Schizophrenia Spectrum and Other Psychotic Disorder

Schizophrenia spectrum and other psychotic disorders include schizophrenia, other psychotic
disorders, and schizotypal (personality) disorder. They 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.
Key Features That Define the Psychotic Disorders
Delusions
Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Their
content may include a variety of themes (e.g., persecutory, referential, somatic, religious,
grandiose). Persecutory delusions (i.e., belief that one is going to be harmed, harassed, and so
forth by an individual, organization, or other group) are most common. Referential delusions
(i.e., belief that certain gestures, comments, environmental cues, and so forth are directed at
oneself) are also common. Grandiose delusions (i.e., when an individual believes that he or she
has exceptional abilities, wealth, or fame) and erotomanie delusions (i.e., when an individual
believes falsely that another person is in love with him or her) are also seen.
Nihilistic delusions involve the conviction that a major catastrophe will occur, and somatic
delusions focus on preoccupations regarding health and organ function. Delusions are deemed
bizarre if they are clearly implausible and not understandable to same-culture peers and do not
derive from ordinary life experiences. An example of a bizarre delusion is the belief that an
outside force has removed his or her internal organs and replaced them with someone else's
organs without leaving any wounds or scars. An example of a nonbizarre delusion is the belief
that one is under surveillance by the police, despite a lack of convincing evidence. Delusions that
express a loss of control over mind or body are generally considered to be bizarre; these include
the belief that one's thoughts have been "removed" by some outside force {thought withdrawal),
that alien thoughts have been put into one's mind (thought insertion), or that one's body or
actions are being acted on or manipulated by some outside force (delusions of control). The
distinction between a delusion and a strongly held idea is sometimes difficult to make and
depends in part on the degree of conviction with which the belief is held despite clear or
reasonable contradictory evidence regarding its veracity.
Hallucinations
Hallucinations are perception-like experiences that occur without an external stimulus. They are
vivid and clear, with the full force and impact of normal perceptions, and not under voluntary
control. They may occur in any sensory modality, but auditory hallucinations are the most
common in schizophrenia and related disorders. Auditory hallucinations are usually experienced
as voices, whether familiar or unfamiliar, that are perceived as distinct from the individual's own
thoughts. The hallucinations must occur in the context of a clear sensorium; those that occur
while falling asleep (hypnagogic) or waking up (hypnopompic) are considered to be within the
range of normal experience. Hallucinations may be a normal part of religious experience in
certain cultural contexts.
Disorganized Thinking (Speech)
Disorganized thinking (formal thought disorder) is typically inferred from the individual's
speech. The individual may switch from one topic to another {derailment or loose associations).
Answers to questions may be obliquely related or completely unrelated (tangentiality). Rarely,
speech may be so severely disorganized that it is nearly incomprehensible and resembles
receptive aphasia in its linguistic disorganization {incoherence or "word salad"). Because mildly
disorganized speech is common and nonspecific, the symptom must be severe enough to
substantially impair effective communication. The severity of the impairment may be difficult to
evaluate if the person making the diagnosis comes from a different linguistic background than
that of the person being examined. Less severe disorganized thinking or speech may occur
during the prodromal and residual periods of schizophrenia.
Grossly Disorganized or Abnormai iViotor Behavior (inciuding Catatonia)
Grossly disorganized or abnormal motor behavior may manifest itself in a variety of ways,
ranging from childlike "silliness" to unpredictable agitation. Problems may be noted in any form
of goal-directed behavior, leading to difficulties in performing activities of daily living.
Catatonic behavior is a marked decrease in reactivity to the environment. This ranges from
resistance to instructions {negativism); to maintaining a rigid, inappropriate or bizarre posture; to
a complete lack of verbal and motor responses {mutism and stupor). It can also include
purposeless and excessive motor activity without obvious cause {catatonic excitement). Other
features are repeated stereotyped movements, staring, grimacing, mutism, and the echoing of
speech. Although catatonia has historically been associated with schizophrenia, catatonic
symptoms are nonspecific and may occur in other mental disorders (e.g., bipolar or depressive
disorders with catatonia) and in medical conditions (catatonic disorder due to another medical
condition).
Negative Symptoms
Negative symptoms account for a substantial portion of the morbidity associated with
schizophrenia but are less prominent in other psychotic disorders. Two negative symptoms are
particularly prominent in schizophrenia: diminished emotional expression and avolition.
Diminished emotional expression includes reductions in the expression of emotions in the face,
eye contact, intonation of speech (prosody), and movements of the hand,head, and face that
normally give an emotional emphasis to speech. Avolition is a decrease in motivated self-
initiated purposeful activities. The individual may sit for long periods of time and show little
interest in participating in work or social activities. Other negative symptoms include alogia,
anhedonia, and asociality. Alogia is manifested by diminished speech output. Anhedonia is the
decreased ability to experience pleasure from positive stimuli or a degradation in the recollection
of pleasure previously experienced. Asociality refers to the apparent lack of interest in social
interactions and may be associated with avolition, but it can also be a manifestation of limited
opportunities for social interactions.
Disorders in Tliis CInapter
This chapter is organized along a gradient of psychopathology. Clinicians should first consider
conditions that do not reach full criteria for a psychotic disorder or are limited to one domain of
psychopathology. Then they should consider time-limited conditions. Finally, the diagnosis of a
schizophrenia spectrum disorder requires the exclusion of another condition that may give rise to
psychosis.
Schizotypal personality disorder is noted within this chapter as it is considered within the
schizophrenia spectrum, although its full description is found in the chapter "Personality
Disorders." The diagnosis schizotypal personality disorder captures a pervasive pattern of social
and interpersonal deficits, including reduced capacity for close relationships; cognitive or
perceptual distortions; and eccentricities of behavior, usually beginning by early adulthood but in
some cases first becoming apparent in childhood and adolescence. Abnormalities of beliefs,
thinking, and perception are below the threshold for the diagnosis of a psychotic disorder. Two
conditions are defined by abnormalities limited to one domain of psychosis: delusions or
catatonia. Delusional disorder is characterized by at least 1 month of delusions but no other
psychotic symptoms. Catatonia is described later in the chapter and further in this discussion.
Brief psychotic disorder lasts more than 1 day and remits by 1 month. Schizophreniform disorder
is characterized by a symptomatic presentation equivalent to that of schizophrenia except for its
duration (less than 6 months) and the absence of a requirement for a decline in functioning.
Schizophrenia lasts for at least 6 months and includes at least 1 month of active-phase symptoms.
In schizoaffective disorder, a mood episode and the active-phase symptoms of schizophrenia
occur together and were preceded or are followed by at least 2 weeks of delusions or
hallucinations without prominent mood symptoms. Psychotic disorders may be induced by
another condition. In substance/medicationinduced psychotic disorder, the psychotic symptoms
are judged to be a physiological consequence of a drug of abuse, a medication, or toxin exposure
and cease after removal of the agent. In psychotic disorder due to another medical condition, the
psychotic symptoms are judged to be a direct physiological consequence of another medical
condition. Catatonia can occur in several disorders, including neurodevelopmental, psychotic,
bipolar, depressive, and other mental disorders. This chapter also includes the diagnoses
catatonia associated with another mental disorder (catatonia specifier), catatonic disorder due to
another medical condition, and unspecified catatonia, and the diagnostic criteria for all three
conditions are described together. Other specified and unspecified schizophrenia spectrum and
other psychotic disorders are included for classifying psychotic presentations that do not meet
the criteria for any of the specific psychotic disorders, or psychotic symptomatology about which
there is inadequate or contradictory information.
Clinician-Rated Assessment of Symptoms and Related Clinical Phenomena in Psychosis
Psychotic disorders are heterogeneous, and the severity of symptoms can predict important
aspects of the illness, such as the degree of cognitive or neurobiological deficits. To move the
field forward, a detailed framework for the assessment of severity is included in Section III
"Assessment Measures," which may help with treatment planning, prognostic decision making,
and research on pathophysiological mechanisms. Section III "Assessment Measures" also
contains dimensional assessments of the primary symptoms of psychosis, including
hallucinations, delusions, disorganized speech (except for substance/ medication-induced
psychotic disorder and psychotic disorder due to another medical condition), abnormal
psychomotor behavior, and negative symptoms, as well as dimensional assessments of
depression and mania. The severity of mood symptoms in psychosis has prognostic value and
guides treatment. There is growing evidence that schizoaffective disorder is not a distinct
nosological category. Thus, dimensional assessments of depression and mania for all psychotic
disorders alert clinicians to mood pathology and the need to treat where appropriate. The Section
III scale also includes a dimensional assessment of cognitive impairment. Many individuals with
psychotic disorders have impairments in a range of cognitive domains that predict functional
status. Clinical neuropsychological assessment can help guide diagnosis and treatment, but brief
assessments without formal neuropsychological assessment can provide useful information that
can be sufficient for diagnostic purposes. Formal neuropsychological testing, when conducted,
should be administered and scored by personnel trained in the use of testing instruments. If a
formal neuropsychological assessment is not conducted, the clinician should use the best
available information to make a judgment. Further research on these assessments is necessary
in order to determine their clinical utility; thus, the assessments available in Section III should
serve as a prototype to stimulate such research.
Schizotypal (Personality) Disorder
Criteria and text for schizotypal personality disorder can be found in the chapter "Personality
Disorders." Because this disorder is considered part of the schizophrenia spectrum of disorders,
and is labeled in this section of ICD-9 and ICD-10 as schizotypal disorder, it is listed in this
chapter and discussed in detail in the DSM-5 chapter "Personality Disorders."
Delusional Disorder
Diagnostic Criteria 297.1 (F22)
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are related to the delusional
theme (e.g., the sensation of being infested with insects associated with delusions of
infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not
markedly impaired, and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative
to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or
another medical condition and is not better explained by another mental disorder,
such as body dysmorphic disorder or obsessive-compulsive disorder.
Specify whether:
Erotomanie type: This subtype applies when the central theme of the delusion is
that another person is in love with the individual.
Grandiose type: This subtype applies when the central theme of the delusion is the
conviction of having some great (but unrecognized) talent or insight or having made
some important discovery.
Jeaious type: This subtype applies when the central theme of the individuals
delusion is that his or her spouse or lover is unfaithful.
Persecutory type: This subtype applies when the central theme of the delusion
involves the individuals belief that he or she is being conspired against, cheated,
spied on, followed, poisoned or drugged, maliciously maligned, harassed, or
obstructed in the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme of the delusion involves
bodily functions or sensations. Mixed type: This subtype applies when no one
delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot
be clearly determined or is not described in the specific types (e.g., referential
delusions without a prominent persecutory or grandiose component).
Specify if:
With bizarre content: Delusions are deemed bizarre if they are clearly implausible,
not understandable, and not derived from ordinary life experiences (e.g., an
individuals belief that a stranger has removed his or her internal organs and
replaced them with someone elses organs without leaving any wounds or scars).
Specify if:
The following course specifiers are only to be used after a 1 -year duration of the
disorder:
First episode, currently in acute episode: First manifestation of the disorder meeting
the defining diagnostic symptom and time criteria. An acute episode is a time period
in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period
during which an improvement after a previous episode is maintained and in which
the defining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods
being very brief relative to the overall course.
Unspecified Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor
behavior, and negative symptoms. Each of these symptoms may be rated for its
current severity (most severe in the last 7 days) on a 5-point scale ranging from 0
(not present) to 4 (present and severe). (See Clinician-Rated Dimensions of
Psychosis SymptomSeverity in the chapter Assessment Measures.)
Note: Diagnosis of delusional disorder can be made without using this severity
specifier.
Subtypes
In erotomanie type, the central theme of the delusion is that another person is in love with the
individual. The person about whom this conviction is held is usually of higher status (e.g., a
famous individual or a superior at work) but can be a complete stranger. Efforts to contact the
object of the delusion are common. In grandiose type, the central theme of the delusion is the
conviction of having some great talent or insight or of having made some important discovery.
Less commonly, the individual may have the delusion of having a special relationship with a
prominent individual or of being a prominent person (in which case the actual individual may be
regarded as an impostor). Grandiose delusions may have a religious content. In jealous type, the
central theme of the delusion is that of an unfaithful partner. This belief is arrived at without due
cause and is based on incorrect inferences supported by small bits of "evidence" (e.g., disarrayed
clothing). The individual with the delusion usually confronts the spouse or lover and attempts to
intervene in the imagined infidelity. In persecutory type, the central theme of the delusion
involves the in dividual's belief of being conspired against, cheated, spied on, followed,
poisoned, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small
slights may be exaggerated and become the focus of a delusional system. The affected individual
may engage in repeated attempts to obtain satisfaction by legal or legislative action. Individuals
with persecutory delusions are often resentful and angry and may resort to violence against those
they believe are hurting them. In somatic type, the central theme of the delusion involves bodily
functions or sensations. Somatic delusions can occur in several forms. Most common is the belief
that the individual emits a foul odor; that there is an infestation of insects on or in the skin; that
there is an internal parasite; that certain parts of the body are misshapen or ugly; or that parts of
the body are not functioning.
Diagnostic Features
The essential feature of delusional disorder is the presence of one or more delusions that persist
for at least 1 month (Criterion A). A diagnosis of delusional disorder is not given if the
individual has ever had a symptom presentation that met Criterion A for schizophrenia (Criterion
B). Apart from the direct impact of the delusions, impairments in psychosocial functioning may
be more circumscribed than those seen in other psychotic disorders such as schizophrenia, and
behavior is not obviously bizarre or odd (Criterion C). If mood episodes occur concurrently with
the delusions, the total duration of these mood episodes is brief relative to the total duration of
the delusional periods (Criterion D). The delusions are not attributable to the physiological
effects of a substance (e.g., cocaine) or another medical condition (e.g., Alzheimer's disease) and
are not better explained by another mental disorder, such as body dysmorphic disorder or
obsessive-compulsive disorder (Criterion E). In addition to the five symptom domain areas
identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom
domains is vital for making critically important distinctions between the various schizophrenia
spectrum and other psychotic disorders.
Associated Features Supporting Diagnosis
Social, marital, or work problems can result from the delusional beliefs of delusional disorder.
Individuals with delusional disorder may be able to factually describe that others view their
beliefs as irrational but are unable to accept this themselves (i.e., there may be "factual insight"
but no true insight). Many individuals develop irritable or dysphoric mood, which can usually be
understood as a reaction to their delusional beliefs. Anger and violent behavior can occur with
persecutory, jealous, and erotomanie types. The individual may engage in htigious or
antagonistic behavior (e.g., sending hundreds of letters of protest to the government). Legal
difficulties can occur, particularly in jealous and erotomanie types.
Prevalence
The lifetime prevalence of delusional disorder has been estimated at around 0.2%, and the most
frequent subtype is persecutory. Delusional disorder, jealous type, is probably more common in
males than in females, but there are no major gender differences in the overall frequency of
delusional disorder.
Development and Course
On average, global function is generally better than that observed in schizophrenia. Although the
diagnosis is generally stable, a proportion of individuals go on to develop schizophrenia.
Delusional disorder has a significant familial relationship with both schizophrenia and
schizotypal personality disorder. Although it can occur in younger age groups, the condition may
be more prevalent in older individuals.
Culture-Related Diagnostic Issues
An individual's cultural and religious background must be taken into account in evaluating the
possible presence of delusional disorder. The content of delusions also varies across cultural
contexts.
Functional Consequences of Delusional Disorder
The functional impairment is usually more circumscribed than that seen with other psychotic
disorders, although in some cases, the impairment may be substantial and include poor
occupational functioning and social isolation. When poor psychosocial functioning is present,
delusional beliefs themselves often play a significant role. A common characteristic of
individuals with delusional disorder is the apparent normality of their behavior and appearance
when their delusional ideas are not being discussed or acted on.
Differential Diagnosis
Obsessive-compulsive and related disorders. If an individual with obsessive-compulsive
disorder is completely convinced that his or her obsessive-compulsive disorder beliefs are true,
then the diagnosis of obsessive-compulsive disorder, with absent insight/delusional beliefs
specifier, should be given rather than a diagnosis of delusional disorder. Similarly, if an
individual with body dysmorphic disorder is completely convinced that his or her body
dysmorphic disorder beliefs are true, then the diagnosis of body dysmorphic disorder, with
absent insight/delusional beliefs specifier, should be given rather than a diagnosis of delusional
disorder.
Delirium, major neurocognitive disorder, psychotic disorder due to another medical
condition, and substance/medication-induced psychotic disorder. Individuals with these
disorders may present with symptoms that suggest delusional disorder. For example, simple
persecutory delusions in the context of major neurocognitive disorder would be diagnosed as
major neurocognitive disorder, with behavioral disturbance. A substance/ medication-induced
psychotic disorder cross-sectionally may be identical in symptomatology to delusional disorder
but can be distinguished by the chronological relationship of substance use to the onset and
remission of the delusional beliefs.
Schizophrenia and schizophreniform disorder. Delusional disorder can be distinguished from
schizophrenia and schizophreniform disorder by the absence of the other characteristic
symptoms of the active phase of schizophrenia.
Depressive and bipolar disorders and schizoaffective disorder. These disorders may be
distinguished from delusional disorder by the temporal relationship between the mood
disturbance and the delusions and by the severity of the mood symptoms. If delusions occur
exclusively during mood episodes, the diagnosis is depressive or bipolar disorder with psychotic
features. Mood symptoms that meet full criteria for a mood episode can be superimposed on
delusional disorder. Delusional disorder can be diagnosed only if the total duration of all mood
episodes remains brief relative to the total duration of the delusional disturbance. If not, then a
diagnosis of other specified or unspecified schizophrenia spectrum and other psychotic disorder
accompanied by other specified depressive disorder, unspecified depressive disorder, other
specified bipolar and related disorder, or unspecified bipolar and related disorder is appropriate.
Brief Psychotic Disorder
Diagnostic Criteria 298.8 (F23)
A. Presence of one (or more) of the following symptoms. At least one of these must be
(1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month,
with eventual full return to premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder
with psychotic features or another psychotic disorder such as schizophrenia or
catatonia, and is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.
Specify if:
With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to
events that, singly or together, would be markedly stressful to almost anyone in
similar circumstances in the individuals culture.
Without marited stressor(s): If symptoms do not occur in response to events that,
singly or together, would be markedly stressful to almost anyone in similar
circumstances in the individuals culture.
With postpartum onset: If onset is during pregnancy or within 4 weeks postpartum.
Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental
disorder, pp. 119-120, for definition)
Coding note: Use additional code 293.89 (F06.1) catatonia associated with brief
psychotic disorder to indicate the presence of the comorbid catatonia.
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor
behavior, and negative symptoms. Each of these symptoms may be rated for its
current severity (most severe in the last 7 days) on a 5-point scale ranging from 0
(not present) to 4 (present and severe). (See Clinician-Rated Dimensions of
Psychosis Symptom Severity in the chapter Assessment Measures.)
Note: Diagnosis of brief psychotic disorder can be made without using this severity
specifier._____________________________________________________________
Diagnostic Features
The essential feature of brief psychotic disorder is a disturbance that involves the sudden onset of
at least one of the following positive psychotic symptoms: delusions, hallucinations,
disorganized speech (e.g., frequent derailment or incoherence), or grossly abnormal psychomotor
behavior, including catatonia (Criterion A). Sudden onset is defined as change from a
nonpsychotic state to a clearly psychotic state within 2 weeks, usually without a prodrome. An
episode of the disturbance lasts at least 1 day but less than 1 month, and the individual eventually
has a full return to the premorbid level of functioning (Criterion B). The disturbance is not better
explained by a depressive or bipolar disorder with psychotic features, by schizoaffective
disorder, or by schizophrenia and is not attributable to the physiological effects of a substance
(e.g., a hallucinogen) or another medical condition (e.g., subdural hematoma) (Criterion C). In
addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of
cognition, depression, and mania symptom domains is vital for making critically important
distinctions between the various schizophrenia spectrum and other psychotic disorders.
Associated Features Supporting Diagnosis
Individuals with brief psychotic disorder typically experience emotional turmoil or
overwhelming confusion. They may have rapid shifts from one intense affect to another.
Although the disturbance is brief, the level of impairment may be severe, and supervision may be
required to ensure that nutritional and hygienic needs are met and that the individual is protected
from the consequences of poor judgment, cognitive impairment, or acting on the basis of
delusions. There appears to be an increased risk of suicidal behavior, particularly during the
acute episode.
Prevaience
In the United States, brief psychotic disorder may account for 9% of cases of first-onset
psychosis. Psychotic disturbances that meet Criteria A and C, but not Criterion B, for brief
psychotic disorder (i.e., duration of active symptoms is 1-6 months as opposed to remission
within 1 month) are more common in developing countries than in developed countries. Brief
psychotic disorder is twofold more common in females than in males.
Development and Course
Brief psychotic disorder may appear in adolescence or early adulthood, and onset can occur
across the lifespan, with the average age at onset being the mid 30s. By definition, a diagnosis of
brief psychotic disorder requires a full remission of all symptoms and an eventual full return to
the premorbid level of functioning within 1 month of the onset of the disturbance. In some
individuals, the duration of psychotic symptoms may be quite brief (e.g., a few days).
Risk and Prognostic Factors
Temperamental. Preexisting personality disorders and traits (e.g., schizotypal personality
disorder; borderline personality disorder; or traits in the psychoticism domain, such as perceptual
dysregulation, and the negative affectivity domain, such as suspiciousness) may predispose the
individual to the development of the disorder.
Culture-Related Diagnostic issues
It is important to distinguish symptoms of brief psychotic disorder from culturally sanctioned
response patterns. For example, in some religious ceremonies, an individual may report hearing
voices, but these do not generally persist and are not perceived as abnormal by most members of
the individual's community. In addition, cultural and religious background must be taken into
account when considering whether beliefs are delusional.
Functionai Consequences of Brief Psycliotic Disorder
Despite high rates of relapse, for most individuals, outcome is excellent in terms of social
functioning and symptomatology.
Differential Diagnosis
Other medical conditions. A variety of medical disorders can manifest with psychotic
symptoms of short duration. Psychotic disorder due to another medical condition or a delirium is
diagnosed when there is evidence from the history, physical examination, or laboratory tests that
the delusions or hallucinations are the direct physiological consequence of a specific medical
condition (e.g., Cushing's syndrome, brain tumor) (see 'Tsychotic Disorder Due to Another
Medical Condition" later in this chapter).
Substance-related disorders. Substance/medication-induced psychotic disorder, substance-
induced delirium, and substance intoxication are distinguished from brief psychotic disorder by
the fact that a substance (e.g., a drug of abuse, a medication, exposure to a toxin) is judged to be
etiologically related to the psychotic symptoms (see ''Substance/Medication-Induced Psychotic
Disorder" later in this chapter). Laboratory tests, such as a urine drug screen or a blood alcohol
level, may be helpful in making this determination, as may a careful history of substance use
with attention to temporal relationships between substance intake and onset of the symptoms and
to the nature of the substance being used.
Depressive and bipolar disorders. The diagnosis of brief psychotic disorder cannot be made if
the psychotic symptoms are better explained by a mood episode (i.e., the psychotic symptoms
occur exclusively during a full major depressive, manic, or mixed episode).
Other psychotic disorders. If the psychotic symptoms persist for 1 month or longer, the
diagnosis is either schizophreniform disorder, delusional disorder, depressive disorder with
psychotic features, bipolar disorder with psychotic features, or other specified or unspecifi ed
schizophrenia spectrum and other psychotic disorder, depending on the other symptoms in the
presentation. The differential diagnosis between brief psychotic disorder and schizophreniform
disorder is difficult when the psychotic symptoms have remitted before 1 month in response to
successful treatment with medication. Careful attention should be given to the possibility that a
recurrent disorder (e.g., bipolar disorder, recurrent acute exacerbations of schizophrenia) may be
responsible for any recurring psychotic episodes.
Malingering and factitious disorders. An episode of factitious disorder, with predominantly
psychological signs and symptoms, may have the appearance of brief psychotic disorder, but in
such cases there is evidence that the symptoms are intentionally produced. When malingering
involves apparently psychotic symptoms, there is usually evidence that the illness is being
feigned for an understandable goal.
Personality disorders. In certain individuals with personality disorders, psychosocial stressors
may precipitate brief periods of psychotic symptoms. These symptoms are usually transient and
do not warrant a separate diagnosis. If psychotic symptoms persist for at least 1 day, an
additional diagnosis of brief psychotic disorder may be appropriate.