1. Schizophrenia Psychopathology & Diagnosis
Dr Sarmad Nadeem
Consultant Psychiatrist
Northwestern School of Psychiatry MRCPsych Course

2. Overview of the presentation
ICD-10 diagnosis
Course
Subtypes
Clinical features
Differential diagnosis

3. ICD -10 definition and criteria
The Schizophrenic disorders are characterised
in general by fundamental & characteristic
distortions of thinking, perception& affects that are inappropriate or blunted

4. ICD -10 definition and criteria
1 of the following
2 of the following
Thought alienation
Delusions of control ,influence or passivity ,actions or sensations, delusional perceptions
Hallucinatory voices
(running commentary Discussing the patients between them)
Persistent delusions
(culturally inappropriate or completely impossible)
A) Persistent hallucinations in any modality B) Neologisms ,breaks in the train of thoughts , resulting in incoherent or irrelevant speech (FTD) C) Catatonic behaviour D) Negative symptoms

5. ICD -10 definition and criteria
Pattern of course In view of the considerable variation of the course of schizophrenic disorders it may be desirable (especially for research) to specify the pattern of course by using a fifth character. Course should not usually be coded unless there has been a period of observation of at least 1 year.

6. Course
Continuous
No remission of psychotic symptoms throughout the period of observation.
Episodic with progressive deficit
Progressive development of negative symptoms in the intervals between psychotic episodes.

7. Course Episodic with stable deficit
Persistent but non-progressive symptoms in the intervals between psychotic episodes.

8. Course Episodic remittent
Complete or virtually complete remissions between psychotic episodes.
Incomplete remission
Complete remission
Other
Course uncertain, period of observation too short

9. Subtypes of Schizophrenia
Paranoid ( the commonest subtype)
Hebephrenic
Catatonic
Undifferentiated
Post-Schizophrenic depression
Residual schizophrenic depression
Residual Schizophrenia
Simple Schizophrenia
Other Schizophrenia
Schizophrenia ,unspecified

10. Paranoid Schizophrenia-1
The general criteria for schizophrenia must be met.
Delusions or hallucinations must be prominent (such as delusions of persecution, reference, exalted birth, special mission, bodily change, or jealousy; threatening or commanding voices, hallucinations of smell or taste, sexual or other bodily sensations).

11. Paranoid Schizophrenia-2
Flattening or incongruity of affect, catatonic symptoms, or incoherent speech must not dominate the clinical picture, although they may be present to a mild degree.

12. Hebephrenic schizophrenia-1
The general criteria for schizophrenia must be met.
Either of the following must be present:
definite and sustained flattening or shallowness of affect;
definite and sustained incongruity or inappropriateness of affect.

13. Hebephrenic schizophrenia-2
Either of the following must be present:
behaviour that is aimless and disjointed rather than goal-directed;
definite thought disorder, manifesting as speech that is disjointed, rambling, or incoherent.
Hallucinations or delusions must not dominate the clinical picture, although they may be present to a mild degree

14. Catatonic schizophrenia-1
The general criteria for schizophrenia must eventually be met, although this may not be possible initially if the patient is uncommunicative.
For a period of at least 2 weeks one or more of the following catatonic behaviours must be prominent:
stupor (marked decrease in reactivity to the environment and reduction of spontaneous movements and activity) or mutism;

15. Catatonic schizophrenia-2
excitement (apparently purposeless motor activity, not influenced by external stimuli);
posturing (voluntary assumption and maintenance of inappropriate or bizarre postures);
negativism (an apparently motiveless resistance to all instructions or attempts to be moved, or movement in the opposite direction);

16. Catatonic schizophrenia-3
rigidity (maintenance of a rigid posture against efforts to be moved);
waxy flexibility (maintenance of limbs and body in externally imposed positions);
command automatism (automatic compliance with instruction).

17. Undifferentiated schizophrenia
The general criteria for schizophrenia must be met. Either of the following must apply:
insufficient symptoms to meet the criteria for any of the subtypes
so many symptoms that the criteria for more than one of the subtypes listed above are met.

18. Postschizophrenic depression
The general criteria for schizophrenia must have been met within the past 12 months but are not met at the present time.
One of the conditions in Criterion G1(2) a, b, c, or d for general schizophrenia must still be present.
The depressive symptoms must be sufficiently prolonged, severe, and extensive to meet criteria for at least a mild depressive episode.

19. Residual schizophreni-1
The general criteria for schizophrenia must have been met at some time in the past but are not met at the present time.
At least four of the following negative symptoms have been present throughout the previous 12 months:
psychomotor slowing or underactivity;
definite blunting of affect;
passivity and lack of initiative;

20. Residual schizophreni-2
poverty of either the quantity or the content of speech;
poor nonverbal communication by facial expression, eye contact, voice modulation, or posture;
poor social performance or self-care.

21. Simple schizophreni-1
There is slow but progressive development, over a period of at least 1 year, of all three of the following:
a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of drive and interests, aimlessness, idleness, a self- absorbed attitude, and social withdrawal;

22. Simple schizophreni-2
gradual appearance and deepening of negative symptoms such as marked apathy, paucity of speech, underactivity, blunting of affect, passivity and lack of initiative, and poor nonverbal communication (by facial expression, eye contact, voice modulation, and posture);
marked decline in social, scholastic, or occupational performance.

23. Other categories
Other schizophrenia
Schizophrenia, unspecified

24. Positive Symptoms: Behavioural excesses
Delusions
Firmly held beliefs
Contrary to reality
Resistant to disconfirming evidence
Persecutory delusions common
“The CIA planted a listening device in my head”
Other common forms :
Thought insertion
Thought broadcasting
Grandiose delusions
Ideas of reference
Hallucinations
Sensory experiences in the absence of sensory stimulation
Types of hallucinations
Audible thoughts
Voices commenting
Voices arguing
Increased levels of activity in Broca’s area during hallucinations

25. Negative Symptoms: Behavioural deficits
Avolition
Lack of interest; apathy
Alogia
Reduction in speech
Anhendonia
Inability to experience pleasure
Consummatory pleasure
Anticipatory pleasure
Flat affect
Exhibits little or no affect in face or voice
Asociality
Inability to form close personal relationships
Negative symptoms predict poor quality of life post-hospitalization

26. Disorganized Symptoms
Disorganized speech (Formal thought disorder)
Incoherence
Inability to organize ideas
Loose associations (derailment)
Rambles, difficulty sticking to one topic
Disorganized behaviour
Odd or peculiar behaviour
Silliness, agitation, unusual dress

27. Catatonia
Motor abnormalities
Repetitive, complex gestures
Usually of the fingers or hands
Excitable, wild flailing of limbs
Catatonic immobility

28. Maintain unusual posture for long periods of time e. g
Maintain unusual posture for long periods of time e.g., stand on one leg
Waxy flexibility- limbs can be manipulated and posed by another person
Inappropriate affect- Emotional responses inconsistent with situation e.g. laugh uncontrollably at a funeral

29. Personality in schizophernia
Only Schizotypal PD is aetiologically related to Schizophrenia
Eccentricity
Affect constriction
Excessive social anxiety

30. Suicide 10% of patients commit suicide Early in illness
Paranoid schizophrenics 3 times more likely than non paranoid schizophrenic to commit suicide

31. ROY IN 1982 found that its more likely in following cases:
Being male
Being young
Being unemployed
Having chronic illness ,relapse and remissions
Having a high educational attainment level prior to onset
Akathesia
Abrupt stoppage of drugs
Recent discharge from inpatient care

32. Differential diagnosis
Wide
Initially a lot of uncertainty
In general
Broader range of psychotic symptoms
Greater functional impairment

33. Substance induced psychotic disorder
Psychotic disorder due to general medical condition (Head injury, CNS infection, CNS tumour, TLE, Epilepsy , Metabolic or endocrine disorder)
Mood disorder with psychotic features
Delusional disorder

34. References & further readings
Kaplan & Sadock’s synopsis of Psychiatry
Revision notes in Psychiatry
NICE Guidelines
Oxford Shorter text book in psychiatry
Oxford Handbook of Psychiatry

35. Any questions

36. Thank you