CMN 552
Module 4
Primary Study Guide
University of South Alabama
, CMN 552
Module 4 Primary Study Guide
DSM5 Section II: Schizophrenia Spectrum
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)
● Erotomanic delusions (i.e., when an individual believes falsely that another person is in love with
him or her)
● Nihilistic delusions involve the conviction that a major catastrophe will occur
● 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. 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).
An example of a nonbizarre delusion is the belief that one is under surveillance by the police, despite a lack
of convincing evidence.
The distinction between a delusion and a strongly held idea is sometimes difficult to determine and depends in
part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence
regarding its veracity. Assessing delusions in individuals from a variety of cultural backgrounds can be
difficult. Some religious and supernatural beliefs (e.g., evil eye, causing illness through curses, influence of
spirits) may be viewed as bizarre and possibly delusional in some cultural contexts but be generally accepted
in others. However, elevated religiosity can be a feature of many presentations of psychosis. Individuals who
have experienced torture, political violence, or discrimination can report fears that may be misjudged as
persecutory delusions; these may represent instead intense fears of recurrence or posttraumatic symptoms. A
careful evaluation of whether the person’s fears are justified given the nature of the trauma can help to
differentiate appropriate fears from persecutory delusions.
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. For example, some religious groups engage in
glossolalia (“speaking in tongues”); others describe experiences of possession trance (trance states in
which personal identity is replaced by an external possessing identity). These phenomena are characterized
by disorganized speech. These instances do not represent signs of psychosis unless they are accompanied
by other clearly psychotic symptoms. Less severe disorganized thinking or speech may occur during the
prodromal and residual periods of schizophrenia.
Grossly Disorganized or Abnormal Motor Behavior (Including 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, 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. Individuals with schizophrenia can still
enjoy a pleasurable activity in the moment and can recall it, but show a reduction in the frequency of
engaging in pleasurable activity
● 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.
Schizotypal (Personality) Disorder: Diagnostic Criteria
, A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced
capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of
behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of
the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms
(e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents,
bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with
paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder
with psychotic features, another psychotic disorder, or autism spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid”
Schizotypal (Personality) Disorder: Differential Diagnosis
Other mental disorders with psychotic symptoms
Schizotypal personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or
depressive disorder with psychotic features because these disorders are all characterized by a period of
persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of
schizotypal personality disorder, the personality disorder must have been present before the onset of
psychotic symptoms and persist when the psychotic symptoms are in remission. When an individual
has a persistent psychotic disorder (e.g., schizophrenia) that was preceded by schizotypal personality disorder,
schizotypal personality disorder should also be recorded, followed by “premorbid”
Neurodevelopmental disorders.
There may be great difficulty differentiating children with schizotypal personality disorder from the
heterogeneous group of solitary, odd children whose behavior is characterized by marked social isolation,
eccentricity, or peculiarities of language and whose diagnoses would probably include milder forms of autism
spectrum disorder or language communication disorders. Communication disorders may be differentiated by
the primacy and severity of the disorder in language and by the characteristic features of impaired
language found in a specialized language assessment. Milder forms of autism spectrum disorder are
differentiated by the even greater lack of social awareness and emotional reciprocity and stereotyped
behaviors and interests.
Personality change due to another medical condition
Schizotypal personality disorder must be distinguished from personality change due to another medical
condition, in which the traits that emerge are a direct physiological consequence of another medical condition.
Substance use disorders
Schizotypal personality disorder must also be distinguished from symptoms that may develop in association
with persistent substance use.
Other personality disorders and traits
Module 4
Primary Study Guide
University of South Alabama
, CMN 552
Module 4 Primary Study Guide
DSM5 Section II: Schizophrenia Spectrum
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)
● Erotomanic delusions (i.e., when an individual believes falsely that another person is in love with
him or her)
● Nihilistic delusions involve the conviction that a major catastrophe will occur
● 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. 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).
An example of a nonbizarre delusion is the belief that one is under surveillance by the police, despite a lack
of convincing evidence.
The distinction between a delusion and a strongly held idea is sometimes difficult to determine and depends in
part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence
regarding its veracity. Assessing delusions in individuals from a variety of cultural backgrounds can be
difficult. Some religious and supernatural beliefs (e.g., evil eye, causing illness through curses, influence of
spirits) may be viewed as bizarre and possibly delusional in some cultural contexts but be generally accepted
in others. However, elevated religiosity can be a feature of many presentations of psychosis. Individuals who
have experienced torture, political violence, or discrimination can report fears that may be misjudged as
persecutory delusions; these may represent instead intense fears of recurrence or posttraumatic symptoms. A
careful evaluation of whether the person’s fears are justified given the nature of the trauma can help to
differentiate appropriate fears from persecutory delusions.
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. For example, some religious groups engage in
glossolalia (“speaking in tongues”); others describe experiences of possession trance (trance states in
which personal identity is replaced by an external possessing identity). These phenomena are characterized
by disorganized speech. These instances do not represent signs of psychosis unless they are accompanied
by other clearly psychotic symptoms. Less severe disorganized thinking or speech may occur during the
prodromal and residual periods of schizophrenia.
Grossly Disorganized or Abnormal Motor Behavior (Including 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, 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. Individuals with schizophrenia can still
enjoy a pleasurable activity in the moment and can recall it, but show a reduction in the frequency of
engaging in pleasurable activity
● 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.
Schizotypal (Personality) Disorder: Diagnostic Criteria
, A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced
capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of
behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of
the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms
(e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents,
bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with
paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder
with psychotic features, another psychotic disorder, or autism spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid”
Schizotypal (Personality) Disorder: Differential Diagnosis
Other mental disorders with psychotic symptoms
Schizotypal personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or
depressive disorder with psychotic features because these disorders are all characterized by a period of
persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of
schizotypal personality disorder, the personality disorder must have been present before the onset of
psychotic symptoms and persist when the psychotic symptoms are in remission. When an individual
has a persistent psychotic disorder (e.g., schizophrenia) that was preceded by schizotypal personality disorder,
schizotypal personality disorder should also be recorded, followed by “premorbid”
Neurodevelopmental disorders.
There may be great difficulty differentiating children with schizotypal personality disorder from the
heterogeneous group of solitary, odd children whose behavior is characterized by marked social isolation,
eccentricity, or peculiarities of language and whose diagnoses would probably include milder forms of autism
spectrum disorder or language communication disorders. Communication disorders may be differentiated by
the primacy and severity of the disorder in language and by the characteristic features of impaired
language found in a specialized language assessment. Milder forms of autism spectrum disorder are
differentiated by the even greater lack of social awareness and emotional reciprocity and stereotyped
behaviors and interests.
Personality change due to another medical condition
Schizotypal personality disorder must be distinguished from personality change due to another medical
condition, in which the traits that emerge are a direct physiological consequence of another medical condition.
Substance use disorders
Schizotypal personality disorder must also be distinguished from symptoms that may develop in association
with persistent substance use.
Other personality disorders and traits
