condition)
Specify current severity:
Rating is based on how many and how severe the primary symptoms are.
• reality distortion (having delusions or hallucinations)
• negative symptoms (for example, doesn’t express as much emotion or lacks any motivation to do things)
• disorganization cognitive impairment (trouble remembering or learning new things, can’t concentrate, has a hard time making decisions)
• motor symptoms (doesn’t move in a normal way)
• mood symptoms (has depression or mania)
Each of these symptoms is rated for how severe it has been during the last seven days.
The rating scale is from 0 (no symptoms) to 4 (severe symptoms).
Note: This is not required to diagnose schizophrenia.
|Subtypes||• catatonic type|
• disorganized type
• paranoid type
• residual type
• undifferentiated type
Schizophrenia usually begins around early adulthood. Males tend to first show symptoms when they’re at the end of their teenage years or in their early 20s. Women don’t usually show symptoms until their early 20s through their early 30s.
The first changes happen slowly and may begin years before they have their first episode of psychosis. Once a person has received a schizophrenia diagnosis, they will have the condition throughout their life.
You can also reach out to a trusted healthcare provider. They’re the only ones who can properly diagnose the condition. This may be your general practitioner, a mental health professional, or another healthcare professional in whom you can confide.