Many changes to this chapter in the DSM-5 are conceptual in nature and provide enhanced attention to dimensional assessment. For example, the name of the chapter changed slightly to reference the “schizophrenia spectrum” rather than just “schizophrenia.” Like other sections of the DSM-5, the chapter was reordered to reflect what is assumed to be a developmental progression of psychotic experiencing. Tandon (2013a, 2013b) noted limitations of the DSM-IV-TR as including confusion regarding differences between schizoaffective disorder and schizophrenia, variability in treatment of catatonia, undue special treatment of Schneiderian first-rank symptoms (i.e., bizarre delusions or special hallucinations), and lack of reliability and validity within the schizophrenia subtypes. Most changes to DSM-5 criteria were designed to facilitate a simpler and more straightforward diagnostic process.

Although not required, clinicians who diagnose psychotic disorders are encouraged to use one of several dimensional assessments printed in the DSM-5 to determine current severity of disorder. The Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS; see pp. 742–744 of the DSM-5) includes attention to eight symptoms associated with psychotic disorders: hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania. Clinicians rate the most recent 7-day period using a 5-point severity scale ranging from 0 (not present) to 4 (present and severe). Overall, the scale shows acceptable psychometric properties and appears to be feasible for use in clinical settings (Ritsner, Mar, Arbitman, & Grinshpoon, 2013). Tandon (2013b) noted that use of the CRDPSS may benefit practice by allowing clinicians to focus on specific domains of concern and track changes in each area. In addition to encouraging use of the CRDPSS throughout this section, we present most disorders with new course specifiers to indicate number of episodes (first or multiple) and current remission status (acute, partial remission, or full remission).

Schizophrenia has undergone many changes in conceptualization over the last century (see Keller, Fischer, & Carpenter, 2010). In the DSM-IV-TR, Criterion A for schizophrenia served as the foundation for diagnosis of most psychotic disorders. Major changes to Criterion A included elimination of special treatment of bizarre delusions and hallucinations in which an individual heard two or more voices conversing or heard a running commentary regarding his or her behavior. Tandon (2013b) noted limited impact of this change given that less than 2% of clients diagnosed with schizophrenia met criteria through this provision alone. Similarly, the requirement for two positive symptoms to meet Criterion A should increase reliability of diagnoses without affecting clinical practice.

A major change to schizophrenia involves removal of DSM-IV-TR subtypes (Gaebel, Zielasek, & Cleveland, 2012; Tandon, 2013a) based on their “limited diagnostic stability, low reliability, poor validity, and little clinical utility” (Tandon, 2013a, p. 16). Rather than conceptualize differences in presentations as representing catatonic, disorganized, paranoid, residual, or undifferentiated schizophrenia, clinicians will conduct a dimensional assessment using the CRDPSS.

One small yet significant change to schizoaffective disorder includes the specification that depressive and/or manic episodes be present “the majority of the total duration of the active and residual portions of the illness” (APA, 2013, p. 105). This change was implemented in hopes of addressing consistent issues with diagnostic stability for this disorder. Although this may decrease prevalence of schizoaffective disorder, Tandon (2013b) proposed that the change will help clinicians more accurately distinguish among schizophrenia with and without mood symptoms, schizoaffective disorder, and mood disorder with psychotic features.

The presence of core positive symptoms of psychosis does not automatically indicate the presence of a psychotic disorder. Rather, psychotic symptoms may be a regular part of substance intoxication or withdrawal, medical conditions, and other mental health disorders. Etiology, precipitating factors, and unique constellation of other symptoms will determine whether a client who presents with psychotic symptoms meets criteria for a disorder in this chapter.

Because medical conditions and substance use can lead to onset or exacerbation of psychotic symptoms, we suggest counselors refer all clients who report new onset of psychotic symptoms for a thorough medical evaluation. This evaluation is critical for informing accurate diagnosis and, in turn, appropriate treatment. A client who experiences brief, new onset of psychotic symptoms in response to a medication will have very different needs compared with a client who hallucinates while withdrawing from alcohol. And both clients will have different needs from someone who experiences a long, slow deterioration in functioning before developing paranoid delusions. Later in the chapter, we will mention specific medical conditions and substances that may trigger psychotic symptoms.

Severe depressive disorders, bipolar disorders, and PTSD frequently involve elements of psychotic process such as delusions and hallucinations. The CRDPSS includes attention to depressive and manic symptoms as a reminder regarding the importance of assessing for preexisting or co-occurring mood concerns that require clinical attention and inform diagnosis. Depression and the negative symptoms of these disorders have much in common, especially as hallmarks of both include a lack of interest or pleasure in everyday living and may result in poor self-care. Negative symptoms and cognitive deficits in schizophrenia spectrum disorders may mirror social impairment associated with ASD and decline associated with neurocognitive disorders. Dissociation common with acute stress disorder and PTSD may also appear as part of thought or speech disorders within the schizophrenia spectrum. Similarly, beliefs associated with some obsessive-compulsive and related disorders and somatic symptom disorders often take on delusional qualities, and individuals who are experiencing psychotic symptoms may find themselves quite anxious and agitated as a result of their hallucinations and delusions. Differential diagnostic concerns include the order in which symptoms developed and core experiences of each.

Individuals with schizophrenia spectrum disorders often experience an array of coexisting health and mental health concerns. Rubin and Trawver (2011) characterized individuals with schizophrenia as having “close to universal” (p. 13) exposure to trauma. Nearly three quarters of these individuals experience depression, half experience anxiety, and half meet criteria for a substance use disorder (Helseth, Lykke-Enger, Johnsen, & Waal, 2009; Potuzak, Ravichandran, Lewandowski, Ongür, & Cohen, 2012; Rubin & Trawver, 2011). Individuals with schizophrenia are 3 times more likely to be addicted to nicotine (NIMH, 2009) than the general population, thus potentially placing them at risk for a plethora of related health concerns. When combined with functional consequences of schizophrenia, decreased engagement in health-related activities (APA 2013; Rubin & Trawver, 2011), and a suicide rate as high as 10% (NIMH, 2009), people with schizophrenia have much lower life expectancies and quality of life than the general population. Counselors who work with this population must remain alert to the likelihood of these concerns.

Researchers are still working to determine specific causes of psychotic disorders. As mentioned previously, effects of substance use and medical conditions may cause brain changes that lead to psychotic symptoms. Research indicates strong genetic and physiological components of schizophrenia (NIMH, 2009). Individuals with first-degree relatives who have schizophrenia are at 10 times greater risk for developing the disorder, and neuroscience research has revealed that people with schizophrenia have different brain structure, function, and neurotransmitter activity compared with those without (APA, 2013; Gaebel, 2011; NIMH, 2009).