Schizophrenia and catatonia: from ICD-10 to ICD-11
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- 04.09.2025
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Abstract
Introduction
The diagnostic criteria for schizophrenia and catatonic syndromes have undergone numerous conceptual and nosological changes throughout history—most recently, in a substantial way, with the introduction of the Eleventh Revision of the International Classification of Diseases (ICD-11). In this article, we examine the key innovations of the ICD-11 regarding the classification of schizophreniform disorders and catatonia. The focus lies on the abandonment of traditional subtypes, the introduction of symptom and course specifiers, and the reevaluation of catatonia as an independent, cross-diagnostic entity (see Table 1). The group formerly referred to in ICD-10 as “Schizophrenia, schizotypal, and delusional disorders” has been renamed “Schizophrenia or other primary psychotic disorders” in ICD-11.
Table 1
Comparison of the diagnostic groups “Schizophrenia, schizotypal and delusional disorders” in ICD-10 and “Schizophrenia or other primary psychotic disorders” in ICD-11
ICD-10 | ICD-11 (Draft version) |
|---|---|
Schizophrenia, schizotypal and delusional disorders | Schizophrenia and other primary psychotic disorders |
Paranoid schizophrenia (F20.0) | Schizophrenia, first episode (6A20.0) |
Hebephrenic schizophrenia (F20.1) | Schizophrenia, multiple episodes (6A20.1) |
Undifferentiated schizophrenia (F20.3) | Schizophrenia, continuous (6A20.2) |
Postschizophrenic depression (F20.4) | – |
Residual schizophrenia (F20.5) | – |
Schizophrenia simplex (F20.6) | – |
Other schizophrenia (F20.8) | Other specified episode of schizophrenia (6A20.Y) |
Schizophrenia, unspecified (F20.9) | Schizophrenia, episode unspecified (6A20.Z) |
Schizotypal disorder (F21) | Schizotypal disorder (6A22) |
Persistent delusional disorders (F22) | Delusional disorder (6A24) |
Induced delusional disorders (F24) | |
Acute polymorphic psychotic disorders (F23) | Acute and transient psychotic disorders (6A23) |
Schizoaffective disorders (F25) | Schizoaffective disorders (6A21) |
Diagnostic criteria for schizophrenia according to ICD-10
According to ICD-10, a diagnosis of schizophrenia was made based on characteristic constellations of symptoms that persisted for a period of at least 1 month. ICD-10 distinguished between two complexes of four symptoms each:
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At least one unambiguous symptom from groups one to four (or two or more if less unambiguous) over a period of at least 1 month:
1.
Thought echo; thought insertion or withdrawal; thought broadcasting
2.
Delusions of control or influence; experiences of passivity in relation to body movements, thoughts, actions, or sensations; delusional perception
3.
Hallucinatory voices that provide a running commentary on the patient or having a dialog about the patient among themselves
4.
Persistent culturally inappropriate, bizarre delusions
Or at least two clear symptoms from groups five to eight over a period of at least 1 month:
5.
Persistent hallucinations in any sensory modality
6.
Neologisms, thought blocking or insertion into the train of thought
7.
Catatonic symptoms (excitement, posturing, negativism, etc.)
8.
Negative symptoms such as poverty of speech, affective flattening, or apathy
ICD-11 diagnostic criteria for schizophrenia (code: 6A20)
In contrast to the old concept, diagnosis under ICD-11 is based on a combined (or hybrid) categorical–dimensional approach. The full criteria can be found on the WHO website (https://icd.who.int/en).
Core diagnosis code (categorical approach)
When the categorical threshold is met (two symptoms, at least one of which is a core symptom), with a duration of ≥ 1 month and exclusion of other causes (differential diagnosis), schizophrenia can be diagnosed. The ICD-11 task group had explored arguments for harmonizing the minimum required symptom duration with the DSM‑5 (≥ 6 months), but due to lack of evidence favoring one duration over the other, the ICD-11 retained the 1‑month criterion from ICD-10.
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Thus, as in ICD-10, the following symptoms must be present for at least 1 month to diagnose schizophrenia.
Core symptoms
At least two symptoms must be present from a list of seven categories. At least one must stem from the so-called core symptoms (a–d):
a)
Delusions (persistent delusional beliefs): Examples given in ICD-11 include persecutory, grandiose, or referential delusions.
b)
Hallucinations (persistent hallucinations): Auditory hallucinations are most common, but they can occur in any sensory modality.
c)
Disorganized thinking: Typically manifests as formal thought disorder—e.g., loose associations, neologisms, incoherence, or “word salad.”
d)
Experiences of influence, passivity, or control: ICD-11 describes this as the experience that emotions, impulses, thoughts, bodily functions, or behavior are being controlled by an external force—e.g., thought insertion, withdrawal, or broadcasting.
Additional symptoms (e–g)
e)
Negative symptoms (e.g., affective flattening, poverty of speech, lack of motivation)
f)
Disorganized behavior (e.g., bizarre or purposeless behavior, unpredictable or inappropriate emotional responses)
g)
Psychomotor disturbances (including catatonic symptoms such as catatonic excitement)
Note.
In ICD-11, catatonia is classified as an independent disorder, no longer as a subtype of schizophrenia. If catatonic symptoms are present and diagnostic criteria are met (see below), a separate diagnosis of catatonia should be coded in addition to schizophrenia (Code 6A40: Catatonia associated with another mental disorder).
Exclusion of other causes
As in ICD-10, symptoms must not be attributable to other medical conditions, substance use, or mood disorders; ICD-11 remains somewhat vague on this. In clinical practice, it is therefore advisable to follow the recommendations of the AWMF/DGPPN S3 Guideline on Schizophrenia [1] for organic initial, differential, and course diagnostics [2]. The guideline adopts a clinically pragmatic approach based on “red flag” symptoms that indicate an organic cause and necessitate further diagnostics (e.g., lumbar puncture, rheumatological labs, EEG, etc.). In general, it is recommended that—unless contraindicated—every person with schizophrenia undergoes magnetic resonance imaging (MRI) of the brain at least once in their lifetime. Secondary psychotic syndromes will be coded in the future as 6E61.1.
Extension codes (dimensional approach)
The former subtypes (paranoid, hebephrenic, catatonic, etc.) have been removed. Instead, course and symptom specifiers can now be used.
Course specifiers
The episode status is integrated into the main code, as the first digit after the period (Table 2).
Table 2
Episode status as a course specifier of schizophrenia
Code | Significance |
|---|---|
6A20.0 | Schizophrenia, first episode |
6A20.1 | Schizophrenia, multiple episodes |
6A20.2 | Schizophrenia, continuous |
6A20.Y | Other symptoms |
6A20.Z | Not further specified |
The remission status is also integrated into the main code, as the second digit after the period (Table 3).
Table 3
Remission status as a course specifier of schizophrenia
Code | Significance |
|---|---|
6A20.x0 | Currently symptomatic |
6A20.x1 | In partial remission |
6A20.x2 | In full remission |
6A20.xZ | Unspecified |
Symptom classifiers in the dimensional concept
Symptom classifiers are listed in Table 4.
Table 4
Schizophrenia symptom classifiers
Code | Symptom dimension |
|---|---|
6A25.0 | Positive symptoms |
6A25.1 | Negative symptoms |
6A25.2 | Depressive symptoms |
6A25.3 | Manic symptoms |
6A25.4 | Psychomotor symptoms |
6A25.5 | Cognitive symptoms |
Severity classifiers
These are applied as extension codes (e.g., XS0T, XS5W) and are post-coordinated to the main code. They describe the intensity of the symptom dimension, independently of the disorder itself (Table 5).
Table 5
Schizophrenia severity classifiers
Code | Severity |
|---|---|
XS8H | No symptoms |
XS5W | Mild symptoms |
XS0T | Moderate symptoms |
XS25 | Severe Symptoms |
Infobox ICD-11 diagnostic criteria of schizophrenia
The ICD-11 diagnostic criteria for schizophrenia (WHO) explicitly require:
-
At least two symptoms from a list of seven symptom domains.
-
At least one must come from points (a) through (d).
-
Duration: Symptoms must be present “most of the time over a period of ≥ 1 month.”
Thus, the criteria do not represent a purely open dimensional approach, but rather a hybrid form:
-
Categorical threshold: (two symptoms, at least one from a–d)
-
Dimensional additions: (symptom qualifiers, severity, functional impact, course)
Changes in ICD-11 compared to previous ICD-10 criteria for schizophrenia
The diagnosis of schizophrenia in ICD-11 is now based on a more modern, holistic, and hybrid categorical–dimensional approach, which weighs various symptom clusters (positive, negative, disorganized, cognitive, and catatonic symptoms) in relation to functional status, severity of impairment, and individual course of illness. This replaces the rigid classification into specific subtypes as in ICD-10 in favor of a more flexible and individualized diagnostic process. ICD-11 aims to better account for the individual trajectory of the illness rather than relying solely on the presence of a fixed number of specific symptoms. The subtypes used in ICD-10 have also been eliminated (see below).
Notably, catatonia is now classified as an independent diagnosis, and no longer part of the schizophrenia spectrum.
ICD-11 diagnostic criteria for catatonia
The new ICD-11 classification marks a paradigmatic shift in the diagnosis of catatonia: For the first time since Karl Kahlbaum’s original description, it once again centers on the psychomotor nature of the syndrome—departing from the century-long interpretation initially described by Emil Kraepelin and Eugen Bleuler [3, 4]. ICD-11 thus enables syndrome-oriented diagnostics and facilitates the distinction from clinically similar conditions such as neuroleptic malignant syndrome (NMS) or delirium.
Catatonia according to ICD-11 can be diagnosed based on 15 clinical signs and symptoms (see Table 6), categorized into three groups of psychomotor abnormalities: reduced, increased, and abnormal psychomotor activity [5]. This classification reflects research findings that differentiate between hypokinetic, hyperkinetic, and parakinetic forms [6, 7].
Table 6
Symptoms of catatonia according to ICD-11
Reduced psychomotor activity | Increased psychomotor activity | Abnormal psychomotor activity |
|---|---|---|
Staring | Extreme hyperactivity or agitation without cause, with non-purposeful movements | Grimacing |
Ambitendency | Uncontrollable, extreme emotional reactions | Mannerisms |
Negativism | Impulsivity | Posturing |
Stupor | Aggression toward others | Stereotypies |
Mutism | Rigidity | |
Echolalia/Echopraxia | ||
Verbigeration | ||
Waxy flexibility | ||
Catalepsy |
Interestingly, these criteria are unevenly distributed:
-
Nine features are assigned to the abnormal group.
-
Five features to the reduced group.
-
And only one combined criterion for increased psychomotor activity.
Although this domain is formally counted as a single criterion, it actually includes several clinically relevant phenomena: extreme hyperactivity or agitation without obvious cause, purposeless movements, and/or uncontrollable extreme emotional reactions; impulsivity (sudden, unprovoked inappropriate behavior); and aggression toward others, with or without risk of injury. Despite this symptom diversity, the simultaneous presence of several of these forms is counted only as one criterion, unlike the other two symptom groups [5].
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As a result, purely hypokinetic or parakinetic forms of catatonia can be diagnosed based on their symptoms, whereas hyperkinetic catatonia requires additional symptoms from the other two groups ([5]; see Table 7).
Table 7
The newly established diagnostic group of catatonia in ICD-11 and the previously classified diagnosis of catatonic schizophrenia in ICD-10
ICD-10 | ICD-11 (Draft version) |
|---|---|
Catatonia | |
Catatonic schizophrenia (F20.2) | Catatonia associated with another mental disorder (6A40) |
– | Catatonia induced by substances or medications (6A41) |
– | Secondary catatonia syndrome (6E69) |
– | Catatonia, unspecified (6A4Z) |
Another diagnostically relevant ICD-11 criterion for catatonia concerns duration. Typically, signs must persist for several hours to be considered diagnostically significant. However, in cases of particularly striking symptoms—such as stupor, catalepsy, mutism, or negativism—or when accompanied by autonomic disturbances (e.g., cardiovascular or respiratory dysregulation), a shorter duration of around 15 min may suffice. This temporal flexibility reflects clinical reality, where catatonic states may be acute and transient.
ICD-11 also explicitly notes that catatonia can occur across the lifespan, consistent with evidence that catatonic syndromes can be observed in childhood and adolescence [8, 9]. At the same time, catatonia represents an important differential diagnosis in older adults, making it a relevant clinical phenomenon for both child/adolescent psychiatry and geriatric psychiatry [10].
ICD-11 diagnostic subcategories for catatonia
-
Catatonia associated with other mental disorders (Code 6A40): Can occur with conditions such as schizophrenia, developmental disorders, bipolar disorder, or depression.
-
Catatonia induced by substances or medications (Code 6A41): A distinct diagnostic category for catatonic syndromes associated with intoxication or withdrawal.
-
Secondary catatonia syndrome/catatonia due to medical conditions (Code 6E69): Allows for a diagnosis in the context of neurological or other physical illnesses. Conditions that can be associated include: diabetic ketoacidosis, hypercalcemia, hepatic encephalopathy, homocystinuria, neoplasms, head trauma, cerebrovascular disease, and encephalitis. In cases of early-onset, acute psychosis or rapid deterioration of a developmental disorder, especially with focal neurological symptoms, autoimmune encephalitis (e.g., anti-NMDAR) must be ruled out.
-
Unspecified catatonia (Code 6A4Z): A residual category when no specific cause can be assigned.
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With catatonia now recognized as an independent diagnosis, ICD-11 better reflects the etiological and clinical heterogeneity of catatonic syndromes. By clearly separating it from schizophrenia, it brings both conceptual clarity and therapeutic relevance to clinical practice: Antipsychotics are no longer considered the standard treatment for catatonia. On the contrary, they may worsen symptoms, trigger neuroleptic malignant syndrome, or obscure diagnosis due to extrapyramidal side effects [11]. While antipsychotic use may be considered in specific cases—such as catatonic states within psychotic episodes—caution is essential. ICD-11 provides critical therapeutic flexibility, allowing for targeted treatment with benzodiazepines or electroconvulsive therapy (ECT) independent of a schizophrenia diagnosis. Future research should focus on identifying which symptoms most specifically and reliably indicate catatonic states. Additionally, standardization of catatonic signs and symptoms in both research and clinical settings is desirable to further improve diagnostic clarity and international comparability.
Practical conclusion
-
ICD-11 replaces the previous subtype system of schizophrenia according to ICD-10 with a hybrid categorical–dimensional approach, integrating symptom and course specifiers into diagnosis.
-
Categorical: Diagnosis of schizophrenia requires at least two symptoms, one of which must be from the core group (delusions, hallucinations, thought disorder, disturbances of self-experience) present for at least 1 month.
-
Dimensional: Symptom and course specifiers (e.g., remission status, dominant symptom dimension such as negative, psychomotor, or cognitive) can be coded additionally.
-
ICD-11 thus marks a departure from the historical emphasis on first-rank symptoms per Kurt Schneider.
-
Catatonia is no longer a schizophrenia subtype but an independent, cross-diagnostic entity with specific ICD-11 criteria.
-
The new catatonia classification includes symptoms from three psychomotor domains (reduced, increased, abnormal) and eliminates the 1‑month duration requirement from ICD-10, also accounting for shorter-lasting states.
-
The ICD-11 catatonia diagnosis represents a clinically meaningful advancement, recognizing catatonic syndromes outside of schizophrenia and harmonizing diagnostic criteria regardless of underlying condition.
-
Catatonic syndromes can now be diagnosed more precisely, independently of the underlying illness—whether affective, developmental, substance-related, or medical.
-
This opens new diagnostic and therapeutic options: Catatonia can be treated independently of a schizophrenia diagnosis, e.g., with benzodiazepines or ECT, while antipsychotics should be used with caution.
-
Overall, ICD-11 offers enhanced opportunities for refined diagnostics and initiation of tailored, individualized treatments.
Acknowledgements
This article contains excerpts from the chapters “Schizophrenia, Schizotypal and Delusional Disorders (F2)” and “Catatonia” from the book Facharztwissen Psychiatrie, Psychosomatik und Psychotherapie, edited by Schneider and Schneider, Springer, Heidelberg, 2025.
Funding
This work was supported by the German Center for Mental Health (DZPG) (Munich-Augsburg, Grant No. 01EE2303C; Magdeburg, Grant No. 01EE2305D). It was also funded by the German Research Foundation (DFG) (Grant No. DFG HI 1928/5‑1 awarded to D. Hirjak). The DFG had no involvement in the writing of this article or the decision to submit the manuscript for publication.
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Declarations
Conflict of interest
T. Nickl-Jockschat has received lecture honoraria from Janssen-Cilag and has been invited to conferences by Boehringer-Ingelheim. J. Steiner has received lecture honoraria from Janssen-Cilag and Boehringer-Ingelheim; invitations to conferences or other activities were declined. D. Hirjak has received honoraria from Rovi and Teva, lecture fees from the DGPPN, and editorial honoraria from Elsevier and Thieme Verlag. A. Hasan has received lecture honoraria from AbbVie, Advanz, Janssen, Otsuka, Rovi, Recordati, and Lundbeck. He has also served on advisory boards for Boehringer-Ingelheim, Teva, AbbVie, Janssen, Otsuka, Rovi, Recordati, and Lundbeck; invitations to conferences or other activities were declined. A. Hasan is also the lead editor of the AWMF S3 Guideline on Schizophrenia.
For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.
The supplement containing this article is not sponsored by industry.
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