Using the DSM-5 to Diagnose Schizophrenia

The gold standard for making a schizophrenia diagnosis is a book called the DSM-5. This book contains information on many mental health conditions. Psychiatrists use it to help them diagnose schizophrenia.^1,2

What is the DSM-5?

DSM-5 stands for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. The book was written and is updated every few years by doctors and researchers. These experts specialize in biology, genetics, statistics, neuroscience, and more. These experts come from many different backgrounds, including psychiatry, pediatrics, nursing, and social work.^1,3

The DSM-5 has symptom lists for different conditions called criteria. Schizophrenia and schizophrenia spectrum disorders, mood disorders, personality disorders, and many others are included. Mental health providers use the criteria in the DSM-5 to make diagnoses so it is only used to help find out what illness a person may have.^1,3

Ruling out other health conditions

There is no single test that diagnoses schizophrenia. First, your primary care doctor will look for medical causes of your symptoms. They will assess you for conditions that can cause symptoms similar to those of schizophrenia. These conditions include thyroid problems, drug side effects, infections, and more.^4-7

Blood tests and brain imaging are tools your doctor may use to help them find these conditions. An example of a brain imaging test is magnetic resonance imaging (MRI).^4-7

Mental health screening tools

Once other medical issues are ruled out, diagnosis of a mental health condition is more likely. At this point, mental health screening questionnaires are a helpful step toward diagnosis. These surveys ask questions that are similar to the DSM-5 criteria for certain mental health issues.^2,8

Some screenings used in primary care settings focus on diagnosing depression or anxiety. These include the PHQ-9 (Patient Health Questionnaire) and the GAD-7 (Generalized Anxiety Disorder questionnaire).^2,8

The questionnaires are multiple choice. The responses to each question will help your provider understand more about what you are experiencing and may indicate you are more likely to have a specific condition.⁸

Some primary care doctors treat mental health conditions with medicine. But people with mental health conditions that are complicated will likely need to see a psychiatrist or other specialized provider like a nurse practitioner. A psychiatrist is a type of specialist who diagnoses and treats mental health conditions. Schizophrenia typically needs a mental health specialist for care because of how complicated it can be.^2,7

Psychological testing and evaluation

Mental health providers do more in-depth testing to make a final diagnosis. This process may include tests that look at the way you think or remember things (cognition). It also may include mood tracking or personality tests. You may take (or retake) mental health screening questionnaires, too.^2,7

One other major part of a mental health assessment is the mental status exam (MSE). During this exam, a trained professional will assess your:⁹

• Appearance, including things like grooming, changes in facial expression, and alertness
• Motor function (movement)
• Speech, including speed, volume, and amount
• Mood and any changes to it while you are being evaluated
• Affect or whether you look the way you say you feel
• Thought content, including any delusions or depressive thoughts
• Thought process, including the organization of your speech and your logic
• Perceptions of reality
• Knowledge base
• Insight into or awareness of you current situation
• Judgment or your ability to make good decisions

The MSE is a test that the provider completes by observing you during your meeting. Your doctor may perform it while asking about your symptoms or just talking. Along with your symptom history and other mental health screenings, your doctor can use the MSE to help determine if you have schizophrenia.^1,2,4,9

What are the DSM-5 criteria for schizophrenia?

The criteria for schizophrenia focus on what specific symptoms are present and for how long. To be diagnosed with schizophrenia, a person must have:¹

• Two or more of the following symptoms present most of the time each month:
• Strongly believing things that are not true (delusions)
• Experiencing things that are not there (hallucinations)
• Speech that is hard to follow or does not make sense (disorganized speech)
• Disorganized behavior or abnormal motor movements (catatonic behavior)
• Negative symptoms (may include lack of emotional expression, lack of motivation, lack of pleasure, and lack of desire)
• At least 1 of the symptoms above must be delusion, hallucination, or disorganized speech
• Problems functioning in a major area of life due to symptoms. This may be at work, in relationships, or while taking care of yourself.
• Symptoms that are present for at least 6 months
• No other medical causes of symptoms, like drug side effects, infection, or neurological conditions
• No other coexisting mood disorders, like depression or bipolar disorder
• Hallucinations or delusions if a communication or thought process issue already exists (like autism)

As a simple example, a previously healthy person would meet the criteria for a schizophrenia diagnosis if they:

• Have daily hallucinations,
• Have not found pleasure in things they used to love for the past 7 months,
• Have no other medical issues or mood disorders, and
• Have a hard time keeping a job due to symptoms

However, diagnosing schizophrenia can be hard. Not everyone has clear-cut symptoms and timelines. Some people may also be free of active symptoms (in remission) when they are assessed. Psychiatrists and other specialists have to use their best judgment to determine whether each person meets the DSM-5 criteria. It can be helpful to have a record of experiences or symptoms to help the provider get the clearest picture possible.^1,2,4

Schizophrenia specifiers

Once a doctor diagnoses schizophrenia, they can add details called specifiers. These specifiers help describe where a person is in their journey or how severe their schizophrenia is. Specifiers may include:¹

• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episodes, currently in acute episode
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous symptoms
• With catatonia (a group of abnormal movement or speech symptoms)

Each person’s symptoms and path to diagnosis is different. The DSM-5 provides a common ground to collect information and communicate it with other doctors on your team. Getting the right diagnosis is very important before deciding what treatment options are best for you.³