Jabol, Federico B. December 8, 2009
BSCP III-3 Prof. Serafina Maxino
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
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
• 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
1) blunted, flat, or inappropriate affect
2) delusions or hallucinations
3) catatonic or other grossly disorganized behavior
B. Deterioration from a previous level of functioning in areas as work, social relations,
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
Promodal or Residual symptoms
• Social isolation or withdrawal
• marked impairment in role functioning as wage-earner, student, or
• 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.
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 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
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
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
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
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.
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
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 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.
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
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 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
Essential feature of Diagnostic Criteria
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
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
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
Inappropriate Responses- a typical emotional reaction of schizophrenic is an
incongruous or inappropriate response to life situations.