First, consider the basic criteria for schizophrenia, the coding notes, and the TIPS on this page.  By the way, these examples are made up people.

Basic Criteria for Schizophrenia

  Symptoms (the "A" symptoms of the DSM-IV.  For a substantial part of at least one month (or less, if effectively treated), the patient has had two or more of:
        - Delusions (only one symptom is required if a delusion is bizarre, such as being abducted in a space ship from the sun)
        - Hallucinations (only one symptom is required if hallucinations are of at least two voices talking to each other or of a voice that keeps running commentary on the patient's thoughts or actions)
        - Speech that shows incoherence, derailment, or other disorganization
        - Severely disorganized or catatonic behavior
        - Any negative symptom such as flat affect, reduced speech, or lack of volition
  Duration.  For at least six months, the patient has shown some evidence of the disorder.  At least one month must include symptoms of frank psychosis mentioned above.  During the balance of this time (as either prodromal or residual indications of the illness), the patient must either or both of these:
        - Negative symptoms as mentioned above
        - In attenuated form, at least two of the other symptoms mentioned above (example: deteriorating personal hygiene, plus an increasing suspicion that people are talking behind one's back)
  Dysfunction.  For much of this time, the disorder has materially impaired the patient's ability to work. study, socialize, or provide self-care.  (If the illness begins in childhood or adolescence, the criteria for dysfunction require only that the patient fail to achieve the expected occupational, scholastic, or social level.)
  Mood exclusions.  Mood disorders with psychotic features and Schizoaffective Disorder have been ruled out, because the duration of any depressive or manic episodes that have occurred during the psychosis phase has been brief.
  Other exclusions.  This disorder is not directly caused by a general medical condition or the use of substances, including prescription medications.
  Developmental Disorder exclusions.  If the patient has a history of any pervasive developmental disorder (such as Autistic Disorder), Schizophrenia is diagnosed only if prominent hallucinations or delusions are also present for a month or more (less, if treated).

First Person, Lyonel Childs

  The patient meets the basic criteria for schizophrenia.
  The patient is preoccupied with delusions or frequent auditory hallucinations.
  None of these symptoms is prominent.
        - Disorganized speech
        - Disorganized behavior
        - Inappropriate or flat affect
        - Catatonic behavior

295.10 Schizophrenia, Disorganized Type
The disorganized type of schizophrenia was first recognized nearly 150 years ago.  It was originally termed hebephrenia because it began early in life (hebe  is Greek for youth).  Patients with the disorganized type are frequently the most obviously psychotic of all schizophrenia patients.  They often deteriorate rapidly, talk gibberish, and neglect hygiene and appearance.
Criteria:
 The patient meets the basic criteria for schizophrenia.
  All of these symptoms are prominent:
        - Disorganized behavior
        - Disorganized speech
        - Affect that is flat or inappropriate
  The patient does not fulfill criteria for schizophrenia, catatonic type.

Second Person, Bob Naples
As his sister told it, Bob Naples was always quiet when he was a kid, but not what you'd call peculiar or strange.  Nothing like this had ever happened in their family before.
        Bob sat in a tiny consulting room down the hall.  His lips moved soundlessly, and one bare leg dangled across the arm of his chair.  His sole article of clothing was a red-and-white-striped pajama top.  An attendant tried to drape a green sheet across his lap, but he giggled and flung it to the floor.
        It was hard for his sister, Sharon to say when Bob first began to change.  He was never very sociable, even a loner.  He hardly ever laughed and always seemed rather distant, almost cold; he never appeared to enjoy anything he did very much.  In the five years since he'd finished high school, he had lived at their house while he worked in her husband's machine shop, but he never really lived with them.  He had never had a girlfriend--or a boyfriend, for that matter, though he sometimes used to talk with a couple of high school classmates if they dropped around.  About a year and a half ago, Bob had completely stopped going out and wouldn't even return phone calls.  When Sharon asked him why, he said he had better do things to do.  But all he did when he wasn't working was stay in his room.
        Sharon's husband had told her that at work, Bob stayed at his lathe during breaks and talked even less than before.  "Sometimes Dave would hear Bob giggling to himself.  When he'd ask what as funny, Bob would just kind of shrug and just turn away, back to his work."
        For over a year, things didn't change much.  Then, about two months earlier, Bob had started staying up at night.  The family would hear him thumping around his room, banging drawers, occasionally throwing things.  Sometimes it sounded like he was talking to someone, but his bedroom was on the second floor and he had no phone.
        He stopped going in to work.  "Of course, Dave'd never fire him," Sharon continued."  But he was sleepy from being up all night, and he kept nodding off at the lathe.  Sometimes he'd just leave it spinning and wander over to stare out the window.  Dave was relieved when he stopped coming in.
      In the last several weeks, all Bob would say was "Gilgamesh."  One Sharon asked what it meant and he answered, "It's no red shoe on the backspace."  This astonished her so much that she wrote it down.  After that, she gave up trying to ask him for explanations.
        Sharon wasn't sure how Bob got into the hospital.  When she'd come home from the grocery store a few hours earlier, he was gone.  Then the phone rang and it was the police, saying that they were bringing him in.  A security guard down at the mall had taken him into custody.  He was babbling something about Gilgamesh and wearing nothing but a pajama top.  Sharon blotted the corner of her eye with the cuff of her sleeve.  "They aren't even his pajamas--they belong to my daughter."

Evaluation of Bob Naples
Bob fully met the criteria for Schizophrenia.  He had several psychotic symptoms.  Besides his badly disorganized speech and behavior, he had the negative symptoms of inappropriate affect and lack of volition (he just stopped going to work).  However, even with these typical features it is difficult to rule in the Disorganized Type of Schizophrenia during a first interview, because of the several exclusions that must first be met.
        Bob would say only one word when he was admitted, so it could not be determined whether he had cognitive deficit, as would be the case in Delirium Due to a General Medical Condition or in a Substance-Induced Psychotic Disorder caused by amphetamines or PCP.  Only after treatment was begun might be known for sure.  Other evidence of gross brain disease could be sought with skull X-rays, MRI, and blood tests as appropriate.
        Bipolar I patients can show gross defect of judgment by refusing to remain clothed, but Bob did not have any of the other typical features of mania, such as euphoric mood, hyperactivity, or pressured speech.  The absence of prominent mood symptoms would rule out Major Depressive Episode and Schizoaffective Disorder.  Over a year earlier, Bob had been found giggling to himself at his lathe, so the early manifestations of Bob's illness had been present for far longer than the six-month minimum for Schizophrenia.  This would rule out Schizophreniform Disorder.
        What about other forms of Schizophrenia?  Bob has none of the disorders of motion characteristics of Schizophrenia, Catatonic Type.  He did have each of the three symptoms required for a diagnosis of Schizophrenia, Disorganized Type.  His affect was inappropriate (he laughed without apparent cause), though reduced lability (termed flat or blunted) would also qualify.  By the time of his evaluation, his speech had been reduced to a single word, but earlier it had been incoherent (and peculiar enough that his sister even wrote some of it down).  Finally, there was loss of volition (the will to do things):  He had stopped going to work and spent most of his time in his room, apparently accomplishing nothing.  Of course, his symptoms had been continuous for a longer than a year and included prominent negative symptoms; hence the Continuous specifier would be appropriate.
        From Sharon's information, a premorbid diagnosis of Schizoid Personality Disorder also seemed warranted.  Bob's specific symptoms included the following:  no close friends, not desiring relationships, choosing solitary activities, lack of pleasure in activities, and no sexual experiences.  As noted earlier, premorbid Schizoid Personality Disorder is often found in patients later diagnosed as having Schizophrenia.
        Although Bob's eventual diagnosis would seem evident, the results of lab testing to rule out non-schizophrenia causes of psychosis should be awaited.  Therefore, a qualifier of (Provisional) should be added to the Axis I diagnosis.

295.20 Schizophrenia, Catatonic Type
The catatonic type is one of the classic schizophrenic subtypes.  It was first described in 1874; in 1896, Emil Kraeplin included it with the disorganized and paranoid types as a major subgroup of dementia praecox.  During the early part of the 20th century, each of these subtypes constituted about a third of all U.S. hospital admissions for schizophrenia.  Since that time, the prevalence of the catatonic type has declined markedly, until now it is unusual to encounter such a patient on an acute care inpatient service.  The case of Edward Clapham was abstracted from admission and discharge summaries dating to the early 1970's.
        Catatonic type patients may have any of the basic symptoms of schizophrenia, but their abnormal physical movements set them apart.  Although motor activity may be speeded up, catatonic behavior is more typically slow or retarded, sometimes to the point of stupor.
Criteria:
  The patient meets the basic criteria for schizophrenia.
  At least two catatonic symptoms symptoms.
        - Stupor or motor immobility (catalepsy or waxy flexibility)
        - Hyperactivity that has no apparent purpose and is not influenced by external stimuli
        - Mutism of marked negativism
        - Peculiar behavior such as posturing, sterotypies, mannerisms, or grimacing
        - Echolalia or echopraxia

(Coding Notes)
  Some of the terms used above require definition:
        - Negativism is demonstrated when the patient (1) refuses to follow all instructions without apparent motive, or (2) maintains a rigid posture despite the examiner's physical attempts to move the patient.
        - Mannerisms are unnecessary movements that are part of goal-directed behavior, such as flourish of the pen when signing a document.
        - Stereotypes are behaviors that do not appear to be goal-directed, such as flashing a "Victory" sign with two appraised fingers ever few seconds.
        - Posturing means that the patient spontaneously poses or assumes posture that is bizarre or inappropriate.
        - Echolalia and echopraxia are involuntary and apparently meaningless repetitions of another person's words and actions, respectively.

Third Person, Edward Clapham
Edward Clapham, a 43-year-old, single man, was admitted to the university hospital's mental health service.  He gave no chief complaint; he was entirely mute.  He had been transferred from the state psychiatric hospital, where his diagnosis had been schizophrenia, catatonic type.  For the past eight years, he had not communicated by speech or writing.
        According to the transfer note, Edward had been intensively treated with neuroleptics during his entire hospitalization, though none of these medications had helped him.  He reportedly spent the entire day every day lying on his back, toes pointing towards the foot of this bed, fists clenched and turned inward.  From years of maintaining this position, he had developed severe muscle contractures at both ankles and both wrists.  Most of the time he could be spoon-fed, but occasionally he refused to swallow and had to be fed by nasogastric tube.  This had often been the case during the past six months; despite the tube feedings, he had lost about 30 pounds.
        Ten days earlier Edward had developed a high fever (104.6 degrees F) and had been transferred to the medical service, where the staff treated a Klebsiella pneumonia with tetracycline.  Subsequently he was moved to the mental health service, where this evaluation took place.
        Very little was known about Edward's background.  He had been reared in the Midwest, the second child of a farm family.  He may have attended some college, and he had worked for approximately 10 years as tractor salesman.  On admission, his mental status examination read as follows:
 

Evaluation of Edward Clapham:
Edward fulfilled the generic criteria for Schizophrenia.  His illness had lasted far longer than the minimum of six months; it is hard to imagine how it could have had a greater effect on every aspect of his life.  Nonetheless, on admission to the mental health unit, he was given as Axis I diagnosis of 298.9 (Psychotic Disorder Not Otherwise Specified).  This provisional diagnosis was given because the clinician could not be sure from the initial presentation whether the symptoms were due to the effects of his dehydration and loss of weight (a general medical condition), Schizophrenia, or another cause such as a mood disorder, which is perhaps the most frequent cause of a catatonic syndrome.
        This list of general medical conditions that can produce catatonic behavior includes liver disease, strokes, epilepsy, and uncommon disorders such as Wilson's disease (a defect of copper metabolism).  These possibilities should be vigorously pursued with neurological and medical consultation and with appropriate laboratory and X-ray studies.  Urine or blood screens for toxic substances or drugs of abuse should be considered a part of every such patient's workup.  Any patient who presents with a first episode of catatonia should probably have an MRI.
        For patients who have catatonic excitement, mania should be carefully considered.  Many patients who have been diagnosed as having Schizophrenia, Catatonic Type, really have a manic phase of Axis I Bipolar Disorder.  On the other hand, a patient with severe psychomotor retardation should be considered for a diagnosis of Major Depressive Disorder With Melancholic Features.  Although patients with Somatization Disorder are occasionally mute or have abnormal  motor activity, such episodes are usually short-lived, lasting only a few hours or days, not years.
        Edward's symptoms were classic for Schizophrenia, Catatonic Type.  He demonstrated grimacing, muteness, waxy flexibility, and catalepsy.  He could not be called stuporous because he was alert enough to turn away from approaching stimulus (negativism).  His behavior did not include enough range to show other typical catatonic behaviors.
        After a careful review of the options, Edward was given a course of electroconvulsive therapy (ECT).  Although the first three bilateral ECT sessions produced no noticeable effect, after the fourth he asked for a glass of water.  After a total of 10 sessions, he was conversing with others on the ward, feeding himself, and walking--always on tiptoe because of the severe contractures at his ankles.  Although he continued to show residual symptoms of his disease, he lost all of his catatonic symptoms and eventually left the hospital, whereupon he was lost to follow-up.
        Edward's eight-year course of illness had been continuous.  After appropriate medical investigations and additional history ruled out other possible causes of his abnormal behavior, his revised diagnosis was as follows:
 

Axis I	295.20	Schizophrenia, Catatonic Type, Continuous
Axis II	V71.09	No diagnosis
Axis III	718.47 718.43	Contractures of ankles Contractures of wrists
Axis IV		None
Axis V	GAF = 60	(at discharge)

295.90 Schizophrenia, Undifferentiated Type
The undifferentiated type of schizophrenia is a diagnosis of exclusion.  if the actively psychotic schizophrenia patient meets criteria for none of the previously described subtypes, undifferentiated is what is left.  The criteria for this diagnosis are essentially identical to the basic criteria for schizophrenia.
Criteria:
  The patient meets the basic criteria for schizophrenia.
  The patient does not meet the criteria for paranoid, disorganized, or catatonic types.

Fourth Person, Natasha Oblamov
"She's nowhere as bad as Ivan."  Mr. Mr Oblav was talking about his grown children.  At 30 years of age, Ivan had such severe schizophrenia of the disorganized type that, despite neuroleptics and trial of ECT, he could not put 10 words together so they made sense.  Now Natasha, three years younger than her brother, had been brought to the clinic with similar complaints.
        Natasha was an artist.  She specialized in oil-on-canvas copies of the photographs she took of the countryside near her home.  Although she had had a one-woman exhibition in a local art gallery two years earlier, she still had never earned a dollar from her art work.  She had a room in her father's apartment, where the two lived on his retirement income.  Her brother lived on a back ward of the state mental hospital.
        "I suppose it's been going on for quite a while now," said Mr. Oblamov.  "I should have done something earlier, but I didn't want to believe it was happening to her, too."
        The signs had first been there about 10 months ago, when Natasha stopped attending class at the art institute and gave up her two or three drawing pupils.  Mostly she stayed in her room, even at mealtimes; she spent much of her time sketching.
        Her father finally brought Natasha for evaluation because she kept opening the door.  Perhaps six weeks earlier she had begun emerging from her room several times each evening, standing uncertainly in the hallway for several moments, then opening the front door.  After peering up and down the hallway, she would retreat to her own room.  In the past week, she had reenacted this ritual a dozen times each evening.  Once or twice, her father thought he heard her mutter something about "Jason."  When he asked her who Jason was, she only looked blank, and turned away.
        Natasha was a slender woman with a round face and watery blue eyes that never seemed to focus.  Although she volunteered almost nothing, she answered every question clearly and logically, if briefly.  She was fully oriented and had no suicidal ideas or other problems with impulse control.  Her affect was as flat as one of her canvases.  She would describe her most frightening experiences with no more emotion than if she was making a bed.
        Jason was an instructor at the art institute.  Some months earlier, one afternoon when her father was out, he had come to the apartment to help her with "some special stroking techniques," as she put it (referring to her brush).  Although they had ended up naked together on the kitchen floor, she had spent most of the time explaining why she felt she should put her clothes back on.  He left unrequited, and she never returned to the art institute.
        Not long afterward, Natasha "realized" that Jason was hanging about, trying to see her again.  She would sense his presence just outside her door, but each time she opened it, he vanished.  This puzzled her, but she couldn't say that she felt depressed, angry, or anxious.  Within a few weeks she started to hear a voice quite a bit like Jason's, which seemed to be speaking to her from the photographic enlarger she had set up in the tiny second bathroom.
        "It usually just said the 'C' word," she explained in response to a question.
        "The 'C' word?"
        "You know, the place on a woman's body where you do the 'F' word."  Unblinking and calm, Natasha sat with her hands folded in her lap.
        Several times in the past several weeks, Jason had slipped through her window at night and climbed into her bed while she slept.  She had awakened to feel the pressure of his body on hers; it was especially intense in her groin area.  By the time she had fully awakened, he would be gone.  The previous week when she went in to use the bathroom, the head of an eel--or perhaps it was a large snake--emerged from the toilet bowl and lunged at her.  She lowered the lid on the animal's neck and disappeared.  Since then, she had only used the toilet in the hall bathroom.

Evaluation of Natasha Oblamov
Natasha had a variety of psychotic symptoms.  They included hallucinations (visual in this case--the eel in the toilet) and a nonbizarre delusions about Jason.  She also had the negative symptom of flat affect (she talked about eels in her toilet without showing any emotion at all).  Although her active symptoms had been evident for only a few months, the prodromal symptom of staying in her room had been present for about 10 months.  Her disorder obviously interfered with her ability to complete a canvas, though she did not suffer from lack of volition.
        Nothing in Natasha's history would suggest a general medical condition.  However, a certain amount of time of routine lab testing might be ordered initially:  complete blood count, routine blood chemistries, urinalysis.  No evidence is given in the vignette to suggest that she had a Substance-Induced Psychotic Disorder, and her affect, though flat, was pleasant and nothing like the severely depressed mood of Major Depressive Disorder With Psychotic Features.  Furthermore, she had never had suicidal ideas.  There was nothing to suggest that she had ever had a Manic Episode.  The gradual onset of illness that persisted for longer than six months would rule out Schizophreniform Disorder and Brief Psychotic Disorder.  Finally, her brother had Schizophrenia.  About 10% of the first-degree relatives (parents, siblings, children) of patients with Schizophrenia also develop this condition.
        The subtype of Natasha's disease is easily settled.  She had no motor symptoms that would qualify her for a diagnosis of Catatonic Type; her flat affect would rule out Paranoid Type.  Her affect suggested Disorganized Type, but she did not have the other symptoms (disorganization of speech and behavior) for this diagnosis.  By the process of elimination, then, she had Undifferentiated Type, Continuous.  Although she not fulfill the criteria for Disorganized Type, she did have fairly prominent flat affect; the clinician who interviewed Natasha added a specifier to her diagnosis to reflect this symptom.  Other might not.
 

Axis I	295.20	Schizophrenia, Undifferentiated Type, Continuous, With Prominent Negative Symptoms
Axis II	799.99	Diagnosis Deferred
Axis III		None
Axis IV		None
Axis V	GAF = 30	(current)

TIP As a postscript, it should be noted that this picture of nonspecific symptoms is often found in Schizophrenia patients after they have been treated with neuroleptic medications.  When this is the case, these patients are better classified according to the symptoms observed during the most recent untreated psychotic episode.



295.60 Schizophrenia, Residual Type
The residual type of schizophrenia is essentially a place filler--a diagnosis that ought to exist but is probably seldom used in clinical practice.  It may be used for a patient whose diagnosis of schizophrenia is already established, and who has either been treated or improved spontaneously to the point of no longer having enough symptoms for a diagnosis of active disease.  Why would such a patient come for an evaluation?  Perhaps the patient comes in for an insurance-related or forensic evaluation; perhaps a colleague refers a partly treated patient for consultation.  When possible, it is better to use the diagnosis originally given the patient, with Episodic with Interepisode Residual Symptoms or Single Episode In Partial Remission as a qualifier.  There is no information about prevalence and other demographic data concerning the residual type diagnosis.
Criteria:
  The patient at one time met criteria for schizophrenia, catatonic, disorganized, paranoid, or undifferentiated type.
  The patient no longer has pronounced catatonic behavior, delusions, hallucinations, or disorganized speech or behavior.
  The patient is still ill, as indicated by either of the following:
        - Negative symptoms such as flattened affect, reduced speech output, or lack of volition, or
        - An attenuated form of at least two characteristic symptoms of schizophrenia, such as odd beliefs (related to delusions), distorted perceptions or illusions (hallucinations), odd speech (disorganized speech), or peculiarities of behavior (disorganized behavior).

Fifth Person, Ramona Kelt
When she was 20 and had been married only a few months, Ramona Kelt was hospitalized for the first time with what was called "hebephrenic schizophrenia."  According to records, her mood had been silly and inappropriate, her speech disjointed and hard to follow.  She had been admitted after putting coffee grounds and orange peels on her head.  She talked about television cameras in her closet that spied upon her whenever she had sex.
        Since then she had several additional episodes, widely scattered across 25 years.  Whenever she fell ill, her symptoms were the same.  Each time she recovered enough to return home to her husband.
        Every morning Ramon's husband had to prepare a list that spelled out her day's activities, even including meal planning and cooking.  Without it, he might arrive home to find that she had accomplished nothing that day.  The couple had no children and few friends.
        Ramona's most recent evaluation was prompted by a change in medical care plans.  Her new clinician noted that she was still taking neuroleptics; each morning her husband carefully counted them out onto her plate and watched her swallow them.  During the interview she winked and smiled when it did not seem appropriate.  She said that it had been several years since television cameras had bothered her, but she wondered whether her closet "might be haunted."

TIP As you read through the criteria for the various forms of Schizophrenia, a pattern emerges for assigning subtype diagnosis.  Catatonic symptoms take precedence over all others, even if there are prominent negative or paranoid symptoms.  If there are no catatonic symptoms, Disorganized Type is diagnosed, if the patient has the required negative symptoms.  If the patient qualifies for neither the Catatonic nor the Disorganized Type, and has prominent delusions or hallucinations, Paranoid Type will be the diagnosis.  Finally, if all else fails, diagnosis is Undifferentiated Type.

Evaluation of Ramona Kelt
Although the information contained in the vignette is sketchy, there is enough to support a strong presumption of Schizophrenia.  Ramona had been ill for many years with symptoms that included disorganized behavior and a delusion about television cameras.  The early diagnosis of Disorganized Type (hebephrenic) would seem warranted from her inappropriate affect and her bizarre speech and behavior.  However, she did not now meet the basic criteria for Schizophrenia.  Between episodes (during the most recent interview), she continued to show peculiarities or affect (winking) and ideation (the closet might be haunted) that suggested attenuated psychotic symptoms.  She also has a serious negative symptom, avolition:  If her husband didn't plan her day for her, she would accomplish nothing.
        Of course, to have any type of Schizophrenia, Ramona would have to have none of the exclusions (general medical conditions, Substance-Induced Psychotic Disorder, mood disorders, Schizoaffective Disorder).  If we assume that this was still the case, her current diagnosis would be as follows:
 

Axis I	295.260	Schizophrenia, Residual Type, Episodic With Interepisode Residual Symptoms, With Prominent Negative Symptoms
Axis II	V71.09	No diagnosis
Axis III		None
Axis IV		None
Axis V	GAF = 51	(current)

Ramona Kelt could also be diagnosed as follows:
 

Axis I

295.260

Schizophrenia, Disorganized Type, Episodic With Interepisode Residual Symptoms, With Prominent Negative Symptoms

This would convey somewhat more information about the nature and course of her illness.



Other conditions related to schizophrenia, but I don't have examples for yet, are...

- Schizophreniform Disorder
- Schizoaffective Disorder
- Delusional Disorder
- Brief Psychotic Disorder
- Shared Psychotic Disorder
- Psychotic Disorder Due to a General Medical Condition
- Substance-Induced Psychotic Disorder
- Psychotic Disorder Not Otherwise Specified



Most of this is from the book DSM-IV Made Easy, The Clinicians Guide to Diagnosis by James Morrison