Diagnostic Assessment of Schizophrenia

  • Oliver Freudenreich
Part of the Current Clinical Psychiatry book series (CCPSY)


Diagnosis matters as it guides treatment with the goal of improving prognosis. In this chapter, I review how to make a clinical diagnosis of schizophrenia with the help of diagnostic criteria. Diagnostic errors leading to a missed or mistaken diagnosis of schizophrenia are discussed. In addition, this chapter describes the elements of a comprehensive assessment of schizophrenia, beyond the categorical diagnosis of schizophrenia. For treatment goals and outcomes, clinicians need to assess psychotic and nonpsychotic symptom clusters (dimensions of schizophrenia), function, and quality of life. Rating scales can inform and enhance clinical care.


Diagnosis Diagnostic criteria DSM-5 ICD-11 Diagnostic errors Comprehensive assessment Symptoms Function Quality of life Rating scales 


  1. 1.
    Miller H. The cosmological eye. New York: New Directions; 1939.Google Scholar
  2. 2.
    World Health Organization. International classification of diseases 11th revision (ICD-11). Available from: Accessed on 7/1/2019.
  3. 3.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Arlington: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  4. 4.
    Freudenreich O, Querques J, Kontos N. Checklist psychiatry’s effect on psychiatric education. Am J Psychiatry. 2004;161:930; author reply 930.CrossRefGoogle Scholar
  5. 5.
    Hyman SE. The diagnosis of mental disorders: the problem of reification. Annu Rev Clin Psychol. 2010;6:155–79.CrossRefGoogle Scholar
  6. 6.
    Keshavan MS, Morris DW, Sweeney JA, Pearlson G, Thaker G, Seidman LJ, et al. A dimensional approach to the psychosis spectrum between bipolar disorder and schizophrenia: the Schizo-Bipolar scale. Schizophr Res. 2011;133:250–4.CrossRefGoogle Scholar
  7. 7.
    Heckers S. Is schizoaffective disorder a useful diagnosis? Curr Psychiatry Rep. 2009;11:332–7.CrossRefGoogle Scholar
  8. 8.
    Kontos N, Freudenreich O, Querques J. Thoughtful diagnoses: not checklist psychiatry [Pearls series]. Curr Psychiatry. 2007;6:112.Google Scholar
  9. 9.
    Westen D. Prototype diagnosis of psychiatric syndromes. World Psychiatry. 2012;11:16–21.CrossRefGoogle Scholar
  10. 10.
    de Leon J. Is psychiatry only neurology? Or only abnormal psychology? Deja vu after 100 years. Acta Neuropsychiatr. 2015;27:69–81.CrossRefGoogle Scholar
  11. 11.
    Tiemstra J. The poor historian. Acad Med. 2009;84:723.CrossRefGoogle Scholar
  12. 12.
    Gara MA, Minsky S, Silverstein SM, Miskimen T, Strakowski SM. A naturalistic study of racial disparities in diagnoses at an outpatient behavioral health clinic. Psychiatr Serv. 2019;70:130–4.CrossRefGoogle Scholar
  13. 13.
    Verdoux H, van Os J. Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophr Res. 2002;54:59–65.CrossRefGoogle Scholar
  14. 14.
    Shapiro D. Neurotic styles. New York: Basic Books; 1965.Google Scholar
  15. 15.
    Scotti-Muzzi E, Saide OL. Schizo-obsessive spectrum disorders: an update. CNS Spectr. 2017;22:258–72.CrossRefGoogle Scholar
  16. 16.
    Freudenreich O, Viron M, Shtasel D. Serious mental illness. In: Stern TA, Fava M, Wilens TE, Rosenbaum JF, editors. Massachusetts general hospital comprehensive clinical psychiatry. 2nd ed. London: Elsevier; 2016. p. 703–8.Google Scholar
  17. 17.
    Lambert M, Naber D, Schacht A, Wagner T, Hundemer HP, Karow A, et al. Rates and predictors of remission and recovery during 3 years in 392 never-treated patients with schizophrenia. Acta Psychiatr Scand. 2008;118:220–9.CrossRefGoogle Scholar
  18. 18.
    McGlashan TH, Fenton WS. Classical subtypes for schizophrenia: literature review for DSM-IV. Schizophr Bull. 1991;17:609–32.CrossRefGoogle Scholar
  19. 19.
    Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep. 1962;10:799–812.CrossRefGoogle Scholar
  20. 20.
    Freudenreich O. Schizophrenia? Target 6 symptom clusters [Pearls series]. Curr Psychiatry. 2009;8:74.Google Scholar
  21. 21.
    Goldman HH. Do you walk to school, or do you carry your lunch? [editorial]. Psychiatr Serv. 2005;56:419.CrossRefGoogle Scholar
  22. 22.
    World Health Organization. WHO disability assessment schedule 2.0 (WHODAS 2.0). Available from: Accessed on 7/1/2019.
  23. 23.
    World Health Organization. The World Health Organization Quality of Life (WHOQOL). Available from: Accessed on 7/1/2019.
  24. 24.
    Boyer L, Lancon C, Baumstarck K, Parola N, Berbis J, Auquier P. Evaluating the impact of a quality of life assessment with feedback to clinicians in patients with schizophrenia: randomised controlled trial. Br J Psychiatry. 2013;202:447–53.CrossRefGoogle Scholar
  25. 25.
    Aboraya A, Nasrallah HA, Elswick DE, Ahmed E, Estephan N, Aboraya D, et al. Measurement-based care in psychiatry-past, present, and future. Innov Clin Neurosci. 2018;15:13–26.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.CrossRefGoogle Scholar
  27. 27.
    Freudenreich O. Self-rating scales tell you more than the score [Pearls series]. Curr Psychiatry. 2008;7:110.Google Scholar

Additional Resources


    1. – Good introduction to the importance of quality of life for patient care and how to assess it quickly yet comprehensively, using a rating scale developed by the World Health Organization.


    1. North C, Yutzy S. Goodwin and Guze’s psychiatric diagnosis. 7th ed. New York: Oxford University Press; 2019. – Published originally in 1974, this book (particularly the preface to the first edition which is included in the 7th edition) is a must read for any psychiatrist who wants to critically examine the diagnostic validity of many of our current psychiatric diagnoses. The late Donald Goodwin and Samuel Guze (together with Eli Robins and George Winokur) belonged to an influential group of psychiatrists at the University of Washington in St. Louis that aligned psychiatric diagnosis with medical practice by introducing diagnostic criteria, ultimately resulting in the publication of DSM-III in 1980.Google Scholar


    1. Jansson LB, Parnas J. Competing definitions of schizophrenia: what can be learned from polydiagnostic studies? Schizophr Bull. 2007;33:1178–200. – Read this article to understand the vexing problem of validity of psychiatric diagnosis (and the limitations of our current approach to diagnosing schizophrenia). The issues raised over a decade ago are as pertinent today as they were then.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Oliver Freudenreich
    • 1
  1. 1.Department of PsychiatryMassachusetts General HospitalBostonUSA

Personalised recommendations