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A comprehensive overview of schizophrenia, focusing on its classification according to the dsm-5 and icd-10 systems. It delves into key features, subtypes, and diagnostic criteria, including paranoid, hebephrenic, catatonic, undifferentiated, post-schizophrenic, residual, and simple schizophrenia. The document also explores the epidemiology of schizophrenia and its impact on quality of life.
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M.Sc. 1ST^ SEMESTER, DEPARTMENT OF CLINICAL PSYCHOLOGY, MZU DATE: 29/09/
philosopher Socrates (470-339 BC) who inked in Plato’s Phaedrus “madness is a nobler thing than sober sense … madness comes from God, whereas sober sense is merely human.” Hippocrates (460-377 BC) thought that madness was an illness due to an imbalance of four bodily humors and that it could be cured by rebalancing these humors with treatments such as special diets, purgatives, and blood-lettings. Middle ages-demonic affliction (1500 AD) - In the 15th century Europe, delusions and hallucinations continued to be seen as proof of demonic possession shared almost by all cultures. Change of beliefs (1700 AD) - Phillip Pinel (1745–1826) started “moral treatment” which included respect for the person, a trusting and confiding doctor–patient relationship, decreased stimuli, routine activity, and the abandonment of old-fashioned Hippocratic treatments. He emphasized the need of hygiene, physical exercise, and preservation of detailed case histories for research. Schizophrenia at last (1900 AD) - In 1868 German psychiatrist, Karl Kahlbaum gave the term “juvenile madness” and isolated a form of a movement disorder characterized by a mannequin-like muscle stiffness associated with unusual postures and a pervading fear to be later called as “katatonia.”[3] EwaldHecker another German psychiatrist did a series of studies on young psychotic patients at Kahlbaum’s clinic in Görlitz, Prussia. Hecker coined the word “cyclothymia” and “hebephrenia” a disorder that began in adolescence with erratic behavior followed by a rapid decline of all mental functions; named after Hebe, Goddess of youth and frivolity (1871). In 1878, German Psychiatrist, Emil Kraepelin combined these various “disorders” into a single disease and gave 4 subtypes, namely, paranoid, catatonic, hebephrenic, and simple. This entity that brings to a man early decline in cognitive function was
then called “dementia praecox” to differentiate it from other forms of dementia. He also coined another term “manic-depressive psychosis” for those who showed affective symptoms during psychosis. In 1900, Swiss psychiatrist Eugene Bleuler coined the term “Schizophrenia” meaning split mind replacing the previous terminology dementia praecox. He also gave the very famous 4 A’s of schizophrenia along with other terms such as “Autism” and “Schizoid.” DSM-V The fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM V) understands all psychoses as variants of schizophrenia (American Psychiatric Association, 2013). This schizophrenia spectrum includes schizophrenia, other psychotic disorders, as well as schizotypal disorder (which is generally diagnosed as a personality disorder). The DSM V lists the following schizophrenia spectrum disorders: schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, substance/medication induced psychotic disorder, psychotic disorder due to another medical condition, unspecified schizophrenia and other psychotic disorder (pp. 87-160). When we examine these schizophrenia spectrum disorders, it becomes obvious that there are many similarities among the disorders and that they differ only in duration or emphasis on a particular symptom. For instance, schizophrenia, schizophreniform disorder, and brief psychotic disorder differ in terms of duration, while schizophrenia, delusional disorder, and schizoaffective disorder differ in symptomatic content. Psychotic disorder due to a general medical condition and substance-induced psychotic disorder are both related to psychoses that result from chemical or structural
of convincing evidence. Delusions that express a loss of control over mind or body are generally considered to be bizarre; these include the belief that one’s thoughts have been “removed” by some outside force ( thought withdrawal ), that alien thoughts have been put into one’s mind ( thought insertion ), or that one’s body or actions are being acted on or manipulated by some outside force ( delusions of control ). Hallucinations Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. They may occur in any sensory modality, but auditory hallucinations are the most common in schizophrenia and related disorders. Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are perceived as distinct from the individual’s own thoughts. The hallucinations must occur in the context of a clear sensorium; those that occur while falling asleep (hypnagogic) or waking up (hypnopompic) are considered to be within the range of normal experience. Hallucinations may be a normal part of religious experience in certain cultural contexts. Disorganized Thinking (Speech) Disorganized thinking (formal thought disorder) is typically inferred from the individual’s speech. The individual may switch from one topic to another ( derailment or loose associations ). Answers to questions may be obliquely related or completely unrelated ( tangentiality ). Rarely, speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization ( incoherence or “word salad”).
Because mildly disorganized speech is common and nonspecific, the symptom must be severe enough to substantially impair effective communication. The severity of the impairment may be difficult to evaluate if the person making the diagnosis comes from a different linguistic background than that of the person being examined. Less severe disorganized thinking or speech may occur during the prodromal and residual periods of schizophrenia. Grossly Disorganized or Abnormal Motor Behaviour (Including Catatonia) Grossly disorganized or abnormal motor behaviour may manifest itself in a variety of ways, ranging from childlike “silliness” to unpredictable agitation. Problems may be noted in any form of goal-directed behaviour, leading to difficulties in performing activities of daily living. Catatonic behaviour is a marked decrease in reactivity to the environment. This ranges from resistance to instructions ( negativism ); to maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and motor responses ( mutism and stupor ). It can also include purposeless and excessive motor activity without obvious cause ( catatonic excitement ). Other features are repeated stereotyped movements, staring, grimacing, mutism, and the echoing of speech. Although catatonia has historically been associated with schizophrenia, catatonic symptoms are nonspecific and may occur in other mental disorders (e.g., bipolar or depressive disorders with catatonia) and in medical conditions (catatonic disorder due to another medical condition). Negative Symptoms Negative symptoms account for a substantial portion of the morbidity associated with schizophrenia but are less prominent in other psychotic disorders. Two negative symptoms are particularly prominent in schizophrenia: diminished
Diagnostic Criteria of Schizophrenia in DSM- A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
D. Schizoaffective disorder and depressive or bipolar disorderwith psychotic features have been ruled out because either 1)no major depressive or manic episodes have occurredconcurrently with the active-phase symptoms, or 2) if moodepisodes have occurred during active-phase symptoms, theyhave been present for a minority of the total duration of theactive and residual periods of the illness. E. The disturbance is not attributable to the physiological effectsof a substance (e.g., a drug of abuse, a medication) oranother medical condition. F. If there is a history of autism spectrum disorder or acommunication disorder of childhood onset, the additionaldiagnosis of schizophrenia is made only if prominentdelusions or hallucinations, in addition to the other requiredsymptoms of schizophrenia, are also present for at least 1month (or less if successfully treated). SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS
changed to schizophrenia. While social and occupational functioning impairments may be present, they are not necessary for a diagnosis of Schizophreniform disorder. Relatives of individuals with Schizophreniform disorder have an increased risk for schizophrenia. Most individuals with Schizophreniform experience dysfunction in several areas of daily functioning, such as school or work, interpretation relationships, and self-care Individuals who recover from Schizophreniform disorder have better functional outcomes.
In delusional disorder, a person exhibits non-bizzare delusions, which means that the delusions must be about situations that can occur in real life, such as being followed, infected, loved at a phenomenon that, although not real, are nonetheless possible. The delusions are not attributable to the physiological effects of a substance (e.g.cocaine) another medical conditions (e.g.Alzheimer's disease), and not better explained by another mental disorder.
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder This category applies to presentations in which symptomscharacteristic of a schizophrenia spectrum and other psychoticdisorder that cause clinically significant distress or impairment insocial, occupational, or other important areas of functioningpredominate but do not meet the full criteria for any of thedisorders in the schizophrenia spectrum and other psychoticdisorders diagnostic class. The other specified schizophreniaspectrum and other psychotic disorder category is used insituations in which the clinician chooses to communicate thespecific reason that the presentation does not meet the criteriafor any specific schizophrenia spectrum and other psychoticdisorder. This is done by recording “other specified schizophreniaspectrum and other psychotic disorder” followed by the specificreason (e.g., “persistent auditory hallucinations”). Examples of presentations that can be specified using the“other specified” designation include the following:
social and interpersonal deficits, as well as cognitive or perceptual distortions and eccentric behavior. Key Features
ICD-10 Code: F20 – Schizophrenia The schizophrenic disorders are characterised in general by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted affect. Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits may evolve in the course of time. The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-direction. The most intimate thoughts, feelings, and acts are often felt to be known to or shared by others, and explanatory delusions may develop, to the effect that natural or supernatural forces are at work to influence the afflicted individual's thoughts and actions in ways that are often bizarre. The individual may see himself or herself as the pivot of all that happens. In a proportion of cases, which may vary in different cultures and populations, the outcome is complete, or nearly complete, recovery. The sexes are approximately equally affected but the onset tends to be later in women. General Criteria for Schizophrenia (F20): According to APA, Schizophrenia is a serious mental illness characterized by incoherent or illogical thoughts, bizarre behavior and speech, and delusions or hallucinations, such as hearing voices. For the diagnosis of schizophrenia, ICD-10 requires the presence of at least one of the following core symptoms for most of the time during an episode lasting at least one month:
