Schizophrenia

Definition, Signs and Symptoms, Diagnostic Criteria, and Subtypes

Schizophrenia Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history. About 1 percent of Americans have this illness. People with the disorder may hear voices other people dont hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated. People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking. Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or caring for themselves, so they rely on others for help. Treatment helps relieve many symptoms of schizophrenia, but most people who have the disorder cope with symptoms throughout their lives. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness. Signs and Symptoms The symptoms of schizophrenia fall into three broad categories: positive symptoms, negative symptoms, and cognitive symptoms. Positive symptoms Positive symptoms are psychotic behaviors not seen in healthy people. People with positive symptoms often lose touch with reality. These symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiving treatment. They include the following: Hallucinations are things a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. Voices are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices. The voices may talk to the person about his or her behavior, order the person to do things, or warn the person of danger. Sometimes the voices talk to each other. People with schizophrenia may hear voices for a long time before family and friends notice the problem. Other types of hallucinations include seeing people or objects that are not there, smelling odors that no one else detects, and feeling things like invisible fingers touching their bodies when no one is near. Delusions are false beliefs that are not part of the persons culture and do not change. The person believes delusions even after other people prove that the beliefs are not true or logical. People with schizophrenia can have delusions that seem bizarre, such as believing that neighbors can control their behavior with magnetic waves. They may also believe that people on television are directing special messages to them, or that radio stations are broadcasting their thoughts aloud to others. Sometimes they believe they are someone else, such as a famous historical figure. They may have paranoid delusions and believe that others are trying to harm them, such as by cheating, harassing, poisoning, spying on, or plotting against them or the people they care about. These beliefs are called delusions of persecution.

Thought disorders are unusual or dysfunctional ways of thinking. One form of thought disorder is called disorganized thinking. This is when a person has trouble organizing his or her thoughts or connecting them logically. They may talk in a garbled way that is hard to understand. Another form is called thought blocking. This is when a person stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking, the person may say that it felt as if the thought had been taken out of his or her head. Finally, a person with a thought disorder might make up meaningless words, or neologisms. Movement disorders may appear as agitated body movements. A person with a movement disorder may repeat certain motions over and over. In the other extreme, a person may become catatonic. Catatonia is a state in which a person does not move and does not respond to others. Catatonia is rare today, but it was more common when treatment for schizophrenia was not available.

Negative symptoms Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognize as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following: Flat affect (a persons face does not move or he or she talks in a dull or monotonous voice) Lack of pleasure in everyday life Lack of ability to begin and sustain planned activities Speaking little, even when forced to interact. People with negative symptoms need help with everyday tasks. They often neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves, but the problems are symptoms caused by the schizophrenia.

Cognitive symptoms Cognitive symptoms are subtle. Like negative symptoms, cognitive symptoms may be difficult to recognize as part of the disorder. Often, they are detected only when other tests are performed. Cognitive symptoms include the following: Poor executive functioning (the ability to understand information and use it to make decisions) Trouble focusing or paying attention Problems with working memory (the ability to use information immediately after learning it). Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause great emotional distress.

Diagnostic Criteria DSM-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 6-month 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 active-phase 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). Subtypes Subtypes of schizophrenia are characterized by particular constellations of symptoms and include the following: paranoid, catatonic, hebephrenic (or disorganized), and simple (which has also been referred to as simple deteriorative disorder). Patients whose illness does not fall into any of these subtypes are said to have an undifferentiated subtype. Subtype diagnosing is not an academic exercise, for, as discussed under Course, the different subtypes may have different prognoses. Furthermore, knowing the subtype allows one to predict with better confidence how any given patient might react in any specific situation.

Paranoid schizophrenia, which tends to have a later onset than the other subtypes, is characterized primarily by hallucinations and delusions. Other symptoms, such as loosening of associations, bizarre behavior, or flattened or inappropriate affect, are either absent or relatively minor. The hallucinations are generally auditory and typically hostile or threatening. The delusions are generally persecutory and referential. Voices warn patients that their supervisors plot against them. They begin to suspect that their co-workers talk about them behind their backs and laugh quietly as they pass by. Newspaper headlines pertain to them; the CIA is involved; meal portions at the factory cafeteria are secretly poisoned, and patients may refuse to eat at work. At times these patients may appeal to the police for help, or they may suffer their slights in rigid silence. Their attitude becomes one of intense, constrained anger and suspiciousness. Occasionally they may move away to escape their persecutors, yet eventually they are followed. At times they may turn on their supposed attackers, and violent outbursts may be seen. In paranoid schizophrenia, more so than in the other subtypes, the delusions may be somewhat systematized, even plausible. In most cases, however, inconsistencies appear, which, however, have no impact on the patients. Often, along with persecutory delusions, one may also see some grandiose delusions. Patients believe themselves persecuted not for a trivial reason; others now know that the patient recently acquired a controlling interest in the company. Rarely, grandiose delusions may be more prominent than persecutory ones and may dominate the entire clinical picture. A patient may believe herself anointed with holy oil; trumpets blared forth her appearance as a prophet. She has a message that will save the world, and sets about spreading it. Catatonic schizophrenia manifests in one of two forms: stuporous catatonia or excited catatonia. In the stuporous form one sees varying combinations of immobility, negativism, mutism, posturing, and waxy flexibility. One patient curled into a rigid ball and lay on the bed, unspeaking, for days, moving neither for defecation nor urination, and catheterization was eventually required. Saliva drooled from the mouth, and as there was no chewing, food simply lay in the oral cavity and there was danger of aspiration. Another patient stood praying in a corner, mumbling very softly. A degree of waxy flexibility was present, and the patients arm would, for a time, remain in any position it was placed, only eventually to slowly return to the position of prayer. In the excited form of catatonia one may see purposeless, senseless, frenzied activity, multiple stereotypies, and at times extreme impulsivity. Patients may scream, howl, beat their sides repeatedly, jump up, hop about, or skitter back and forth. A patient leaped up and attacked a bystander for no reason, then immediately returned to a corner and restlessly marched in place, squeaking loudly. Often speech is extremely stereotyped and bizarre. Patients may shout, declaim, preach, and pontificate in an incoherent fashion. Words and phrases may be repeated hundreds of times. Typically, despite their extreme activity, these patients remain for the most part withdrawn. They often make little or no effort to interact with others; they keep their excitation to themselves, perhaps in a corner, perhaps under a bed. Rarely Stauders lethal catatonia may occur. Here, as the excitation mounts over days or weeks, autonomic changes occur with hyperpyrexia, followed by coma and cardiovascular collapse. Although some patients with catatonic schizophrenia may display only one of these two forms, in most cases they are seen to alternate in the same patient. In some cases a form may last days, weeks, or longer, before passing through to the other. In other cases, however, a rapid and unpredictable oscillation from one form to another may occur. A stuporous patient suddenly, without warning, jumped from his bed, screamed incoherently, and paced agitatedly from one wall of the room to another. Then, in less than an hour, the patient again rapidly fell into mute immobility. Hebephrenic schizophrenia tends to have an earlier onset than the other subtypes and tends to develop very insidiously.

Although delusions and hallucinations are present, they are relatively minor, and the clinical picture is dominated by bizarre behavior, loosened associations, and bizarre and inappropriate affect. Overall the behavior of these patients seems at times a caricature of childish silliness. Senselessly they may busy themselves first with this, then with that, generally to no purpose, and often with silly, shallow laughter. At other times they may be withdrawn and inaccessible. Delusions, when they occur, are unsystematized and often hypochondriacal in nature. Some may display very marked loosening of associations to the point of a fatuous, almost driveling incoherence. Simple schizophrenia has perhaps the earliest age of onset, often first beginning in childhood, and shows very gradual and insidious progression over many years. Delusions, hallucinations, and loosening of associations are sparse, and indeed are for the most part absent. Rather the clinical picture is dominated by the annihilation of the will, impoverishment of thought, and flattening of affect. Gradually over the years these patients fall away from their former goals and often become cold and distant with their former acquaintances. They may appear shiftless, and some are accused of laziness. Few thoughts disturb their days, and they may seem quite content to lie in bed or sit in a darkened room all day. Occasionally some bizarre behavior or a fragmentary delusion may be observed. For the most part, however, these patients do little to attract any attention; some continue to live with aged parents; others pass from one homeless mission to another. Undifferentiated schizophrenia is said to be present when the clinical picture of any individual case does not fit well into one of the foregoing subtypes. This is not uncommonly the case, and it also appears that in some instances the clinical picture, which initially did fit a subtype description, may gradually change such that it no longer squares with one of the specific subtypes: this appears to be more common with the catatonic and hebephrenic subtypes than with paranoid or simple schizophrenia.