Perez, Raphael Rey Prof. Serafina MaxinoBSCP III-3

ABNORMAL PSYCHOLOGY

DSM-III Classification

DSM-III reflects the idea that the category of schizophrenia includes a group of disorders, and specifies the following as essential characteristics: disorganization from the previous level of daily functioning in at least two areas, such as work, social relations, and self-care; the presence of at least one symptom from a least of six during the active phase of the illness; at least a 6-month duration of illness, during which the symptom or symptoms necessary for making the diagnosis are present; onset of illness before age 45; and not due to organic mental disorder or mental retardation. The symptom lists in DSM-III for a diagnosis of a schizophrenic disorder include six items. Three are delusional in nature, two are hallucinatory, and the last item is thought disorder accompanied by affective disorder , delusions or hallucinations, disorganized behavior, or catatonic symptoms. DSM III place great diagnostic significance on what it terms characteristic delusions and hallucinations (Table 1).

ICD-9 list the four basic types, but comments on simple schizophrenia that is schizophrenic symptoms are not clear-cut and that should, therefore, be diagnose sparingly, if at all. Other schizophrenic subtypes in ICD-9 include acute schizophrenic episode, latent schizophrenia, schizoaffective type, other, and – to be used only as a five resort – unspecified. DSM-III lists only five types under schizophrenic disorders: Disorganized (Hebephrenic), catatonic, paranoid, undifferentiated, and residual.It does not include simple schizophrenia. It does not include special schizophrenia, and neither ICD-9, nor DSM-III lists the pseudoneurotic type, which according to ICD-9, can be recorded under the category of latent schizophrenia. DSM-III does provide a special diagnostic category for the schizoaffective disorders, thus indicating that these disorders cannot be readily included under either the schizophrenic disorders or the affective disorders. DSM-III also provides a separate diagnostic for schizophreniform disorder, using Langfeldt’s concept of a diagnostic entity for any schizophrenic condition that has lasted less than 6 months. (see Table II).

TABLE IDiagmostic Criteria for a Schizophrenic Disorder

A. At least one of the following during a phase of the illness:1) Bizarre delusions (content is patently absurd and has no possible basis in fact),

such as delusions of being controlled, thought broadcasting, thought insertion, or thought withdrawal.

2) Somatic, grandiose, religious, nihilistic, or other delusions without persecutory or jealous content.

3) Delusions with persecutory or jealous content if accompanied by hallucinations of any type.

4) Auditory hallucinations in which either a voice keeps up running commentary on the individual’s behavior or thoughts, or two or more voices converse with each other.

5) Auditory hallucinations on several occasions with content of more than one or two words having no apparent relation to depression or elation.

6) Incoherence, marked loosening of associations, markedly illogical thinkng, or marked poverty of content of speech if associated with at least one of the following:

a. blunted, flat, or inappropriate affectb. delusions or hallucinationsc. catatonic or other grossly disorganized behavior

B. Deterioration from a previous level of functioning in areas as work, social relations, and self-care.

C. Duration: Continuous signs of the illness for at least 6 months at some time during the person’s life, with some signs of the illness at present. The 6-month period must include an active phase during which there were symptoms from A, with or without a prodromal or residual phase, as defined below.

Prodromal Phase: A clear deterioration in functioning before the active phase of the illness not due to a disturbance in mood or to a Substance Use Disorder and involving at least two of the symptoms noted below.

1. Social isolation or withdrawal2. marked impairment in role functioning as wage-earner, student, or homemaker3. markedly peculiar behavior (e.g. collecting garbage, talking to self in public, or

hoarding food)4. markedly impairment in personal hygiene and grooming5. blunted, flat, or inappropriate affect6. digressive, vague, overelaborate, circumstantial, or metaphorical speech7. odd or bizarre ideation, or magical thinking, e.g.superstitiousness, clairvoyance,

telepathy, “sixth sense”, “others can feel my feelings”, overvalued ideas, ideas of reference

8. unusual perceptual experiences, e.g. recurrent illusions, sensing the presence of a force of person not actually present.

Residual Phase: Persistence, following the active phase of illness, of at least two of the symptoms noted above, not due to a disturbance in mood or to a Substance Use Disorder.

D. The full depressive or manic syndrome or manic syndrome (criteria A and B of major depressive or manic episode), if present, developed after any psychotic symptoms, or was brief in duration relative to the duration of the psychotic symptoms in A.

E. Onset of prodromal or active phase of the illness before age 45.F. Not due to any Organic Mental Disorder of Mental Retardation.

TABLE IINosology of Types of Schizophrenia DSM-III ICD-9

Catatonic CatatonicDisorganized HebephrenicParanoid Paranoid/ ParaphrenicUndifferentiated (No equivalent term in ICD-9)Residual ResidualSchizophreniform (Brief Acute Schizophrenic Episode

Reactive Psychosis) (Oneirophrenia)(Schizophreniform)

(No equivalent term in DSM-III) Latent(Borderline)(Prepsychotic)(Prodromal)(Pseudopsychopathic)(Psychoneurotic)

(No equivalent term in DSM-III) SimpleSchizoaffective Schizoaffective

TABLE IIIDiagnostic Criteria for Catatonic Type

1. Catatonic Stupor (marked decrease in reactivity to environment and/or reduction of spontaneous movements and activity) or mutism

2. Catatonic Negativism (an apparently motiveless resistance to all instructions or attempts to be moved)

3. Catatonic Rigidity (maintenance of a rigid posture against efforts to be moved)

4. Catatonic Excitement (excited motor activity, apparently purposeless and not influenced by external stimuli)

5. Catatonic posturing (voluntary assumption of inappropriate or bizarre posture)

Catatonic schizophrenia (marked abnormality of motor behavior) occurs in two forms: inhibited or stuporous catatonia and excited catatonia.

a. Stuporous Catatonia – may be in a state of complete stupor, or he may show a pronounces decrease of spontaneous movements and activity.

He may be mute or nearly so, or he may show distinct negativism, stereotypies, echopraxia, or automatic obedience. Occasionally, a catatonic schizophrenics exhibit the phenomenon of catalepsy or waxy flexibility.

b. Excited Catatonia – is in a state of extreme psychomotor agitation. He talks and shouts almost continuously. His verbal productions are often incoherent. Patients in catatonic excitement urgently require physical and medical control, since they are often destructive and violent o others, and their dangerous excitement can cause injure themselves or to collapse from complete exhaustion.

TABLE IVDiagnostic Criteria for Disorganized Type A type of schizophrenia which there are:a. Frequent incoherence.b. Absence of systematized delusions.c. Blunted, inappropriate, or silly affect.

The disorganized or hebephrenic subtype is characterized by a marked regression to primitive, disinhibited, and unorganized behavior. The hebephrenic patient is usually active but in an aimless, nonconstructive manner. His thought disorder is pronounced, and his contact with reality is extremely poor. His personal appearance and his social behavior are dilapidated. His emotional response is inappropriate, and he often bursts out laughing without any apparent reasons. Incongruous grinning and grimacing are common in this type of patients, whose behavior is best describes as silly or fatuous.

TABLE VDiagnostic Criteria for Paranoid Type A type of Schizophrenia dominated by one or more of the following:1. persecutory delusions2. grandiose delusions3. delusional jealousy4. hallucinations with persecutory or grandiose content

The paranoid type of schizophrenia is characterized mainly by the presence of delusions of persecution or grandeur. Paranoid schizophrenics are usually older than catatonics or hebephrenics when they break down; that is they usually in their life of late twenties or in their thirties. Their ego resources are greater than those of catatonic and hebephrenic patients. Paranoids shows less regression of mental faculties, emotional response, and behavior than do subtypes of schizophrenia. A typical paranoid schizophrenic is tense and suspiscious, guarded, and reserved. He is often hostile and aggressive. His intelligence in areas are not invaded by his delusions may remain high.

TABLE VDiagnostic Criteria for Undifferentiated Type

A. A type of Schizophrenia in which there are; prominent delusions, hallucinations, incoherence, or grossly disorganized behavior.

B. Does not meet the criteria for any of the other listed types or meets the criteria for more than one.

Frequently, patients who are clearly schizophrenia cannot be easily fitted into one of the other subtypes, usually because they meet the criteria for more than lone subtype. Some acute, excited schizophrenic patients – diagnosed in ICD – 9 as suffering from acute schizophrenic episode- and some inert, chronic patients fall into this category, for which DSM-III provides the designation “undifferentiated”.

Latent schizophrenia is diagnosed in those patients who may have a marked schizoid personality and who show occasional behavioral peculiarities or thought disorders, without consistently manifesting any clearly psychotic pathology. The syndrome is also known as borderline schizophrenia. Latent schizophrenia is not listed in DSM-III, but is listed in ICD-9, although is not a diagnosis recommended for general use. In DSM-III latent schizophrenia most nearly corresponds to schizotypal personality disorder.

Simple schizophrenia does not appear in DSM-III as a subtype of schizophrenia. However, schizophrenia, simple type, listed in ICD-9, although clinicians are cautioned to resort to the diagnosis only rarely. The simple schizophrenic’s principal disorder is a gradual, insidious loss of drive, interest, ambition, and initiative. He is not usually not hallucinating or delusional, and if these symptoms do occur, they do not persist. He withdraws from contact with other people, tends to stay in his room, avoid meeting or eating with other members of the family, stops working, and stops seeing his friends. If he is still in school, his marks drops to low level, even if they were consistently high in the past.

In the schizoaffective disorders, a strong element of either depressive or euphoric affect is added to otherwise schizophrenic symptoms. Schizoaffective patients may be depressed, retarded, and suicidal. At the same time, they may express absurd delusions of persecution, complain of being controlled by outside forces, and have a distinct schizophrenic thought disorder. Or patients with various schizophrenic symptoms may be euphoric, playful, and overactive. The schizoaffective subtype of schizophrenia is listed as a schizophrenic disorder in the ninth revision of the ICD-9; however, the APA, in the DSM-III, lists schizoaffective disorder as a diagnostic entity by itself, and includes it

neither under schizophrenic disorders nor affective disorders, but under psychotic disorders not elsewhere classified.

TABLE VIDiagnostic Criteria for Residual Type

A. A history of at least one previous episode of Schizophrenia with prominent psychotic symptoms.

B. A clinical picture without any prominent psychotic symptoms that occasioned evaluation or admission to clinical care.

C. Continuing evidence of the illness, such as blunted or inappropriate affect, social withdrawal, eccentric behavior, illogical thinking, or loosening of associations.

Residual schizophrenia is a chronic form of schizophrenia which follows an acute episode of illness. Latent schizophrenia is the stage before a schizophrenic breakdown, and residual schizophrenia is the stage after the attack. Residual schizophrenia is also known as ambulatory schizophrenia.

TABLE VIIDiagnostic Features of Brief Reactive Psychosis Essential Features Associated Features Other Features Recognizable stressful event Perplexity Disorder is often un-Preceding the appearance of Bizarre Behavior officially called symptoms. hysterical psychosisEmotional turmoil and at Inappropriate volatile affectLeast one of the following: Disorientation; clouding of

1. Incoherence; markedly consciousnessIllogical thinking Poor insight

2. Delusions Patient is usually incapacitated3. Hallucinations and dependent on the close4. Grossly disorganized assistance of others

behavior Sometimes followed by mild Duration of disorder more depressionThan a few hours but less than1 weekDisorder may be superimposedon other disorders, such as personality disordersRule out organic mentaldisorder, manic episode, andfactitious illness with

psychological symptoms(Ganser’s Syndrome)

In the oneiroid state, the patients feels and behaves as thought he were in a dream. He may be deeply perplexed and not fully oriented in time and place. During state of clouded consciousness, he may experience feelings of ecstasy and rapidly shifting hallucinated senses. Illusionary distortions of his perceptional processes, including disturbances of time perception, and the symptomatic picture, may resemble those of a hysterical twilight state. During most oneroid reactions, the observer can most clearly observe the schizophrenic peculiar “double bookkeeping”,as it has been called. The patient may be convinced that he is traveling through the satellite and, at the same time, conscientiously follow the hospital mental routine. Oneroid states are usually limited in duration and occur most frequently in acute schizophrenic breakdowns. They are usually called brief reactive psychotic episodes in DSM-III.

Essential Features of Various Diagnosis Criteria for Schizophrenia

KURT SCHNEIDER

1. First-rank symptomsa. Audible thoughtsb. Voices arguing or discussing or bothc. Voices commentingd. Somatic passivity experiencese. Thought withdrawal and other experiences of influenced thoughtf. Thought broadcastingg. Delusional perceptionsh. All other experiences involving volition, made affects, and made impulses

2. Second-rank symptomsa. Other disorders of perceptionb. Sudden delusional ideasc. Perplexityd. Depressive and euphoric mood changese. Feelings of emotional impoverishmentf. “…and several others as well”

GABRIEL LANGFELDT

1. Symptom criteriaSignificant clues to a diagnosis of schizophrenia are (if no sign of organic mental disorder, infection, or intoxication can be demonstrated):a. Changes in personality, which manifest as a special type of emotional blunting

following by lack of initiative, and altered, frequently peculiar behavior. (In

hebephrenia, especially, these change are quite characteristic and are a principal clue to the diagnosis.)

b. In catatonic types, the history and the typical signs in periods of restlessness and stupor (with negativism, oily faces, catalepsy, special vegetative symptoms, etc.)

c. In paranoid psychoses, essential symptoms of split personality (or depersonalization symptoms) and a loss or reality feeling (derealization symptoms) or primary delusions

d. Chronic hallucinations2. Course criterion A final decision about diagnosis cannot be made before a follow-up of at least five years has shown a chronic course of disease. NEW HAVEN SCHIZOPHRENIA INDEX 1. a. Delusions: not specified or other-than-depressive: 2 points

b. Auditory hallucinationsc. Visual hallucinationsd. other hallucinations

2. a. bizarre thoughtsb. Autism or grossly unrealistic private thoughtsc. looseness of associations, illogical thinking, overinclusiond. Blockinge. concretenessf. Derealizationg. Depersonalization

3. Inappropriate affect: 1 point4. Confusion: 1 point5. Paranoid ideation (self-referential thinking, suspiciousness): 1 point6. Catatonic behavior

a. Excitementb. Stuporc. Waxy flexibilityd. Negativisme. Mutismf. Echolaliag. Stereotyped motor activity

Scoring: To be considered part of the schizophrenic group, the patient must score on item 1 or item 2a, 2b, or 2c, and must receive a total score of at least 4 points. FLEXIBLE SYSTEM

Minimum number of symptoms required can be four to eight, depending on investigator’s choice.1. Restricted affect

2. Poor insight3. Thoughts aloud4. Poor rapport5. Wide spread delusions6. Incoherent speech7. Unreliable information8. Bizarre delusions9. Nihilistic delusions10. Absence of early awakening (one to three hours)11. Absence of depressed facies12. Absence of elation RESEARCH DIAGNOSTIC CRITERIA Criteria 1 through 3 required for diagnosis.1. At least of the following for definite illness, and one for probable (not couting those occurring during period of drug or alcohol abuse or withdrawal):a. Thought broadcasting, insertion, or withdrawalb. Delusions of being controlled or influenced, other bizarre delusions, or multiple delusionsc. Delusions other than persecution or jealousy lasting at least one weeke. Auditory hallucinations in which either a voice keeps up running commentary on subject’s behaviors or thoughts as they occur or two or more voices converse with each otherf. Nonaffective verbal hallucinations spoken to subjectg. Hallucinations of any type throughout day for several days or intermittently for at least one monthh. Definite instances of marked formal thought disorders accompanied by blunted or inappropriate affect, delusions or hallucinations of any type, grossly disorganized behavior2. One of the following:a. Current period of illness lasted at least two weeks from onset of noticeable change in subject’s usual conditionb. Subject has has a previous period of illness lasting at least two weeks, during which he or she met criteria, and residual signs of illness have remained (e.g. extreme social withdrawal, blunted or inappropriate affect, formal thought disorder, or unusual thoughts or perceptual experiences)3. At no time during active period of illness being considered did subject meet criteria for probable or definite manic or depressive syndrome to the degree that it was a prominent part of illness.

ST. LOUIS CRITERIA 1. Both necessary:a. Chronic illness at least six months of symptoms before index evaluation, without return to premorbid level of psychosocial adjustment.

b. Absence of period of depressive or manic symptoms sufficient to qualify for moog (affective) disorder or probable mood (affective) disorder.2. At least one of the following:a. Delusions or hallucinations without significant perplexity or disorientationb. Verbal production that makes communication difficult owing to lack of logical or understandable organization (in presence of muteness, diagnostic decision must be deferred)3. At least three for definite, two for probable, illness:a. Never marriedb. Poor premorbid social adjustment or work historyc. Family history of schizophreniad. Absence of alcoholism or drug abuse within one year of onsete. Onset before age 40

TAYLOR AND ABRAMS’ CRITERIA All criteria must be met for diagnosis.1. Duration of episode greater than six months2. Clear consciousness3. Presence of delusions, hallucinations, or formal thought disorder (verbigeration, non sequiturs, word approximations, neologisms, blocking, and derailment)4. Absence of broad affect5. Absence signs and symptoms insufficient to kae diagnosis of affective disease6. No alcoholism or drug abuse within one year of index episode7. Absence of focal signs and symptoms of coarse brain disease or major medical illness known to produce significant behavioral changes

Signs and Symptoms

The presence of some key symptoms, for schizophrenic weighs heavily in favor of a diagnosis of schizophrenia.

1. Loosening of Associations- the specific thought disorder of the schizophrenic- is perhaps the most valuable diagnostic criteria. But a good knowledge of psychopathology is required to be sure of its presence, and to avoid confusing it with other forms of disturbed thinking, such as manic flight of ideas, disintegration of thought process due to clouding of consciousness, and impaired reasoning due to fatigue or distraction.

2. Bizarre Behavior – The patient’s behavior may furnish a significant clues for the diagnosis. Bizarre postures and grimacing are the certainly characteristic of schizophrenic conditions, but what constitutes a bizarre posture is not always easy to establish unequivocally. Religious rituals and special positions for meditation or rock-and-roll dancing with which the observer is not familiar may be called bizarre.

3. Hallucinations – sensory experiences or perception without corresponding external stimuli are common without symptoms of schizophrenia. Most common are auditory

hallucinations, or the hearing of voices. Most characteristically, two or more voices talk about the patient, discussing him in the third person.

4. Dream content – studies of the dream content of schizophrenia patients have shown that dreams of schizophrenia are less coherent and less complex also less bizarre than are the dreams of normal persons. Unpleasant emotions are the common in the dreams of schizophrenics than in the dreams of normals.

5. Disturbances of thinking- the schizophrenic disturbance of thinking and conceptualization is one of the most characteristics features of the disease.

6. Delusion- by definition, delusion is false ideas that cannot be corrected by reasoning, and that are idiosyncratic for the patient that is not part of his cultural environment. they are the most common symptoms of schizophrenia.7. Incoherence- for the schizophrenic, language is primarily a means of self expression, rather than a means of communication. His verbal and graphic productions are often either empty or obscure.

8. Neologisms- occasionally, the schizophrenic creates a completely new expression, a neologism, when he needs to express a concept for which no ordinary word exits.

9. Mutism- this function inhibition of speech and vocalization may last for hours or days, but, before the area of modern treatment methods, it often used to last for years in chronic schizophrenics of the catatonic type. Many schizophrenics tend to be monosyllabic and to answer question as briefly as possible.

10. echolalia- occasionally, the schizophrenic patient exhibit echolalia, repeating in his answers to the interviewer’s question’s many of the same words the questioner has used.

11. Verbigeration- this rare symptom is found almost exclusively in chronic and very regressed schizophrenia. It consists of senseless repetition of the same words or phrases, and it may, at the times, go on for days.

12. Stilted language- some schizophrenics make extraordinary efforts to maintain their social relations in order to maintain their relatively stable adjustment. But they may betray their rigidity and artificiality in their interpersonal relations by a peculiarly stilted and grotesquely quaint language.

13. Stuporous states- these states used to be common in the catatonic subtype of schizophrenia. Today, a modern physical treatment method permits therapists to interrupt stupors.

14. Echopraxia- this motor symptom is analogous to echolalia in the verbal sphere – imitation of movements and gestures of a person the schizophrenic is observing.

15. Automatic Obedience- Another symptoms sometimes observed in catatonic patients is automatic obedience, a patient may, without hesitation and in robot like fashion, carry out most simple commands given to him.

16. Negativism- the term negativism refers to a patient’s failure to cooperate, without any apparent reason for that failure. The patient does not appear to be fatigued, depressed, suspicious, or angry. He is obviously capable of physical movement.

17. Stereotyped Behavior- this behavior is occasionally seen in chronic schizophrenics, and not only in the back wards of old time mental hospitals. It may present itself as repetitive patterns of moving or walking or perhaps pacing the same circle day in and day out.

18. Deteriorated appearance and manners- schizophrenic patients tend to deteriorate in their appearance. Their efforts at grooming and self care may become minimal and they may have to be reminded to wash, bathe, shave, change their underwear, and so on.

19. Reduced Emotional responses- the quantitative change invariably consists of reduction in the intensity of emotional response. Many schizophrenics seems to be different or, at times, totally apathetic.

20. Anhedonia- anhedonia is a particularly distressing symptom of many schizophrenics. The anhedonia person is incapable of experiencing or even imagining any unpleasant emotionally barren.

21. Inappropriate Responses- a typical emotional reaction of schizophrenic is an incongruous or inappropriate response to life situations.

22.