ICD-116A25	SYMPTOMATIC MANIFESTATIONS OF PRIMARY PSYCHOTIC DISORDERS Symptomatic manifestations of primary psychotic disorders
ICD-10—	No ICD-10 equivalent
DSM-5-TRF29	Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

1. Definition and nosology

6A25 In ICD-11, the group of primary psychotic disorders (6A20–6A24) has a dimensional sub-structure. It is not a separate clinical nosological unit — the diagnosis is placed as an additional qualifier onto the primary disorder (e.g., 6A20 Schizophrenia). Six symptom domains — Each is assessed separately for severity level (none / mild / moderate / severe).

The basis of the concept — to describe the heterogeneous clinical presentation of psychotic disorders using a more valid and dimensional measure instead of classic subtypes (paranoid, hebephrenic, catatonic).

2. History

• Bleuler's “4A” symptoms (1911) and Schneider's “first-rank symptoms” (1959) — categorical approach.
• Crow T.J. (1980) — Concept of Type I (positive symptom dominant) and Type II (negative dominant) — the basis of the dimensional approach.
• Liddle P.F. (1987) — three-dimensional factor — reality distortion, disorganization, psychomotor poverty.
• DSM-5 (2013) — Section III research category proposes dimensional assessment.
• ICD-11 (2019) — 6A25 integrated as an official dimensional qualifier.

3. Six symptom domains

3.1 Positive symptoms

Delusion, hallucination — “excessive/added” symptoms in perception and thought processes. Severity: from absence to severe level (according to degree of impact on patient's daily activities).

3.2 Negative symptoms

Affective flattening, avolition (loss of motivation), alogia (poverty of speech), anhedonia, social withdrawal. A major factor in functional impairment; responds poorly to pharmacotherapy.

3.3 Depressive symptoms

Low mood, hopelessness, suicidal ideation, psychomotor retardation, anhedonia (emotional component dominant, as opposed to negative symptom).

3.4 Manic symptoms

Elevated or irritable mood, rapid thinking, grandiose ideas, decreased sleep need, rapid speech, psychomotor agitation.

3.5 Psychomotor symptoms

Catatonic components (mutism, negativism, waxy flexibility, posturing), agitation, retardation, stereotypy.

3.6 Cognitive symptoms

Working memory, attention, executive function, processing speed, social cognition. Present in 75–85% of patients; strong impact on long-term functional level.

4. Clinical use

4.1 Assessment tools

• PANSS (positive, negative, general psychopathology subscales).
• SANS / SAPS — negative and positive symptoms separately.
• HAM-D, MADRS — depressive component.
• YMRS — manic component.
• Bush-Francis Catatonia Rating Scale — psychomotor component.
• MATRICS Consensus Cognitive Battery (MCCB) — cognitive component.

4.2 Treatment implications

• Positive symptoms predominate — standard antipsychotic (D2 antagonist).
• Negative symptoms predominate — Atypical antipsychotic superior (clozapine, cariprazine); amisulpride low dose; psychosocial rehabilitation.
• Depressive component — Adjunctive SSRI (sertraline) or antidepressant; suicide risk monitoring.
• Manic component — mood stabilizer (lithium, valproate) adjunct; reevaluation as schizoaffective disorder.
• Catatonic component — lorazepam test or ECT.
• Cognitive component — cognitive remediation (Wykes 2011 meta-analysis); enhances effect on functional level when applied together with supported employment.

5. Source-specific specifications

• ICD-11 (6A25): periodic reassessment recommended as severity per domain changes during illness course.
• DSM-5-TR: Section III research category ‘Clinician-Rated Dimensions of Psychosis Symptom Severity’ — parallel to ICD-11 6A25; not an official diagnostic qualifier, but can be used in practice.
• NICE CG178: dimensional assessment recommended as clinical approach — basis for individualized treatment.

6. Myths and misconceptions

Myth 1: “6A25 is a separate disorder, can be diagnosed as such”

Reality: 6A25 is not a separate clinical entity — it is a qualifier of the primary disorder (6A20–6A24).

Myth 2: “Dimensional approach replaces categorical diagnosis”

Reality: both complementary — categorical diagnosis provides nosological unit, dimensional qualifier describes specific clinical presentation.

Myth 3: “Negative symptoms are side effects of antipsychotics, not ‘real’”

Reality: Primary negative symptoms are a core feature of schizophrenia — observed even before antipsychotics. Secondary negative symptoms (sedation, EPS, depression, positive symptom effect) are distinct and manageable.

7. Sources

1. WHO. ICD-11. 6A25 Symptomatic manifestations of primary psychotic disorders. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG178. 2014/2019.
4. Crow T.J. Molecular pathology of schizophrenia: more than one disease process? Br Med J 1980;280(6207):66–68.
5. Liddle P.F. The symptoms of chronic schizophrenia. A re-examination of the positive-negative dichotomy. Br J Psychiatry 1987;151:145–151.
6. Kay S.R., Fiszbein A., Opler L.A. PANSS. Schizophr Bull 1987;13(2):261–276.
7. Wykes T. et al. Am J Psychiatry 2011;168(5):472–485.