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Last Modified: March 2016
Date Created: May 2011

MPC 00607

ICD-9 295

ICD-10 F20

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Schizophrenia is a condition in the Diagnostic and Statistical Manual Of Mental Disorders Fifth Edition (DSM-5) category of Schizophrenia Spectrum and Other Psychotic Disorders.

The following is a list of terms contained in Criterion A of the Criteria Set for Schizophrenia:

Delusion - a false fixed belief. The content may include a variety of themes:

  • persecutory, e.g., - belief one is being followed
  • referential,e.g., - a passage from a book is specifically directed at oneself
  • religious, e.g.,- belief one is an important religious figure.

Nonbizarre delusions are derived from plausable life experiences (e.g., belief one is under surveillance by the police). Bizarre delusions are clearly implausable (e.g., belief one's internal organs are removed and replaced with someone else's organs).

A belief is not considered to be a delusion if it is reasonable given the context (e.g., belief he or she will be assaulted in a threatening environment).

Hallucination - a sensory experience (sight, touch, sound, smell or taste) that has no basis in external stimulation. In Schizophrenia, auditory hallucinations are the most common (e.g., hearing a voice maintaining a running commentary on the person's behavior or thoughts).

Disorganized Speech - infers the presence of disorganized thinking. Elements may include derailment or loose associations (switching from one topic to another), tangentiality (answers to questions may be obliquely related or completely unrelated), or speech may be incoherent (word salad). Speech content impairment is severe enough to impair communication.

Grossly Disorganized Behavior - may be manifested in a variety of ways (e.g., dressing in an unusual manner, unpredictable and untriggered agitation or catatonic behavior).Catatonic behaviors can be a complete lack of verbal and motor responses (mutism and stupor), maintenance of a rigid, inappropriate or bizarre posture or purposeless or excessive motor activity without obvious cause (catatonic excitement).

Negative symptoms - a diminution or loss of normal functions which account for a substantial portion of the morbidity associated with schizophrenia.

The two negative symptoms which are prominent in schizophrenia are diminished emotional expression and avolition.

Diminished emotional expression is a reduction in nonverbal communication such as facial expression, eye contact or gestures of the head or hands.

Avolition is a decrease in motivation for self-initiated and purposeful activities (e.g., showing little interest in work or social activities).

Other negative symptoms include alogia, anhedonia and asociality.

Alogia is diminished speech output.

Anhedonia is the decreased ability to experience pleasure from current or past experiences.

Asociality is a lack of interest in social interactions.

Criteria Set for Schizophrenia

The Schizophrenia criteria set is derived from the DSM-5.


Criterion A

Two (or more) of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated). 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.
  5. Negative symptoms (i.e., diminished emotional expression or avolition).

Criterion B

For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

Criterion C

Continuous signs of the disturbance persist for at least 6 months. This 6 month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Criterion D

Schizoaffective and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

Criterion E

The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Criterion F

If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Diagnostic Standard

A diagnosis from a qualified medical practitioner (family physician or psychiatrist) or a registered/licensed psychologist is required.

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

NOTE: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means the signs and symptoms of the condition have existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

A. Causes and/or Aggravation

Causal or Aggravating Factors versus Predisposing Factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

NOTE: The factors listed in Section A of the Entitlement Considerations include specific timelines for the clinical onset or aggravation of Schizophrenia. The timelines are not binding. Each case should be adjudicated on the evidence provided and its own merits. If the medical evidence indicates an alternate timeline, consultation with Medical Advisory is strongly recommended.

NOTE: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate Schizophrenia. Other factors may be considered based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

  1. Having experienced severe childhood abuse before the clinical onset or aggravation of Schizophrenia

    Severe childhood abuse is:

    1. serious physical, emotional, psychological or sexual harm to a child under the age of 16 years; or
    2. neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing of a child under the age of 16 years;

    where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around the child, or any other adult in contact with the child.

  2. Experiencing the death of a related child (biological, adopted, step or foster child) within the five years before the clinical onset or aggravation of Schizophrenia

  3. Experiencing the early-death of a parent (before the individual attains the age of 18 years) within the ten years before the clinical onset of Schizophrenia

  4. Having a Substance Use Disorder, involving cannabis, within the ten years before the clinical onset of Schizophrenia

  5. Using cannabis at least twice a week for a continuous period of at least six months before the age of 18 years, within the ten years before the clinical onset of Schizophrenia

  6. Having a clinically significant psychiatric condition at the time of the aggravation of Schizophrenia

    A clinically significant psychiatric condition is a mental disorder as defined in the DSM-5.

  7. Directly experiencing a traumatic event(s) within the six months before the aggravation of Schizophrenia

    Traumatic events include, but are not limited to:

    1. exposure to military combat
    2. threatened physical assault or being physically assaulted
    3. threatened sexual assault or being sexually assaulted
    4. being kidnapped
    5. being taken hostage
    6. being in a terrorist attack
    7. being tortured
    8. incarceration as a prisoner of war
    9. being in a natural or human-made disaster
    10. being in a severe motor vehicle accident
    11. killing or injuring a person in a non-criminal act
    12. experiencing a sudden, catastrophic medical incident
  8. Witnessing, in person, a traumatic event(s) as it occurred to another person(s) within the six months before the aggravation of Schizophrenia

    Witnessed traumatic events include, but are not limited to:

    1. threatened or serious injury to another person
    2. an unnatural death
    3. physical or sexual abuse of another person
    4. a medical catastrophe in a close family member or close friend.
  9. Experiencing repeated or extreme exposure to aversive details of a traumatic event(s) within the six months before the aggravation of Schizophrenia

    Exposures include, but are not limited to:

    1. viewing and/or collecting human remains
    2. viewing and/or participating in the clearance of critically injured casualties
    3. repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
    4. dispatch operators exposed to violent or accidental traumatic event(s)

    NOTE: Factor 9 applies to exposure through electronic media, television, movies and pictures only if the exposure is work related.

  10. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the aggravation of Schizophrenia

    Situations or settings which have a pervasive threat to life or bodily integrity including but not limited to:

    1. being under threat of artillery, missile, rocket, mine or bomb attack
    2. being under threat of nuclear, biologic or chemical agent attack
    3. being involved in combat or going on combat patrols
  11. Inability to obtain appropriate clinical management of Schizophrenia

B. Medical Conditions Which Are To Be Included in Entitlement/Assessment

NOTE: If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of Schizophrenia.

If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of Schizophrenia.

  • Other Schizophrenia Spectrum and other Psychotic Disorders
  • Trauma- and Stressor-Related Disorders
  • Anxiety Disorders
  • Obsessive-Compulsive and Related Disorders
  • Depressive Disorders
  • Bipolar and Related Disorders
  • Personality Disorders
  • Feeding and Eating Disorders
  • Substance-Related and Addictive Disorders
  • Dissociative Disorders
  • Somatic Symptom and Related Disorders
    • Somatic Symptom Disorder
    • Illness Anxiety Disorder
    • Conversion Disorder
  • Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
  • Sleep-Wake Disorders
    • Insomnia Disorder
    • Hypersomnolence Disorder
  • Neurodevelopmental Disorders
    • Attention-Deficit/Hyperactivity Disorder
  • Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Schizophrenia Entitlement Eligibility Guideline.

C. Common Medical Conditions Which May Result in Whole or in Part From Schizophrenia and/or its Treatment

Section C medical conditions may result in whole or in part as a direct result of Schizophrenia, from the treatment of Schizophrenia or the combined effects of Schizophrenia and its treatment.

Conditions listed in Section C of the Entitlement Considerations are only granted entitlement if the individual merits and medical evidence of the case determines a consequential relationship exists. Consultation with Medical Advisory is strongly recommended.

If it is claimed a medication required to treat Schizophrenia resulted in whole, or in part, in the clinical onset or aggravation of a medical condition the following must be established:

  1. The individual was receiving the medication at the time of the clinical onset or aggravation of the medical condition.
  2. The medication was used for the treatment of the Schizophrenia.
  3. The medication is unlikely to be discontinued or the medication is known to have enduring effects after discontinuation.
  4. The individual's medical information and the current medical literature support the medication can result in the clinical onset or aggravation of the medical condition.
  5. Note: Individual medications may belong to a class, or grouping, of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered and not the effects of the group.

The list of Section C conditions is not all inclusive. Conditions, other than those listed in Section C, may be claimed to have a consequential relationship to Schizophrenia and/or its treatment. Other conditions may be considered for entitlement based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

  • Tardive Akathisia
  • Persistent Medication-Induced Parkinsonism
  • Tardive Dyskinesia

References For Schizophrenia

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision (DSM-IV-TR) Washington: American Psychiatric Association, 2000.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (DSM-5) Washington: American Psychiatric Association, 2013.
  3. Australia. (2009). Statement of principles concerning schizophrenia. No. 15 of 2009.
  4. Australia. (2009). Statement of principles concerning schizophrenia. No. 16 of 2009.
  5. Australia. (2011). Amendment statement of principles concerning schizophrenia. No. 93 of 2011.
  6. Bradley. (2008) Neurology in Clinical Practice, 5th ed. Butterworth-Heinemann.
  7. Burns J. ( Oct 2013). Pathways from cannibas to psychosis: a review of the evidence. Frontiers in Psychiatry, 4,(128).
  8. Davis, GP et al. (Dec 2013). Association between cannibas use, psychosis, and schizotypal personality disorder: findings from the National Epidemiological Survey on Alcohol and Related Conditions. Schizophr Res, 151(1-3), 197-202.
  9. Hill, M. (Mar 2014). Clearing the smoke: What do we know about adolescent cannabis use and schizophrenia? J Psychiatry Neurosci, 39(2),75-77.
  10. Smith F.A., Wittman C.W., Stern T.A. (2008). Medical Complications of Psychiatric Treatment. Critical Care Clinics.
  11. Stern. (2008). Massachusetts General Hospital Comprehensive Clinical Psychiatry. Mosby.
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