The major differences between both systems are in the longitudinal course criteria. The DSM-IV-TR requires duration of 6 months (with at least 1 month of active symptoms) as opposed to only 1 month in the ICD-10. Also, the DSM-IV-TR requires deterioration in social and occupational function, in contrast to the ICD-10, which does not have such a requirement for the diagnosis of schizophrenia. In addition, the ICD-10 continues to include a category of simple schizophrenia that does not require the presence of psychotic symptoms for the diagnosis. This subtype is not included in the DSM-IV-TR
Table 12.2-3. ICD-10 Diagnostic Criteria for Schizophrenia | ||||
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Paranoid Schizophrenia
The distinctive feature of paranoid schizophrenia is the presence of one or more delusions and frequent auditory hallucinations. Although in other contexts, paranoid means persecutory, in the case of the paranoid subtype, the delusions and hallucinations do not need to be persecutory in nature. The contents of the auditory hallucinations are often related to the contents of the delusions, but this is not always the case. In DSM-IV-TR, the diagnosis of the paranoid subtype is largely made
by excluding the other subtypes. Since some of the worst prognostic features (disorganized speech, disorganized behavior, and flat or inappropriate affect) are excluded, this subtype has a relatively favorable prognosis. The diagnostic criteria for paranoid schizophrenia in DSM-IV-TR and ICD-10 are presented in Table 12.2-4.
Disorganized (or Hebephrenic) Schizophrenia
Disorganized schizophrenia was first described by Ewald Hecker, who used the term hebephrenia to name this subtype. The term hebephrenia has been retained only in the ICD-10. The distinctive feature of this subtype is thought disorder, although in DSM-IV-TR disorganized behavior and flat or inappropriate affect are also required to make the diagnosis. Delusions and hallucinations, if present, are often fragmentary or poorly systematized. Poor premorbid function, an insidious onset, a continuous course, and a poor prognosis are characteristics of this subtype.
Catatonic Schizophrenia
Catatonia was first formally reported by Karl Ludwig Kahlbaum, who described a syndrome with prominent motor and behavioral symptoms. Kraepelin and Bleuler regarded catatonia as part of schizophrenia, a position that is still reflected in current diagnostic systems. However, catatonic symptoms can be found in affective disorders and encephalopathies as well as schizophrenia. In developed countries, catatonia is seen now much less frequently than in the past, perhaps due to the widespread use of medical treatments early in the course of psychosis. The criterion for the catatonic subtype requires two of five characteristic symptoms: Immobility (stupor or catalepsy); excessive purposeless motor activity; negativism, peculiar movements (posturing, stereotypies, mannerisms, or grimacing); echolalia; or echopraxia
Undifferenciated schizophrenia
Residual Schizophrenia
This diagnostic category is used for patients who have at least one psychotic episode in the past and have met the criteria for schizophrenia before, but no longer have psychotic symptoms. However, they continue exhibiting evidence of illness with negative symptoms, residual symptoms, or both that are attenuated forms of psychotic symptoms. The condition can be chronic or may be a transition to a complete remission of the illness.
Simple Schizophrenia
This category is not included in DSM-IV-TR, but it still exists in ICD-10. The diagnosis is based solely on deficit or negative symptoms. Psychotic symptoms are not necessary for the diagnosis
Psychotic Symptoms
The psychotic symptoms of schizophrenia define schizophrenia for the general public and for most physicians. They are the most obvious and dramatic symptoms of the illness, and for most people they are what is fascinating and frightening about schizophrenia. In psychiatry there has also been an interest in delusions and hallucinations that has overshadowed investigation and treatment of the other facets of the psychopathology of schizophrenia. The break from the impressionistic diagnostic scheme of DSM-II to a symptom-based diagnosis in DSM-III depended in large part on clinicians' ability to recognize positive symptoms considered characteristic of schizophrenia.
It is now clear that there is no particular symptom, not even the most carefully specified kind of hallucination or delusion, that in itself generates or justifies a diagnosis of schizophrenia. It is also clear that a focus on treating positive symptoms to the exclusion of the other signs and symptoms of schizophrenia will ignore significant sources of morbidity and might increase psychopathology and disability in clinically significant ways. Nonetheless, psychotic symptoms, because of their unique nature and easy identifiability, both aid assignment of diagnoses and serve as markers of treatment response, and they will remain at the core of concepts about the nature of schizophrenia.
The use of the term psychotic in relation to symptoms should be restricted to hallucinations and delusions. Earlier, symptoms of inappropriate affect, purposeless activity, and disorganization of speech and behavior were also considered psychotic symptoms but now are better considered in the separate disorganization dimension
In the Netherlands study, younger age, living in an urban environment, low income, less education, unemployment, female gender, and being single were all associated with increased rates of hallucinations.
Auditory hallucinations are the most common type, followed by visual hallucinations, and tactile (or haptic),olfactory, and gustatory hallucinations are less common. Visceral and other deep tissue hallucinations (cenesthetic hallucinations) can provoke odd descriptions that are inconsistent with the internal sensory apparatus, with complaints of burning in the brain or movement of the thoracic organs to new positions. There is very little contemporary research regarding visceral hallucinations and their prevalence, nature, or associations with other symptoms, but they are likely less frequent than gustatory and olfactory hallucinations.
Nonetheless, evidence from the WHO's IPSS and other sources confirms that the most prevalent type of hallucination and the most common symptom of psychosis in schizophrenia is auditory hallucinations.
the hallucination is usually so unpleasant, so intrusive that it makes no sense that it would arise from within the person who experiences it.
The content of the hallucinations, both in verbal content and in prosody, is generally derogatory and often quite profane. Patients will hear expletives, threats, demeaning personal comments, and accusations of vile thoughts or behaviors. Not surprisingly patients are often distressed and frightened, or angered by these experiences, and can have a complicated sense of guilt, depression, or belligerence in response. Emotional experiences, most often sadness, often precede hallucinations, but patients also commonly experience the somatic symptoms of anxiety, and less frequently fear or anger, before the recurrence of hallucinations. Social stressors, and physical illness and chronic pain, all can increase the frequency of hallucinations, and the intrusiveness and dysphoria of the experience. Hallucinations can be unremitting and last from waking until bedtime, or can come in irregular, infrequent periods of seconds or minutes a few times a month. Although it is not a rule, evenings and nights before retiring are often times when auditory hallucinations arise or escalate. It is common that people with schizophrenia will have some period during their illness where their auditory hallucinations are present for the majority of the day.
Voices are the most common kind of hallucination and tend to be clear and understood, but unintelligible sounds of whispers or distant conversations are not rare. Patients can also hear footsteps, telephones ringing, the sounds of pebbles hitting a window, helicopters, buzzing, clicking, and musical phenomena that range from single notes present throughout the day to discrete complex passages of orchestral music. When it is voices that are heard, the gender of the speaker can usually be identified. The person afflicted often hears middle-aged voices, with a different accent than is spoken by the patient. Younger patients will tend to hear somewhat younger voices, while older patients hear somewhat older voices. The location, loudness, and clarity of the voices can all be reliably assessed, and in general the person who experiences the persistent auditory hallucinations will eventually settle on identities for their voices
With the passage of time, most patients will experience a decrease in the frequency of their hallucinations or a change in the nature of their hallucinatory experience. Where hallucinations are initially very upsetting, provoking anger or panic, after the first stages of illness have subsided patients may generate coping strategies through a process of trial and error over a period of years and can come to mitigate the effects of their hallucinations on their lives. Simple strategies like yelling at the voices can sometimes decrease or stop the experience, though clinicians and families may see this as a distressing sign of deterioration. Less disturbing to people around the patient, singing or humming or listening to music can block the experience, and sometimes shifts in posture or talking to someone else can help. Unfortunately, for people with chronic schizophrenia the only available regular contact with the voices of other people may be through the radio or television, and these can reliably exacerbate hallucinations in some people with schizophrenia. After years or decades patients often start to question the content of their hallucinations, and if their questions do not lead to insight, at least they sometimes provoke awareness that the threats or predictions rarely come true. Some patients can gain limited control of their hallucinations and can shift the prosody or content of the discussion; there is a sizable minority of patients who can regularly start and stop their hallucinations at least some of the time. Religious themes are common in auditory hallucinations, and while they commonly start with a focus on the sins of the patient, with time there can be a conversion to a view of the patient having a special relationship with his or her god or gods, or that the individual might have some special message to spread or task to perform. As a person gets used to the presence of these voices, the hallucinatory voice or voices can become companions for a person with schizophrenia, and given the frequent social isolation that is experienced in schizophrenia this companionship can be welcome. The voices can take on the role of guide through daily life for the person with schizophrenia, often in middle age or later, so that the hallucinations will tell a person what to buy at the grocery store, how to structure his or her day, sometimes even how to respond in social interactions. The voices might even take on a moral role for the patient, suggesting the emotional consequences of particular behaviors, or act as a conscience that spurs generosity or remorse in response to the patient's actions. Although some people with schizophrenia will with time develop good insight into the nature of their hallucinations, despite ongoing delusions or negative symptoms, other patients with predominately positive symptoms or residual schizophrenia will go through long periods with few obvious symptoms and no hallucination but retain a full delusional interpretation of their past hallucinatory experiences
There is a broad range of visual experiences that afflicts people with schizophrenia. The most commonly noted visual hallucinations are formed images of animate objects, people, or parts of people (especially heads and faces), religious images, fantastic creatures that may be similar to images in movies and on television, and animals.Inanimate objects are less common, but flashes of light, streaks of color, or grids or lines in the visual field may also be described. Images can be in color or black or white, and hallucinations in only shades of white have even been described. Visual hallucinations are generally more discrete and more limited in duration than auditory hallucinations, but there are unfortunate patients who will experience visual hallucinations throughout the course of a day. In vision the continuum with illusions (distortions of objects seen in the environment) is more obvious than it is with auditory perceptions. Shadows that seem like people or animals but reveal themselves as only shadows with closer inspection, objects that change size or shape, outlines of objects that seem to float just outside the object itself, and objects that have some transparency are all kinds of visual distortions that may be repeated. Less often, the world itself will seem distorted; the ground beneath someone will seem to be at angles that are inconsistent with the patient's proprioceptive awareness, sidewalks will seem to briefly point into the air.Lilliputian hallucinations—hallucinations of small people, frequently busy attending to some task—are generally considered a sign of an encephalopathic process, but rarely are they present in schizophrenia.
Olfactory, Gustatory, and Tactile Hallucinations
Tactile hallucinations are present in a range of 15 to 25 percent of people with schizophrenia, with no clear pattern of variance across cultures apparent. Particular tactile hallucinations, like the sense of bugs crawling on or under the skin (formication), are found in a variety of mental illnesses. The tactile hallucinations of schizophrenia can take on a broad variety of forms. Feelings of being touched, burned, and cut are common, and there are surprising numbers of patients who will feel as though they are subject to a kind of sexual assault, inflicted on their genitals or anus by unseen (and sometimes seen) entities. Less localized sensations of electric shocks or tearing or stabbing in the limbs and torso also occur. Patients with tactile hallucinations can also have a physical sense that somehow other people or magical beings enter into and exit their bodies, and while they can communicate that this sense is particularly distressing for them, articulating what it actually feels like leads to very vague statements.
Olfactory and gustatory hallucinations tend to be reported by a small minority of patients, with olfactory hallucinations the more common of the two types. As with other kinds of hallucinations, the experience tends to be unpleasant for most patients, with the smells of rotting meat, garbage, and feces common, and the taste of blood or metal frequently described. Often tastes and smells will go together in an unpleasant combination
Further, the delusions that are held by persons with schizophrenia are frequently quite flexible. There are patients who will cling tenaciously to the idea that they have been persecuted by agents of a foreign government, or who have had chips implanted in their brains by aliens from space, but every day in clinics and hospitals around the world other patients will check out fantastic ideas with nursing staff and doctors, and happily accept the assurance that their odd concerns are unfounded.
When delusions are examined as they exist in schizophrenia, there is a clear continuum with the overvalued ideas everyone is prone to. Delusions can vary from fleeting concerns about personal meanings taken from the way a television news reader intonated a particular word, to a preoccupation with ideas about how giant corporations and governments are organized to persecute a particular person with schizophrenia.
What does seem to distinguish delusions in schizophrenia is analogous to what distinguishes schizophrenia itself; the severity of the impact of the symptom on the patient's life and the pattern of deficits, instead of any unique or pathognomonic sign. The number of delusional beliefs, the strength of preoccupation with delusions, and the amount of distress they cause for patients all seem to distinguish delusions in schizophrenia. Although delusions in schizophrenia are not always “firmly sustained,” there is in general a stronger conviction that their conclusions are accurate despite contradictory views from others. Delusions are common in many psychiatric syndromes, but are held with more strongly, preoccupy more time, and are more pervasive in their influence on patient cognition than is found in other psychiatric illnesses. Most people with schizophrenia will have delusions, and the percentage who will experience clinically significant delusions may exceed 70 percent. As is the case with hallucinations, many patients will moderate the effects of delusions on their lives, often by titrating amounts of social contact. This increasing engagement can decrease their preoccupation, although when the delusions center on concerns of persecution, this relief may not be available. For most patients the presence of one delusion predicts the presence of other delusions
It is an unfortunate feature of delusions in schizophrenia that the focus of the delusion is so often based around fears of persecution or threats to a person's safety. People with schizophrenia are more likely than people in the general population to fear that people look at them in an unusual or odd way, that they are being watched or being harmed, or that their feelings and actions are not under their control. In schizophrenia most delusions will fall into some broad patterns of content. The most common delusions in schizophrenia are delusions of persecution, which are endorsed by up to 80 percent of inpatients. These persecutory fears can range from transient doubts about the intentions of strangers in the environment to profound convictions that charitable organizations or family members are plotting to have the patient tortured or killed. These may arise from misinterpretation of social interactions or social events or from misattribution of intent on the part of others. Other highly prevalent delusions, like delusions of bodily control and of having one's thoughts audible by others, are also delusions that can lead to persistent dysphoria. Delusions of reference refers to delusions in which neutral stimuli or events or people take on a particular significance in reference to the person who experiences the delusions; per the DSM-IV-TR glossary, they are those delusions “whose theme is that events, objects, or other persons in one's immediate environment have a particular and unusual significance.” There is usually a persecutory slant to these delusions, although there may also be self-aggrandizing or religious meaning derived from them. In DSM-IV-TR they are considered distinct from ideas of reference, which are considered to be less tenaciously held or organized; as noted above, delusional ideas lie on a continuum with normal beliefs, and the distinction between delusions of reference and ideas of reference seems of little value. As important, “delusions of reference” and “ideas of reference” are frequently treated as synonyms in clinical settings. Other common delusions encountered in schizophrenia, whose names do not clearly define their meaning, include thought broadcasting and thought insertion. These refer to a delusion that the afflicted person's thoughts are audible to others, and a delusion that a thought or thoughts are inserted into the deluded person's mind, respectively. Also common are grandiose ideas of personal power or significance and religious themes, which can be persecutory as often as grandiose in their content. There are a series of eponymous delusions, often referring to delusions that focus on questions of the identity of the deluded person or those around him or her or referring to a particular impossible state of existence. When first identified, each of these eponymous delusions was supposed to convey a particular diagnostic association with schizophrenia, but since they can be found in almost any medical or psychiatric condition where delusions arise, the value of knowing each particular name seems limited.
A type of delusion that does hold special significance in schizophrenia is the concept of “bizarre delusions.” In DSM-IV-TR, bizarre delusions are deemed important enough that their existence, in isolation from other characteristic symptoms, is sufficient to meet Criteria A for schizophrenia. In DSM-IV-TR, bizarre delusions are those that are considered implausible by people who are in the patient's culture, and this is generally taken to mean something that is judged physically impossible. There have been many criticisms of the concept of bizarre delusions, the most prominent being that when assessing their presence or absence interrater reliability varies from very low to fair, even when trained raters are used. There remain reasons to retain the concept. Although bizarre delusions are not a universal finding and are not pathognomonic of any disorder, they are more common in schizophrenia than in any other psychiatric illness, and when present they do discriminate schizophrenia from other psychiatric illness with fair reliability
In the original conceptions of schizophrenia, negative symptoms held a more prominent place. In Dementia Praecox and Paraphrenia, Kraepelin remarked on “emotional dullness” and related it to “the loss of interest, the loss of inner sympathy, with the giving way of those emotional main-springs which move us to exert our mental powers, to accomplish our tasks, to follow trains of thought.” For Bleuler “‘emotional deterioration’ stands at the forefront of the clinical picture.” Kurt Schneider appreciated the emotional withdrawal and lack of empathy that clinicians frequently experienced in dealing with patients with schizophrenia, but did not include these disturbances in his characteristic symptoms of schizophrenia. Following Schneider, the emphasis on reducing or hopefully even eliminating hallucinations and delusions as the primary goal in treatment of schizophrenia led to the underrecognition and undertreatment of negative symptoms, and that lack of recognition and treatment persists to the present.
The publication of DSM-III did little to change the emphasis on positive symptoms. The only acknowledgment of negative symptoms came in a reference to blunted or flat affect, which could make a formal thought disorder constitute a symptom when it occurred in conjunction with the disturbance of affect.. In DSM-IV-TR, negative symptoms manifest through “affective flattening, alogia, and anhedonia” constitute one of the characteristic symptoms necessary for fulfilling Criteria A for the diagnosis of schizophrenia. Adding negative symptoms to the diagnostic criteria in the DSM has not increased the incidence of schizophrenia, an indirect confirmation that these symptoms have been present but unrecognized throughout the period of modern diagnostic criteria.
A recent consensus conference, convened under the auspices of the National Institutes of Mental Health (NIMH), suggested there are five general categories of negative symptoms. The most common negative symptoms are avolition and anhedonia. Avolition is the loss of will or drive (in neurology, this is sometimes referred to as abulia). In psychiatry the loss of will or drive is sometimes considered to be a manifestation of anhedonia, but in fact these refer to separate kinds of pathology. Avolition is similar to apathy, and these may be considered closely related, with avolition identifying a deficit in the ability to act, and apathy a loss of concern for an idea or task. The definition of avolition in the DSM-IV-TR glossary is “an inability to initiate and persist in goal-directed activities.” Avolition in particular seems associated with deficits in grooming and hygiene, and it seriously impairs educational and vocational progress. Although often overlooked, this loss of will can be severely disabling for patients
Anhedonia is a loss of the ability to find or derive pleasure from activities or relationships and may be the most persistent of the negative symptoms. In DSM-IV-TR anhedonia “is manifested by a loss of interest or pleasure.” Estimates of the prevalence of anhedonia in schizophrenia vary widely, but probably half of patients experience considerable anhedonia. Although present in depressive disorders, when anhedonia in schizophrenia is part of a negative syndrome, it should not be considered a manifestation of depression.
Affective blunting, consisting of both an inability to understand or recognize displays of emotion from others and an inability to express emotion, is an important predictor of functional impairment in schizophrenia
Alogia is a decrease in verbal communication, and it is found in up to 25 percent of people with schizophrenia. Although alogia has been considered both the loss of production and a deficit of content with a normal volume of words, only the loss of production is a negative symptom. The lack of speech production is considered to result from a decreased rate of verbal cognition
Poor attention had been considered a negative symptom, but it also appears to be more related to disorganization symptoms than other negative sympt
According to Bleuler, “It has been known since the early years of modern psychiatry that an ‘acute curable’ psychosis became ‘chronic’ when the affects began to disappear.” When there are multiple negative symptoms and a careful history suggests that these are enduring and not due to secondary causes, the deficit syndrome (Table 12.2-8) is established.
Not all symptoms and prognostic factors are worse in people with the deficit syndrome; they have no more delusions or hallucinations than nondeficit groups, they are less likely to have severe delusions around social themes and tend to have less severe suspiciousness, they are less likely to endorse prominent dysphoria, and they are less likely to have suicidal ideation or suicide attempts than nondeficit populations
However, the disorganization syndrome appears to be the most heritable of the subsyndromes of schizophrenia. Family and twin studies show an association between degrees of relatedness and the presence of prominent disorganization. This evidence parallels the finding that hebephrenia is the most heritable of the traditional subtypes of schizophrenia
The disorganization symptoms certainly include the formal thought disorders, bizarre and catatonic behaviors, and inappropriate affect. Current evidence includes attention impairments in the disorganization syndrome and puts poverty of content of speech in the formal thought disorders. Disorganization symptoms can affect almost any kind of behavior and disrupt almost any form of thought. The disruptions of behavior can be marked, with wildly inappropriate expressions of affect including odd or exaggerated gestures, sing-song or child-like changes in prosody, silly or inappropriately bright affects, or alternatively, grimacing and wide-eyed expressions of surprise or anger. This disruption of affect can be socially disabling and unfortunately seems to respond more poorly to treatment than other symptoms in the disorganization subsyndrome. During acute episodes, approximately 20 percent of patients exhibit an inappropriate affect. Although previous versions of the DSM referred to “flat, blunted, or inappropriate affect” in the diagnostic criteria for schizophrenia, there is no reason to group inappropriate affect with the negative symptoms of flat or blunted affects
Disorganization can also include erratic episodes of agitation and aggression, including assuming postures suggesting the person is preparing for violence, swearing, or broad movements of arms or the trunk as the patient ambulates. Hygiene is frequently poor, and as a group those with disorganized schizophrenia are more indifferent to routine activities of daily living, or health care and health care maintenance, than are other patients with schizophrenia. Attire can be simply unusual or inappropriate (e.g., adults squeezing on adolescents' clothing, multiple layers of clothes during hot summer days or light-weight attire in the middle of winter), or sometimes dramatically eccentric
Motor Symptoms
Disturbance of motor activity seems to be most related to the disorganization symptoms of schizophrenia, although some studies suggest that these symptoms are an independent dimension of psychopathology. Motor behaviors can include subtle repetitive hand movements or broad, complex, and purposeless movements that involve the limbs and trunk. These movements can occur when speaking, and seem to be the gestural equivalent of a neologism, or can involve multiple movements of a limb or limbs, as though the person were performing some complex but undecipherable manual task. When repeated these ritualistic motor activities are called mannerisms. Patients may sometimes mimic the motor behaviors of others, which is referred to as echopraxia. Rocking when sitting down or standing is common, as is patients hugging themselves, wringing their hands, or toying with their clothing, or hair, or small objects around them. More complex motor behaviors, odd but apparently purposeful, have been described. There can be repetitive directed behaviors like gestures and hugging others, or patients might have periods of appearing to read materials over and over (even if the text is upside down), or staring for protracted periods into the mirror. An early onset of prominent motor symptoms has been associated with significant thought disorder and may predict greater disability and a deteriorating course.
Symptoms of catatonia are included in the disorganization symptom, although it is important to note that catatonia may be as common in cases with brain injury and in psychotic mood disorders as it is in schizophrenia. Catatonia is suggested to be motor behavior generated with “a marked decrease in reactivity to the environment” in DSM-IV-TR, and in its appearance it does suggest that central motor programs are engaged without direction from frontal areas that direct higher level planning. There is a long history of description of catatonic symptoms, and many general classes have been identified. Catatonic excitement, with constant purposeless motor activity, often including both upper and lower limbs, might be the most common type seen in psychiatric settings in the Western world. Catatonic negativism refers to the automatic resistance to attempts to move limbs, postures, or direct ambulation. Catatonic posturinginvolves patients holding odd or exaggerated postures for prolonged periods, and catatonic rigidity is similar but refers to patients holding simple, fixed, rigid postures. Some people withcatatonic stupor can be obviously awake but immobile without rigidity and will sit or lay in these postures until moved. In catatonia, catalepsy refers to waxy flexibility or cerea flexibilitas, the tendency of patients to hold postures that are manipulated by others
Thought Disorder
Thought disorder is the most studied form of the disorganization symptoms. It is referred to as “formal thought disorder,” or “conceptual disorganization,” or as the “disorganization factor” in various studies that examine cognition or subsyndromes in schizophrenia. It has been said that the thought disorder of schizophrenia expressed in speech is easy to recognize but hard to define, but that has not limited attempts to define it. As a primary care physician uses the fundoscopic examination as a way to visualize the vasculature of the central nervous system (CNS), in psychiatry speech is examined as a means to determine a patient's verbal cognition. Thought disorder here refers to disorganization of the form of thought, and not content.
In its more mild manifestations, thought disorders do not preclude essential communication. Speech is frequently stilted or vague, and sentences may be incomplete. Speech may be tangential, so that the associative chain moves obliquely off topic. With the progression of time, speech can further deteriorate, and inappropriate content can intrude. Loosening of associations or derailment is frequent, and this refers to a cognitive “slip off track” (DSM-IV-TR glossary). Patients with prominent thought disorder have more confabulation, more concrete speech, and engage in more symbolic speech. In its most severe form, patients can present with mutism, use of neologisms (novel words, and in schizophrenia, taken to indicate that the word has an idiosyncratic or nonsense meaning), echolalia (in DSM-IV-TR “pathological, parrotlike, and apparently senseless repetition of a word or phrase”), and incoherence (incomprehensible speech without meaning or logical internal connections—word salad).
There are disturbances of thought or language found in many psychiatric disorders, but the thought disorder in schizophrenia is distinctive. When compared to subjects with bipolar disorders, siblings, and controls, those with schizophrenia are found to be more impaired in comprehension, attention, semantic organization, and fluency and complexity of speech
Depression
Many, probably most, people with schizophrenia will experience significant depression and anxiety during the course of their illness, and it has been claimed that depression is an integral part of the disorder. Clinicians and families may not notice depression and anxiety in their patients and relatives with schizophrenia, or may be too distracted by patients' positive symptoms to notice. Depression can also be obscured by negative symptoms, and both families and clinicians can consider the depression symptoms they see to be manifestations of negative symptoms, when there is almost no concordance between negative symptoms and depression in schizophrenia
Disturbances of sleep, appetite, energy, and concentration can be so common in schizophrenia that they become useless in screening for depression in these patients
Depression in schizophrenia
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It does appear that the prevalence of OCD in schizophrenia exceeds the prevalence in the general population, with estimates of up to a third of people with schizophrenia having comorbid OCD. There are also reports of increased rates of agoraphobia and generalized anxiety (up to one quarter of patients). There is more information about the presence of social phobia in schizophrenia.
Twenty to 40 percent of people with schizophrenia will make a suicide attempt sometime during their illness. The figure commonly cited for a suicide rate in schizophrenia is 10 percent, although there is little contemporary evidence to support this figure. Recent reanalysis of the evidence suggests that 5 percent of people with schizophrenia will commit suicide, with increased risk early in the course of illness, with frequent relapse, and at around the time of admission or immediately following discharge from a psychiatric facility
For those with schizophrenia, and for their families and advocates for those with mental illness, the real problem is that people with schizophrenia are far more likely to be the victims of violence than the perpetrators
A common finding suggests that people with schizophrenia are four times as likely as people without schizophrenia to be engaged in violent acts. Large cohort studies and smaller diagnosis specific studies, conducted in a variety of countries that have varying baseline rates of violence, show that the presence of a diagnosis of schizophrenia increases the risks of committing violence or being arrested.
There are some people with schizophrenia for whom the first acts of violence follow the onset of the illness. For many of these people, persecutory delusions that make them believe their lives are at risk are a significant contributor to their violent behaviors, and to those with schizophrenia suffering from the delusions these are acts of self-defense. The influence of paranoid delusions on an increased rate of violence persists even when the results are controlled for the effects of demographic factors and substance abuse. In particular, systematized persecutory delusions that suggest the person is a particular target, with co-occurring delusions of control, may increase the rates of violence. In this group there is a higher rate of violence by women, and in inpatient psychiatric units the rates of assault by men and women may be equivalent.
A frequent cause for concern among the general public, and also a frequent cause for concern among health care workers, is the effect of command auditory hallucinations. Although a dramatic example of the psychiatric pathology that accompanies schizophrenia, there is no firm evidence that command auditory hallucinations increase the risks of violence in schizophrenia. Auditory hallucinations are common symptoms of schizophrenia, and over even short evaluation periods a substantial minority of patients will have command hallucinations; the lifetime prevalence of command hallucinations may approach the prevalence of auditory hallucinations as a whole. Patients rarely follow the commands for violence, and when they do so it is almost always when the hallucinations occur in the presence of other risk factors for violence.
People with schizophrenia are also overrepresented in the numbers of people who commit homicide. The victims of homicide are usually people well known to the person with schizophrenia, and the fear that people with schizophrenia put the public at high risk is clearly overblown. In what might be the most complete study yet conducted, all homicides in England and Wales over a period of years were examined. People with schizophrenia accounted for 5 percent of murders, although people with this diagnosis account for somewhat less than 1 percent of the population. The large majority of these individuals were men; many were in the early stages of their illness, with a recent exacerbation of their illness, and had a recent change in the quality of their delusions
More specifically, poor insight is correlated with negative symptoms, inappropriate affect and thought disorder, and delusions, although the strength of the correlations is fairly weak. The effects of impaired insight are best recognized in the clinical problems of a reduced awareness of illness and functional impairment and of a need for treatment. Poor insight is associated with decreased compliance, worse overall function, increased levels of psychopathology, recurrent illness, and poor outcomes
Schizophrenia Subtypes
The current diagnostic system retains some of the earlier classification of schizophrenia proposed by Kraepelin and Bleuler and identifies several subtypes that include hebephrenic, catatonic, paranoid, undifferentiated, and simple schizophrenia. Hebephrenia is characterized by prominent disorganized behavior and speech and thus termed disorganized schizophrenia in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revision (DSM-IV-TR). This subtype is not associated with predominant hallucinations and delusions. Predominant paranoid delusions are observed in the paranoid subtype, which occurs more frequently in males, and is associated with a later age of onset and relatively fewer changes in cognition and affect. In recent years, one rarely encounters cases of catatonic schizophrenia, which is defined by stupor, posturing, and other extreme psychomotor manifestations. The reasons for this apparent disappearance of catatonic schizophrenia remain unclear. Several investigators have speculated that this is a true decrease in its incidence, perhaps explained by forces of natural selection or factors such as changes in diagnostic criteria or neuroleptic treatment that may have an effect on the clinical observations. Simple schizophrenia represents mild psychosis, with other symptoms of the illness such as emotional blunting, social anhedonia, and reduced drive. Undifferentiated schizophrenia is a category used to subclassify schizophrenia when none of the other subtype diagnostic criteria is met
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