Everything To Know About Schizophrenia, According To The DSM-5

When it comes to specific mental health disorders, mental health professionals often rely on a tool called the DSM-V (or DSM-5) to identify, diagnose, and guide treatment for patients. One of the most recognizable and easily misunderstood disorders that lie within the DSM-V is schizophrenia. Schizophrenia is a psychotic disorder marked by delusions, hallucinations, disorganized speech, and other symptoms. Schizophrenia affects more than 24 million people across the globe according to the World Health Organization, with about 31% of them receiving treatment each year. If you or someone you love is living with schizophrenia, understanding this mental illness may help you learn how to care for yourself or your loved one most effectively.

Online therapy may be one component of a supportive treatment plan for individuals living with schizophrenia, particularly for those who may be on a waiting list to see a traditional, in-person therapy provider. Cognitive behavioral therapy (CBT) is a proven treatment method to help individuals diagnosed with schizophrenia develop coping mechanisms, change their behaviors, and reduce their symptoms. In conjunction with other treatment modalities, like medications, CBT may help those living with this disorder manage their diagnosis.

What is the DSM-V?

The DSM-V, a diagnostic material more formally known as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), is a comprehensive tool that is used to identify and diagnose mental health disorders. Mood disorders such as depression and anxiety are found in the book, as are developmental disorders like autism spectrum disorder and serious psychiatric disorders such as schizophrenia. 

The first DSM manual was compiled in 1952 when the American Psychiatric Association’s Committee on Nomenclature and Statics developed the first formal edition of the book. In recent decades and as psychologists and medical doctors (MD) have expanded their knowledge about mental health, new editions of the DSM have been published. The most current edition, the DSM-V, was released in 2013 after DSM-IV. The DSM-V is the most up-to-date classification system for mental health disorders. 

What is schizophrenia?

Schizophrenia is a serious psychotic disorder. It is characterized by a combination of "positive," "negative," and cognitive symptoms. Note that “positive” does not mean “good,” and “negative” does not mean “bad” in this context. In the DSM-V, schizophrenia is listed under the category of “Schizophrenia Spectrum and Other Psychotic Disorders”. 

Symptoms of schizophrenia can include delusions, hallucinations, disorganized speech, catatonic behavior, and abnormal movements. These symptoms are chronic and usually appear in early adulthood and can be treated with the proper support. According to the National Institutes of Health survey, about 30% of individuals diagnosed with this disorder may achieve remission of symptoms, while the remainder may require lifelong treatment.

Positive vs. negative symptoms

Positive symptoms are characterized by new changes in behavior or thoughts. These symptoms may be the most characteristic signs of this disorder. They include a range of symptoms—delusions, hallucinations, disorganized speech, and unusual movements—that are not typically seen in the general population. According to the DSM-V, symptoms include:

• Hallucinations: Hallucinations may include seeing, hearing, or smelling things that are not present. For instance, hearing voices which are derogatory or threatening is one of the most reported examples of hallucinations.

• Delusions: Delusions are strong beliefs in ideas that are not grounded in reality. For example, someone experiencing delusions may think they are being watched without any evidence this is the case. An individual experiencing delusion may continue to believe delusional thoughts even when evidence is presented that proves it wrong.

• Thought disorder: Thought disorder includes difficulty forming cohesive thoughts and difficulty being understood by others. Thought disorder often manifests as disorganized speech, which involves abnormal sentence structure, repetition, and other changes in speech patterns. Episodes of thought blocking, where an individual is unable to think, move, or speak, may occur for people with this disorder.

• Unusual movements: Unusual movements may appear as repetitive movements or lengthy episodes of being very still. Unusually slow movements have also been reported in individuals with schizophrenia.

Negative symptoms are those symptoms that represent things or emotions in an individual’s life that have stopped happening. Unlike delusions, hallucinations, and other positive symptoms, negative symptoms may seem subtler and may mimic signs of depression. They include:

• Lack of emotions: A lack of emotions may present as a general lack of interest in life.

• Difficulty maintaining relationships: A lack of emotions and disinterest in others may make it easy for individuals with this disorder to drift away from those they care about.

• Flat voice: Many with this disorder speak in a dull, flat tone without inflection or emotion.

• Poor appearance: Personal hygiene may suffer due to those with this disorder having little interest in caring for themselves.

Cognitive symptoms are those symptoms that impact overall functioning. These include:

• Difficulty understanding information: Some may experience confusion about everyday situations or objects.

• Trouble making decisions: This is often referred to as a problem with “executive functioning.” It may include difficulty understanding new information and using information effectively.

• Lack of attention: This symptom includes a general inability to focus.

• Memory issues: Memory challenges may range from misplacing objects often to immediately forgetting information as soon as it is learned.

The symptoms must severely impact an individual's ability to work, their relationships, or the capacity to care for themselves. These impairments to social, academic, and occupational functioning must be present “for a significant portion of time” after the onset of the disorder. 

The Duration criterion states that professionals must ensure “continuous signs of the disturbance persist for at least six months”, during which time they must have experienced the requisite month of active-phase symptoms, as described above. During the other months, the individual may experience only negative symptoms or at least two less severe forms of other active-phase symptoms, such as odd beliefs or mild hallucinations. If the individual has experienced symptoms for fewer than six months, they may be living with schizophreniform disorder. 

Absence of schizoaffective disorder, substance use, and depressive or bipolar disorder

Before a diagnosis of schizophrenia can be made, some potential psychiatric disorders must be ruled out while others must not be the source of symptoms (even if they can be present). Symptoms of schizoaffective disorder and mood disorders with psychotic features (e.g., hallucinations, disorganized speech) can mimic those of schizophrenia. The DSM-V states that schizoaffective disorder and mood disorders with psychotic features must be ruled out for a diagnosis of schizophrenia to be made. Mood disorders with psychotic features can include either major depressive disorder or bipolar disorder, and they may be ruled out if their episodes have not occurred concurrently with active-phase symptoms. If mood episodes have occurred alongside active-phase symptoms, their duration must have been limited. 

If the individual is living with autism spectrum disorder, which the DSM-IV referred to as an “autistic disorder or another pervasive developmental disorder”, the DSM-V states that schizophrenia can only be diagnosed “if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month”.

Diagnosing this disorder requires time and patience. Many individuals have difficulty recognizing their symptoms, as the condition may distort their perception of reality. Additionally, because there is no formal laboratory test for schizophrenia, symptoms must be assessed over time, and delays in diagnosis may occur. However, once it is detected and diagnosed, the symptoms are treatable. It is also important to note that there is a link between schizophrenia and substance abuse or substance use disorder, including drug abuse or alcoholism.

If you are struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources. Support is available 24/7.

Specifiers

There are several specifiers that healthcare professionals can provide to give more detail to a schizophrenia diagnosis. These include multiple additions to diagnoses that help describe the current phase of an individual’s disorder: “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”. There are also specifiers regarding the presence of catatonia and the severity of symptoms. 

Many symptoms can arise in other disorders—and vice versa—so it is often necessary for healthcare professionals to provide a differential diagnosis that includes several other conditions. The differentials for schizophrenia include bipolar disorder, paranoid personality disorder, delusional disorder, mood disorders with psychotic features, and sleep disorders.

How is this disorder treated?

Treatment largely depends on the severity of the symptoms and the progression of the illness. In most cases, this disorder requires lifelong treatment. According to the Substance Abuse and Mental Health Services Association, treatment methods may include:

• Medications: Various medications treat schizophrenia, and antipsychotics are usually the best treatment option for people with this disorder. Antipsychotic medications may help individuals manage symptoms of schizophrenia like delusions or hallucinations. Antipsychotics may require a few weeks to take effect, and, in some cases, they may be prescribed alongside antidepressants and anti-anxiety drugs. Because of this, it may take some time before the right dosage or combination of medications is identified. It is important that individuals with this disorder never stop taking medication or change their dosage without speaking to their doctor first.

• Therapy for schizophrenia: Psychotherapy may help individuals with schizophrenia manage their day-to-day symptoms or learn to identify when a relapse is imminent. Social skills training, family therapy, and vocational rehabilitation are also useful for individuals who require additional support in their daily lives.

• ECT: If antipsychotic medications don’t improve individuals’ symptoms, electroconvulsive therapy (ECT) may be used. ECT is primarily used in severe depression but can be effective for this disorder when other treatment options are unavailable or when an individual is at risk of harming themselves or others.

What to do if you have schizophrenia

If you have been diagnosed with this disorder, the most important thing is to start your treatment plan immediately and to follow it closely. Schizophrenia is treatable, and by adhering to an evidence-based treatment plan, you may learn to manage your symptoms effectively.

Find a support network, such as a support group, family, or partner who can help you stick to your treatment plan. Because some symptoms can distort your view of reality, it’s important to have someone you trust who can help keep you on track no matter what. 

Online therapy

Online CBT may be an effective component of a treatment plan to help minimize psychotic symptoms as well as related depressive, anxiety, phobia, or obsessive-compulsive symptoms related to schizophrenia. 

Online therapy, which is more cost-effective than in-person therapy and requires no transportation costs, requires only an internet connection and a device, and may be a helpful treatment modality for people with this mental illness. Additionally, some individuals with schizophrenia may feel social stigma surrounding their mental illness