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Specifier scales for symptomatic manifestations of primary psychotic disorders

191 Specifier scales for symptomatic manifestations of primary psychotic disorders 6A25.0 These domains are: ICD-11 includes the option of providing a specification of the level of severity for six symptom domains for the disorders included in schizophrenia and other primary psychotic disorders. 6A25.3 6A25.4 Manic mood symptoms Psychomotor symptoms 6A25.5 Cognitive symptoms 6A25.1 Negative symptoms 6A25.2 Depressive mood symptoms Specifier scales for symptomatic manifestations of primary psychotic disorders Positive symptoms The contribution of each of these symptom domains can be recorded in the form of specifiers, which can be rated as not present/none (XS8H), mild (XS5W), moderate (XS0T) or severe (XS25), using the anchor points and descriptions provided in Tables 6.6–6.12 below. The ratings should be made based on the severity of the symptoms corresponding to that domain during the past week. Each domain that contributes significantly to the individual clinical presentation should be rated. As many symptom specifiers should be applied as necessary to describe the current clinical presentation accurately. A symptom domain can also be recorded with unspecified severity – for example, if symptoms corresponding to a particular domain are present but insufficient information is available in order to rate their severity. In this case, the code for the symptom domain would be recorded (e.g. 6A25.0) without a severity rating. In cases where multiple symptoms fall within a particular domain, the rating should reflect the most severe symptom within that domain. For example, hallucinations and delusions are both part of the positive symptoms domain. A person may experience hallucinations that result in minimal distress (indicative of mild positive symptoms) and delusions that affect the person’s behaviour but not to the point of impairing their functioning (indicative of moderate positive symptoms). In that case, the person’s positive symptoms should be rated as moderate. Note that individuals with primary psychotic disorders typically do not present with all the symptoms that are part of a given specifier domain. For example, in the positive symptoms domain, a person may present with only hallucinations, only delusions, both or neither. The descriptions corresponding to each rating in the tables below are intended to convey examples of symptom presentations that would justify a rating at a particular level of severity; they are not intended to be used as required criteria. Specifier scales for symptomatic manifestations of primary psychotic disorders

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Note that the mild, moderate and severe ratings for the depressive mood symptoms specifier are not equivalent to the corresponding diagnostic requirements for a mild, moderate or severe depressive episode. In other words, a rating of mild for depressive mood symptoms in the psychotic disorder specifiers does not indicate that the individual meets the requirements for a mild depressive episode. The same is true of the manic mood symptoms specifier. The rating of depressive and manic mood symptoms in these specifiers indicates the severity of depressed, elevated, or irritable mood, and does not include other symptoms (e.g. disrupted sleep, anhedonia, appetite change) that can occur as a part of mood episodes. Symptom specifier ratings are intended to characterize the current clinical presentation among individuals diagnosed with schizophrenia and other primary psychotic disorders, and should not be used in individuals without such a diagnosis. Symptoms attributable to the direct pathophysiological consequences of a comorbid medical condition or injury not classified under mental, behavioural and neurodevelopmental disorders (e.g. a brain tumour or traumatic brain injury), or to the direct physiological effects of substances or medications (including withdrawal effects), should not be included in the specifier ratings. However, in individuals with schizophrenia and other primary psychotic disorders, the specific etiology of symptoms is often unclear (e.g. whether a mood symptom is due to the psychotic disorder or a result of substance use). In these cases, the relevant symptom should be considered in making the specifier rating until it becomes clear that the pathogenesis of the symptom is unrelated to the primary psychotic disorder. Severity Anchor points None XS8H No significant symptoms from the respective domain have been present during the past week Mild XS5W Symptoms in the domain have been present during the past week, but these are minimal in number or do not have a substantial degree of impact. Everyday functioning is not affected by these symptoms, or is affected only minimally. No significant negative social or personal consequences have occurred as a consequence of the symptoms. The symptoms may be intermittent and show fluctuations in severity, and there may be periods during which the symptoms are absent. Compared to other individuals with similar symptoms, the severity of symptoms in the domain is in the mildest third. Moderate XS0T A greater number of symptoms in the domain have been present during the past week, or a smaller number of symptoms that have a substantial degree of impact. Everyday functioning may be moderately affected by the symptoms. There are negative social or personal consequences of the symptoms, but these are not severe. Most of the symptoms are present the majority of the time. Compared to other individuals with similar symptoms, the severity of symptoms in the domain is in the middle third. Severe XS25 Many symptoms in the domain have been present during the past week, or a smaller number that have a severe or pervasive degree of impact (i.e. they are intense and frequent or constant). Everyday functioning is persistently impaired due to the symptoms. There are serious negative social or personal consequences. Compared to other individuals with similar symptoms, the severity of symptoms in the domain is in the most severe third. Severity unspecified Symptoms from the respective domain have been present during the past week, but it is not possible to make a severity rating based on the available information. Table 6.6. Symptomatic manifestations of primary psychotic disorders: anchor points and descriptions for specifier severity ratings Specifier scales for symptomatic manifestations of primary psychotic disorders

193 Specifier scales for symptomatic manifestations of primary psychotic disorders This specifier may be used together with a diagnosis from the grouping of schizophrenia and other primary psychotic disorders to indicate the degree to which positive psychotic symptoms are a prominent part of the current clinical presentation (see Table 6.7). Positive symptoms include delusions, hallucinations (most commonly verbal auditory hallucinations), disorganized thinking (formal thought disorder such as loose associations, thought derailment or incoherence), disorganized behaviour (behaviour that appears bizarre, purposeless and not goal-directed), and experiences of passivity and control (the experience that one’s feelings, impulses or thoughts are under the control of an external force). Abnormal psychomotor behaviour (e.g. catatonic restlessness or agitation, waxy flexibility, negativism) is not included in this domain but instead would be rated in the 6A25.4 Psychomotor symptoms domain below. The rating should be made based on the severity of positive symptoms during the past week. Positive symptoms Severity Anchor points None 6A25.0&XS8H No significant positive symptoms have been present during the past week Mild 6A25.0&XS5W Example symptoms (not all are required) Delusions The person believes the delusion (lack of reality testing), but does not feel pressure to act upon it, and the delusion leads to minimal distress. Hallucinations Hallucinations are recurrent but relatively infrequent, and the person expresses only minimal distress regarding their content. Experiences of passivity and control Some distortions of self-experience are present, such as feeling that one’s thoughts are not one’s own, but these are relatively infrequent and there is only minimal associated distress. Disorganized thinking Some circumstantial or tangential thought processes are present, but for the most part the individual is able to convey the point of the intended communication. Disorganized behaviour Infrequent episodes of purposeless behaviour that is not goal-directed and causes only minimal impairment in functioning are present. Moderate 6A25.0&XS0T Example symptoms (not all are required) Delusions The person’s behaviour is clearly affected by the delusional beliefs but the person’s behavioural response does not significantly impair functioning (e.g. a person with persecutory delusions is watchful of their surroundings but continues to venture outside). Hallucinations Hallucinations are relatively frequent and may be distressing at times but are tolerated at other times, and do not persistently preoccupy the person. The content of hallucinations may prompt action, but the person only inconsistently or occasionally responds, and these actions do not put the person or others at risk of harm. Table 6.7. Rating scale for positive symptoms in primary psychotic disorders Specifier scales for symptomatic manifestations of primary psychotic disorders | Positive symptoms 6A25.0

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Table 6.7. contd Negative symptoms This specifier may be used together with a diagnosis from the grouping of schizophrenia and other primary psychotic disorders to indicate the degree to which negative psychotic symptoms are a prominent part of the current clinical presentation (see Table 6.8). Negative symptoms include constricted, blunted or flat affect; alogia or paucity of speech; avolition (general lack of drive, or lack of motivation to pursue meaningful goals); asociality (reduced or absent engagement with others and interest in social interaction) and anhedonia (inability to experience pleasure from normally pleasurable activities). To be considered negative psychotic symptoms, relevant symptoms should not be entirely attributable to depression or to an understimulating environment, be a direct consequence of a positive symptom (e.g. persecutory delusions causing a person to become socially isolated due to fear of harm), or be attributable to the direct physiological effects of substances or medications, including withdrawal effects. Catatonia, including catatonic mutism, should be considered as part of the 6A25.4 Psychomotor symptoms domain below rather than here. Severity Anchor points Experiences of passivity and control Distortions of self-experience are relatively frequent and lead to some behaviours to ward against alteration of thoughts (e.g. superstitious rituals) or noticeable distress. Disorganized thinking Evidence of frequent circumstantial or tangential thought process that impairs the individual’s ability to convey the point of the communication. Disorganized behaviour Frequent episodes of purposeless behaviour that is not goal-directed and that causes some impairment in functioning. Severe 6A25.0&XS25 Example symptoms (not all are required) Delusions The person is preoccupied with delusional beliefs that dictate many of their actions and significantly impair functioning (e.g. a person with persecutory delusions refuses to eat most food because of a conviction that food has been poisoned). Hallucinations The person is markedly distressed or preoccupied by frequent hallucinations, or there are recurrent hallucinations that prompt potentially harmful behaviour to which the person feels compelled to respond. Experiences of passivity and control Distortions of self-experience are markedly distressing, and significantly affect the individual’s behaviour (e.g. wearing a hat made of aluminium foil to prevent thought broadcasting). Disorganized thinking Loose associations in thought processes are present that are so severe that speech is mostly incoherent. Disorganized behaviour Purposeless behaviour that is not goal-directed dominates the individual’s behavioural repertoire, and causes severe impairment in functioning. Severity unspecified 6A25.0 Positive symptoms have been present during the past week, but it is not possible to make a severity rating based on the available information. Specifier scales for symptomatic manifestations of primary psychotic disorders | Negative symptoms 6A25.1

195 Specifier scales for symptomatic manifestations of primary psychotic disorders The rating should be made based on the severity of negative symptoms during the past week. Depressive mood symptoms This specifier may be used together with a diagnosis from the grouping of schizophrenia and other primary psychotic disorders to indicate the degree to which depressive mood symptoms are a prominent part of the current clinical presentation (see Table 6.9). The specifier refers only to depressive mood symptoms, as reported by the individual (feeling down, sad) or as observed by the clinician (e.g. tearful, defeated appearance). The severity of associated non-mood symptoms of a depressive episode (e.g. anhedonia or other negative symptoms, changes in sleep or appetite) should not be considered in making a rating for this specifier. In this regard, the depressive mood symptoms specifier is different from the severity rating applied to a depressive episode (see p. 216). If suicidal ideation is present, a rating of moderate or severe depressive mood symptoms should automatically be applied (see below). This specifier may be used regardless of whether the depressive symptoms meet the diagnostic requirements for a depressive episode. Severity Anchor points None 6A25.1&XS8H No significant negative symptoms have been present during the past week. Mild 6A25.1&XS5W Example symptoms (not all are required) Blunted emotional experience or expression is present, with subtle but detectable affective changes. Initiation of speech is limited, but the individual is responsive to questions. The person shows little interest in external events, but exhibits sufficient motivation to engage in basic activities of daily living or to complete a task when prompted Moderate 6A25.1&XS0T Example symptoms (not all are required) Flat emotional expression is present. Initiation of speech for purposes other than indicating immediate needs and desires is minimal, but the individual is responsive to questions with terse phrases. Lack of volition leads to neglect of hygiene or required activities, but the person will complete them with significant prompting. Severe 6A25.1&XS25 Example symptoms (not all are required) The person reports feeling empty or robotic most of the time. Generally the individual does not initiate speech, even to indicate immediate needs and desires. The person is not capable of initiating behaviour even with significant prompting, which may lead to serious neglect of self-care to the extent that it puts the person at risk of harm (e.g. infrequently taking life-sustaining medication). Severity unspecified 6A25.1 Negative symptoms have been present during the past week, but it is not possible to make a severity rating based on the available information. Table 6.8. Rating scale for negative symptoms in primary psychotic disorders Specifier scales for symptomatic manifestations of primary psychotic disorders | Depressive mood symptoms 6A25.2

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders The rating should be made based on the severity of depressive mood symptoms during the past week. Table 6.9. Rating scale for depressive mood symptoms in primary psychotic disorders Severity Anchor points None 6A25.2&XS8H No significant depressive mood symptoms have been present during the past week Mild 6A25.2&XS5W The person expresses significant depressed mood, but there are intermittent periods of relief. The depressive symptoms have some, but not considerable, impact on at least some areas of personal, social or occupational functioning. Moderate 6A25.2&XS0T The depressed mood is present continually, although its intensity may vary. Suicidal ideation may accompany the depressed mood when it is more intense. The depressive symptoms cause considerable difficulty with personal, social or occupational functioning. Severe 6A25.2&XS255 The intensity of the depressed mood is overwhelming to the person. This level of severity may be indicated by intense suicidal ideation or suicide attempts. The depressive symptoms seriously affect all areas of functioning (personal, social and occupational) to such an extent that the person is unable to function, except to a very limited degree. Severity unspecified 6A25.2 Depressive mood symptoms have been present during the past week, but it is not possible to make a severity rating based on the available information. Manic mood symptoms This specifier may be used together with a diagnosis from the grouping of schizophrenia and other primary psychotic disorders to indicate the extent to which manic mood symptoms are a prominent part of the clinical presentation (see Table 6.10). The specifier includes elevated, euphoric, irritable or expansive mood states, including rapid changes among different mood states (i.e. mood lability). It also includes increased subjective experience of energy, which may be accompanied by increased goal-directed activity. The severity of associated non-mood symptoms of a manic or hypomanic episode (e.g. decreased need for sleep, distractibility) should not be considered in making a rating for this specifier. Increased non-goal-directed psychomotor activity should be considered as part of the 6A25.4 Psychomotor symptoms domain below rather than here. This specifier may be used regardless of whether the manic symptoms meet the diagnostic requirements for a manic episode. The rating should be made based on the severity of manic mood symptoms during the past week. Specifier scales for symptomatic manifestations of primary psychotic disorders | Manic mood symptoms 6A25.3

197 Specifier scales for symptomatic manifestations of primary psychotic disorders Table 6.10. Rating scale for manic mood symptoms in primary psychotic disorders Severity Anchor points None 6A25.3&XS8H No significant manic mood symptoms have been present during the past week. Mild 6A25.3&XS5W Hypomanic elevation of mood or increased irritability is present. The hypomanic symptoms do not cause marked impairment in personal, social or occupational functioning. Moderate 6A25.3&XS0T Marked elevation of mood, irritability or subjective energy level is present. The manic symptoms cause considerable difficulty with personal, social or occupational functioning. Severe 6A25.3&XS25 Extreme elevation of mood or irritability is present that results in hazardous, dangerous or markedly inappropriate behaviour to a degree that intensive supervision is required. Severity unspecified 6A25.3 Manic mood symptoms have been present during the past week, but it is not possible to make a severity rating based on the available information. Psychomotor symptoms This specifier may be used together with a diagnosis from the grouping of schizophrenia and other primary psychotic disorders to indicate the degree to which psychomotor symptoms are a prominent part of the clinical presentation (see Table 6.11). Psychomotor symptoms include psychomotor agitation or increased motor activity, usually manifested in purposeless behaviours such as fidgeting, shifting, fiddling, inability to sit or stand still, wringing of the hands, stereotypy and grimacing. Psychomotor symptoms also include psychomotor retardation (a visible generalized slowing of movements and speech), as well as catatonic symptoms such as extreme restlessness with purposeless motor activity to the point of exhaustion, posturing, waxy flexibility, negativism, mutism or stupor. To be considered psychomotor symptoms for the purpose of this specifier rating, symptoms should not be attributable to a neurodevelopmental disorder or disease of the nervous system, or to the direct physiological effects of substances or medications, including withdrawal effects. If the full syndrome of catatonia is present, the diagnosis of 6A40 Catatonia associated with another mental disorder (p. 202) should also be assigned. The rating should be made based on the severity of psychomotor symptoms during the past week. Specifier scales for symptomatic manifestations of primary psychotic disorders | Psychomotor symptoms 6A25.4

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Table 6.11. Rating scale for psychomotor symptoms in primary psychotic disorders Severity Anchor points None 6A25.4&XS8H No significant psychomotor symptoms have been present during the past week Mild 6A25.4&XS5W The majority of the time the person exhibits a normal level of activity, but there are occasional periods of psychomotor excitation or slowing. Psychomotor symptoms do not interfere significantly with important personal, social or occupational functioning. Moderate 6A25.4&XS0T The person experiences frequent periods of marked psychomotor agitation or retardation, but psychomotor symptoms are not continuous. Psychomotor symptoms interfere significantly with important personal, social or occupational functioning. Severe 6A25.4&XS25 The individual experiences severe and nearly continuous psychomotor agitation or slowing, which may include the full syndrome of catatonia (see p. 202). The psychomotor symptoms are sufficiently severe to be potentially harmful to the person or others (e.g. agitation to the point of severe physical exhaustion, stupor that prevents the person from feeding themselves). Severity unspecified 6A25.4 Psychomotor symptoms have been present during the past week, but it is not possible to make a severity rating based on the available information. Cognitive symptoms This specifier may be used together with a diagnosis from the grouping of schizophrenia and other primary psychotic disorders to indicate the degree to which cognitive impairment is a prominent aspect of the clinical presentation (see Table 6.12). Deficits may appear in any of the following cognitive domains: speed of processing, attention/concentration, orientation, judgement, abstraction, verbal or visual learning, or working memory. The cognitive impairment is not attributable to a neurodevelopmental disorder, to delirium or another neurocognitive disorder, or to the direct effects of a substance or medication on the central nervous system, including withdrawal effects. When available, the severity rating for this domain should be based on the results of locally validated, standardized neuropsychological assessments, but such measures are not available in all settings and are not required to provide a rating. The rating should be made based on the severity of cognitive symptoms during the past week. Specifier scales for symptomatic manifestations of primary psychotic disorders | Cognitive symptoms 6A25.5

199 Specifier scales for symptomatic manifestations of primary psychotic disorders Table 6.12. Rating scale for cognitive symptoms in primary psychotic disorders Severity Anchor points None 6A25.5&XS8H No significant cognitive symptoms have been present during the past week Mild 6A25.5&XS5W The person has minor difficulties in cognition (e.g. difficulty with recall during the interview, drifting concentration, showing some disorientation to time but not person or place). Everyday functioning is largely unimpaired by the difficulties Moderate 6A25.5&XS0T The individual shows clear difficulties in cognition (e.g. impaired or inconsistent recall for some autobiographical information, inability to perform some basic operations that are expected of the person’s educational attainment and level of intellectual functioning – such as simple calculation tasks, disrupted orientation for time and place but intact for person, difficulty learning or retaining new information). Everyday functioning is impaired as a result, but only some external assistance is necessary. Severe 6A25.5&XS25 The person shows pronounced difficulties in cognition (e.g. severe deficits in verbal memory or other cognitive tasks relative to educational attainment and level of intellectual functioning, substantial difficulty with concentration and paying attention to what the rater asks during the interview, difficulty formulating plans to accomplish a specific objective, inability to consider alternative solutions to problems, grossly disturbed orientation). The problems severely interfere with everyday functioning, leading to the necessity of considerable external assistance. Severity unspecified 6A25.5 Cognitive symptoms have been present during the past week, but it is not possible to make a severity rating based on the available information. Specifier scales for symptomatic manifestations of primary psychotic disorders | Cognitive symptoms

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders