Perez, Raphael Rey Prof. Serafina Maxino
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).
Diagmostic 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
2) Somatic, grandiose, religious, nihilistic, or other delusions without persecutory or
3) Delusions with persecutory or jealous content if accompanied by hallucinations of
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
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
a. blunted, flat, or inappropriate affect
b. delusions or hallucinations
c. 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 withdrawal
2. marked impairment in role functioning as wage-earner, student, or homemaker
3. markedly peculiar behavior (e.g. collecting garbage, talking to self in public, or
4. markedly impairment in personal hygiene and grooming
5. blunted, flat, or inappropriate affect
6. digressive, vague, overelaborate, circumstantial, or metaphorical speech
7. odd or bizarre ideation, or magical thinking, e.g.superstitiousness, clairvoyance,
telepathy, “sixth sense”, “others can feel my feelings”, overvalued ideas, ideas of
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.
Nosology of Types of Schizophrenia
Paranoid Paranoid/ Paraphrenic
Undifferentiated (No equivalent term in ICD-9)
Schizophreniform (Brief Acute Schizophrenic Episode
Reactive Psychosis) (Oneirophrenia)
(No equivalent term in DSM-III) Latent
(No equivalent term in DSM-III) Simple
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
4. Catatonic Excitement (excited motor activity, apparently purposeless and
not influenced by external stimuli)
5. Catatonic posturing (voluntary assumption of inappropriate or bizarre
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
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.
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.
Diagnostic Criteria for Paranoid Type
A type of Schizophrenia dominated by one or more of the following:
1. persecutory delusions
2. grandiose delusions
3. delusional jealousy
4. 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.
Diagnostic 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
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
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.
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
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.
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 psychosis
Emotional turmoil and at Inappropriate volatile affect
Least one of the following: Disorientation; clouding of
1. Incoherence; markedly consciousness
Illogical thinking Poor insight
2. Delusions Patient is usually incapacitated
3. Hallucinations and dependent on the close
4. Grossly disorganized assistance of others
behavior Sometimes followed by mild
Duration of disorder more depression
Than a few hours but less than
Disorder may be superimposed
on other disorders, such as
Rule out organic mental
disorder, manic episode, and
factitious illness with
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
1. First-rank symptoms
a. Audible thoughts
b. Voices arguing or discussing or both
c. Voices commenting
d. Somatic passivity experiences
e. Thought withdrawal and other experiences of influenced thought
f. Thought broadcasting
g. Delusional perceptions
h. All other experiences involving volition, made affects, and made impulses
2. Second-rank symptoms
a. Other disorders of perception
b. Sudden delusional ideas
d. Depressive and euphoric mood changes
e. Feelings of emotional impoverishment
f. “…and several others as well”
1. Symptom criteria
Significant 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 hallucinations
2. 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 hallucinations
c. Visual hallucinations
d. other hallucinations
2. a. bizarre thoughts
b. Autism or grossly unrealistic private thoughts
c. looseness of associations, illogical thinking, overinclusion
3. Inappropriate affect: 1 point
4. Confusion: 1 point
5. Paranoid ideation (self-referential thinking, suspiciousness): 1 point
6. Catatonic behavior
c. Waxy flexibility
g. 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.
Minimum number of symptoms required can be four to eight, depending on investigator’s
1. Restricted affect
2. Poor insight
3. Thoughts aloud
4. Poor rapport
5. Wide spread delusions
6. Incoherent speech
7. Unreliable information
8. Bizarre delusions
9. Nihilistic delusions
10. Absence of early awakening (one to three hours)
11. Absence of depressed facies
12. 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 withdrawal
b. Delusions of being controlled or influenced, other bizarre delusions, or multiple
c. Delusions other than persecution or jealousy lasting at least one week
e. 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
f. Nonaffective verbal hallucinations spoken to subject
g. Hallucinations of any type throughout day for several days or intermittently for at least
h. Definite instances of marked formal thought disorders accompanied by blunted or
inappropriate affect, delusions or hallucinations of any type, grossly disorganized
2. One of the following:
a. Current period of illness lasted at least two weeks from onset of noticeable change in
subject’s usual condition
b. 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 disorientation
b. Verbal production that makes communication difficult owing to lack of logical or
understandable organization (in presence of muteness, diagnostic decision must be
3. At least three for definite, two for probable, illness:
a. Never married
b. Poor premorbid social adjustment or work history
c. Family history of schizophrenia
d. Absence of alcoholism or drug abuse within one year of onset
e. Onset before age 40
TAYLOR AND ABRAMS’ CRITERIA
All criteria must be met for diagnosis.
1. Duration of episode greater than six months
2. Clear consciousness
3. Presence of delusions, hallucinations, or formal thought disorder (verbigeration, non
sequiturs, word approximations, neologisms, blocking, and derailment)
4. Absence of broad affect
5. Absence signs and symptoms insufficient to kae diagnosis of affective disease
6. No alcoholism or drug abuse within one year of index episode
7. 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
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
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
21. Inappropriate Responses- a typical emotional reaction of schizophrenic is an
incongruous or inappropriate response to life situations.