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Schizophrenia Spectrum and Other Psychotic Disorders

Two changes were made to Criterion A for schizophrenia: 1) the elimination of

the special attribution of bizarre delusions and Schneiderian first-rank auditory

hallucinations (e.g., two or more voices conversing), leading to the requirement

of at least two Criterion A symptoms for any diagnosis of schizophrenia, and 2)

the addition of the requirement that at least one of the Criterion A symptoms

must be delusions, hallucinations, or disorganized speech. The DSM-IV subtypes

of schizophrenia were eliminated due to their limited diagnostic stability, low

reliability, and poor validity. Instead, a dimensional approach to rating severity for

the core symptoms of schizophrenia is included in DSM-5 Section ΠΙ to capture

the important heterogeneity in symptom type and severity expressed across

individuals with psychotic disorders. Schizoaffective disorder is reconceptualized

as a longitudinal instead of a cross-sectional diagnosis—more comparable to

schizophrenia, bipolar disorder, and major depressive disorder, which are

bridged by this condition—and requires that a major mood episode be present for

a majority of the total disorder's duration after Criterion A has been met. Criterion

A for delusional disorder no longer has the requirement that the delusions must

be nonbizarre; a specifier is now included for bizarre type delusions to provide

continuity with DSM-IV. Criteria for catatonia are described uniformly across

DSM-5. Furthermore, catatonia may be diagnosed with a specifier (for

depressive, bipolar, and psychotic disorders, including schizophrenia), in the

context of a known medical condition, or as an other specified diagnosis.

Bipolar and Related Disorders Diagnostic criteria for bipolar disorders now include both

changes in mood and changes in activity or energy. The DSM-IV diagnosis of bipolar I

disorder, mixed episodes—requiring that the individual simultaneously meet full criteria

for both mania and major depressive episode—is replaced with a new specifier "with

mixed features." Particular conditions can now be diagnosed under other specified

bipolar and related disorder, including categorization for individuals with a past history of

a major depressive disorder whose symptoms meet all criteria for hypomania except the

duration criterion is not met (i.e., the episode lasts only 2 or 3 days instead of the

required 4 consecutive days or more). A second condition constituting an other

specified bipolar and related disorder variant is that too few symptoms of hypomania are

present to meet criteria for the full bipolar II syndrome, although the duration, at least 4

consecutive days, is sufficient. Finally, in both this chapter and in the chapter

"Depressive Disorders," an anxious distress specifier is delineated. Depressive

Disorders To address concerns about potential overdiagnosis and overtreatment of

bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is

included for children up to age 18 years who exhibit persistent irritability and frequent

episodes of extreme behavioral dyscontrol. Premenstrual dysphoric disorder is now

promoted from Appendix B, "Criteria Sets and Axes Provided for Further Study," in

DSM-IV to the main body of DSM-5. What was referred to as dysthymia in DSM-IV now

falls under the category of persistent depressive disorder, which includes both chronic

major depressive disorder and the previous dysthymic disorder. The coexistence within

a major depressive episode of at least three manic symptoms (insufficient to satisfy

criteria for a manic episode) is now acknowledged by the specifier"with mixed features."
In DSM-IV, there was an exclusion criterion for a major depressive episode that was

applied to depressive symptoms lasting less than 2 months following the death of a

loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for

several reasons, including the recognition that bereavement is a severe psychosocial

stressor that can precipitate a major depressive episode in a vulnerable individual,

generally beginning soon after the loss, and can add an additional risk for suffering,

feelings of worthlessness, suicidal ideation, poorer medical health, and worse

interpersonal and work functioning. It was critical to remove the implication that

bereavement typically lasts only 2 months, when both physicians and grief counselors

recognize that the duration is more commonly 1-2 years. A detailed footnote has

replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical

distinction between the symptoms characteristic of bereavement and those of a major

depressive disorder. Finally, a new specifier to indicate the presence of mixed

symptoms has been added across both the bipolar and the depressive disorders.