CMN 552 Module 4 Exam Study Guide 2026 Update –USA.
Module 4 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) and erotomanic delusions (i.e., when an individual believes falsely that
another person is in love with him or her) are also seen. Nihilistic delusions involve the conviction that a major
catastrophe will occur, and 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. An example of a nonbizarre delusion is the belief that one is under surveillance by the police, despite a lack of
convincing evidence. 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).
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”).
CMN 552 Module 4
, 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
Delusional Disorder
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and
are related to the delusional theme (e.g., the sensation of being infested with insects associated with
delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and
behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the
delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition
and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-
compulsive disorder.
CMN 552 Module 4
, Specify whether:
Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with
the individual.
Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great
(but unrecognized) talent or insight or having made some important discovery.
Jealous type: This subtype applies when the central theme of the individual’s delusion is that his or her spouse or
lover is unfaithful.
Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that
he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned,
harassed, or obstructed in the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.
Mixed type: This subtype applies when no one delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not
described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).
Specify if:
With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not
derived from ordinary life experiences (e.g., an individual’s belief that a stranger has removed his or her internal
organs and replaced them with someone else’s organs without leaving any wounds or scars).
Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder:
First episode, currently in acute episode: First manifestation of the disorder meeting the defining
diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period during which an
improvement after a previous episode is maintained and in which the defining criteria of the disorder are only
partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a previous episode
during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the
majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
Unspecified
Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms.
Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of delusional disorder can be made without using this severity specifier.
CMN 552 Module 4
, Schizotypal (Personality) Disorder: Differential Diagnosis
Obsessive-compulsive and related disorders
Delirium, major neurocognitive disorder, and psychotic disorder due to another medical condition.
Substance/medication-induced psychotic disorder.
Schizophrenia and schizophreniform disorder
Depressive and bipolar disorders and schizoaffective disorders.
Brief Psychotic Disorder: Diagnostic Criteria
A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to
premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or
another psychotic disorder such as schizophrenia or catatonia and is not attributable to the physiological effects
of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Specify if:
With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to events that, singly or
together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture.
Without marked stressor(s): If symptoms do not occur in response to events that, singly or together, would be
markedly stressful to almost anyone in similar circumstances in the individual’s culture.
With peripartum onset: If onset is during pregnancy or within 4 weeks postpartum.
Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disorder, p. 135, for
definition).
Coding note: Use additional code F06.1 catatonia associated with brief psychotic disorder to indicate the presence
of comorbid catatonia.
Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms.
Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of brief psychotic disorder can be made without using this severity specifier.
Brief Psychotic Disorder: Diagnostic Features
The essential feature of brief psychotic disorder is a disturbance that involves at least one of the following positive
psychotic symptoms: delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), or
grossly abnormal psychomotor behavior, including catatonia (Criterion A). An episode of the disturbance lasts at
least 1 day but less than 1 month, and the individual eventually has a full return to the premorbid level of
functioning (Criterion B). The disturbance is not better explained by a depressive or bipolar disorder with psychotic
features, by schizoaffective disorder, or by schizophrenia and is not attributable to the physiological effects of a
substance (e.g., a hallucinogen) or another medical condition (e.g., subdural hematoma) (Criterion C). In addition to
the four symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and
mania symptom domains is vital for making critically important distinctions between the various schizophrenia
spectrum and other psychotic disorders.
CMN 552 Module 4
Module 4 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) and erotomanic delusions (i.e., when an individual believes falsely that
another person is in love with him or her) are also seen. Nihilistic delusions involve the conviction that a major
catastrophe will occur, and 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. An example of a nonbizarre delusion is the belief that one is under surveillance by the police, despite a lack of
convincing evidence. 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).
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”).
CMN 552 Module 4
, 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
Delusional Disorder
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and
are related to the delusional theme (e.g., the sensation of being infested with insects associated with
delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and
behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the
delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition
and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-
compulsive disorder.
CMN 552 Module 4
, Specify whether:
Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with
the individual.
Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great
(but unrecognized) talent or insight or having made some important discovery.
Jealous type: This subtype applies when the central theme of the individual’s delusion is that his or her spouse or
lover is unfaithful.
Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that
he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned,
harassed, or obstructed in the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.
Mixed type: This subtype applies when no one delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not
described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).
Specify if:
With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not
derived from ordinary life experiences (e.g., an individual’s belief that a stranger has removed his or her internal
organs and replaced them with someone else’s organs without leaving any wounds or scars).
Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder:
First episode, currently in acute episode: First manifestation of the disorder meeting the defining
diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period during which an
improvement after a previous episode is maintained and in which the defining criteria of the disorder are only
partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a previous episode
during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the
majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
Unspecified
Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms.
Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of delusional disorder can be made without using this severity specifier.
CMN 552 Module 4
, Schizotypal (Personality) Disorder: Differential Diagnosis
Obsessive-compulsive and related disorders
Delirium, major neurocognitive disorder, and psychotic disorder due to another medical condition.
Substance/medication-induced psychotic disorder.
Schizophrenia and schizophreniform disorder
Depressive and bipolar disorders and schizoaffective disorders.
Brief Psychotic Disorder: Diagnostic Criteria
A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to
premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or
another psychotic disorder such as schizophrenia or catatonia and is not attributable to the physiological effects
of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Specify if:
With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to events that, singly or
together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture.
Without marked stressor(s): If symptoms do not occur in response to events that, singly or together, would be
markedly stressful to almost anyone in similar circumstances in the individual’s culture.
With peripartum onset: If onset is during pregnancy or within 4 weeks postpartum.
Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disorder, p. 135, for
definition).
Coding note: Use additional code F06.1 catatonia associated with brief psychotic disorder to indicate the presence
of comorbid catatonia.
Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms.
Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of brief psychotic disorder can be made without using this severity specifier.
Brief Psychotic Disorder: Diagnostic Features
The essential feature of brief psychotic disorder is a disturbance that involves at least one of the following positive
psychotic symptoms: delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), or
grossly abnormal psychomotor behavior, including catatonia (Criterion A). An episode of the disturbance lasts at
least 1 day but less than 1 month, and the individual eventually has a full return to the premorbid level of
functioning (Criterion B). The disturbance is not better explained by a depressive or bipolar disorder with psychotic
features, by schizoaffective disorder, or by schizophrenia and is not attributable to the physiological effects of a
substance (e.g., a hallucinogen) or another medical condition (e.g., subdural hematoma) (Criterion C). In addition to
the four symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and
mania symptom domains is vital for making critically important distinctions between the various schizophrenia
spectrum and other psychotic disorders.
CMN 552 Module 4
