Paranoid Schizophrenia in the DSM-5

“The DSM-IV schizophrenia subtypes were eliminated due to their limited diagnostic stability, poor reliability, and poor validity. Instead, a dimensional approach to classifying the severity of core symptoms of schizophrenia is included.

Hello friends!

At the request of our dear reader Beth, I write today about paranoid schizophrenia. According to the DSM-5, “the spectrum of schizophrenia and other psychotic disorders includes schizophrenia, other psychotic disorders, and schizotypal (personality) disorder. These disorders are defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms” (DSM-5, p. 87).

In this new version of the DSM-5 we do not find a diagnosis called Paranoid Schizophrenia. We found, however, Delusional Disorder, persecutory type. Let’s first look at this Disorder in the DSM-5 and talk further below about the previous DSM-IV definition and why it was changed.

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Delusional Disorder

A. The presence of a delusion (or more) lasting a month or more.

B. Criterion A for schizophrenia is met. Note: hallucinations, when present, are not prominent and are related to the theme of the delusion (eg, the feeling of being infested with insects associated with delusions of infestation).

C. Except for the impact of the delusion(s) or its offshoots, functioning is not markedly impaired and the behavior is not clearly bizarre or odd.

D. If manic or depressive episodes occurred, they were brief compared 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 accounted for by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

Determine the subtype:

persecutory type: This subtype applies when the central theme of the delusion involves the belief that the individual himself is being colluded, deceived, spied on, stalked, poisoned or drugged, maliciously defamed, harassed, or obstructed in the pursuit of long-term goals. (DSM-5, p. 90)

In addition to this subtype, we find the subtypes: erotomanic, grandiose, jealous, somatic, mixed, unspecified.

“In the persecutory delusion… small rudeness can be exaggerated, becoming the focus of a delusional system. The affected individual may engage in repeated attempts to gain satisfaction by some legal or legislative action. People with persecutory delusions are often resentful and enraged, and may even resort to violence against those they believe are causing them harm” (DSM-5, p. 92)

Paranoid Schizophrenia

In the previous version of the Diagnostic and Statistical Manual of Mental Disorders of the APA (American Psychiatric Association), the DSM-4, we still find the definition of paranoid schizophrenia.

F20 – SCHIZOPHRENIA

A. Characteristic Symptoms: At least two of the following, each present for a significant amount of time over a period of one month (or less if successfully treated):
(1) delusions
(2) hallucinations
(3) disorganized speech (eg, frequent derailment or incoherence)
(4) totally disorganized or catatonic behavior
(5) negative symptoms, i.e. flat affect, alogia, or avolition

(Note: only one A symptom is required if the delusions are bizarre or the hallucinations consist of a voice carrying on a commentary about the person’s behavior or thoughts or two or more voices talking to each other.)

B. Occupational/Social Dysfunction: For a significant amount of time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relationships, or self-care have been significantly below the level achieved prior to onset (or when onset occurs in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational performance).

C. Duration: Ongoing signs of the disorder persist for at least six months. This six-month period must include at least one month with symptoms that meet Criterion A (ie, active-phase symptoms) and may include prodromal and/or residual periods when Criterion A is not fully met. During these periods, the signs of the disorder may be manifested by negative symptoms or by two or more of the symptoms listed in Criterion A present in an attenuated form (eg, the total duration of the active and residual periods).

D. Schizoaffective Disorder and Mood Disorder with Psychotic Features were ruled out because: (1) no significant depressive or manic episodes occurred concurrently with the active-phase symptoms; or (2) if mood episodes occurred during the psychotic episode, their total duration was brief relative to the duration of the psychotic episode (ie, the total duration of the active and residual periods).

E. Substance/General Medical Condition Exclusion: The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or a Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least one month (or less , if the treatment is successful).

Paranoid type

A type of schizophrenia in which the following criteria are met:

A. Preoccupation with one or more frequent auditory delusions or hallucinations.

B. None of the following are prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Why was paranoid schizophrenia dropped from the DSM-5?

The paranoid type or subtype, within schizophrenia (along with the others, disorganized, catatonic, undifferentiated, residual) was modified in the new version published in 2013 due to differential inconsistency.

“The DSM-IV schizophrenia subtypes were eliminated due to their limited diagnostic stability, poor reliability, and poor validity. Instead, a dimensional approach to classifying the severity of core symptoms of schizophrenia is included in Section III of the DSM-5 to capture the heterogeneity in symptom type and severity that manifests among individuals with psychotic disorders” (DSM-5, p. 810).

Therefore, the subtypes were dropped as they were in DSM-IV, thus excluding the designation of paranoid schizophrenia as a possible diagnosis. The closest, given the typical features of paranoia, seems to me to be the persecutory-type delusional disorder. This similarity seems correct to us due to the classic definition of paranoia.

What is paranoia?

According to National Institute of Mental Health:

Paranoia is a term used by metal health experts to describe highly exaggerated or unwarranted distrust or suspicion. The word is often used in everyday conversation, often in spiteful moments and incorrectly. Simple distrust is not paranoia – especially if it is based on past experience or on expectations based on others’ experience.

The paranoia may be mild and the affected person reasonably well adjusted socially, or it may be so severe that the individual becomes incapacitated. Diagnosis is sometimes difficult, as many psychiatric disorders are accompanied by some paranoid feature. Paranoids can be classified into three main categories: paranoid personality disorder, paranoid delusional disorder, and paranoid schizophrenia.

Questions, suggestions, comments, please write below.

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