Recognizing DSM-5 Schizophrenia: The Evolving Understanding Of Psychosis

The medical community’s understanding of the psychotic disorder we now call schizophrenia has changed in many ways since doctors first began to describe it. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, introduced some potentially significant changes to the way this condition is identified. This article will explore what DSM-5 schizophrenia looks like and how today’s mental health professionals think about psychotic illnesses.

Current standards for diagnosing schizophrenia typically involve identifying positive or psychotic symptoms, such as hallucinations, delusions, and incoherent speech or thought patterns. They also consider negative symptoms, such as diminished motivation and emotion. Schizophrenia is usually treated with a combination of therapy and doctor-prescribed medication.

Evidence-based therapy may relieve schizophrenia symptoms

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What is the DSM-5?

The Diagnostic and Statistical Manual of Mental Disorders is a handbook produced by the American Psychiatric Association (APA) to describe different types of mental illnesses. It’s used by most U.S. mental health professionals as a reference when making clinical diagnoses. Many also use it for purposes like training new practitioners and educating clients about their mental health. 

Several editions and revisions of this text have been produced since the original manual was released in 1952. It’s common practice to abbreviate the title as “DSM,” followed by the edition number. The latest version is the 2022 text revision of the fifth edition, or the DSM-5-TR. Many people shorten this to “DSM-5” in everyday use. 

The various updates to the DSM over the decades since it was first released generally document the changing understanding of mental illness. Many conditions described by the DSM-5 were not found in older versions of the manual, and others have seen shifts in their core diagnostic criteria as the psychiatric consensus has evolved and adapted in the face of new research.

How does the DSM-5 describe schizophrenia?

In the current edition of the DSM, schizophrenia is listed among a group of related conditions known collectively as “Schizophrenia spectrum and other psychotic disorders.” While there can be many differences between these conditions, all of them tend to involve psychotic features, which can be defined as instances in which an individual’s understanding or perception of reality is significantly distorted in some way. 

The DSM-5 criteria for schizophrenia diagnosis indicate that the individual must experience two or more schizophrenia symptoms for at least one month, “or less if successfully treated.” These symptoms can include the following:

• Delusions: Strongly held ideas that contradict observed reality and are held despite evidence to the contrary
• Hallucinations: Sensory perceptions that don’t correspond to real objects or events
• Disorganized speech: Incoherent speech patterns that don’t communicate ideas or that fail to respond to the statements of others in a logical way
• Negative symptoms: Diminishment of certain functions present in most healthy people, such as emotional responses, interest in activities, motivation to act, or experiences of enjoyment and pleasure
• Grossly disorganized or catatonic behavior: Acting in erratic, unusual, or unpredictable ways, often doing things that don’t appear to serve any logical purpose; this may or may not involve catatonia, a type of disordered motor function in which the person’s ability to direct their own actions seems diminished — for example, they may remain in the same position until moved by someone else, even if it takes hours

Other diagnostic requirements

While all of the above can be symptoms of schizophrenia, a person must display at least one of the following to be diagnosed:

• Delusions
• Hallucinations
• Disorganized speech

These are considered “active phase” or “acute phase” symptoms. They usually occur during the active stages of schizophrenia, which are sometimes referred to as “psychotic episodes.” In between active phases, individuals tend to exhibit mostly negative symptoms.

The individual in question must also have experienced a substantial drop in their ability to function in everyday life due to their symptoms. For example, they may have difficulty maintaining steady employment, interacting socially with others, or fulfilling their responsibilities as a parent. 

The DSM-5 also requires clinicians diagnosing schizophrenia to rule out certain other disorders. These conditions may involve psychotic symptoms or other similarities with schizophrenia, but they typically have significant differences and may not have the same prognosis or treatment protocol. They usually include those discussed below:

Schizoaffective disorder

Formerly viewed as a subtype or milder version of schizophrenia, this condition can be difficult to diagnose in practice. Schizoaffective disorder usually involves core symptoms of schizophrenia combined with mood disorder symptoms, such as persistent depression or alternating mania and depression. Those with DSM-5 schizophrenia generally don’t exhibit these kinds of mood difficulties at the same time as active phase symptoms.

Depressive or bipolar disorder with psychotic features

People with severe depression or bipolar disorder may experience some psychosis-like symptoms, such as hallucinations or delusions. This disorder can be distinguished from schizoaffective disorder by the fact that these symptoms only appear during periods of severe mood disruption, instead of always being present at a low level. 

Autism spectrum disorder (ASD)

Both schizophrenia and autism spectrum disorder are believed to be caused in part by neurodevelopmental factors, and there may be some overlap in genetic risk factors and symptoms. According to the DSM-5, a person with ASD (or another “pervasive developmental disorder”) can only be diagnosed with schizophrenia if they experience severe hallucinations or delusions for a period of one month or longer.

Changes in the DSM diagnosis of schizophrenia 

The scientific understanding of mental illness has undergone many changes over the years. Some of these shifts can be seen in the evolution of the DSM description of schizophrenia. 

DSM-1 schizophrenia

Even before the first edition of the APA’s manual, concepts of schizophrenia had departed from the earliest conceptions of this condition. When it was first described by Dr. Emil Kraeplin in 1899, schizophrenia was called “dementia praecox,” reflecting Kraeplin’s belief that it was a form of degenerative neurological illness. As subsequent studies revealed that this disease did not always involve progressive degeneration, the term “schizophrenia,” meaning “split mind,” began to replace the older name.

The DSM-1, published in 1959, referred to this disorder using the term “schizophrenic reaction.” Many mental illnesses were also called “reactions” in the text because clinicians at the time regarded them as adaptations to stressful circumstances. 

The initial DSM description also included the categorization of several subtypes of schizophrenia, such as “paranoid,” “catatonic,” and “hebephrenic,” representing various broad patterns of emotionality and mental function.

DSM-2 and DSM-3 schizophrenia

Descriptions of schizophrenia didn’t change much between the first and second editions of the DSM, aside from dropping the term “reaction.” However, the DSM-3 made significant updates to several disease categories, including schizophrenia, as part of a broader shift in psychiatry toward data-driven, symptom-based classification of mental illness.

The DSM-3 dropped many subtypes of schizophrenia and reintroduced the description of the schizophrenia prodrome, which can be described as the early stage of the disorder before psychotic symptoms manifest to a significant degree. (The other phases are the active and residual periods.)

Another change in the DSM-3 was dividing schizophrenia symptoms into “negative” and “positive” categories. Positive symptoms generally include the severe distortions of thought and behavior that are considered characteristic of schizophrenia, such as hallucinations, delusions, and disorganized speech, cognition, and behavior. They’re mainly present during the active phase of the disorder.

In contrast, negative symptoms, like limited speech and blunted emotionality, can also be observed in the prodromal or residual periods. 

DSM-4 and DSM-5 schizophrenia

The classification of schizophrenia laid out in the DSM-3 remained mostly consistent in the DSM-4. The language describing how schizophrenia differs from other psychotic disorders changed somewhat, as did the way prodromal and residual symptoms were described. 

The DSM-5, published in 2013, also kept many of the key features of the disorder. However, two high-level changes were made to the diagnostic process:

1. Dropping first-rank symptoms: Earlier editions of the DSM allowed a diagnosis of schizophrenia based on a single “first-rank symptom” or FRS. First described in 1959 by Dr. Kurt Schneider, these symptoms typically included things like an individual hearing voices commenting on their behavior or believing that their thoughts were being broadcast to others.

The DSM-5 dropped this distinction based on evidence that relying on one FRS alone could carry a significant risk of misdiagnosis. 

2. Removing subtypes: The APA determined that subtypes, such as paranoid schizophrenia or disorganized schizophrenia, were not distinctive enough in clinical practice and did not add much helpful information for diagnosis and treatment.

Though these changes were controversial among some clinicians and researchers, subsequent studies suggest that the changes in the DSM-5 description of schizophrenia did not reduce its diagnostic accuracy.

Current treatment approaches to schizophrenia

Despite many shifts in the psychiatric understanding of schizophrenia, the core approach to treatment has remained fairly consistent since the middle of the 20th century. During the 1950s, researchers developed a range of antipsychotic medications that effectively suppressed the active symptoms of schizophrenia, such as hallucinations and delusions, in many individuals. 

Psychotherapy and social support interventions, such as cognitive-behavioral therapy (CBT), may relieve residual symptoms of schizophrenia once the active phase symptoms are under control. These treatment approaches can help people with schizophrenia develop effective skills for managing emotions, motivation, and daily tasks. Regular sessions with a therapist may also assist with adherence to a medication regimen.

If you’re seeking therapy for schizophrenia but your symptoms or circumstances make it hard to attend sessions in person, you might benefit from online therapy. Receiving counseling from a mental health professional through the internet generally removes the need to travel to sessions, which may be more convenient for many people. However, please note that if you’re experiencing active phase symptoms, such as hallucinations or delusions, it may be necessary to seek care in person.

When delivered by a qualified practitioner, internet-based therapy may be effective in treating some symptoms of schizophrenia. For instance, a 2016 trial reported significant reductions in depression (a common negative symptom) among people with schizophrenia who received online therapy. 

Takeaway

The DSM-5 description of schizophrenia can be seen as the result of many revisions to the psychological understanding of this disorder. The current diagnostic criteria incorporate a modern, evidence-based understanding of the features that distinguish schizophrenia from other disorders. Schizophrenia can usually be treated with a combination of medication and online or in-person therapy.