CLASSIFICATION
OF SCHIZOPHRENIA
International Classification of Diseases, Revision 10
F20-F29
Schizophrenia, schizotypal
and delusional disorders
F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
A fifth character may he
used to classify course:
F20.x 0 Continuous
F20.x I Episodic
with progressive deficit
F20.x2 Episodic with stable
deficit
F20.x3 Episodic remittent
F20.x4 Incomplete remission
F20. x5 Complete remission
F20.x8 Other
F20.x9 Period of
observation less than one year
F21 Schizotypal disorder
F22 Persistent
delusional disorders
F22.0 Delusional disorder
F22.8 Other persistent
delusional disorders
F22.9 Persistent delusional
disorder, unspecified
F23 Acute and transient
psychotic disorders
F23.0 Acute polymorphic psychotic disorder without
symptoms of schizophrenia
F23.l Acute polymorphic psychotic disorder with
symptoms of schizophrenia
F23.2 Acute
schizophrenia-like psychotic disorder
F23.3 Other acute
predominantly delusional psychotic disorder
F23.8 Other acute and
transient psychotic disorders
F23.9 Acute and transient
psychotic disorder. unspecified
F20 - F29
SCHIZOPHRENIA, SCHIZOTYPAL AND DELUSIONAL DISORDERS
A fifth character may be
used to identify the presence or absence of associated acute stress:
F23. xO Without associated
acute stress F23.xJ With associated acute stress
F24 Induced delusional
disorder
F25 Schizoaffective
disorders
F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive
type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
F28 Other nonorganic
psychotic disorders F29 Unspecified nonorganic psychosis
Introduction
Schizophrenia is the
commonest and most important disorder of this group. Schizotypal disorder
possesses many of the characteristic features of schizophrenic disorders and is
probably genetically related to them; however, the hallucinations, delusions. and
gross behavioural disturbances of schizophrenia itself are absent and so this
disorder does not always come to medical attention. Most of the delusional
disorders are probably unrelated to schizophrenia. although they may be
difficult to distinguish clinically, particularly in their early stages. They
form a heterogeneous and poorly understood collection of disorders. which can
conveniently he divided according to their typical duration into a group of
persistent delusional disorders and a larger group of acute and transient
psychotic disorders. The latter appear to be particularly common in developing
countries. The subdivisions listed here should be regarded as provisional.
Schizoaffective disorders have been retained in this section in spite of their
controversial nature.
Schizophrenia
The schizophrenic disorders
arc characterized in general by fundamental and characteristic distortions of
thinking and perception. and by inappropriate or blunted affect. Clear
consciousness and intellectual capacity are usually maintained. although certain
cognitive deficits may evolve in the course of time. The disturbance involves
the most basic functions that give the normal person a feeling of
individuality. uniqueness. and self-direction. The most intimate thoughts.
feelings. and acts are often felt to be known to or shared by others. and
explanatory delusions may develop. to the effect that natural or supernatural
forces are at work to influence the afflicted individual’s thoughts and actions
in ways that are often bizarre. The individual may see himself or herself as
the pivot of all that happens. Hallucinations. especially auditory. are common
and may comment on the individual’s behaviour or thoughts. Perception is
frequently disturbed in other ways: colours or sounds may seem unduly vivid or
altered in quality. and irrelevant features of ordinary things may appear more
important than the whole object or situation. Perplexity is also common early
on and frequently leads to a belief that everyday situations possess a special.
usually sinister. meaning intended uniquely for the individual. In the
characteristic schizophrenic disturbance of thinking. peripheral and irrelevant
features of a total concept, which are inhibited in normal directed mental
activity. are brought to the fore and utilized in place of those that are
relevant and appropriate to the situation. Thus thinking becomes vague,
elliptical, and obscure, and its expression in speech sometimes
incomprehensible. Breaks and interpolations in the train of thought are
frequent. and thoughts may seem to be withdrawn by some outside, agency. Mood
is characteristically shallow, capricious. or incongruous. Ambivalence and
disturbance of volition may appear as inertia, negativism, or stupor. Catatonia
may be present. The onset may be acute, with seriously disturbed behaviour, or
insidious, with a gradual development of odd ideas and conduct. The course of
the disorder shows equally great variation and is by no means inevitably
chronic or deteriorating (the course is specified by five-character categories).
In a proportion o)f cases, which may vary in different cultures and
populations, the outcome is complete, or nearly complete recovery. The sexes
are approximately equally affected but the onset tends to be later in women.
Although no strictly
pathognomnonic symptoms can be identified, for practical purposes it is useful
to divide the above symptoms into groups that have special importance for the
diagnosis and often occur together, such as:
thought echo, thought
insertion or withdrawal. amid thought broadcasting:
delusions of control,
influence. or passivity, clearly referred to body or limb movements or specific
thoughts. actions, or sensations: delusional perception,’
hallucinatory voices giving
a running commentary on the patient’s behaviour, or discussing the patient
among themselves. or other types of hallucinatory voices coming from some part
of the body;
persistent delusions of
other kinds that are culturally inappropriate and completely impossible. such
as religious or political identity. or superhuman powers and abilities (e.g.
being able to) control the weather. or being in commummication with aliens from
another world.
persistent hallucinations
in any modality. when accompanied either by fleeting or half-formed delusions
without clear affective content, or by persistent over-valued ideas, or w’hen
occurring every day’ for weeks or months on end;
( f) breaks or interpolations in the train of thought. resulting in incoherence
or irrelevant speech. or neologisms:
catatonic behaviour, such
as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;
“negative” symptoms such as
marked apathy, paucity of speech, and blunting or incongruity of emotional
responses, usually resulting in social withdrawal and lowering of social
performance; it must be clear that these are not due to depression or to
neuroleptic medication;
a significant and
consistent change in the overall quality of some aspects of personal behaviour,
manifest as loss of interest, aimlessness. idleness, a self-absorbed attitude,
and social withdrawal.
Diagnostic guidelines
The normal requirement for
a diagnosis of schizophrenia is that a minimum of one very clear symptom (and
usually two or more if less clear-cut) belonging to any one of the groups
listed as (a) to (d) above, or symptoms from at least two of the groups
referred to as (e) to (h), should have been clearly present for most of the
time during a period of 1 month or more Conditions meeting such
symptomatic requirements but of duration less than I month (whether treated or
not) should be diagnosed in the first instance as acute schizophrenia-like
psychotic disorder (F23.2) and reclassified as schizophrenia if thsymptoms
persist for longer periods.
Viewed retrospectively, it
may be clear that a prodromal phase in which symptoms and behaviour, such as
loss of interest in work, social activities,and personal appearance and
hygiene. together with generalized anxiety and mild degrees of depression and
preoccupation. preceded the onset of psychotic symptoms by weeks or even
months. Because of the difficulty in timing onset, the 1-month duration
criterion applies only to the specific symptoms listed above and not to any
prodromal nonpsychotic phase.
The diagnosis of
schizophrenia should not be made in the presence of extensive depressive or
manic symptoms unless it is clear that schizophrenic symptoms antedated the
affective disturbance. If both schizophrenic and affective symptoms develop together
and are evenly balanced, the diagnosis of schizoaffective disorder (F25. - )
should be made, even if the schizophrenic symptoms by themselves would have
justified the diagnosis of schizophrenia. Schizophrenia should not be diagnosed
in the presence of overt brain disease or during states of drug intoxication or
withdrawal. Similar disorders developing in the presence of epilepsy or other
brain disease should be coded under F06.2 and those induced by drugs under
Flx.5.
Pattern of course
The course of schizophrenic disorders
can be classified by using the following five-character codes:
F20.x 0 Continuous
F20. xl Episodic with
progressive deficit
F20. x2 Episodic with
stable deficit
F20.x3 Episodic remittent
F20.x4 Incoinp]ete
remission
F20.xS Complete remission
F20.x 8 Other
F20.x 9 Period of
observation less than one year
F20.O Paranoid
schizophrenia
This is the commonest type
of schizophrenia in most parts of the world. The clinical picture is dominated
by relatively stable, often paranoid. delusions, usually accompanied by
hallucinations, particularly of the auditory variety. and perceptual
disturbances. Disturbances of affect, volition, and speech, and catatonic
symptools, are not prominent.
Examples of the most common
paranoid symptoms are:
delusions of persecution.
reference, exalted birth. special mission, bodily change. or jealousy;
hallucinatory voices that
threaten the patient or give commands, or auditory hallucinations w’ithout
verbal form, such as whistling, humming. or laughing;
hallucinations of smell or
taste, or of sexual or other bodily sensations: visual hallucinations may occur
but are rarely predominant.
Thought disorder may be
obvious in acute states, but if so it does not prevent the typical delusions or
hallucinations from being described clearly. Affect is usually less blunted
than in other varieties of schizophrenia, but a minor degree of incongruity is
common, as are mood disturbances such as irritability, sudden anger,
fearfulness, and suspicion. ‘Negative” symptoms such as b]unting of affect and
impaired volition are often present but do not dominate the clinical picture.
The course of paranoid
schizophrenia may be episodic, with partial or complete remissions, or chronic.
In chronic cases, the florid symptoms persist over years and it is difficult to
distinguish discrete episodes. The onset tends to be later than in the
hebephrenic and catatonic forms.
Diagnostic guidelines
The general criteria for a
diagnosis of schizophrenia (see introduc-lion to F20 above) must be satisfied.
In addition. hallucinations and/or delusions must be prominent. and
disturbances of affect, volition and speech, and catatonic symptoms must be
relatively inconspicuous. The hallucinations will usually be of the kind
described in (b) and © above. Delusions can be of almost any kind but delusions
of control. influence. or passivity, and persecutory beliefs of various kinds
are the most characteristic.
Includes paraphrenic schizophrenia
Differential diagnosis It is important to exclude epileptic
and drug-induced psychoses. and to remember that persecutory delusions might
carry little diagnostic w eight in people from certain countries or cultures.
Excludes: involutional paranoid state ( F2 1 8) paranoia (
F22.Uj
F20.1 Hebephrenic
schizophrenia
A form of schizophrenia in
which affective changes are prominent. delusions and hallucinations fleeting
and fragmentary, heha’ inur irresponsible and unpredictable, and mannerisms
common. The moodl is shal low and inappropriate and often accompanied by giggling
or self-satisfied. self-absorbed smiling, or by a lofly manner. grimaces.
mannerisms, pranks. hypochondriacal complaints. and reiterated phrases. Thought
is disorganized and speech rambling and incoherent. There is a tendency to
remain solitary, and behaviour seems empty of purpose and feeling. This form of
schizophrenia usually starts between the ages of 15 and 25 years and tends to
have a poor prognosis because of the rapid development of “negative” symptoms.
particularly flattening of affect and loss of volition.
In addition, disturbances
of affect and volition, and thought disorder are usually prominent.
Hallucinations and delusions may be present but are not usually prominent.
Drive and determination are lost and goals abandoned, so that the patient’s
behaviour becomes characteristically aimless and empty of purpose. A
superficial and manneristic preoccupation with religion, philosophy, and other
abstract themes may add to the listener’s difficulty in following the train of
thought.
Diagnostic guidelines
The general criteria for a
diagnosis of schizophrenia (see introduction to F20 above) must be satisfied.
Llebephrenia should normally be diagnosed for the tmrst time only in
adolescents or young adults. The premo)rbid personality is characteristically.
but not necessarily, rather shy and solitary. For a confident diagnosis of
hebephrenia, a period of 2 or 3 months of continuous observatio)n is usually
necessary. in order to ensure that the characteristic behaviours described
above are sustained.
Includes disorganized schizophrenia: hebeplirenia
F20.2 Catatonic
schizophrenia
Prominent psychomotor
disturbances are essential amid dominant features and may alternate hetween
extremes such as hyperkinesis and stupor. or automatic obedience and negativism
Constrai ned attitudes and postures may be maintained for long periods.
Episodes of violent excitement may be a striking feature of the condition.
For reasons that are poorly
understood. catatonic schizophrenia is now rarely seen in industrial countries,
though it remains common elsewhere. These catatonic phenomena may be combined
with a dream-like (oneiroid ) state w’ith vivid scenic hallucinations.
Diagnostic guidelines
The general criteria for a
diagnosis of schizophrenia (see introduction to F20 above) must be satisfied.
Transitory and isolated catatonic symptoms may occur in the context of any
other subtype of schizophrenia. but for a diagnosis of catatonic schizophrenia
one or more of the following behay iours should dominate the clinical picture:
stupor (marked decrease in
reactivity to the environment and in spontaneous movements and activity) or
mutism;
excitement (apparently
purposeless motor activity, not influenced by external stimuli);
posturing (voluntary
assumptiun and maintenance of inappropriate or bizarre postures);
negativism (an apparently
motiveless resistance to all instructions or attempts to be moved, or movement
in the opposite direction);
rigidity (maintenance of a
rigid posture against efforts to be moved);
waxy flexibility
(maintenance of limbs and body in externally imposed positions): and
other symptoms such as
command automatism (automatic compliance with instructions). and perseveration
of words and phrases.
In uncommunicative patients
with behavioural manifestations of catatonic disorder, the diagnosis of
schizophrenia may have to be provisional until adequate evidence of the
presence of other symptoms is obtained. It is also vital to appreciate that
catatonic symptoms are not diagnostic of schizophrenia. A catatonic symptom or
symptoms may also be provoked by brain disease. metabolic disturbances, or
alcohol and drugs. and may also occur in mood disorders.
Includes catatonic stupor
schizophrenic catalepsy schizophrenic
catatonia
schizophrenic flexibilitas
cerea
F20.3 Undifferentiated
schizophrenia
Conditions meeting the
general diagnostic criteria for schizophrenia (see introduction to F20 above)
but not conforming to any of the above subtypes (F20.0- F20.2). or exhibiting
the features of more than one of them without a clear predominance of a
particular set of diagnostic characteristics. This rubric should be used only
for psychotic conditions (i.e. residual schizophrenia, F20.5. and
post-schizophrenic depression, F20.4, are excluded) and after an attempt has
been made to classify the condition into one of the three preceding categories.
Diagnostic guidelines
This category should be
reserved for disorders that:
meet the diagnostic
criteria for schizophrenia;
do not satisfy the criteria
for the paranoid, hebephrenic, or catatonic subtypes;
do not satisfy the criteria
for residual schizophrenia or postschizophrenic depression.
Includes: a typical schizophrenia
F20.4 Post-schizophrenic
depression
A depressive episode, which
may be prolonged, arising in the aftermath of a schizophrenic illness. Some
schizophrenic symptoms must still be present but no longer dominate the
clinical picture. These persisting schizophrenic symptoms may be “positive” or
“negative”, though the latter are more common. It is uncertain, and immaterial
to the diagnosis, to w’hat extent the depressive symptoms have merely been
uncovered by the resolution of earlier psychotic symptoms (rather than being a
new’ development) or are an intrinsic part of schizophrenia rather than a
psychological reaction to it. They are rarely sufficiently severe or extensive
to meet criteria for a severe depressive episode (F32.2 and F32.3), and it is
often difficult to decide which of the patient’s symptoms are due to depression
and which to neuroleptic medication or to the impaired volition and affective
flattening of schizophrenia itself. This depressive disorder is associated with
an increased risk of suicide.
Diagnostic guidelines
The diagnosis should be made
only if:
the patient has had a
schizophrenic illness meeting the general criteria for schizophrenia (see
introduction to F20 above) within the past 12 months;
some schizophrenic symptoms
are still present; and
the depressive symptoms are
prominent and distressing, fulfilling at least the criteria for a depressive
episode (F32. - ), and have been present for at least 2 weeks.
If the patient no longer
has any schizophrenic symptoms, a depressive episode should be diagnosed (F32.
- ). If schizophrenic symptoms are still florid and prominent. the diagnosis
should remain that of the appropriate schizophrenic subtype (F20.0. F20. I,
F2().2, or F20.3).
F20.5 Residual
schizophrenia
A chronic stage in the
development of a schizophrenic disorder in which there has been a clear
progression from an early stage (comprising one or more episodes with psychotic
symptoms meeting the general criteria for schizophrenia described above) to a
later stage characterized by long-term. though not necessarily irreversible,
“negative” symptoms.
Diagnostic guidelines
For a confident diagnosis,
the following requirements should be met:
prominent “negative”
schizophrenic symptoms, i.e. psychomotor slowing, underactivity, blunting of
affect, passivity and lack of initiative, poverty of quantity or content of
speech, poor nonverbal communication by facial expression. eye contact, voice
modulation, and posture, poor self-care and social performance;
evidence in the past of at
least one clear-cut psychotic episode meeting the diagnostic criteria for
schizophrenia;
a period of at least I
year during which the intensity and frequency of florid symptoms such as
delusions and hallucinations have been minimal or substantially reduced aod the
“negative” schizophrenic syndrome has been present;
absence of dementia or
other organic brain disease or disorder, and of chronic depression or
institutionalism sufficient to explain the negative impairments.
If adequate information
about the patient’s previous history cannot be obtained. and it therefore
cannot be established that criteria for schizophrenia have been met at some
time in the past. it may be necessary to make a provisional diagnosis of
residual schizophrenia.
Includes: chronic undifferentiated schizophrenia “Restzustand”
schizophrenic residual
state
F20.6 Simple schizophrenia
An uncommon disorder in
which there is an insidious but progressive development of oddities of conduct,
inability to meet the demands of society, and decline in total petformance.
Delusions and hallucinations are not evident, and the disorder is less
obviously psychotic than the hebephrenic, paranoid, and catatonic subtypes of
schizophrenia. The characteristic “negative” features of residual schizophrenia
(e.g. blunting of affect, loss of volition) develop without being preceded by
any overt psychotic symptoms. With increasing social impoverishment. vagrancy
may ensue and the individual may then become self-absorbed. idle. and aimless.
Diagnostic guidelines
Simple schizophrenia is a
difficult diagnosis to make with any confidence because it depends on
establishing the slowly progressive development of the characteristic
“negative” symptoms of residual schizophrenia (see F20.5 above) without any
history of hallucinations, delusions, or other manifestations of an earlier
psychotic episode, and with significant changes in personal behaviour, manifest
as a marked loss of interest. idleness. and social withdrawal.
l,mcludcs: schizophrenia simplex
F20.8 Other
schizophrenia
Includes: cenesthopathic schizophrenia
schizophreniform disorder
NOS
Excludes: acute schizophrenia-like disorder (F23.2) cyclic
schizophrenia (F25.2)
latent schizophrenia (
F23.2)
F20.9 Schizophrenia,
unspecified
Schizotypal disorder
A disorder characterized by
eccentric behaviour and anomalies of thinking and affect which resemble those
seen in schizophrenia, though no definite and charactenstic schizophrenic
anomalies have occurred at any stage. There is no dominant or typical disturbance,
but any of the following may be present:
inappropriate or
constricted affect (the individual appears cold and aloof);
behaviour or appearance
that is odd, eccentric, or peculiar;
poor rapport with others
and a tendency to social withdrawal;
odd beliefs or magical
thinking, influencing behaviour and inconsistent with subcultural norms;
suspiciousness or paranoid
ideas;
obsessive ruminations
without inner resistance, often with dysmorphophobic, sexual or aggressive
contents;
unusual perceptual
experiences including somatosensory (bodily) or other illusions,
depersonalization or derealization;
vague, circumstantial,
metaphorical. over elaborate, or stereotyped thinking, manifested by odd speech
or in other ways, without gross incoherence;
occasional transient
quasi-psychotic episodes with intense illusions, auditory or other
hallucinations, and delusion-like ideas, usually occurring without external
provocation.
The disorder runs a chronic
course with fluctuations of intensity. Occasionally it evolves into overt
schizophrenia. There is no definite onset and its evolution and course are
usually those of a personality disorder. It is more common in individuals
related to schizophrenics and is believed to be part of the genetic “spectrum”
of schizophrenia.
Diagnostic guidelines
This diagnostic rubric is
not recommended for general use because it is not clearly demarcated either
from simple schizophrenia or from schizoid or paranoid personality disorders.
If the term is used, three or four of the typical features listed above should
have been present, continuously or episodically. for at lecist 2 years.
The individual must never have met criteria for schizophrenia itself. A
history of schizophrenia in a first-degree relative gives additional weight to
the diagnosis but is not a prerequisite.
Includes:
borderline schizophrenia l
atent schizophrenia
latent schizophrenic
reaction
prepsychotic schizop
prodromal schizophrenia
pseudoneurotic
schizophrenia
pseudopsychopathic
schizophrenia
schizotypal personality
disorder
Excludes: Asperger’s syndrome (F84.5)
schizoid personality
disorder (F60. 1)
Persistent delusional
disorders
This group includes a
variety of disorders in which long-standing delusions constitute the only, or
the most conspicuous, clinical characteristic and which cannot be classified as
organic, schizophrenic, or . They are probably heterogeneous, and have
uncertain relationships to schizophrenia. The relative importance of genetic
factors, personality characteristics, and life circumstances in their genesis
is uncertain and probably variable.
F22.O Delusional
disorder
This group of disorders is
characterized by the development either of a single delusion or of a set of
related delusions which are usually persistent and sometimes lifelong. The
delusions are highly variable in content. Often they are persecutory.
hypochondriacal, or gran-diose, but they may be concerned with litigation or
jealousy, or express a conviction that the individual’s body is mis-shapen, or
that others think that he or she smells or is homosexual. Other psychopathology
is characteristically absent. but depressive symptoms may be present
intermittently. and olfactory and tactile hallucinations may develop in some
cases. Clear and persistent auditory hallucinations(voices). schizophrenic
symptoms such as delusions of control and marked blunting of affect, and
definite evidence of brain disease are all incompatible with this diagnosis.
However, occasional or transitory auditory hallucinations, particularly in
elderly patients. do not rule out this diagnosis, provided that they are not
typically schizophrenic and form only a small part of the overall clinical
picture. Onset is commonly in middle age but sometimes, particularly in the
case of beliefs about having a mis-shapen body. in early adult life. The
content of the delusion, and the timing of its emergence. can often be related
to the individual’s life situation, e.g. persecutory delusions in members of
minorities. Apart from actions and attitudes directly related to the delusion
or delusional system, affect, speech. and behaviour are normal.
Diagnostic guidelines
Delusions constitute the
most conspicuous or the only clinical characteristic. They must be present for
at least 3 months and be clearly personal rather than subcultural. Depressive
symptoms or even a full-blown depressive episode (F32. -) may be present intermittently,
provided that the delusion persists at times when there is no disturbance of
mood. There must be no evidence of brain disease, no or only occasional
auditory hallucinations, and no history of schizophrenic symptoms (delusions of
control, thought broadcasting, etc.).
Includes:
paranoia
paranoid psychosis paranoid
state
paraphrenia (late)
sensitiver Beziehungswahn
Excludes: paranoid personality disorder ( F60.0)
psychogenic paranoid
psychosis (F23.3)
paranoid reaction (F23.3)
paranoid schizophrenia
(F2().0)
F22.8 Other persistent
delusional disorders
This is a residual category
for persistent delusional disorders that do not meet the criteria for
delusional disorder (F22.0). Disorders in which delusions are accompanied by
persistent hallucinatory voices or by schizophrenic symptoms that are
insufficient to meet criteria for schizophrenia (F20. - ) should be coded here.
Delusional disorders that have lasted for less than 3 months should, however,
be coded. at least temporarily, under F23.-.
Includes:
delusional dysmorphophobia
involutional paranoid state
paranoia querulans
F22.9 Persistent
delusional disorder, unspecified
Acute and transient
psychotic disorders
Systematic clinical
information that would provide definitive guidance on the classification of
acute psychotic disorders is not yet available, and the limited data and
clinical tradition that must therefore be used instead do) not give rise to
concepts that can be clearly defined and separated from each other. In the
absence of a tried and tested multiaxial system. the method used here to avoid
diagnostic confusion is to construct a diagnostic sequence that reflects the
order of priority given to selected key features of the disorder. The order of
priority used here is:
an acute onset (within 2
weeks) as the defining feature of the whole group;
the presence of typical
syndromes;
the presence of associated
acute stress.
The classification is
nevertheless arranged so that those who do not agree vvith this order of
priority can still identify acute psychotic disorders with each of these
specified features.
It is also recommended that
whenever possible a further subdivision of onset be used. if applicable. fl)r
all the disorders of this group. Acute onset is defined as a change from
a state without psychotic features to a clearly abnormal psvchotic state,
within a period of 2 weeks or less. There is some evidence that acute onset is
associated vyith a good outcome. and it may be that the more abrupt the onset,
the better the outcome. It is iherefl)re recommended that. whenever appropri
ate. abrupt onset ( vyithin 48 hours or less) be specified.
The typical symptoms that
have been selected are first. the rapidly changing and variable state. called
here “polymorphic”, that has been given prominence in acute psychotic states in
several countries, and second, the presence of typical schizophrenic symptoms.
Associated acute stress can also be specified. with a fifth
character if desired, in view of its traditional linkage with acute psychosis.
The limited evidence available. however, indicates that a substantial
proportion of acute psychotic disorders arise without associated stress, and
provision has therefore been made for the presence or the absence of stress to
be recorded. Associated acute stress is taken to mean that the first psychotic
symptoms occur within about 2 weeks of one or more events that would be
regarded as stressful to most people in similar circumstances, within the
culture of the person concerned. Typical events would be bereavement,
unexpected loss of partner or job, marriage, or the psychological trauma of
combat, terrorism, and torture. Long-standing difficulties or problems should
not be included as a source of stress in this context.
Complete recovery usually
occurs within 2 to 3 months, often within a few weeks or even days, and only a
small proportion of patients with these disorders develop persistent and
disabling states. linfortunately, the present state of knowledge does not allow
the early prediction of that small proportion of patients who will not recover
rapidly.
These clinical descriptions
and diagnostic guidelines are written on the assumption that they will be used
by clinicians who may need to make a diagnosis when having to assess and treat
patients within a few days or weeks of the onset of the disorder, not knowing
how long the disorder will last. A number of reminders about the time limits
and transition from one disorder to another have therefore been included, so as
to alert those recording the diagnosis to the need to keep them up to date.
The nomenclature of these
acute disorders is as uncertain as their nosological status. but an attempt has
been made to use simple and familiar terms. “Psychotic disorder” is used as a
term of convenience for all the members of this group (psychotic is defined in
the general introduction. page 3) with an additional qualifying term indicating
the major defining feature of each separate type as it appears in the scquence
noted above.
Diagnostic guidelines
None of the disorders in
the group satisfies the criteria for either manic (F30. ) or depressive (F32. -
) episodes. although emotional changes and individual affective symptoms may be
prominent from time to time.
These disorders are also
defined by the absence of organic causation, such as states of concussion.
delirium. or dementia. Perplexity, preoccupation. and inattention to the
immediate conversation are often present, but if they are so marked or
persistent as to suggest delirium or dementia of organic ca, the diagnosis
should be delayed until investigation or observation has clarified this point.
Similarly, disorders in F23.- should not be diagnosed in the presence of
obvious intoxication by drugs or alcohol. However, a recent minor increase in
the consumption of, for instance, alcohol or marijuana, with no evidence of
severe intoxication or disorientation, should not rule out the diagnosis of one
of these acute psychotic disorders.
It is important to note
that the 48-hour and the 2-week criteriaare not put forward as the times of
maximum severity and disturbance, but as times by which the psychotic symptoms
have become obvious and disruptive of at least some aspects of daily life and
work. The peak disturbance mav be reached later in both instances; the symptoms
and disttirbance have only to be obvious by the stated times, in the sense that
they will usually have brought the patient into contact with some form of
helping or medical agency. Prodromal periods of anxiety. depression. social
withdrawal, or mildly abnormal behaviour do not qualify for inclusion in these
periods of time.
A fifth character may be
used to indicate whether or not the acute psychotic disorder is associated with
acute stress:
F23 ..x 0 Without
associated acute stress
F23 .x I With associated
acute stress
F23.O Acute polymorphic psychotic disorder without
symptoms of schizophrenia
An acute psychotic disorder
in which hallucinations, delusions. and perceptual disturbances are obvious
btit markedly variable, changing from day to day or even from hour to hour.
Emotional turmoil, with intense transient feelings of happiness and ecstasy or
anxieties and irritability, is also frequently present. This polymorphic and
unstable. changing clinical picture is characteristic, and even though
individual affective d)r psychotic symptoms may at times be present. the
criteria for manic episode (F30.-). depressive episode (F32.-), or
schizophrenia (F20.-) are not fulfilled. This disorder is particularly likely
to have an abrupt onset (within 48 hours) and a rapid resolution of symptoms;
in a large proportion of cases there is no obvious precipitating stress.
If the symptoms persist for
more than 3 months, the diagnosis should be changed. (Persistent delusional
disorder (F22. ) or other nonorganic psychotic disorder (F28) is likely to be
the most appropriate.)
Diagnostic guidelines
For a definite diagnosis:
the onset must be acute
(from a nonpsychotic state to a clearly psychotic state within 2 weeks or
less);
there must be several types
of hallucination or delusion, changing in both type and intensity from day to
day or within the same day;
there should be a similarly
varying emotional state; and
in spite of the variety of
symptoms, none should be present with sufficient consistency to fulfil the
criteria for schizophrenia (F20. -) or for manic or depressive episode (F30. -
or F32. - ).
Includes: bouffee delirante without symptoms of schizophrenia or
unspecified
cycloid psychosis without
symptoms of schizophrenia or unspecified
F23.1 Acute polymorphic psychotic disorder with
symptoms of schizophrenia
An acute psychotic disorder
which meets the descriptive criteria for acute polymorphic psychotic disorder
(F23.0) but in which typically schizophrenic symptoms are also consistently
present.
Diagnostic guidelines
For a definite diagnosis,
criteria (a). (b), and © specified for acute polymorphic psychotic disorder
(F23.0) must be fulfilled; in addition, symptoms that fulfil the criteria for
schizophrenia (F20. - ) must have been present for the majority of the time
since the establishment of an obviously psychotic clinical picture.
If the schizophrenic
symptoms persist for more than 1 month, the diagnosis should be changed to
schizophrenia (F20. - ).
Includes: bouffee delirante with symptoms of schizophrenia cycloid
psychosis with symptoms of schizophrenia
F23.2 Acute
schizophrenia-like psychotic disorder
An acute psychotic disorder
in which the psychotic symptoms are comparatively stable and fulfil the
criteria for schizophrenia (F20. - ) but have lasted for less than 1 month.
Some degree of emotional variability or instability may be present, but not to
the extent described in acute polymorphic psychotic disorder (P23.0).
Diagnoslic guidelines
For a definite diagnosis:
the onset of psychotic
symptoms must be acute (2 weeks or less from a nonpsychotic to a clearly
psychotic state);
symptoms that fulfil the
criteria for schizophrenia (F20. - ) must have been present for the majority of
the time since the establishment of an obviously psychotic clinical picture;
the criteria for acute
polymorphic psychotic disorder are not fulfilled.
If the schizophrenic
symptoms last for more than I month, the diagnosis should be changed to
schizophrenia (F20.-)
Includes:
acute(undifferentiated)schizophrenia
brief schizophreniform
disorder
brief schizophreniform
psychosis oneirophrcnia
schizophrenic reaction
Excludes: organic delusional [schizophrenia-likel disorder (F06.2)
schizophreniform disorder NOS (F20.8)
F23~3 Other acute predominantly delusional
psychotic disorders
Acute psychotic disorders
in which comparatively stable delusions or hallucinations are the main clinical
features, but do not fulfil the criteria for schizophrenia (F20. - ). Delusions
of persecution or reference are common, and hallucinations are usually auditory
(voices talking directly to the patient).
Diagnostic guidelines
For a definite diagnosis:
the onset of psychotic
symptoms must be acute (2 weeks or less from a nonpsychotic to a clearly
psychotic state);
delusions or hallucinations
must have been present for the majority of the tmmne smnce the establishment of
an obviously psychotic state; and
the criteria for neither
schizophrenia (F20.-) nor acute poly morphic psychotic disorder (F23.0) are
fulfilled.
If delusions persist for
more than 3 months, the diagnosis should be changed to persistent delusional
disorder (F22.- ). If only hallucinations persist for more than 3 months. the
diagnosis should be changed to other nonorganic psychotic disorder (F28).
Includes: paranoid reaction
psychogenic paranoid
psychosis
F23.8 Other acute and
transient psychotic disorders
Any other acute psychotic
disorders that are unclassifiable under any other category in F23 (such as
acute psychotmc states in which definite delusions or hallucinations occur but
persist for only small proportions of the time) should be coded here. States of
undifferentiated excitement should also be coded here if more detailed
information about the patient’s mental state is not available. provided that
there ms no evidence of an organic cause.
F23.9 Acute and
transient psychotic disorder, unspecified
Includes: ( brief) reactive psychosis NOS
F24 Induced delusional disorder
A rare delusional diso)rdcr
shared by two or occasmonally more people with close emotional l inks. Only one
person suffers fro)m a genuine psychotic disorder: the del usions are induced
in the other(s) and usually disappear w’hen the people are separated. The
psychotic illness of the dominant person ms most commonly schizophrenic, but
this is not necessarily or invariably so. Both the original delusions in the
dominant person and the induced delusions are usually chronic and either
persecutory or grandiose in nature. Delusional beliefs are transmitted this way
only in uncommon circumstances. Almost invariably. the people concerned have an
unusually close relationship and are isolated from others by language. culture.
or geography. The individual in whom the delusions are induced is usually
dependent on or subservient to the person w’ith the genuine psychosis.
Diagnostic guidelines
A diagnosis of induced
delusional disorder should be made only if:
two or more people share
the same delusion or delusional system and support one another in this belief;
they have an unusually
close relationship of the kind described above;
‘there is temporal or other
contextual evidence that the delusion was induced in the passive member(s) of
the pair or group by contact with the active member.
Induced hallucinations
areunusual but do not negate the diagnosis. However, if there are reasons for
believing that two people living together have independent psychotic disorders
neither should be coded here, even if some of the delusions are shared.
Includes: folie a deux
induced paranoid or
psychotic disorder symbiotic psychosis
Excludes. folie simultanee
Schizoaffective
disorders
These are episodic
disorders in which both affective and schizophrenic symptoms are prominent
within the same episode of illness, preferably simultaneously, but at least
within a few days of each othcr. Their relationship to typicamood [affective]
disorders (F30~F39) and to schizophrenic disorders (F20- F24) is uncertain.
They are given a separate category because they are too common to be ignored.
Other conditions in which affective symptoms are superimposed upon or form part
of a pre-existing schizophrenic illness, or in which they coexist or alternate
with other types of persistent delusional disorders, arc classified under the
appropriate category in F20- F29. Mood-incongrtment delusions or hallucinations
in affective disorders ( F30.2. F3 l .2. F3 l .5. F32.3, or F33.3) do not by
themselves justify a diagnosis of schizoaffective disorder.
Patients who stiffer from
recurrent schizoaffective episodes, particularly those whose symptoms are of
the manic rather than the
depressive type, usually
make a full recovery and only rarely develop a defect state.
Diagnostic guidelines
A diagnosis of
schizoaffective disorder should be made only when both definite schizophrenic
and definite affective symptoms are prominent simultaneously, or within
a few days of each other, within the same episode of illness, and when, as a
consequence of this, the episode of illness does not meet criteria for either
schizophrenia or a depressive or manic episode. The term should not be applied
to patients who exhibit schizophrenic symptoms and affective symptoms only in
different episodes of illness. It is common, for example, for a schizophrenic
patient to present with depressive symptoms in the aftermath of a psychotic
episode (see post-schizophrenic depression (F20.4)). Some patients have
recurrent schizoaffective episodes, which may be of the manic or depressive
type or a mixture of the two. Others have one or two schizoaffective episodes
interspersed between typical episodes of mania or depression. In the former
case, schizoaffective disorder is the appropriate diagnosis. In the latter, the
occurrence of an occasional schizoaffective episode does not invalidate a
diagnosis of bipolar affective disorder or recurrent depressive disorder if the
clinical picture is typical in other respects.
F25.O Schizoaffective
disorder, manic type
A disorder in which
schizophrenic and manic symptoms are both prominent in the same episode of
illness. The abnormality of mood usually takes the form of elation, accompanied
by increased self-esteem and grandiose ideas, but sometmmes excitement or
irritability are more obvious and accompanied by aggressive behaviour and
persecutory ideas. In both cases there is increased energy. overactivity,
impaired concentration, and a loss of normal social inhibition. Delusions of
reference, grandeur, or persecution may be present, but other more typically
schizophrenic symptoms are required to establish the diagnosis. People may
insist, for example, that their thoughts are being broadcast or interfered
with, or that alien forces are trying to control them, or they may report hearing
voices of varied kinds or express bizarre delusional ideas that are not merely
grandiose or persecutory. Careful questioning is often required to establish
that an individual really is experiencing these morbid phenomena, and not
merely joking or talking in metaphors.
Diagnostic guidelines
There must be prominent
depression, accompanied by at least two characteristic depressive symptoms or
associated behavioural abnormalities as listed for depressive episode (F32. )
within the same episode. at least one and preferably two typically
schizophrenic symptoms (as specified for schizophrenia (F20. -). diagnostic
guidelines (a) - (d)) should be clearly present.
This category should be
used both for a single schizoaffective episode, depressive type, and for a recurrent
disorder in which the majority of episodes are schizoaffective, depressive
type.
Includes: schizoaffective psychosis, depressive type
schizophreniform psychosis.
depressive type
F25.2 Schizoaffective
disorder, mixed type
Disorders in which symptoms
of schizophrenia (F20. - ) coexist with those of a mixed bipolar affective
disorder (F31.6) should be coded here.
Includes: cyclic schizophrenia
mixed schizophrenic and
affective psychosis
F25.8 Other
schizoaffective disorders
F25.9 Schizoaffective
disorder, unspecified
Includes: schizoaffective psychosis NOS
Other nonorganic
psychotic disorders
Psychotic disorders that do
not meet the criteria for schizophrenia (F20.-) or for psychotic types of mnood
]affective] disorders (F30 - F39). and psychotic disorders that do not meet the
sympto-matic criteria for persistent delusional disorder (F22. ~ ) should be
coded here.
Includes: chronic hallucinatory psychosis NOS
Schizoaffective disorders,
manic type, are usually florid psychoses with an acute onset; although
behaviour is often grossly disturbed, full recovery generally occurs within a
few weeks.
Diagnostic guidelines
There must be a prominent
elevation of mood, or a less obvious elevation of mood combined with increased
irritability or excitement. Within the same episode, at least one and
preferably two typically schizophrenic symptomns (as specified for
schizophrenia (F20. ~), diagnostic guidelines (a)- (d)) should be clearly
present.
This category should be
used both for a single schizoaffective episode of the manic type and for a
recurrent disorder in which the majority of episodes are schizoaffective, manic
type.
Includes: schizoaffective psychosis, manic type
schizophreniform psychosms,
manmc type
F25.l Schizoaffective
disorder, depressive type
A disorder in which
schizophrenic and depressive symptoms arc both prominent in the same episode of
illness. Depression of mood is usually accompanied by several characteristic
depressive symptoms or behavioural abnormalities such as retardation, insomnia,
loss of energy, appetite or weight, reduction of normal interests, impairment
of concentration. guilt, feelings of hopelessness. and suicidal thoughts. At
the same time, or within the same episode, other more typically schizophrenic symptoms
are present; patients may insist. for example. that their thoughts are being
broadcast or interfered with. or that alien forces are trying to control them.
They may bc convinced that they are being spied upon or plotted against and
this is not justified by their own behaviour. Voices may be heard that are not
merely disparaging or condemnatory but that talk of killing the patient or
discuss this behaviour between themselves. Schizoaffective episodes of the
depressive type are usually less florid and alarming than schizoaffective
episodes of the manic type, but they tend to last longer and the prognosis is
less favourable. Although the majority of patients recover completely, some
eventually develop a schizophrenic defect.
Unspecified nonorganic
psychosis
hmcludes: psychosis NOS
Excludes: mental disorder NOS (F99)
organic or symptomatic
psychosis NOS (F09)