Jabol, Federico B. December 8, 2009BSCP III-3 Prof. Serafina Maxino

ABNORMAL PSYCHOLOGY

Schizophrenic Disorder

Schizophrenic is a system that is heterogeneous in its cause, pathogenesis, presenting picture course, response to treatment, and outcome. The syndrome is nevertheless assumed to be an illness or disorder, rather than a socially unacceptable set of behaviors. And because of this a number of different strategies have achieved general clinical acceptance. The fundamental altered signs of Blueler are broadly used throughout. DSM-III Classification In this DSM-III reflects the idea that 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 symptoms are list in DSM III, places great diagnostic significance of what it terms characteristics delusion and hallucination. In table one you will sea the different types of symptoms and illnesses.

Table-1 Diagnostic Criteria for a Schizophrenic disorder.

A. At least one of the following during a phase of the illness:

Bizarre delusion-content is patently absurd and has no possible basis in fact, such as delusions of being controlled, thought broadcasting, thought insertion, or thought withdrawal.

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

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

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.

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

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

1) blunted, flat, or inappropriate affect2) delusions or hallucinations3) 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.

*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.

Promodal or Residual symptoms Social isolation or withdrawal marked impairment in role functioning as wage-earner, student, or

homemaker markedly peculiar behavior (e.g. collecting garbage, talking to self in public,

or hoarding food) markedly impairment in personal hygiene and grooming blunted, flat, or inappropriate affect digressive, vague, over elaborate, circumstantial, or metaphorical speech odd or bizarre ideation, or magical thinking, e.g.superstitiousness,

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

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

Examples:

1).Six months of promodal symptoms with 1week of symptoms from A: no promodal symptoms with 6 months of symptoms from A; no promodal symptoms with 2 weeks of symptoms from A and 6 months of residual symptoms: 6 months of symptoms from a, apparently followed by several years of complete remission, with 1 week of symptoms in A in current episode.

2). 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.

ICD-9

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.

Table-II Nosology 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) Simple

Schizoaffective Schizoaffective

CLINICAL SYNDROMES

The types of schizophrenia which are officially accepted in DSM-III are listed on table II. Other types are recognized in ICD-9, are still others can be found in the psychiatric literature.

Catatonic

Catatonic schizophrenia occurs in two forms: inhibition or stuporous catatonia and excited catatonia. The essential feature of both forms is the marked abnormality of motor behavior. See table III

Table III- Diagnostic 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.

Disorganized and Paranoid

The disorganized or hebepherinic subtype is characterized by a marked regression to primitive, disinhibited, and unorganized behavior. The hebepherinic is usually early, before age of 25. His thought disorder is pronounced and his contact with reality is extremely poor.

Paranoid type of schizophrenia is characterized mainly by the presence of delusion of persecution or grandeur. Paranoid schizophrenics are usually older than catatonic schizophrenics or hebephrenics when they break down.

Table IV- Diagnostic 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.

TableV- Diagnostic Criteria for Paranoid TypeA 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 VI- Diagnostic 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 VII- Diagnostic 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, and

factitious illness with psychological symptoms(Ganser’s Syndrome)

Essential feature of Diagnostic CriteriaKURT 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

Signs and Symptoms in SCHIZOPHRENIC DISORDER

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.

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.

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

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.

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.

Bizarre Behavior – The patient’s behavior may furnish a significant clue 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.

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.

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.

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

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. 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.

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

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.

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.

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.

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.

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.

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.

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.

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

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