Schizophrenia

Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over time, but the effect of the illness is always severe and is usually long lasting. The disorder usually begins before age 25, persists throughout life, and affects persons of all social classes. Both patients and their families often suffer from poor care and social ostracism because of widespread ignorance about the disorder.

Table 1DSM-IV-TR Diagnostic Criteria for Schizophrenia A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): 1. delusions 2. hallucinations 3. disorganized speech (e.g., frequent derailment or incoherence) 4. grossly disorganized or catatonic behavior 5. negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
B. Social/occupational dysfunction: For a significant portion of the time since the onset

of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective and mood disorder exclusion: Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the activephase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a

general medical condition.

F. Relationship to a pervasive developmental disorder: If there is a history of autistic

disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms): Episodic with interepisode residual symptoms (episodes are defined by the reemergence of prominent psychotic symptoms); also specify if: with prominent negative symptoms Episodic with no interepisode residual symptoms Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: with prominent negative symptoms Single episode in partial remission: also specify if: with prominent negative symptoms Single episode in full remission Other or unspecified pattern (From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.) Table 2DSM-IV-TR Diagnostic Criteria for Schizophrenia Subtypes Paranoid type A type of schizophrenia in which the following criteria are met: A. Preoccupation with one or more delusions or frequent auditory hallucinations.
B. None of the following is prominent: disorganized speech, disorganized or catatonic

behaviour, or flat or inappropriate affect. Disorganized type A type of schizophrenia in which the following criteria are met: A. All of the following are prominent: 1. disorganized speech 2. disorganized behaviour 3. flat or inappropriate affect B. The criteria are not met for catatonic type. Catatonic type A type of schizophrenia in which the clinical picture is dominated by at least two of the following: 1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor 2. excessive motor activity (that is apparently purposeless and not influenced by external stimuli) 3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism 4. peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

5. echolalia or echopraxia Undifferentiated type A type of schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the paranoid, disorganized, or catatonic type. Residual type A type of schizophrenia in which the following criteria are met:
A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly

disorganized or catatonic behaviour. 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 Table3Features Weighting Toward Good to Poor Prognosis in Schizophrenia Good Prognosis Poor Prognosis Late onset Young onset Obvious precipitating factors No precipitating factors Acute onset Insidious onset Good premorbid social, sexual, and work histories Poor premorbid social, sexual, and work histories Mood disorder symptoms (especially depressive disorders) Withdrawn, autistic behaviour Married Single, divorced, or widowed Family history of mood disorders Family history of schizophrenia Good support systems Poor support systems Positive symptoms Negative symptoms Neurological signs and symptoms History of perinatal trauma No remissions in 3 years Many relapses History of assaultiveness

Paranoid Type The paranoid type of schizophrenia is characterized by preoccupation with one or more delusions or frequent auditory hallucinations. Classically, the paranoid type of schizophrenia is characterized mainly by the presence of delusions of persecution or grandeur. Patients with paranoid schizophrenia usually have their first episode of illness at an older age than do patients with catatonic or disorganized schizophrenia. Patients in whom schizophrenia occurs in the late 20s or 30s have usually established a social life that may help them through their illness, and the ego resources of paranoid patients tend to be greater than those of patients with catatonic and disorganized schizophrenia. Patients with the paranoid type of schizophrenia show less regression of their mental faculties, emotional responses, and behaviour than do patients with other types of schizophrenia. Patients with paranoid schizophrenia are typically tense, suspicious, guarded, reserved, and sometimes hostile or aggressive, but they can occasionally conduct themselves adequately in social situations. Their intelligence in areas not invaded by their psychosis tends to remain intact. Disorganized Type The disorganized (formerly called hebephrenic) type of schizophrenia is characterized by a marked regression to primitive, disinhibited, and unorganized behaviour and by the absence of symptoms that meet the criteria for the catatonic type. The onset of this subtype is generally early, occurring before age 25. Disorganized patients are usually active but in an aimless, nonconstructive manner. Their thought disorder is pronounced, and their contact with reality is poor. Their personal appearance is disheveled, and their social behaviour and their emotional responses are inappropriate. They often burst into laughter without any apparent reason. Incongruous grinning and grimacing are common in these patients, whose behaviour is best described as silly or fatuous. Catatonic Type The catatonic type of schizophrenia, which was common several decades ago, has become rare in Europe and North America. The classic feature of the catatonic type is a marked disturbance in motor function; this disturbance may involve stupor, negativism, rigidity, excitement, or posturing . Sometimes, the patient shows rapid alteration between extremes of excitement and stupor. Associated features include stereotypies, mannerisms, and waxy flexibility. Mutism is particularly common. During catatonic excitement, patients need careful supervision to prevent them from hurting themselves or others. Medical care may be needed because of malnutrition, exhaustion, hyperpyrexia, or self-inflicted

injury.

Table 4DSM-IV-TR Research Criteria for Simple Deteriorative Disorder (Simple Schizophrenia) 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 symptoms such as affective flattening, alogia, and avolition 3. poor interpersonal rapport, social isolation, or social withdrawal B. Criterion A for schizophrenia has never been met. C. 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

Table 5Diagnostic Criteria for Deficit Schizophrenia At least two of the following six features must be present and of clinically significant severity:

Restricted affect Diminished emotional range Poverty of speech Curbing of interests Diminished sense of purpose

Diminished social drive Two or more of these features have been present for the preceding 12 months and were always present during periods of clinical stability (including chronic psychotic states). These symptoms may or may not be detectable during transient episodes of acute psychotic disorganization or decompensation. Two or more of these enduring features are also idiopathic, that is, not secondary to factors other than the disease process. Such factors include

Anxiety Drug effect Suspiciousness Formal thought disorder Hallucinations or delusions

Mental retardation

Depression The patient meets DSM-IV-TR criteria for schizophrenia.