Symptomatic manifestations of primary psychotic disorders

Description

These categories may be used to characterize the current clinical presentation in individuals diagnosed with Schizophrenia or another primary psychotic disorder, and should not be used in individuals without such a diagnosis. Multiple categories may be applied. Symptoms attributable to the direct pathophysiological consequences of a health condition or injury not classified under Mental, behavioural or neurodevelopmental disorders (e.g., a brain tumour or traumatic brain injury), or to the direct effects of a substance or medication on the central nervous system, including withdrawal effects, should not be considered as examples of the respective types of symptoms. [1]

Diagnostic requirements

WHO clinical descriptions and diagnostic requirements [1,2].

Subcategories

• 6A25.0 Positive symptoms in primary psychotic disorders

  Positive symptoms in primary psychotic disorders include persistent delusions, persistent hallucinations (most commonly verbal auditory hallucinations), disorganised thinking (formal thought disorder such as loose associations, thought derailment, or incoherence), grossly disorganised 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). The rating should be made based on the severity of positive symptoms during the past week. [1]

  This specifier may be used together with a diagnosis from the grouping of Schizophrenia or Other Primary Psychotic Disorders to indicate the degree to which positive psychotic symptoms are a prominent part of the current clinical presentation. 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 Psychomotor Symptoms domain below.

  The rating should be made based on the severity of positive symptoms during the past week.

  Table 6.7: Rating Scale for Positive Symptoms in Primary Psychotic Disorders

  -	-
  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, 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 process, 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.
  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 his 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
  Severe 6A25.0&XS25	Example symptoms (not all are required): Delusions: The person is preoccupied with delusional beliefs that dictate many of the person’s 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 impact the individual’s behaviour (e.g., wearing a hat made of aluminium foil to prevent thought broadcasting). Disorganized Thinking: Loose associations in thought processes 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.

• 6A25.1 Negative symptoms in primary psychotic disorders

  Negative symptoms in primary psychotic disorders 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 antipsychotic drug treatment, a depressive disorder, or an under-stimulating environment, and should not be a direct consequence of a positive symptom (e.g., persecutory delusions causing a person to become socially isolated due to fear of harm). The rating should be made based on the severity of negative symptoms during the past week. [1]

  This specifier may be used together with a diagnosis from the grouping of Schizophrenia or Other Primary Psychotic Disorders to indicate the degree to which negative psychotic symptoms are a prominent part of the current clinical presentation. 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 under-stimulating 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 rating of the Psychomotor Symptoms specifier, rather than here.

  The rating should be made based on the severity of negative symptoms during the past week.

  Table 6.8: Rating Scale for Negative Symptoms in Primary Psychotic Disorders

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  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, with subtle but detectable affective changes. Limited initiation of speech, but is responsive to questions. 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. Minimal initiation of speech for purposes other than indicating immediate needs and desires, but is responsive to questions with terse phrases. Lack of volition leads to neglect of hygiene or required activities, but will complete them with significant prompting.
  Severe 6A25.1&XS25	Example symptoms (not all are required): Person reports feeling empty or robotic most of the time. Generally does not initiate speech, even to indicate immediate needs and desires. 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.

• 6A25.2 Depressive mood symptoms in primary psychotic disorders

  Depressive mood symptoms in primary psychotic disorders refer to depressed mood as reported by the individual (feeling down, sad) or manifested as a sign (e.g. tearful, defeated appearance). If only non-mood symptoms of a depressive episode are present (e.g., anhedonia, psychomotor slowing), this descriptor should not be used. This descriptor may be used whether or not depressive symptoms meet the diagnostic requirements of a separately diagnosed Depressive disorder. The rating should be made based on the severity of depressive mood symptoms during the past week. [1]

  This specifier may be used together with a diagnosis from the grouping of Schizophrenia or Other Primary Psychotic Disorders to indicate the degree to which depressive mood symptoms are a prominent part of the current clinical presentation. 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. 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.

  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

  -	-
  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 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&XS25	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 personal, social, and occupational functioning 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.

• 6A25.3 Manic mood symptoms in primary psychotic disorders

  Manic mood symptoms in primary psychotic disorders refer to 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. Increased non-goal-directed psychomotor activity should be considered as part of the rating of the 'psychomotor symptoms in primary psychotic disorders' rather than here. This descriptor may be used whether or not the manic symptoms meet the diagnostic requirements of a separately diagnosed bipolar disorder. The rating should be made based on the severity of manic mood symptoms during the past week. [1]

  This specifier may be used together with a diagnosis from the grouping of Schizophrenia or Other Primary Psychotic Disorders to indicate the extent to which manic mood symptoms are a prominent part of the clinical presentation. 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 rating of the Psychomotor Symptoms specifier 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.

  Table 6.10: Rating Scale for Manic Mood Symptoms in Primary Psychotic Disorders

  -	-
  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. 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. The manic symptoms cause considerable difficulty with personal, social, or occupational functioning.
  Severe 6A25.3&XS25	Extreme elevation of mood or irritability 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.

• 6A25.4 Psychomotor symptoms in primary psychotic disorders

  Psychomotor symptoms in primary psychotic disorders include psychomotor agitation or excessive motor activity, usually manifested by purposeless behaviours such as fidgeting, shifting, fiddling, inability to sit or stand still, wringing of the hands, psychomotor retardation, or a visible generalised slowing of movements and speech, and catatonic symptoms such as excitement, posturing, waxy flexibility, negativism, mutism, or stupor. The rating should be made based on the severity of psychomotor symptoms during the past week. [1]

  This specifier may be used together with a diagnosis from the grouping of Schizophrenia or Other Primary Psychotic Disorders to indicate the degree to which psychomotor symptoms are a prominent part of the clinical presentation. Psychomotor symptoms include psychomotor agitation or increased motor activity, usually manifested by 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 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 Catatonia Associated with Another Mental Disorder should also be assigned.

  The rating should be made based on the severity of psychomotor symptoms during the past week.
  

  Table 6.11: Table 6.X: Rating Scale for Psychomotor Symptoms in Primary Psychotic Disorders

  -	-
  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 significantly interfere with important personal, social, or occupational functioning.
  Moderate 6A25.4&XS0T	Frequent periods of marked psychomotor agitation or retardation, but psychomotor symptoms are not continuous. Psychomotor symptoms significantly interfere with important personal, social, or occupational functioning.
  Severe 6A25.4&XS25	Severe and nearly continuous psychomotor agitation or slowing, which may include the full syndrome of Catatonia. 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 himself).
  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.

• 6A25.5 Cognitive symptoms in primary psychotic disorders

  Cognitive symptoms in primary psychotic disorders refer to cognitive impairment in any of the following domains: speed of processing, attention/concentration, orientation, judgment, abstraction, verbal or visual learning, and working memory. The cognitive impairment is not attributable to a neurodevelopmental disorder, a delirium or other neurocognitive disorder, or the direct effects of a substance or medication on the central nervous system, including withdrawal effects. Ideally, use of this category should be based on the results of locally validated, standardized neuropsychological assessments, although such measures may not be available in all settings. The rating should be made based on the severity of cognitive symptoms during the past week. [1]

  This specifier may be used together with a diagnosis from the grouping of Schizophrenia or Other Primary Psychotic Disorders to indicate the degree to which cognitive impairment is a prominent aspect of the clinical presentation. Deficits may appear in any of the following cognitive domains: speed of processing, attention/concentration, orientation, judgment, abstraction, verbal or visual learning, or working memory. The cognitive impairment is not attributable to a Neurodevelopmental Disorder or 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.

  Table 6.12: Rating Scale for Cognitive Symptoms in Primary Psychotic Disorders

  -	-
  None 6A25.5&XS8H	No significant cognitive symptoms have been present during the past week.
  Mild 6A25.5&XS5W	Person has minor difficulties in cognition (e.g., difficulty with recall during the interview, concentration may drift, shows some disorientation to time but not person or place). Everyday functioning is largely unimpaired by the difficulties.
  Moderate 6A25.5&XS0T	Person shows clear difficulties in cognition (e.g., recall for some autobiographical information is impaired or inconsistent, cannot perform some basic operations that are expected of the person’s educational attainment and level of intellectual functioning such as simple calculation tasks, orientation disrupted 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	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 attention to what the rater asks during the interview, difficulty formulating plans to accomplish a specific objective, unable to consider alternative solutions to problems, orientation is grossly disturbed). 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.

References

1. World Health Organization. International Classification of Diseases, 11th Revision, for Mortality and Morbidity Statistics (ICD-11 MMS), 2026-01 release. World Health Organization; 2026.
2. World Health Organization. Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders (CDDR). World Health Organization; 2024.

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