sub-types of schizophrenia

7/28/2019 Sub-types of Schizophrenia

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SUB-TYPES OF SCHIZOPHRENIACLINICAL FEATURES AND DIAGNOSIS

Presented by Dr Pavan kumar

Chaired by Dr Safeekh A.T


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INTRODUCTION

Kraepelin in 1899 classified dementia praecox into

hebephrenic, catatonic, and paranoid groups.

E. Bleuler(1911) added simple schizophrenia as 4th group.

Cameron (1947) classified in accordance with behavioristicconcepts into 3 main groups:

the aggressive,

the submissive, and

the detached.


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C. Schneider(1942) described three symptom-complexes in

schizophrenia as disorder of complexes of functions in CNS. These syndromes are

- the thought withdrawal syndrome experience of

alienation of ones own acts and

Gedankenlautwerden ( thoughts becoming loud)- the desultory syndrome disorders of social feeling and

bodily hallucination and

- the drivelling syndrome primary delusions.


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Thought withdrawal syndrome

Thought withdrawal associated with fragmentation of thought,verbal derailment, and blocking.

Inspirations or sudden delusional ideas which appear to come

from natural sources are also a part of this syndrome.

Patients have cosmic, universal, or religious experiences. The experience ofloss of personal control over ones actions

frequently occurs so that the patients experience their own

actions as being made or forced upon them from outside.

The outstanding affective disorder in this syndrome isperplexity (confusion).


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Desultory syndrome

Characterized by desultory (disconnected) thinking, i.e.thought makes jumps and therefore

proceeds in an irregular way.

Lack of inner drive, unable to react quickly and adequately to

environmental changes. Affect is flattened

Patients are unable to feel happy or sad, but may pass into

states of anger, anxiety, whining, or despair.

Feel changed in themselves and have bodily hallucinations.


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Drivelling syndrome

Vague drivelling (silly) thinking No gross grammatical disorder

Although speech and thinking are superficially integrated, the

content is drivel.

Delusions of significance and primary delusional experiences Affect is inadequate

Lack of interest in real things and values.


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Kleist from Frankfurt school regards schizophrenia as a

disease of nervous systemwhich may be confined to one neurological system or

which may affect different systems within neurological system.

Typical schizophrenia made up of many subgroups whichare due to different neurological system illnesses.

More insidious in onset, more steadily progressive

Atypical schizophrenia due to disorders of many differentneurological systems

More episodic, marked remissions

Greater genetic loading than typical.


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He divides schizophrenia into 4 major groups

Paranoid, catatonic, hebephrenic and confused Confused schizophrenia - severe disorder of speech or

thought which gives rise to grossly muddled expressions.

He divided

Paranoid - into 7 typical and one atypical form, catatonia - into 7 typical and one atypical form,

confused - into 3 typical and 2 atypical forms and

Hebephrenia - into 4 typical forms


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Leonard (1936) who studied chronic schizophrenia classified

systematic and non-systematic types which correspondto Kleist's typical and atypical forms.

Like Kleist, he separated from schizophrenia a group of non-

affective functional psychoses having favorable outcome

called cycloid psychoses

The Cycloid Psychosis

Anxiety-Elation Psychosis

Exited-Inhibited Confused Psychosis Hyperkinetic- Akinetic Motility Psychosis

He considers non-systemic schizophrenias more closely

related to cycloid psychoses than to systemic psychoses.


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The Unsystematic Schizophrenias

Affective Paraphrenia Cataphasia (Schizophasia)

Periodic Catatonia

The Systematic Schizophrenias

Simple Systematic Schizophrenias Catatonic Forms

Parakinetic Catatonia

Manneristic Catatonia

Proskinetic Catatonia

Negativistic Catatonia

Speech-Prompt Catatonia

Sluggish Catatonia


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Hebephrenic Forms

Foolish Hebephrenia

Eccentric Hebephrenia

Shallow Hebephrenia

Autistic Hebephrenia

Paranoid Forms

Hypochondrical Paraphrenia

Phonemic Paraphrenia

Incoherrent Paraphrenia

Fantastic Paraphrenia

Confabulatory Paraphrenia Expansive Paraphrenia

Combined Systematic Schizophrenias

Combined Systematic Catatonias

Combined Systematic Hebephrenias

Combined Systematic Paraphrenias


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Clinical Syndromes in chronic schizophrenia

Positive and Negative symptoms (Andreasen et al. 1983)

Positive symptoms Negative symptoms

hallucinations,

delusions,

formal thought disorder,

bizarre behaviour

Avolition

Affective blunting,

Alogia (impoverished thinking and speech),

AsocialityApathy,

Anhedonia,

disturbance of attention


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Positive, Negative, and disorganization syndromes

(Liddle, 1987)Reality Distortion Syndrome

delusions,

hallucinations

Psychomotor Poverty Syndrome poverty of speech, decreased spontaneous movement,

unchanging facial expression, paucity of expressive gesture,

lack of affective responsiveness, lack of vocal inflection

Disorganization syndrome disorganization: inappropriate affect, incoherent speech,

poverty of content of speech syndromes are validated by recent factor-analytic and neuroimaging studies

(Liddle et al. 1992)


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Deficit syndrome (Carpenter et al. 1988)

Primary, enduring negative symptoms reflect a distinct neuralsubstrate

emphasis on distinguishing primary from secondary negative

symptoms (e.g.Parkinsonism, depressed mood)

Continuum of psychosis (Crow, 1990; Greisinger, 1870)

single psychosis, with schizophrenia most severe,

affective disorders least severe,

schizoaffective disorders occupy intermediate position.


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Crow classified schizophrenia patients into

Type 1 and type 2 On basis of presence or absence of positive(productive) and

negative (deficit) symptoms.

Type I Type II

positive symptoms,

good response to treatment,

relatively better outcome

negative symptoms,

poorer response to treatment,

relatively poor outcome,

MRI changes.


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Neurodevelopmental classification (Murray et al. 1992)

Congenital schizophrenia

abnormality is present at birth

more likely to involve minor physical abnormalities, abnormal

personality, or social impairment in childhood more likely to be male and have a poor outcome

Adult-onset schizophrenia

more likely to exhibit positive and affective symptoms

may have a genetic predisposition to manifest

symptomatology anywhere along a continuum from bipolar

disorder, schizoaffective disorder, to schizophrenia


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ICD 10 ICD 9 ICD 8


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Paranoid schizophrenia

Commonest type

dominated by relatively stable, often paranoid delusions,usually accompanied by hallucinations, particularly of the

auditory variety, and perceptual disturbances.

Disturbances of affect, volition, and speech, and catatonic

symptoms, are not prominent.


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Examples of the most common paranoid symptoms are:

(a)delusions of persecution, reference, exalted birth, specialmission, bodily change, or jealousy;

(b)hallucinatory voices that threaten the patient or give

commands, or auditory hallucinations without verbal form,

such as whistling, humming, or laughing;

(c)hallucinations of smell or taste, or of sexual or other bodily

sensations; visual hallucinations may occur but are rarely

predominant.


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Differential diagnosis.

exclude epileptic and drug-induced psychoses, and toremember that persecutory delusions might carry little

diagnostic weight in people from certain countries or cultures.

Excludes: involutional paranoid state (F22.8), paranoia

(F22.0)


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DCR 10

F20.0 Paranoid schizophrenia

A. The general criteria for Schizophrenia must be met. B. Delusions or hallucinations must be prominent (such as

delusions of persecution, reference, exalted birth, special

mission, bodily change or jealousy; threatening or

commanding voices, hallucinations of smell or taste, sexual or

other bodily sensations).

C. Flattening or incongruity of affect, catatonic symptoms, or

incoherent speech must not dominate the clinical picture,

although they may be present to a mild degree.


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DSM IV TR

295.30 Paranoid Type

A type of Schizophrenia in which the following criteria aremet:

A. Preoccupation with one or more delusions or frequent

auditory hallucinations.

B. None of the following is prominent: disorganized speech,disorganized or catatonic behavior, or flat or inappropriate

affect.


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F20.1 Hebephrenic schizophrenia

A form of schizophrenia in which

affective changes are prominent, delusions and hallucinations fleeting and fragmentary,

behaviour irresponsible and unpredictable, and

mannerisms common.

The mood is shallow and inappropriate and often accompanied by giggling or self-satisfied,

self-absorbed smiling, or by a lofty manner, grimaces,

mannerisms, pranks, hypochondriacal complaints, and

reiterated phrases.


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Thought is disorganized and

speech rambling and incoherent. tendency to remain solitary, and

behaviour seems empty of purpose and feeling.

This form of schizophrenia usually starts between the ages of

15 and 25 years and tends to have a poor prognosis because of the rapid

development of "negative" symptoms, particularly flattening of

affect and loss of volition.


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In addition, disturbances of affect and volition, and thought

disorder are usually prominent.

Hallucinations and delusions may be present but are not

usually prominent.

Drive and determination are lost and goals abandoned, so

that the patient's behaviour becomes characteristically

aimless and empty of purpose.

A superficial and manneristic preoccupation with religion,

philosophy, and other abstract themes may add to the

listener's difficulty in following the train of thought.

Di ti id li


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Diagnostic guidelines

The general criteria for a diagnosis of schizophrenia must be

satisfied.

Hebephrenia should normally be diagnosed for the first time

only in adolescents or young adults.

The premorbid personality is characteristically, but not

necessarily, rather shy and solitary.

For a confident diagnosis of hebephrenia, a period of 2 or 3

months of continuous observation is usually necessary, in

order to ensure that the characteristic behaviours described

above are sustained.

Includes: disorganized schizophrenia

hebephrenia

DCR 10 F20 1 H b h i hi h i


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DCR 10 F20.1 Hebephrenic schizophrenia

A. The general criteria for Schizophrenia above must be met.

B. Either (1) or (2): (1) Definite and sustained flattening or shallowness of affect;

(2) Definite and sustained incongruity or inappropriateness of

affect.

C. Either (1) or (2): (1) Behaviour which is aimless and disjointed rather than

goal-directed;

(2) Definite thought disorder, manifesting as speech which is

disjointed, rambling or incoherent. D. Hallucinations or delusions must not dominate the clinical

picture, although they may be present to a mild degree.

DSM IV TR


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DSM IV TR

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria aremet:

A. All of the following are prominent:

(1 ) disorganized speech

(2) disorganized behavior (3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Di i d h b h i hi h i


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Disorganized or hebephrenic schizophrenia

ICD 10 requires flat or inappropriate affect AND either disorganized speech OR

disorganized behavior

DSM 4 tr def is more severe in that disorganized speech, disorganized behaviorAND flat or inappropriate affect are all required.

DSM-IV-TR diagnostic criteria include disorganized speech, disorganized behavior,

and flat/inappropriate

affect and exclude catatonia and delusions and hallucinations that are systematizedinto a lucid theme.

ICD-10 criteria are similar to DSM-IV-TR criteria but add that the

disorganized/hebephrenic subtype should normally be diagnosed for the first time onlyin adolescents or young adults, with a period of 23 months of observation ensuring

sustained characteristic features.

ICD-10 also indicates that the premorbid personality of these individuals includes timid

and solitary behavior.

ICD 10


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ICD 10

F20.2 Catatonic schizophrenia

Prominent psychomotor disturbances are essential anddominant features and

may alternate between extremes such as hyperkinesis and

stupor, or automatic obedience and negativism.

Constrained attitudes and postures may be maintained forlong periods.

Episodes of violent excitement may be a striking feature of

the condition.

For reasons that are poorly understood, catatonicschizophrenia is now rarely seen in industrial countries,

though it remains common elsewhere.

These catatonic phenomena may be combined with a dream-

like (oneiroid) state with vivid scenic hallucinations.



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general criteria for diagnosis of schizophrenia be satisfied.

Transitory and isolated catatonic symptoms may occur in thecontext of any other subtype of schizophrenia, but for a

diagnosis of catatonic schizophrenia one or more of the

following behaviours should dominate the clinical picture:

(a)stupor(marked decrease in reactivity to the environment

and in spontaneous movements and activity) or mutism;

(b)excitement (apparently purposeless motor activity, not

influenced by external stimuli);

(c)posturing (voluntary assumption and maintenance of

inappropriate or bizarre postures);


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(d)negativism (an apparently motiveless resistance to all

instructions or attempts to be moved, or movement in the

opposite direction);

(e)rigidity (maintenance of a rigid posture against efforts to

be moved);

(f) waxy flexibility (maintenance of limbs and body in

externally imposed positions); and

(g)other symptoms such as command automatism

(automatic compliance with instructions),and perseveration

of words and phrases.

Includes: catatonic stupor

schizophrenic catalepsy

schizophrenic catatonia

schizophrenic flexibilitas cerea

DCR 10


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DCR 10

F20.2 Catatonic schizophrenia

A. The general criteria for Schizophrenia must eventually bemet, though this may not be possible initially if the patient is

uncommunicative.

B. For a period of at least two weeks one or more of the

following catatonic behaviours must be prominent:

(1) Stupor or mutism;

(2) Excitement

(3) Posturing

(4) Negativism


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(5) Rigidity

(6) Waxy flexibility (7) Command automatism

C. Other possible precipitants of catatonic behaviour,

including brain disease and metabolic disturbances, have

been excluded.


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Catatonic schizophrenia


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Catatonic schizophrenia

ICD 10 one ore more predominating

DSM 4 TR minimum of 2

Share most features in common except for echolalia and echopraxia (in DSM 4TR) and command automatism (only in ICD 10)

DSM-IV-TR diagnosis includes two or more and ICD-10 specifies at least one of the

following behaviors:stupor (marked reduction or suspended sensibility) or mutism, excitement not

influenced by external stimuli, bizarre postures, meaningless resistance toward

instructions or attempts to be moved, rigidity, waxy flexibility, and echolalia or

echopraxia.

Differential diagnosis includes brain disease, metabolic instability, substance abuse, ormood disorderssuch as bipolar disorder.

F20 3 Undifferentiated schizophrenia


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F20.3 Undifferentiated schizophrenia

Conditions meeting the general diagnostic criteria for

schizophrenia but not conforming to any of the above

subtypes (F20.0-F20.2), or

exhibiting the features of more than one of them without a

clear predominance of a particular set of diagnostic

characteristics.

This rubric should be used only for psychotic conditions (i.e.

residual schizophrenia, F20.5, and

post-schizophrenic depression, F20.4, are excluded) and

after an attempt has been made to classify the condition into

one of the three preceding categories.



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This category should be reserved for disorders that:

(a)meet the general criteria for schizophrenia; (b)either without sufficient symptoms to meet the criteria for

only one of the subtypes F20.0, F20.1, F20.2, F20.4, or

F20.5, or

with so many symptoms that the criteria for more than one ofthe paranoid (F20.0), hebephrenic (F20.1), or catatonic

(F20.2) subtypes are met.

Includes: atypical schizophrenia

DCR 10


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DCR 10

F20.3 Undifferentiated schizophrenia

A. The general criteria for Schizophrenia above must be met. B. Either (1) or (2):

(1) There are insufficient symptoms to meet the criteria of any

of the sub-types F20.0, .1, .4, or .5;

(2) There are so many symptoms that the criteria for morethan one of the subtypes listed in B(1) above are met.


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Undifferentiated schizophrenia


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Undifferentiated schizophrenia

ICD 10 either insufficient symptoms or more than one of the subtype

DSM 4TR- cases that dont meet criteria any of other subtype

Individuals should meet criterion A of DSM-IV-TR (APA 2000) and should not have

symptoms of catatonia or paranoid and disorganized schizophrenia.

ICD-10, although following DSM-IV-TR criteria, includes the stipulation thatundifferentiated schizophrenia should not satisfy the criteria for residual schizophrenia

or Post-schizophrenia depression.


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F20.4 Post-schizophrenic depression

A depressive episode, which may be prolonged, arising in theaftermath of a schizophrenic illness.

Some schizophrenic symptoms must still be present but no

longer dominate the clinical picture.

These persisting schizophrenic symptoms may be "positive"or "negative, though the latter are more common.


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It is uncertain, and immaterial to the diagnosis,

to what extent the depressive symptoms have merely beenuncovered by the resolution of earlier psychotic symptoms

(rather than being a new development) or

are an intrinsic part of schizophrenia rather than a

psychological reaction to it.

They are rarely sufficiently severe or extensive to meet

criteria for a severe depressive episode (F32.2 and F32.3),

it is often difficult to decide

which of the patient's symptoms are due to depression andwhich to neuroleptic medication or to the impaired volition and

affective flattening of schizophrenia itself.

This depressive disorder is associated with an increased risk

of suicide.


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F20.4 Post-schizophrenic depression

A. The general criteria for schizophrenia (F20.0 - F20.3above) must have been met within the past twelve

months, but are not met at the present time.

B. One of F20 G1.2 e, f, g or h must still be present.

C. The depressive symptoms must be sufficiently prolonged,severe and extensive to meet criteria for at least

a mild depressive episode (F32.0).


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Research criteria for postpsychotic depressive disorder

of Schizophrenia

A. Criteria are met for a Major Depressive Episode.

Note: The Major Depressive Episode must include

Criterion Al : depressed mood.

Do not include symptoms that are better accounted for asmedication side effects or negative symptoms of

Schizophrenia.

B. The Major Depressive Episode is superimposed on and

occurs only during the residual phase of Schizophrenia.

C. The Major Depressive Episode is not due to the direct

physiological effects of a substance or a general medical

condition.


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F20.5 Residual schizophrenia

A chronic stage in the development of a schizophrenic

disorder in which there has been a

clear progression from an early stage (comprising one or

more episodes with psychotic symptoms meeting the general

criteria for schizophrenia described above)

to a later stage characterized by long-term, though not

necessarily irreversible, "negative" symptoms.

diagnosis


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diagnosis

(a)prominent "negative" schizophrenic symptoms, i.e.

psychomotor slowing,

underactivity,

blunting of affect,

passivity and

lack of initiative,

poverty of quantity orcontent of speech,

poor nonverbal communication by facial expression,

eye contact, voice modulation, and posture,

poor self-care and social performance; (b)evidence in the past of at least one clear-cut psychotic

episode meeting the diagnostic criteria for schizophrenia;


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(c)a period of at least 1 year during which the intensity and

frequency of florid symptoms such as delusions and

hallucinations have been minimal or

substantially reduced and the "negative" schizophrenic

syndrome has been present;

(d)absence of dementia or other organic brain disease or

disorder, and

of chronic depression or institutionalism sufficient to explain

the negative impairments.


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If adequate information about the patient's previous history

cannot be obtained, and it

therefore cannot be established that criteria for schizophrenia

have been met at some time in the past, it may be necessary

to make a provisional diagnosis of residual schizophrenia.

Includes: chronic undifferentiated schizophrenia

"Restzustand"

schizophrenic residual state

DCR 10


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F20.5 Residual schizophrenia

A. The general criteria for Schizophrenia must have been met

at some time in the past, but are not met at the present time.

B. At least four of the following 'negative' symptoms have

been present throughout the previous twelve months:

(1) Psychomotor slowing or underactivity;

(2) Definite blunting of affect;

(3) Passivity and lack of initiative;

(4) Poverty of either the quantity or the content of speech;

(5) Poor non-verbal communication by facial expression, eyecontact, voice modulation or posture;

(6) Poor social performance or self-care.

DSM 4 TR


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Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are

met:

A. Absence of prominent delusions, hall ucina tions,

disorganized speech, and gross ly

disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as

indicated by the presence of negative

symptoms or two or more symptoms listed in Criterion A for

Schizophrenia,

present in an attenuated form (e.g ., odd beliefs, unusual

perceptual experiences).


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F20.6 Simple schizophrenia


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p p

An uncommon disorder in which there is an insidious but

progressive development of oddities of conduct, inability to

meet the demands of society, and decline in totalperformance.

Delusions and hallucinations are not evident, and the disorder

is less obviously psychotic than the hebephrenic, paranoid,

and catatonic subtypes of schizophrenia. The characteristic "negative" features of residual

schizophrenia (e.g. blunting of affect, loss of volition) develop

without being preceded by any overt psychotic symptoms.

With increasing social impoverishment, vagrancy may ensueand the individual may then become self-absorbed, idle, and

aimless.


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Simple schizophrenia is a difficult diagnosis to make with any

confidence because

it depends on establishing the slowly progressive

development of the characteristic "negative" symptoms of

residual schizophrenia (see F20.5 above)

without any history of hallucinations, delusions, or other

manifestations of an earlier psychotic episode, and

with significant changes in personal behaviour,

manifest as a marked loss of interest, idleness, and social

withdrawal over a period of at least one year.

Includes: schizophrenia simplex

DCR 10


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F20.6 Simple schizophrenia

A. Slowly progressive development over a period of at least

one year, of all three of the following:

(1) A significant and consistent change in the overall quality of

some aspects of personal behaviour, manifest as

loss of drive and interests, aimlessness, idleness, a self-

absorbed attitude, and social withdrawal.

(2) Gradual appearance and deepening of "negative"

symptoms such as marked apathy, paucity of speech,

underactivity, blunting of affect, passivity and lack of initiative,

and poor non-verbal communication (by facial expression,eye contact, voice modulation and posture).

(3) Marked decline in social, scholastic, or occupational

performance.


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B. Absence, at any time, of any symptoms referred to in G1 in

F20.0 - F20.3, and of hallucinations or wellformed

delusions of any kind, i.e. the subject must never have met

the criteria for any other type of schizophrenia, or any other

psychotic disorder.

C. Absence of evidence of dementia or any other organic

mental disorder listed in section F0.

DSM 4 TR


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Research criteria for simple deteriorative disorder

(simple Schizophrenia) 771

A. Progressive development over a period of at least a year of

all of the following:

(1) marked decline in occupational or academic functioning

(2) gradual appearance and deepening of negative symptomssuch as affective flattening, alogia, and avolition

(3) poor interpersonal rapport, social isolation, or social

withdrawal


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B. Criterion A for Schizophrenia has never been met.

e. The symptoms are not better accounted for by Schizotypal

or Schizoid Personality Disorder, a Psychotic Disorder, a

Mood Disorder, an Anxiety Disorder, a dementia, or

Mental Retardation and are not due to the direct physiological

effects of a substance or a general medical condition.


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F20.8 Other schizophrenia

Includes: cenesthopathic schizophrenia

schizophreniform disorder NOS

Excludes: acute schizophrenia-like disorder (F23.2)

cyclic schizophrenia (F25.2)

latent schizophrenia (F23.2) F20.9 Schizophrenia, unspecified

Schizophreniform Disorder 295.40


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A. Criteria A, D, and E of Schizophrenia are met.

B. An episode of the disorder (including prodromal, active,

and residual phases) lasts at least 1 month but less than 6

months. (When the diagnosis must be made without waiting

for recovery, it should be qualified as "Provisional.")

Specify if:

Without Good Prognostic Features

With Good Prognostic Features: as evidenced by two (or

more) of the following:

(1) onset of prominent psychotic symptoms within 4 weeks of

the first noticeable change in usual behavior or functioning

(2) confusion or perplexity at the height of the psychotic

episode


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(3) good pre morbid social and occupational functioning

(4) absence of blunted or flat affect


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DSM V


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Deletion of Subtypes. The current classic subtypes of

schizophrenia provide a poor description of the

heterogeneity of schizophrenia,

have low diagnostic stability,

do not exhibit distinctive patterns of treatment response or

longitudinal course, and are not heritable.

Except for the paranoid and undifferentiated subtypes, other

subtypes are rarely diagnosed.

As a result, it is proposed that these subtypes of

schizophrenia be eliminated from DSM-5.


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Dimensions will be assessed on a 0-4 scale cross-sectionally,

with severity assessment based on past month.

There are distinct psychopathological domains in psychotic

illnesses (most clearly noted in schizophrenia) with distinctive

patterns of treatment-response, prognostic implications, and

course.

The relative severity of symptoms across these domainsvaries across the course of illness and among patients.

This is a major change that will potentially be of great clinical

value and will also be of additional research utility

0- Not Present 3- Present and moderate

1- Equivocal 4- Present and severe

2- Present, but mild


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sub-types of schizophrenia

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