Other Schizophrenia Spectrum and Psychotic Disorders

ByMatcheri S. Keshavan, MD, Harvard Medical School

Reviewed ByMark Zimmerman, MD, South County Psychiatry

Reviewed/Revised Modified Jul 2025

v8914120

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Some significant episodes of psychotic symptoms do not fulfill criteria for other diagnoses in the schizophrenia spectrum. They are either specified or unspecified. They may be treated with psychotherapy or antipsychotic medication.

Psychosis refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and bizarre and inappropriate motor behavior (including catatonia) that indicate loss of contact with reality.

Other psychotic disorders are categorized as specified or unspecified (1).

These categories refer to symptoms that are typical of a schizophrenia spectrum or other psychotic disorder (eg, delusions, hallucinations, disorganized thinking and speech, catatonic behavior), that cause substantial social and occupational distress and impairment, but that do not meet the full criteria for any specific disorder. These categories sometimes apply early in a schizophrenia spectrum disorder before it has fully manifested.

A disorder is classified as specified if the clinician chooses to specify how the characteristics of the symptoms do not meet the criteria for a specific disorder. For example, a patient may have persistent auditory hallucinations with no other symptoms, and thus not meet criteria for schizophrenia, which requires 2 psychotic symptoms. The specified disorders include the following:

Persistent auditory hallucinations ("hearing voices")
Delusions with overlapping episodes of depression or mania
Mild (attenuated) psychotic symptoms
Delusional symptoms in the context of relationship with an individual with prominent delusions (shared delusions)

The unspecified category is used when the information needed to make a diagnosis is insufficient (eg, in an emergency department). The term "psychotic disorder not otherwise specified" is no longer used as a diagnosis.

Antipsychotic medications and psychiatric referral may be used as needed.

Reference

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision, DSM-5-TR (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, 2022, p 139.

Shared Delusions

Shared psychosis occurs when people acquire a delusion from someone with whom they have a close personal relationship.

Shared psychosis (formerly termed folie à deux) was previously considered a subset of delusional disorder, but it is now classified in the DSM-5-TR under Other Specified Schizophrenia Spectrum and Psychotic Disorders and described as "Delusional symptoms in the context of relationship with an individual with prominent delusions" (1). It usually occurs in a person or group of people (usually a family) who are related to a person with a significant delusional disorder or schizophrenia. The prevalence of shared psychosis is not known, but the disorder appears to be rare. The patient with the primary disorder is usually the socially dominant member in the relationship and imposes the delusion on or convinces the patient with the secondary disorder of the unusual beliefs.

Identifying which person in the relationship has the primary psychosis is important because the person with the secondary disorder typically does not maintain the delusional beliefs when separated from the person with the primary disorder.

Psychotherapy can usually help people who have a shared psychosis. Usually, the person with the primary psychotic disorder will require pharmacologic treatment.

Reference

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision, DSM-5-TR (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, 2022, pp 105-109.

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