PSYCHOTIC DISORDERS

DURATION OTHER CRITERIA FOR

SYMPTOMATOLOGY PREVALENCE RISK FACTORS
OF ILLNESS DIAGNOSIS
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.

*Two (or more) of the following, each present for a

significant portion of time during a
1 -month period (or less if successfully treated1.
D
Delusions.
E
2. Hallucinations.
L
3. Disorganized speech (e.g., frequent derailment or
U
incoherence).
S Lifetime prevalence: ~0.2%
4. Grossly disorganized or catatonic behavior.
I
5. Negative symptoms (i.e., diminished emotional The assessment of cognition,
O Most frequent subtype: persecutory
expression or avolition). depression, and mania symptom
N
domains is vital for making critically
A Gender Distribution: No major
1 month or Note: Hallucinations, if present, are not prominent and important distinctions between the
L gender differences in the overall
longer are related to the delusional various schizophrenia spectrum and
frequency of delusional disorder
theme (e.g., the sensation of being infested with other psychotic disorders.
D
insects associated with delusions of
I *Note: Delusional disorder, jealous
infestation).
S type, is probably more
O common in males than in females
C. Apart from the impact of the delusion(s) or its
R
ramifications, functioning is not markedly
D
impaired, and behavior is not obviously bizarre or odd.
E
D. If manic or major depressive episodes have occurred,
R
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 another
medical condition and is not better explained by
another mental disorder, such as body dysmorphic
disorder or obsessive-compulsive disorder.
B
R
I
A. Presence of one (or more) of the following symptoms:
E
1. Delusions.
F Temperamental.
2. Hallucinations.
Preexisting personality
3. Disorganized speech (e.g., frequent derailment or
P disorders and traits (e.g.,
incoherence).
S schizotypal personality
4. Grossly disorganized or catatonic behavior. Prevalence (United States): 9% of
Y The assessment of cognition, disorder; borderline
cases of first-onset psychosis.
C depression, and mania symptom personality disorder; or
B. Duration of an episode of the disturbance is at least 1
H domains is vital for making critically traits in the psychoticism
At least 1 day day but less than 1 month, with Psychotic disturbances are more
O important distinctions between the domain, such
but less than 1 eventual full return to premorbid level of functioning. common in developing countries
T various schizophrenia spectrum and as perceptual
month than in developed countries.
I other psychotic disorders. dysregulation, and the
C negative affectivity domain,
C. The disturbance is not better explained by major Gender Distribution: twofold more
such as suspiciousness)
depressive or bipolar disorder with common in females than in males.
D may predispose the
psychotic features or another psychotic disorder such
I individual to the
as schizophrenia or catatonia,
S development of the
and is not attributable to the physiological effects of a
O disorder.
substance (e.g., a drug of abuse,
R
a medication) or another medical condition.
D
E
R
 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).
S 1. Delusions.
C 2. Hallucinations.
H 3. Disorganized speech (e.g., frequent derailment or
I incoherence).
Z 4. Grossly disorganized or catatonic behavior.
O 5. Negative symptoms (i.e., diminished emotional
P expression or avolition).
H
R B. An episode of the disorder lasts at least 1 month but As with schizophrenia, currently
E less than 6 months. When the diagnosis must be there are no laboratory or
N made without waiting for recovery, it should be psychometric tests for Genetic and physiological.
I At least 1 qualified as “provisional.” schizophreniform disorder. There are Higher incidence in developing Relatives of individuals with
F month but less multiple brain regions where countries compared to developed schizophreniform disorder
O than 6 months C. Schizoaffective disorder and depressive or bipolar neuroimaging, neuropathological, countries. have an increased risk for
R disorder with psychotic features have and neurophysiological research has schizophrenia.
M been ruled out because either 1 ) no major depressive indicated abnormalities, but none are
or manic episodes have occurred diagnostic.
D concurrently with the active-phase symptoms, or 2) if
I mood episodes have occurred during
S active-phase symptoms, they have been present for a
O minority of the total duration
R of the active and residual periods of the illness.
D
E
R 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.
 A. Two (or more) of the following, each present for a Environmental.
significant portion of time during a 1-month period (or Season of birth has been
less if successfully treated). linked to the incidence of
1. Delusions. schizophrenia, including
2. Hallucinations. late winter/early spring in
3. Disorganized speech (e.g., frequent derailment or some locations and
incoherence). summer for the deficit form
4. Grossly disorganized or catatonic behavior. of the disease. The
5. Negative symptoms (i.e., diminished emotional incidence of schizophrenia
expression or avolition). and related disorders is
higher for children growing
B. For a significant portion of the time since the onset of up in an urban environment
the disturbance, level of functioning A schizophrenia diagnosis requires and for some minority
Continuous in one or more major areas, such as work, the presence of delusions or Lifetime prevalence: 0.3%-0.7%, ethnic groups.
signs of the interpersonal relations, or self-care, is hallucinations in the absence of Sex ratio differs across samples
S
disturbance markedly below the level achieved prior to the onset mood episodes. In addition, mood and populations: Genetic and physiological.
C
persist for at (or when the onset is in childhood episodes, taken in total, should be  an emphasis on negative There is a strong
H
least 6 or adolescence, there is failure to achieve expected present for only a minority of the symptoms and longer contribution for genetic
I
months. level of interpersonal, academic, total duration of the active and duration of disorder factors in determining
Z
or occupational functioning). residual periods of the illness. (associated with poorer risk for schizophrenia,
O
This 6-month outcome) shows higher although most individuals
P
period C. Continuous signs of the disturbance persist for at least In addition to the five symptom incidence rates for males, who have been diagnosed
H
must include 6 months. This 6-month period domain areas identified in the whereas definitions allowing with schizophrenia have no
R
at least 1 must include at least 1 month of symptoms (or less if diagnostic criteria, the assessment for the inclusion of more family history of psychosis.
E
month of successfully treated) that meet Criterion of cognition, depression, and mania mood symptoms and brief
N
symptoms (or A (i.e., active-phase symptoms) and may include symptom domains is vital for making presentations Pregnancy and birth
I
less if periods of prodromal or residual critically important distinctions (associated with better complications with hypoxia
A
successfully symptoms. During these prodromal or residual between the various schizophrenia outcome) show equivalent and greater paternal age
treated). periods, the signs of the disturbance may spectrum and other psychotic risks for both sexes. are associated
be manifested by only negative symptoms or by two disorders. with a higher risk of
or more symptoms listed in Criterion schizophrenia for the
A present in an attenuated form (e.g., odd beliefs, developing fetus. In
unusual perceptual experiences). addition, other prenatal
and perinatal adversities,
D. Schizoaffective disorder and depressive or bipolar including stress, infection,
disorder with psychotic features malnutrition, maternal
have been ruled out because either 1) no major diabetes, and
depressive or manic episodes have other medical conditions,
occurred concurrently with the active-phase have been linked with
symptoms, or 2) if mood episodes have schizophrenia. However,
occurred during active-phase symptoms, they have the vast majority
been present for a minority of the of offspring with these risk
 total duration of the active and residual periods of the factors do not develop
illness. schizophrenia.

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 childhood
onset, the additional diagnosis of schizophrenia is
made only if prominent delusions
or hallucinations, in addition to the other required
symptoms of schizophrenia,
are also present for at least 1 month (or less if
successfully treated).
S
C
H
I A. An uninterrupted period of illness during which there
Z is a major mood episode (major depressive or manic)
O concurrent with Criterion A of schizophrenia.
Genetic and physiological.
A Delusions or Note: The major depressive episode must include a
Among individuals with
F hallucinations depressed mood.
In addition to the five symptom schizophrenia, there may
F for 2 or more
domain areas identified in the be an increased risk for
E weeks in the B. Delusions or hallucinations for 2 or more weeks in the
diagnostic criteria, the assessment schizoaffective disorder in
C absence of a absence of a major mood episode (depressive or
of cognition, depression, and mania Lifetime prevalence: 0.3% first-degree relatives. The
T major mood manic) during the lifetime duration of the illness.
symptom domains is vital for making Gender Distribution: higher in risk for schizoaffective
I episode
critically important distinctions females than in males disorder may be increased
V (depressive or C. Symptoms that meet criteria for a major mood
between the various schizophrenia among individuals who
E manic) during episode are present for the majority of the total
spectrum and other psychotic have a first-degree relative
the lifetime duration of the active and residual portions of the
disorders. with schizophrenia, bipolar
D duration of the illness.
disorder, or schizoaffective
I illness.
disorder.
S D. The disturbance is not attributable to the effects of a
O substance (e.g., a drug of abuse,
R a medication) or another medical condition.
D
E
R
S
U
B A. Presence of one or both of the following symptoms:
S 1. Delusions.
T 2. Hallucinations.
A
N B. There is evidence from the history, physical
C examination, or laboratory findings of both
E/ 1. The symptoms in Criterion A developed during or
M soon after substance intoxication
E
or withdrawal or after exposure to a medication.
D
I
2. The involved substance/medication is capable of
C producing the symptoms in Criterion A.
A
T C. The disturbance is not better explained by a psychotic
I disorder that is not substance/
O medication-induced. Such evidence of an independent
N Prevalence in the general
psychotic disorder could include In addition to the four symptom
- population
the following: domain areas identified in the
I is unknown.
The symptoms preceded the onset of the diagnostic criteria, the assessment
N
substance/medication use; the symptoms of cognition, depression, and mania
D Between 7% and 25% of
U
persist for a substantial period of time (e.g., about 1 symptom domains is vital for making
individuals presenting with a first
C month) after the cessation of critically important distinctions
episode of psychosis in different
E acute withdrawal or severe intoxication: or there is between the various schizophrenia
settings are reported to have
D other evidence of an independent spectrum and other psychotic
substance/medication-induced
non-substance/medication-induced psychotic disorder disorders.
psychotic disorder.
P (e.g., a history of recurrent
S non-substance/medication-related episodes).
Y
C D. The disturbance does not occur exclusively during the
H
course of a delirium.
O
T
I E. The disturbance causes clinically significant distress
C or impairment in social, occupational,
or other important areas of functioning.
D Note: This diagnosis should be made instead of a
I diagnosis of substance intoxication or
S substance withdrawal only when the symptoms in
O Criterion A predominate in the clinical
R picture and when they are sufficiently severe to
D
warrant clinical attention.
E
R
P
S
Y
C
H
O
T
I
C Lifetime prevalence: 0.21% to
D 0.54%
I
S Age Group Distribution:
O Individuals older than 65 years
R One consideration is the presence of
have a significantly greater
D a temporal association between the
E prevalence of
A. Prominent hallucinations or delusions. onset, exacerbation, or remission of Course modifiers.
R 0.74% compared with those in
B. There is evidence from the history, physical the medical condition and that of the Identification and treatment
younger age groups.
Due examination, or laboratory findings that the psychotic disturbance. A second of the underlying medical
To disturbance is the direct pathophysiological consideration is the presence of condition has
Conditions most commonly
consequence of another medical condition. features that are atypical for a the greatest impact on
A associated with psychosis:
C. The disturbance is not better explained by another psychotic disorder (e.g., atypical age course, although
N untreated endocrine and metabolic
O mental disorder. at onset or presence of visual or preexisting central nervous
disorders, autoimmune disorders
T D. The disturbance does not occur exclusively during the olfactory hallucinations). The system injury may
(e.g., SLE, N-methyl-D-aspartate
H course of a delirium. disturbance must also be confer a worse course
E (NMDA) receptor autoimmune
E. The disturbance causes clinically significant distress distinguished from a outcome (e.g., head
R encephalitis), or temporal lobe
or impairment in social, occupational, substance/medication-induced trauma, cerebrovascular
epilepsy.
M or other important areas of functioning. psychotic disorder or another mental disease).
E disorder (e.g., an adjustment
D Gender distribution: higher in
disorder).
I females, although additional
C gender-related features are not
A clear and vary considerably with
L
the gender distributions of the
C underlying medical conditions.
O
N
D
I
T
I
O
N
 Applies to presentations in which symptoms characteristic of
a schizophrenia spectrum and other psychotic disorder that
cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning
Other Specified
predominate but do not meet the full criteria for any of the
Schizophrenia
disorders in the schizophrenia spectrum and other
Spectrum and
psychotic disorders diagnostic class.
Other Psychotic
Disorder
Used in cases when the clinician chooses to communicate
the specific reason that the presentation does not meet the
criteria for any specific schizophrenia spectrum and other
psychotic disorder.

Applies to presentations in which symptoms characteristic of

a schizophrenia spectrum and other psychotic disorder that
cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the
Unspecified
disorders in the schizophrenia spectrum and other
Schizophrenia
psychotic disorders diagnostic class.
Spectrum and
Other Psychotic
Used in situations in which the clinician chooses not to
Disorder
specify the reason that the criteria are not met for a specific
schizophrenia spectrum and other psychotic disorder, and
includes presentations in which there is insufficient
information to make a more specific diagnosis (e.g., in
emergency room settings)
 For a diagnosis of bipolar I disorder, it is necessary to meet Environmental.
the following criteria for a manic episode. The manic episode Bipolar disorder is more
may have been preceded by and may be followed by common in high-income
hypomanic or major depressive episodes. than in low-income
countries (1.4 vs. 0.7%).
Manic Episode
A. A distinct period of abnormally and persistently Separated, divorced, or
elevated, expansive, or irritable mood and abnormally widowed individuals have
and persistently increased goal-directed activity or higher rates of
Manic episode energy, lasting at least 1 week and present most of bipolar I disorder than do
lasting at least the day, nearly every day (or any duration if individuals who are married
1 week and hospitalization is necessary). or have never been
present most B. During the period of mood disturbance and increased married, but
of the day, energy or activity, three (or more) of the following the direction of the
nearly every symptoms (four if the mood is only irritable) are association is unclear.
The 12-month prevalence estimate
day present to a significant degree and represent a
in the continental United States
noticeable change from usual behavior: Genetic and physiological.
B was 0.6% for bipolar I
(Possibly with 1. Inflated self-esteem or grandiosity. A family history of bipolar
I It is necessary to meet criteria for a disorder.
hypomanic 2. Decreased need for sleep (e.g., feels rested after disorder is one of the
P manic episode to make a diagnosis
episode only 3 hours of sleep). strongest and
O of bipolar I disorder, but it is not Twelve-month prevalence of
lasting at least 3. More talkative than usual or pressure to keep most consistent risk factors
L required to have hypomanic or major bipolar I disorder across 11
4 consecutive talking. for bipolar disorders. There
A depressive episodes. However, they countries ranged from 0.0% to
days and 4. Flight of ideas or subjective experience that is an average 10-fold
R may precede or follow a manic 0.6%.
present most thoughts are racing. increased risk
episode.
of the day, 5. Distractibility (i.e., attention too easily drawn to among adult relatives of
I The lifetime male-to-female
nearly every unimportant or irrelevant external individuals with bipolar I
prevalence ratio is approximately
day and/or stimuli), as reported or observed. and bipolar II disorders.
1.1:1.
major 6. Increase in goal-directed activity (either socially, at Magnitude of
depressive work or school, or sexually) or psychomotor agitation risk increases with degree
episodes (i.e., purposeless non-goal-directed activity). of kinship. Schizophrenia
present during 7. Excessive involvement in activities that have a high and bipolar disorder likely
the same 2- potential for painful consequences (e.g., engaging in share a genetic
week period) unrestrained buying sprees, sexual indiscretions, or origin, reflected in familial
foolish business investments). co-aggregation of
C. The mood disturbance is sufficiently severe to cause schizophrenia and bipolar
marked impairment in social or occupational disorder.
functioning or to necessitate hospitalization to prevent
harm to self or others, or there are psychotic features. Course modifiers.
D. The episode is not attributable to the physiological After an individual has a
effects of a substance (e.g., a drug of abuse, a manic episode with
medication, other treatment) or to another medical psychotic features,
condition. subsequent
 Note: A full manic episode that emerges during manic episodes are more
antidepressant treatment (e.g., medication, likely to include psychotic
electroconvulsive therapy) but persists at a fully features. Incomplete
syndromal level beyond the physiological effect of that interepisode recovery is
treatment is sufficient evidence for a manic episode more common when the
and, therefore, a bipolar I diagnosis. current episode is
accompanied by mood in
Note: Criteria A-D constitute a manic episode. At least congruent
one lifetime manic episode is required psychotic features.
for the diagnosis of bipolar I disorder.

Hypomanic Episode

A. A distinct period of abnormally and persistently

elevated, expansive, or irritable mood
and abnormally and persistently increased activity
or energy, lasting at least 4 consecutive
days and present most of the day, nearly every
day.
B. During the period of mood disturbance and
increased energy and activity, three (or
more) of the following symptoms (four if the mood
is only irritable) have persisted, represent
a noticeable change from usual behavior, and
have been present to a significant
degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested
after only 3 hours of sleep).
3. More talkative than usual or pressure to keep
talking.
4. Flight of ideas or subjective experience that
thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially,
at work or school, or sexually) or
psychomotor agitation.
7. Excessive involvement in activities that have a
high potential for painful consequences
(e.g., engaging in unrestrained buying sprees,
 sexual indiscretions, or
foolish business investments).
C. The episode is associated with an unequivocal
change in functioning that is uncharacteristic
of the individual when not symptomatic.
D. The disturbance in mood and the change in
functioning are observable by others.
E. The episode is not severe enough to cause
marked impairment in social or occupational
functioning or to necessitate hospitalization. If
there are psychotic features, the
episode is, by definition, manic.
F. The episode is not attributable to the physiological
effects of a substance (e.g., a drug
of abuse, a medication, other treatment).

Note: A full hypomanic episode that emerges

during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists
at a fully syndromal level beyond
the physiological effect of that treatment is
sufficient evidence for a hypomanic episode
diagnosis. However, caution is indicated so that
one or two symptoms (particularly increased
irritability, edginess, or agitation following
antidepressant use) are not taken
as sufficient for diagnosis of a hypomanic episode,
nor necessarily indicative of a bipolar
diathesis.

Note: Criteria A-'F constitute a hypomanic

episode. Hypomanic episodes are common in
bipolar I disorder but are not required for the
diagnosis of bipolar I disorder.

Major Depressive Episode

A. Five (or more) of the following symptoms have been
present during the same 2-week period and represent
a change from previous functioning; at least one of the
symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
Note: Do not include symptoms that are clearly
attributable to another medical condition.
1. Depressed mood most of the day, nearly every day,
as indicated by either subjective
report (e.g., feels sad, empty, or hopeless) or
observation made by others (e.g.,
appears tearful). (Note: In children and adolescents,
can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the
day, nearly every day (as indicated by either
subjective account or observation).
3. Significant weight loss when not dieting or weight
gain (e.g., a change of more than
5% of body weight in a month), or decrease or
increase in appetite nearly every
day. (Note: In children, consider failure to make
expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every
day (observable by others; not
merely subjective feelings of restlessness or being
slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt
about being sick).
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either
by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without
a specific plan, or a suicide attempt or a specific plan
for committing suicide.
B. The symptoms cause clinically significant distress
or impairment in social, occupational,
or other important areas of functioning.
C. The episode is not attributable to the physiological
effects of a substance or another
medical condition.
Note: Criteria A-C constitute a major depressive
episode. Major depressive episodes are
common in bipolar I disorder but are not required for
the diagnosis of bipolar I disorder.
Note: Responses to a significant loss (e.g.,
bereavement, financial ruin, losses from a
natural disaster, a serious medical illness or disability)
may include the feelings of intense
sadness, rumination about the loss, insomnia, poor
appetite, and weight loss noted in Criterion
A, which may resemble a depressive episode.
Although such symptoms may be understandable
or considered appropriate to the loss, the presence of
a major depressive episode in addition to the normal
response to a significant loss should also be carefully
considered. This decision inevitably requires the
exercise of clinical judgment based on the individual’s
history and the cultural norms for the expression of
distress in the context
of loss.^
 Genetic and physiological.
The risk of bipolar II
disorder tends to be highest
among relatives
of individuals with bipolar II
disorder, as opposed to
individuals with bipolar I
disorder
or major depressive
disorder. There may be
Compared with individuals with
genetic factors influencing
The major bipolar I disorder, individuals with
the age at
depressive bipolar II disorder have greater
onset for bipolar disorders.
episode must chronicity of illness and spend, on
A. Criteria have been met for at least one hypomanic and
last at least 2 average, more time in the
at least one major depressive episode. Course modifiers.
weeks, and depressive phase of their illness,
B. There has never been a manic episode. A rapid-cycling pattern is
B the hypomanic which can be severe and/ or The 12-month prevalence
C. The occurrence of the hypomanic episode(s) and associated with a poorer
I episode must disabling. Depressive symptoms co- (internationally): 0.3%.
major depressive episode(s) is not better explained by prognosis. Return
P last at least 4 occurring with a hypomanic episode
schizoaffective disorder, schizophrenia, to previous level of social
O days or hypomanic symptoms co- Prevalence rate of bipolar disorder
schizophreniform disorder, delusional disorder, or function for individuals with
L occurring with a depressive episode yield a combined prevalence rate
other specified or unspecified schizophrenia spectrum bipolar II disorder is more
A Mood are common in individuals with of 1.8% in U.S. and non-U.S.
and other psychotic disorder. likely
R episode(s), bipolar disorder and are community samples,
D. The symptoms of depression or the unpredictability for individuals of younger
With overrepresented in females, with higher rates (2.7% inclusive) in
caused by frequent alternation between periods of age and with less severe
II symptoms particularly hypomania with mixed youths age 12 years or older.
depression and hypomania causes clinically depression, suggesting
present most features. Individuals experiencing
significant distress or impairment in social, adverse effects
of the day, hypomania with mixed features may
occupational, or other important areas of functioning. of prolonged illness on
nearly every not label their symptoms as
recovery. More education,
day hypomania, but instead experience
fewer years of illness, and
them as depression with increased
being married
energy or irritability.
are independently
associated with functional
recovery in individuals with
bipolar
disorder, even after
diagnostic type (I vs. II),
current depressive
symptoms, and presence
of psychiatric comorbidity
are taken into account.