Chapter 13
Schizophrenia Spectrum and Other Psychotic Disorders

They don't sound like voices at first. One day, maybe I hear someone call my name. Another day, I can hear whispers but I don't know what they are saying. Sometimes it's just sounds. I want it to stop but it won't. It won't let me sleep. The beer helps me sleep. —Ray

Schizophrenia spectrum and other psychotic disorders are “defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms” (APA, 2013, p. 87). This chapter includes overviews of delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorder, psychotic disorder due to another medical condition, and catatonia. The DSM-5 also includes cross-referencing of schizotypal personality disorder (see Chapter 16 of this Learning Companion for more information regarding personality disorders).

To grasp major changes and essential features in this chapter, counselors must understand key elements of characteristic domains. Psychotic disorders involve a constellation of positive, negative, and related cognitive symptoms (NIMH, 2009). Whereas positive symptoms involve introduction of thoughts or behaviors one would not expect, negative symptoms involve absence of expected experiences. Core positive symptoms include delusions, hallucinations, and thought or movement disorders in which a person loses touch with reality (Tandon, 2013b). Delusions are fixed beliefs that are not grounded in reality and for which an individual cannot be convinced otherwise. Hallucinations are sensory experiences in which a person sees (visual hallucinations), hears (auditory hallucinations), smells (olfactory hallucinations), tastes (gustatory hallucinations), or feels (tactile or somatic hallucinations) something for which there is no physical stimulus. Auditory hallucinations are most common, tactile hallucinations are often linked to substance withdrawal or intoxication, and olfactory or gustatory hallucinations may indicate a medical problem. Disorganized thinking, also known as thought disorder, involves disruptions in the flow of thoughts in such a way that makes communication difficult (APA, 2013; NIMH, 2009). Disorganized or abnormal motor behavior, also known as movement disorder, involves agitation, repeated motions, or inability to move or respond to stimuli (i.e., catatonia). Negative symptoms include a lack of pleasure, motivation, engagement in activities of daily living, or emotional experiencing (NIMH, 2009). Finally, cognitive symptoms involve difficulty with executive functioning, attention, or memory. Refer to the DSM-5 for a more thorough discussion of key symptoms and clinical terminology associated with them.

Psychotic symptoms and psychotic experiences occur across a wide range of medical and mental health concerns; however, psychotic disorders are relatively uncommon. According to the APA (2013), prevalence rates for disorders reviewed in this chapter range from 0.2% to 0.7%. However, we believe this prevalence to be low, because these numbers do not take into account cross-cultural psychotic problems that are not reflected in the DSM-5 but are commonly found worldwide (Eriksen & Kress, 2005; NIMH, 2009). As we discuss throughout the chapter, individuals who meet criteria for psychotic disorders are diverse and have different experiences. For more than 50% of individuals, a psychotic disorder diagnosis presents a lifelong struggle requiring consistent care and support to maintain even a minimal level of functioning (Gaebel, 2011). A sizable minority, especially those with later age of onset and higher levels of functioning at onset, may remain quite functional in their ability to manage symptoms over time (Rubin & Trawver, 2011).

Counselors in clinical and school settings may encounter clients and family members of clients who are experiencing psychotic disorders. Counselors must be prepared to recognize signs of new onset of psychotic disorders, collaborate with interdisciplinary treatment team members, and support loved ones in providing environments needed to enhance dignity, wellness, and functioning.

Major Changes From DSM-IV-TR to DSM-5

Many changes to this chapter in the DSM-5 are conceptual in nature and provide enhanced attention to dimensional assessment. For example, the name of the chapter changed slightly to reference the “schizophrenia spectrum” rather than just “schizophrenia.” Like other sections of the DSM-5, the chapter was reordered to reflect what is assumed to be a developmental progression of psychotic experiencing. Tandon (2013a, 2013b) noted limitations of the DSM-IV-TR as including confusion regarding differences between schizoaffective disorder and schizophrenia, variability in treatment of catatonia, undue special treatment of Schneiderian first-rank symptoms (i.e., bizarre delusions or special hallucinations), and lack of reliability and validity within the schizophrenia subtypes. Most changes to DSM-5 criteria were designed to facilitate a simpler and more straightforward diagnostic process.

Although not required, clinicians who diagnose psychotic disorders are encouraged to use one of several dimensional assessments printed in the DSM-5 to determine current severity of disorder. The Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS; see pp. 742–744 of the DSM-5) includes attention to eight symptoms associated with psychotic disorders: hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania. Clinicians rate the most recent 7-day period using a 5-point severity scale ranging from 0 (not present) to 4 (present and severe). Overall, the scale shows acceptable psychometric properties and appears to be feasible for use in clinical settings (Ritsner, Mar, Arbitman, & Grinshpoon, 2013). Tandon (2013b) noted that use of the CRDPSS may benefit practice by allowing clinicians to focus on specific domains of concern and track changes in each area. In addition to encouraging use of the CRDPSS throughout this section, we present most disorders with new course specifiers to indicate number of episodes (first or multiple) and current remission status (acute, partial remission, or full remission).

Schizophrenia has undergone many changes in conceptualization over the last century (see Keller, Fischer, & Carpenter, 2010). In the DSM-IV-TR, Criterion A for schizophrenia served as the foundation for diagnosis of most psychotic disorders. Major changes to Criterion A included elimination of special treatment of bizarre delusions and hallucinations in which an individual heard two or more voices conversing or heard a running commentary regarding his or her behavior. Tandon (2013b) noted limited impact of this change given that less than 2% of clients diagnosed with schizophrenia met criteria through this provision alone. Similarly, the requirement for two positive symptoms to meet Criterion A should increase reliability of diagnoses without affecting clinical practice.

A major change to schizophrenia involves removal of DSM-IV-TR subtypes (Gaebel, Zielasek, & Cleveland, 2012; Tandon, 2013a) based on their “limited diagnostic stability, low reliability, poor validity, and little clinical utility” (Tandon, 2013a, p. 16). Rather than conceptualize differences in presentations as representing catatonic, disorganized, paranoid, residual, or undifferentiated schizophrenia, clinicians will conduct a dimensional assessment using the CRDPSS.

One small yet significant change to schizoaffective disorder includes the specification that depressive and/or manic episodes be present “the majority of the total duration of the active and residual portions of the illness” (APA, 2013, p. 105). This change was implemented in hopes of addressing consistent issues with diagnostic stability for this disorder. Although this may decrease prevalence of schizoaffective disorder, Tandon (2013b) proposed that the change will help clinicians more accurately distinguish among schizophrenia with and without mood symptoms, schizoaffective disorder, and mood disorder with psychotic features.

Counselors will also find various minor changes to disorders throughout the Schizophrenia Spectrum and Other Psychotic Disorders chapter. Schizotypal (personality) disorder is now cross-referenced at the beginning of the chapter to be consistent with ICD-10 conceptualization as part of the schizophrenia spectrum (see Chapter 16 in this Learning Companion). In the past, special treatment of bizarre delusions meant that an individual who experienced bizarre delusions automatically met Criterion A for schizophrenia. Changes to Criterion A now mean that individuals who experience bizarre delusions can be diagnosed with delusional disorder through use of a specifier. The DSM-5 also clarifies that individuals who have delusional-level concerns as part of OCD or BDD should be diagnosed with the more specific disorder; presence of psychotic symptoms will be noted through a specifier. Finally, changes to catatonia include requirement of a consistent number of symptoms (minimum of three out of 12) across diagnostic contexts. The DSM-5 also includes catatonia as a stand-alone disorder or as a specifier for disorders both within and outside of this chapter.

Section III of the DSM-5 includes a proposal of attenuated psychosis syndrome as a condition for further study. Designed to identify those at high risk or vulnerability for developing psychotic disorders among adolescents and young adults, this diagnosis generated controversy during the revision process. On one hand, attention to early detection and treatment of schizophrenia spectrum disorders is essential, and those who meet these criteria are 500 times more likely than the general population to develop a psychotic disorder in the next year. On the other hand, about 70% of those who meet criteria for attenuated psychosis syndrome do not go on to develop a psychotic disorder (Tandon, 2013b). Certainly, there is a need to balance benefits of early intervention with risks of stigma, self-fulfilling prophecy, and unnecessary medication interventions.

Differential Diagnosis

The presence of core positive symptoms of psychosis does not automatically indicate the presence of a psychotic disorder. Rather, psychotic symptoms may be a regular part of substance intoxication or withdrawal, medical conditions, and other mental health disorders. Etiology, precipitating factors, and unique constellation of other symptoms will determine whether a client who presents with psychotic symptoms meets criteria for a disorder in this chapter.

Because medical conditions and substance use can lead to onset or exacerbation of psychotic symptoms, we suggest counselors refer all clients who report new onset of psychotic symptoms for a thorough medical evaluation. This evaluation is critical for informing accurate diagnosis and, in turn, appropriate treatment. A client who experiences brief, new onset of psychotic symptoms in response to a medication will have very different needs compared with a client who hallucinates while withdrawing from alcohol. And both clients will have different needs from someone who experiences a long, slow deterioration in functioning before developing paranoid delusions. Later in the chapter, we will mention specific medical conditions and substances that may trigger psychotic symptoms.

Severe depressive disorders, bipolar disorders, and PTSD frequently involve elements of psychotic process such as delusions and hallucinations. The CRDPSS includes attention to depressive and manic symptoms as a reminder regarding the importance of assessing for preexisting or co-occurring mood concerns that require clinical attention and inform diagnosis. Depression and the negative symptoms of these disorders have much in common, especially as hallmarks of both include a lack of interest or pleasure in everyday living and may result in poor self-care. Negative symptoms and cognitive deficits in schizophrenia spectrum disorders may mirror social impairment associated with ASD and decline associated with neurocognitive disorders. Dissociation common with acute stress disorder and PTSD may also appear as part of thought or speech disorders within the schizophrenia spectrum. Similarly, beliefs associated with some obsessive-compulsive and related disorders and somatic symptom disorders often take on delusional qualities, and individuals who are experiencing psychotic symptoms may find themselves quite anxious and agitated as a result of their hallucinations and delusions. Differential diagnostic concerns include the order in which symptoms developed and core experiences of each.

Individuals with schizophrenia spectrum disorders often experience an array of coexisting health and mental health concerns. Rubin and Trawver (2011) characterized individuals with schizophrenia as having “close to universal” (p. 13) exposure to trauma. Nearly three quarters of these individuals experience depression, half experience anxiety, and half meet criteria for a substance use disorder (Helseth, Lykke-Enger, Johnsen, & Waal, 2009; Potuzak, Ravichandran, Lewandowski, Ongür, & Cohen, 2012; Rubin & Trawver, 2011). Individuals with schizophrenia are 3 times more likely to be addicted to nicotine (NIMH, 2009) than the general population, thus potentially placing them at risk for a plethora of related health concerns. When combined with functional consequences of schizophrenia, decreased engagement in health-related activities (APA 2013; Rubin & Trawver, 2011), and a suicide rate as high as 10% (NIMH, 2009), people with schizophrenia have much lower life expectancies and quality of life than the general population. Counselors who work with this population must remain alert to the likelihood of these concerns.

Etiology and Treatment

Researchers are still working to determine specific causes of psychotic disorders. As mentioned previously, effects of substance use and medical conditions may cause brain changes that lead to psychotic symptoms. Research indicates strong genetic and physiological components of schizophrenia (NIMH, 2009). Individuals with first-degree relatives who have schizophrenia are at 10 times greater risk for developing the disorder, and neuroscience research has revealed that people with schizophrenia have different brain structure, function, and neurotransmitter activity compared with those without (APA, 2013; Gaebel, 2011; NIMH, 2009).

Counselors will likely encounter clients with psychotic disorders in one of two primary locations: (a) crisis stabilization hospitals in which individuals present with new onset of psychotic symptoms or crisis in relation to symptoms and (b) community mental health centers in which clients engage in long-term treatment to manage symptoms and promote functioning (Barrio Minton & Prosek, in press). In both cases, counselors will serve on multidisciplinary teams consisting of psychiatrists, nurses, social workers, case managers, and/or rehabilitation specialists. Counselors' roles vary by setting and are likely to include elements of case management, psychosocial services, and family and caregiver support.

Three pillars of treatment of the schizophrenia spectrum include medications for symptom relief and relapse management, psychosocial interventions to support coping and prevent relapse, and rehabilitation to ensure the highest possible degree of social and occupational functioning (Rössler, 2011). APA's (2004) Practice Guideline for the Treatment of Patients With Schizophrenia provides a synthesis of best-practice treatment guidelines tailored to each unique phase of the illness. The principles are often applied to all disorders in the schizophrenia spectrum. For example, during the acute phase, providers will focus on minimizing harm and reducing the most striking of symptoms, often through medication management (Pillar 1) and basic supportive care. In the months following the acute phase, medication will continue, and focus will include introduction of psychosocial treatments designed to reduce stress and educate clients and caregivers regarding elements of the illness (Pillar 2). Once clients are stabilized, clinicians may continue medication and psychoeducation; however, they will turn attention to preventing relapse through psychosocial treatments that include education, skills training, CBT, family intervention, supported employment, and assertive community treatment (Pillar 3; Kopelowicz, Liberman, & Zarate, 2007).

Psychopharmacotherapy for clients with psychotic disorders often focuses on treatment of positive symptoms such as hallucinations, delusions, and disorganized speech and behavior. This trial-and-error process often involves use of atypical antipsychotics such as clozapine (i.e., Clozaril), risperidone (i.e., Risperdal), olanzapine (i.e., Zyprexa), quetiapine (i.e., Seroquel), ziprasidone (i.e., Geodon), aripiprazole (i.e., Abilify), and paliperiodone (i.e., Invega; NIMH, 2012; “Schizophrenia Medications,” 2013). Psychiatrists may also integrate other classes of medications, such as antidepressants, antianxiety drugs, lithium, and antiepileptic drugs, for treatment (“Schizophrenia Medications,” 2013). Clients may find treatment regiments confusing and overwhelming, especially given that cognitive deficits are quite common within psychotic disorders. In addition, side effects may be quite uncomfortable and lead to problems with medication compliance; strong therapeutic relationships are associated with more positive attitudes and compliance with medication (McCabe et al., 2012). Counselors may find themselves helping educate clients and families regarding medication management and facilitating communication between clients and psychiatrists.

There are several evidence-based psychosocial interventions for schizophrenia and related disorders. SAMHSA (2010) provides a free family psychoeducation evidence-based practices kit that reviews research regarding family education for people with psychiatric disabilities such as schizophrenia and provides guidelines for program development. Similarly, the University of California, Los Angeles Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation used outcome research to develop a number of skills training modules focused on the needs of clients with schizophrenia (see, e.g., Psychiatric Rehabilitation Consultants, 2011). Counselors who specialize in work with this population will likely use several of these resources when developing or providing materials.

Once clients have stabilized, counselors may use CBT for psychosis (CBTp; Beck, Rector, Stolar, & Grant, 2009; Kingdon & Turkington, 2002) to help clients develop insight or understanding regarding the disorder, engage in reality testing of experiences, and participate actively in recovery. Multiple research studies regarding CBTp indicate mild to moderate effectiveness of the approach (Jolley & Garety, 2011).

Finally, rehabilitation resources are essential in treatment and long-term management of schizophrenia spectrum disorders (Rössler, 2011). Evidence-based rehabilitation resources include assertive community treatment (ACT) and focused programs such as supported employment and supportive housing (APA, 2004; Rössler, 2011). ACT is an intensive, multidisciplinary approach focused on providing services that allow individuals with severe and persistent mental illness to function outside of institutional settings (National Alliance on Mental Illness, 2013). Services are tailored to the individual and his or her family, and SAMHSA (2008) provides an ACT evidence-based practice kit in which counselors can learn more about best practices for ACT.

Implications for Counselors

It is highly unlikely that counselors will be providing lead diagnostic services when working with clients who have psychotic disorders. However, counselors may encounter clients with psychotic disorders in front-line service settings, such as mental health crisis and emergency services. They may also provide longer term care as part of their work with community mental health settings. Both situations provide unique challenges and opportunities.

When clients present with active psychotic symptoms, counselors should attend closely to facilitating therapeutic communication while linking clients to levels of care and professionals necessary to respond to acute-phase symptoms. Counselors may struggle to facilitate therapeutic communication when the very nature of psychotic symptoms means clients may be out of touch with reality, struggle to communicate in meaningful ways, be distrustful of the counselor and others in his or her life, and be uninterested in social relationships. Even when symptoms are not grounded in reality, it is essential that counselors remember that hallucinations and delusions are very real to clients; clients may well be confused, agitated, or feel terrorized by these symptoms (Walsh, 2011). For these reasons, Walsh (2011) recommended mental health professionals attend to unique needs of clients experiencing psychosis by engaging in five therapeutic communication strategies: (a) remembering the relationship may provide a link between the client with an essential sense of safety in his or her world, (b) exploring and anchoring thoughts and feelings rather than arguing about reality, (c) processing distress, (d) slowly and gently providing alternative explanations of experiences, and (e) introducing possibilities within the social world.

Counselors may use relationship skills to help clients understand the need for future treatment and link to necessary services. During the acute phase, these services are likely to involve hospitalization in which clients can begin to stabilize on medication and make connections needed to support their long-term recovery and management (APA, 2004). The hospitalization process can be particularly frightening to clients and families who have not yet navigated the process or who have had negative inpatient experiences in the past. Counselors can facilitate this transition through patient reflection and discussion with clients and family members regarding what to expect in the days to come.

When providing services in longer term settings, counselors will best serve their clients if they develop a strong understanding regarding schizophrenia spectrum disorders, evidence-based treatments for the disorders, and interdisciplinary perspectives. At the same time, it is important for counselors to consider how our unique training and perspective equips us to contribute to the treatment team. For example, counselors' focus on strengths and resilience, understanding of family systems and human development, and general facilitation skills may be unique among treatment team members. It is precisely this orientation, along with the creativity that often comes with it, that makes counselors well suited for advocating for client needs and maximizing opportunities for success.

In the remainder of the chapter, we outline major disorders within the Schizophrenia Spectrum and Other Psychotic Disorders chapter of the DSM-5. Coverage includes a brief summary of essential features of each disorder as well as notation regarding special considerations such as disorder characteristics, treatment considerations, and coding procedures. In each case, readers should refer to the DSM-5 for a full explication of diagnostic criteria.

297.1 Delusional Disorder (F22)

Essential Features

Delusional disorder is characterized by a period of 1 month or more during which an individual experiences at least one delusion. Other criteria rule out diagnoses such as schizophrenia; co-occurring mood episodes; or onset caused by substances, medications, or medical conditions. Individuals with delusional disorders do not experience functional impairment or exhibit bizarre behaviors when not experiencing delusions. The nature of delusions can range from experiences that may occur in daily life (e.g., belief that one has a special relationship with another) to those that are completely implausible (e.g., belief that one's thoughts are being stolen by an outside entity). The DSM-5 includes a number of subtypes to categorize the specific content of the delusion (APA, 2013).

Special Considerations

Delusional disorder is estimated to have a lifetime prevalence of just 0.2% (APA, 2013); there is relatively little research regarding characteristics of individuals with this disorder. Counselors may struggle to detect delusional disorder because functional consequences may be quite low, especially when one is not focused on the delusion. Delusions may also appear quite plausible to those in the outside world, especially when the person with the delusion is the primary source of information regarding related events. For example, counselors may not question reports of events that may be consistent with this disorder (e.g., affairs as in jealous type, workplace harassment or discrimination as in persecutory type).

When assessing for delusional disorder, counselors should take care to assess whether the delusional content is better accounted for by another mental disorder. For example, an individual who has delusional-level beliefs associated with OCD or BDD should receive the more specific diagnosis instead of delusional disorder (APA, 2013). Similarly, delusions are often present in other psychotic, depressive, and bipolar disorders. Counselors must assess fully to make sure one of these more common diagnoses does not better account for the delusion. In addition, presence of negative symptoms or other longer term impairments may mean schizophrenia is a more appropriate diagnosis (APA, 2013).

There is just one code for delusional disorder: 297.1 (F22); however, the DSM-5 includes a number of specifiers. Subtypes focused on nature of the delusion include erotomanic type, grandiose type, jealous type, persecutory type, somatic type, mixed type, and unspecified type. Individuals who experience delusions that could not possibly happen should receive a specifier of with bizarre content. Counselors may choose from a variety of course specifiers indicating whether an individual is experiencing first episode or multiple episodes and whether that episode is currently in acute episode, partial remission, full remission, or continuous. Clinicians rate severity using the CRDPSS (APA, 2013).

298.8 Brief Psychotic Disorder (F23)

Essential Features

Brief psychotic disorder is characterized by a 1-day to 1-month time period in which one or more positive psychotic symptoms (e.g., delusions, hallucinations, disorganized speech, and/or disorganized behavior) is present. The APA (2013, p. 94) stressed that symptoms must have sudden onset (i.e., “change from a nonpsychotic state to a clearly psychotic state within 2 weeks, usually without a prodrome”) and must involve a full remission and return to functioning at the end of the disturbance. When symptoms continue beyond 30 days, counselors should consider schizophreniform disorder instead.

Special Considerations

Little is known about the lifetime prevalence of brief psychotic disorder; however, the disorder accounts for about 9% of cases of first-onset psychosis, is more common in women, and is more common in developing countries (APA, 2013). Sudden onset of psychotic symptoms is often associated with substance/medication intoxication, substance/medication withdrawal, and medical conditions. For these reasons, counselors should refer clients who appear to meet criteria for this disorder for medical evaluation. Counselors who work with clients who have personality disorders or who may have something to gain from appearing to have mental illness should be alert to the possibility that sudden-onset psychotic symptoms could be intentionally produced or represent a transient response to stressors (APA, 2013).

Brief psychotic disorder has just one diagnostic code: 298.8 (F23). Specifiers include with marked stressor(s), without marked stressor(s), and with postpartum onset. Clinicians should note and dual-code if with catatonia. Severity is assessed through the use of the CRDPSS.

295.40 Schizophreniform Disorder (F20.81)

Essential Features

Schizophreniform disorder is considered a stepping-stone between brief psychotic disorder and schizophrenia. Essential features of this disorder include 1 to 6 months of disturbance in which an individual experiences two or more psychotic symptoms, including hallucinations, delusions, disorganized speech, disorganized or catatonic behavior, or negative symptoms. Delusions, hallucinations, and/or disorganized speech must be present for an individual to qualify for the diagnosis. When symptoms are present for 6 months or more, counselors must consider schizophrenia as an alternative diagnosis (APA, 2013).

Special Considerations

As with other schizophrenia spectrum disorders, relatively little is known about the prevalence and characteristics of schizophreniform disorder. The APA (2013) noted that characteristics of those affected are similar to those with schizophrenia; however, the incidence rate is likely just 0.2%. Approximately two thirds of those with schizophreniform disorder go on to meet the full criteria for schizophrenia. The other one third of the population diagnosed with schizophreniform disorder experience a decrease or resolution of symptoms.

Treatment considerations for schizophreniform disorder are quite similar to those for schizophrenia, although there is an emerging body of literature regarding treatment for first-episode psychosis. Investigation regarding efficacy of early intervention may provide insights regarding life-changing treatment considerations. For example, results of a random control trial for integrated treatment with individuals with first-onset psychosis indicated that 95% of participants had remission of symptoms compared with just 59% of those in a medication-only treatment group (Valencia, Juarez, & Ortega, 2012). Counselors can use such findings to inspire hope that diagnosis on the schizophrenia spectrum does not automatically imply negative outcomes. Certainly, schizophreniform disorder even includes a specifier to denote the presence of good prognostic features, such as rapid onset of symptoms, confusion at the height of symptoms, good functioning at onset, and absence of negative symptoms (APA, 2013). In contrast, those who have slow deterioration in functioning and negative symptoms are more likely to go on to develop schizophrenia.

The DSM-5 includes just one code for schizophreniform disorder: 295.40 (F20.81). Counselors must specify whether the syndrome is with good prognostic features or without good prognostic features. A with catatonia specifier is available for dual coding, and severity is rated on the CRDPSS. When a diagnosis is made in the initial 6 months and outcome is not known, counselors should note the diagnosis as provisional (APA, 2013).

295.90 Schizophrenia (F20.9)

Essential Features

Schizophrenia stands at the heart of this chapter and is characterized by at least 1 month of two or more of the following symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. As with schizophreniform disorder, delusions, hallucinations, and/or disorganized speech must be present. In addition, the individual must experience deterioration in previous functioning such that the total illness duration is at least 6 months. Exclusionary criteria include consideration of concurrent depressive or manic episodes, physiological effects of a substance, coexisting medical considerations, and preexisting neurodevelopmental disorders.

Special Considerations

Schizophrenia affects about 1% of men and women around the world (NIMH, 2009). In most cases, individuals begin showing signs of schizophrenia by late adolescence or early adulthood. Men display signs of the disorder earlier than women. Onset of symptoms in childhood and early adolescence is associated with longer term and more negative impacts (Gearing & Mian, 2009; Pagsberg, 2013). In contrast, those who experience later onset and higher premorbid development have more positive prognoses (Rubin & Trawver, 2011). Both early and late onset are rare. Although prevalence of schizophrenia appears to be stable across cultures, counselors should be aware that the specific ways in which symptoms manifest may be culturally linked, perhaps contributing to over- or underdiagnosis within certain contexts (APA, 2013; Eriksen & Kress, 2005).

Most individuals who have schizophrenia will experience a degree of lifelong disability related to the condition (Gaebel, 2011). This may be due to neurocognitive deficits that remain present even when individuals are not actively experiencing positive symptoms (Horan, Harvy, Kern, & Green, 2011). Horan et al. (2011) advised clinicians to be alert to four key areas in need of attention: real-world functioning in work, independent living, and social domains; well-being and satisfaction with life; ability to engage successfully in treatment; and functional capacity in social situations. When functioning in these areas is enhanced, clients with schizophrenia will have higher quality of life and lower need for daily supports (Helldin, Kane, Karilampi, Norlander, & Archer, 2007). In all cases, family support, education, and engagement are critical for appropriate treatment and management of schizophrenia (Gearing, 2008; Rössler, 2011).

The DSM-5 includes just one code for schizophrenia: 295.90 (F20.9). Counselors may use a variety of course specifiers: first episode, currently in acute episode; first episode, currently in partial remission; first episode, currently in full remission; multiple episodes, currently in acute episode; multiple episodes, currently in partial remission; multiple episodes, currently in full remission; continuous; and unspecified. A with catatonia specifier is available for dual coding, and severity may be rated on the CRDPSS (APA, 2013).

295.70 Schizoaffective Disorder (F25._)

Essential Features

Schizoaffective disorder is characterized by concurrent, overlapping psychosis (i.e., Criterion A of schizophrenia) and mood episodes (i.e., major depressive or manic). More precise DSM-5 criteria require presence of positive symptoms for 2 or more weeks in absence of mood episode as well as presence of mood episode for the majority of the illness. When clients experience only depressive episodes concurrent with the psychosis, the disorder is said to be depressive type. Clients who experience manic episodes alone or in combination with depressive episodes are characterized as bipolar type (APA, 2013).

Special Considerations

The APA (2013) estimated a lifetime prevalence of just 0.3% for schizoaffective disorder, and characteristics of individuals with the disorder are assumed to be similar to those associated with schizophrenia. Schizoaffective disorder is a historically unstable and unreliable diagnosis, and scholars have argued whether schizoaffective disorder is one distinct disorder or better conceptualized by overlapping schizophrenia and mood disorders (Casecade, Kalali, & Buckley, 2009; Heckers, 2012; Kantrowitz & Citrome, 2011; Lake & Hurwitz, 2008). Gaebel et al. (2012) noted that addition of the lifetime criterion regarding presence of mood symptoms at least half the time may increase clarity and decrease diagnoses of this unique disorder (Gaebel et al., 2012; Tandon, 2013b).

Treatment strategies for schizoaffective disorder tend to be similar to those for schizophrenia and mood disorders. In addition to using the three pillars of treatment for schizophrenia spectrum discussed earlier, treatment may include additional medication to target depressive or manic episodes (Casecade et al., 2009). Counselors and treatment teams may find themselves tailoring treatment strategies to match the most pressing or apparent of symptoms.

The DSM-5 includes two codes for schizoaffective disorder: 295.70 (F25.0) for bipolar type and 295.70 (F25.1) for depressive type. Course and catatonia specifiers are identical to those used for schizophrenia. Severity may be rated on the CRDPSS (APA, 2013).

Substance/Medication-Induced Psychotic Disorder

Essential Features

Substance/medication-induced psychotic disorder is diagnosed when an individual has delusions and/or hallucinations; there is evidence that the symptoms were caused by intoxication, withdrawal, or exposure to a medication or substance; and the symptoms cause distress or impairment. The DSM-5 indicates that psychotic disorders may be induced by substances such as alcohol; cannabis; phencyclidine; other hallucinogen; inhalant; sedative, hypnotic, or anxiolytic; amphetamine (or other stimulant); cocaine; or other (or unknown) substance (APA, 2013).

Special Considerations

A clinician who is qualified to assess both physiological impacts of a substance and psychological after-effects must render the diagnosis of substance/medication-induced psychotic disorder. Treatment may include medical attention to manage effects of the substance, attention to coexisting substance use disorders, and management of psychotic symptoms. The disorder includes specifiers to note with onset during intoxication and with onset during withdrawal. Clinicians insert the name of the specific substance into the name of the disorder (e.g., alcohol-induced psychotic disorder). Coding depends on the specific substance causing the condition. ICD-10-CM coding is even more specific and includes coding to indicate comorbidity with corresponding mild and moderate/severe substance use disorders. Again, severity should be noted using the CRDPSS (APA, 2013).

Psychotic Disorder Due to Another Medical Condition

Essential Features

Psychotic disorder due to another medical condition is diagnosed when an individual has delusions and/or hallucinations; there is evidence that the symptoms were caused by a medical condition; and the symptoms cause distress or impairment. The DSM-5 includes lists of neurological conditions, endocrine conditions, metabolic conditions, fluid or electrolyte imbalances, hepatic or renal diseases, and autoimmune disorders that may cause psychotic symptoms.

Special Considerations

As with substance/medication-induced disorders, diagnosis of psychotic disorder due to another medical condition must be made by an individual qualified to confirm the presence of the medical condition and the likelihood that the condition caused the psychotic symptoms. Treatment will include attention to the underlying medical condition causing the disorder as well as management of resulting psychotic symptoms. The name of the medical condition is inserted in the name of the disorder (e.g., psychotic disorder due to hyperthyroidism). Disorders characterized by with delusions are coded as 293.81 (F06.2), and those characterized by with hallucinations are coded as 293.82 (F06.0; APA, 2013).

293.89 Catatonia (F06.1)

Essential Features

Like panic attack, catatonia is not a distinct diagnosis; however, it is a condition associated with a variety of neurodevelopmental, psychotic, bipolar, and mood disorders (APA, 2013) and medical conditions. In essence, catatonia involves psychomotor disturbances that manifest as immobility, decreased engagement, or excessive motor behaviors. The DSM-IV-TR included various different criteria sets for catatonia. The DSM-5 was revised to include one unified criteria set (Tandon, 2013a). To meet criteria for this condition, one must have three or more of the following symptoms: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, or echopraxia. Refer to the DSM-5 for definitions of each symptom.

Special Considerations

Catatonia is designed primarily as a specifier alongside other disorders. It is always coded as 293.89 (F06.1) but will be noted as catatonia associated with another mental disorder, catatonic disorder due to another medical condition, or unspecified catatonia (APA, 2013).

Case Example

Cheryl is a 28-year-old mother of two young children who is separated from her husband and lives alone in Section 8 housing. She is referred to the county mental health center for multidisciplinary services as a condition of her release from a behavioral health hospital. The case manager initiating the referral indicated that this was Cheryl's first hospitalization; the stay was precipitated by her presentation to the county hospital emergency room with a bag of pennies and a request that the staff fill her teeth with the pennies to block the FBI from stealing her thoughts. At admission, a drug screen showed evidence of cannabis and alcohol in her system. The case manager indicated that the children were living with their father because of Cheryl's inability to care for them. She was being discharged to home after stabilizing on several atypical antipsychotic medications.

Upon interview, you note Cheryl to be unusually slim with long, greasy hair and tobacco-stained fingers. Although generally cooperative, Cheryl seems to have difficulty engaging in the interview. She makes little eye contact, speaks in monotone, and rarely says more than a few words at a time. At several points during the interview, Cheryl appears to space out, occasionally shaking her head as if to refocus her attention. She responds to your inquiry regarding hallucinations with a shrug and a comment that the “drugs make everything fuzzy.” When you ask about the situation that precipitated the hospital stay, Cheryl simply says that “the truth will come to be.” She admitted that she occasionally uses alcohol or marijuana when feeling agitated or tense.

Although details are limited, you gather that Cheryl has not had any treatment for prior mental health concerns. During high school, she had several friends and her grades were mostly As and Bs. She graduated from high school, discovered she was pregnant, and married her high school boyfriend. She worked for several years in the retail sector. Her supervisor terminated her employment 2 years ago because she “made others uncomfortable.” About that time, her family asked her to get help, presumably for depression. Although Cheryl denied being sad or down, her family members apparently noted her lack of connections with others, lack of motivation, and progressive deterioration of self-care. Cheryl appeared unaffected that her husband left with the children approximately 6 months ago, shrugging and saying, “He knew what he needed to do.”

Diagnostic Questions

1. Do Cheryl's presenting symptoms appear to meet the criteria for a schizophrenia spectrum disorder? If so, which disorder?
2. Based on your answer to Question 1, which symptom(s) led you to select that diagnosis?
3. What would be the reason(s), if any, a counselor may not diagnose Cheryl with that disorder?
4. Would Cheryl be more accurately diagnosed with a mood disorder? If so, why? If not, why not?
5. What rule-outs would you consider for Cheryl's case?
6. What other information may be needed to make an accurate clinical diagnosis?