Guide To The DSM-5 Diagnostic Criteria For Schizophrenia

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has existed since the 1950s when the American Psychiatric Association (APA) published the first edition in 1952. Since the 50s, several subsequent editions have been released, with the current versions including the DSM-5 and DSM-5-TR. Included in these versions are diagnostic criteria for schizophrenia, a mental illness that can affect how a person behaves and perceives their surroundings. 

For a person to receive a schizophrenia diagnosis, they may be required to meet the criteria set by the DSM-5. For those interested in learning more, it may be beneficial to understand the DSM-5 in further detail, as well as the specific criteria for a schizophrenia diagnosis. 

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What is the DSM-5?

The APA developed the DSM-5 with the help of over 200 subject matter experts in fields such as neuroscience, genetics, biology, epidemiology, social and behavioral sciences, public health, and nosology. The DSM-5-TR and DSM-5 do not contain information or guidelines on treating any of the disorders they describe. However, the APA does note that an accurate diagnosis can be the first step to treating mental disorders appropriately. 

What are the DSM-5 diagnostic criteria for schizophrenia?

According to the National Institute of Health (NIH), the DSM-5 diagnostic criteria for schizophrenia include the following:

Criteria A symptoms 

Schizophrenia is classified under the category of Schizophrenia Spectrum and Other Psychotic Disorders in the DSM-5. Two (or more) of the following symptoms must be present for a significant portion of one month. Of these two, one must be delusions, hallucinations, or disorganized speech: 

1. Delusions
2. Hallucinations
3. Disorganized speech (such as frequent derailment or incoherence)
4. Catatonic behavior, negative symptoms, or grossly disorganized behavior
5. Negative symptoms (such as avolition or diminished emotional expression)

Criteria B symptoms 

One’s level of functioning in one more central area, such as interpersonal relations, self-care, or work, is markedly below the level achieved before the onset of the disturbance. Or, when the onset is in childhood or adolescence, one fails to achieve the expected level of academic, occupational, or interpersonal functioning. 

Criteria C symptoms 

Regarding the duration of a disturbance, continuous signs must persist for at least six months. This period must include at least one month of symptoms, though this amount may be less if successfully treated. 

These symptoms must meet criterion A, referred to in the DSM as “active phase symptoms,” and may include periods of prodromal or residual symptoms. During ritual and prodromal symptomatic periods, disturbance may manifest as only negative symptoms. In addition, the signs of disturbance during these periods may consist of two or more symptoms listed in Criterion A but presented in an attenuated form. Examples of attenuated forms listed in the DSM include odd beliefs and unusual perceptual experiences. 

Criteria D requirements 

To be diagnosed with schizophrenia, several disorders must have been ruled out, such as schizoaffective disorder and depressive or bipolar disorder with psychotic symptoms or features. The person must experience no major depressive or manic episodes occurring at the same time as active-phase symptoms, or if mood episodes and active-phase symptoms have occurred concurrently, these mood episodes have been present for a minority of the total duration of the residual and active periods of the illness. 

Criteria E 

The disturbance cannot be attributed to another medical condition or the psychological effects of a substance, such as a medication or a “drug of abuse.”

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

Criteria F 

If an individual has a history of a communication disorder of childhood onset or autism spectrum disorder (ASD), specific requirements must be met for the additional diagnosis of schizophrenia. These requirements include the presence of prominent delusions or hallucinations for at least one month or less if the individual experiences successful treatment.

Episode specifiers 

If symptoms have lasted for at least one year, the following course specifiers may be used—provided they are not in contradiction to the diagnostic course criteria: 

• First episode (currently in acute episode): This type of episode is the first initial manifestation of the disorder’s symptoms that meet the time criteria and defining diagnostic symptom criteria. The DSM-5 defines an acute episode as a “period in which the symptom criteria are fulfilled.” 
• First episode (currently in partial remission): If improvement from a previous episode is maintained and the disorder's defining criterion is only partially fulfilled, the individual may be in “partial remission.” 
• First episode (currently in full remission): Periods after a period episode during which no disorder-specific symptoms are present are known as “full remission.”

Another group of course specifiers involves multiple episodes. The first specifier, multiple episodes (currently in an acute episode), may be determined after a minimum of two episodes, i.e., after the first initial manifestation of the disorder or “first episode,” followed by remission and at least one relapse.) Other multiple-episode specifiers include multiple episodes (currently in partial remission) and multiple episodes (currently in complete remission.) 

The final two specifiers are continuous and unspecified. While unspecified has no description in the NIH version of the DSM-5, the continuous specifier applies to situations where the diagnostic symptom criteria have been fulfilled by symptoms that remain for most of the illness course. In addition, the DSM-5 states that the subthreshold symptom periods, in this case, are often brief relative to the overall course. 

The DSM-5 also indicates that a provider should specify if the disorder occurs with catatonia, indicating that the diagnostic professional should “refer to the criteria for catatonia associated with another mental disorder for definition.” These professionals can also use the code 293.89 (F06.1) to indicate the presence of comorbid catatonia. 

What is the difference between the DSM-4-TR and DSM-5 criteria for schizophrenia?

According to the APA, the changes between the text-revised version of the DSM-IV and the DSM-5 (concerning schizophrenia and other psychotic disorders) may include:

• Two changes to criterion A, including the elimination of Schneiderian first-rank auditory hallucinations (a situation that may involve two or more hallucinatory voices conversing) and the removal of the special attribution of bizarre delusions. 
• A change to schizoaffective disorder that removes the requirement that a major mood episode occur for the majority of the disorder’s duration after criterion A has been met. 
• The subtypes of schizophrenia, such as disorganized, catatonic behavior, paranoia, active and residual periods, and undifferentiated, were removed. Instead, the DSM-5 rates the severity of core schizophrenia symptoms with a dimension approach included in section III. 
• For delusional disorder, criterion A no longer requires that delusions be “non-bizarre.” 
• For catatonia, the same criteria are used whether the context is bipolar, psychotic, depressive, or another medical disorder. In the DSM-5, these contexts require three catatonia symptoms from 12 characteristic symptoms.

The DSM-4 schizophrenia subtypes were removed due to low reliability, poor validity, and limited diagnostic stability.

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Does the DSM-5 include treatments for schizophrenia?

The DSM-5 is intended for use as an assessment and diagnostic tool and does not include treatments for schizophrenia or any mental health disorder. However, diagnosing professionals can often create a treatment plan based on their knowledge of treating these conditions. These treatments may include the use of medications, such as antipsychotics, or therapeutic approaches, such as psychoeducation, cognitive adaptation training, and cognitive-behavioral therapy (CBT.) 

For those living with schizophrenia, CBT sessions may involve working with a therapist to identify specific thought patterns or behaviors that may be unwanted or harmful. Therapy sessions may also center around how a person with schizophrenia perceives the world around them, which could include discussing hallucinations and other symptoms. 

Exploring DSM-5 diagnostic criteria for schizophrenia and mental health through online therapy

However, in-person therapy may not be available or convenient for everyone. In some cases, an individual living with schizophrenia may be more comfortable attending sessions at home. Some may also prefer other communication formats like telephone calls, video chats, or texting. In these cases, it may be beneficial to explore different options, such as online therapy through a platform like BetterHelp. These platforms can allow clients to attend therapy from home and use resources like journaling prompts, worksheets, and group sessions. 

While some may be concerned about online therapy's efficacy, research indicates that it may be as effective as in-person therapy. One meta-analysis of 12 randomized controlled trials compared the effect these therapeutic approaches had on factors like symptom severity. Researchers found no significant difference in symptom severity between telehealth and face-to-face therapy immediately after treatment, as well as at three, six, and 12 months.