Schizophrenia

The hallmark of schizophrenia is the presence of psychosis, or loss of contact with reality.


Schizophrenia is a psychiatric disorder involving chronic or recurrent psychosis. The word comes from the Greek schizo meaning “split” and phrenia for “mind.” Age of onset is typically during adolescence or early adulthood. Slightly more men are diagnosed with schizophrenia than women. About 3.2 million Americans are thought to have schizophrenia, with about 100,000 new cases diagnosed per year.

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Image by Getty Images

The hallmark of schizophrenia is the presence of psychosis, or loss of contact with reality. The manifestations of psychosis may include hallucinations, delusions including paranoia, disordered thought, and/or disordered behavior. Negative symptoms, including decreased expressiveness, apathy, flat affect, and a lack of energy, are also characteristic of schizophrenia.

Hallucinations may be visual, auditory, tactile, olfactory, or gustatory in nature. Examples include feeling bugs crawling on the skin, hearing voices, and seeing people or things not present. Delusions are false beliefs based on incorrect inferences about external reality that persist despite evidence to the contrary. Examples include believing oneself to be a billionaire or president of the United States, taking benign gestures or comments as malicious, and feeling persecuted by someone or something. Paranoia is a form of delusion in which the patient demonstrates a pervasive mistrust and suspicion of others' motives. In contrast to delusions, illusions are distortions or misinterpretations of real sensory stimuli.

Disorganized thought is observed by speech pattern and content. It can manifest in several different ways, including alogia, loose association, or perseveration.

Disorganized behavior may include withdrawal, aggression, agitation, violence, or catatonia.

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), schizophrenia is recognized by the presence for at least one month of two or more of the following findings, including at least one of the first three: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms such as diminished emotional expression. The symptoms must cause impairment in work, interpersonal relations, or self-care for a significant period of time. Some signs must have been present for a continuous period of at least six months.

Schizoaffective disorder and bipolar or depressive disorder with psychotic features must be ruled out as the cause of the symptoms. There cannot be major depressive or manic episodes occurring concurrently with active-phase symptoms. The disturbance must also not be caused by substance use or another medical condition. Schizoaffective disorder is defined by an uninterrupted period of illness during which there is a major mood episode (manic or depressive) in addition to meeting two or more of the criteria for schizophrenia.

Precise, specific documentation is necessary to permit accurate and compliant coding that correctly captures the severity of illness, costs, and outcomes of care. Diagnosing the specific type of schizophrenia is critical to capturing the complication/comorbidity status, which affects quality analytics and revenue. The typical practice of simply documenting unspecified “schizophrenia” fails to achieve that goal. ICD-10-CM classifies schizophrenia as shown in the Table. Even though the DSM no longer categorizes schizophrenia into five different types (catatonic, disorganized, paranoid, residual, undifferentiated), they are still valid for descriptive and coding purposes. All schizophrenia can be classified as one of these five, so unspecified schizophrenia can always be better described.

For documenting the specific type of schizophrenia, consider whether a patient's schizophrenic condition meets the criteria described for paranoia, catatonia, or disorganized speech and/or behavior. Undifferentiated schizophrenia occurs when two or more diagnostic criteria are met, but criteria for any other type is not, which is very rare. Residual schizophrenia applies when there is continuing evidence of the disturbance, but delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior is not prominent. Schizophreniform disorder is a type of psychosis with symptoms similar to those of schizophrenia, but lasting for less than six months.