The Essence of
Schizophrenia
• Originally called “dementia
praecox”
• Produces severe
incapacity – “dementia”
• Typically begins in
adolescence – “praecox”
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The Tragedy of
Schizophrenia
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A catastrophic illness
Tends to persist chronically
10% suicide rate
Very common -- 0.5-1% of
population
• The “cancer of mental illness”
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The Complexity of
Schizophrenia
• No single defining feature
• Multiple characteristic symptoms
• Symptoms from multiple domains
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Emotion
Personality
Cognition
Motor Activity
• Probably a multisystem disorder,
analogous to syphilis
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Simplifying the Complexity
of Schizophrenia
• Division of symptoms into
two broad groups
• Positive: distortions or
exaggerations of normal
functions
• Negative: diminution of
normal functions
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Hughlings-Jackson: Positive
and Negative Symptoms
• Disease that is said to “cause the symptoms of
insanity.” I submit that disease only produces
negative mental symptoms answering to the
dissolution, and that all elaborate positive
mental symptoms (illusions, hallucinations,
delusions, and extravagant conduct) are the
outcome of activity of nervous elements
untouched by any pathological process; that
they arise during activity on the lower end of
evolution remaining.
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Positive Symptoms
Symptom
Hallucinations
Delusions
Disorganized
Speech
Bizarre Behavior
Function Distorted
Perception
Inferential thinking
Thought/Language
Behavioral
monitoring
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Negative Symptoms
Symptom
Alogia
Affective blunting
Avolition
Anhedonia
Function Diminished
Fluency of
speech/thought
Emotional expression
Volition and drive
Hedonic capacity
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The Importance of
Negative Symptoms
• Impair ability to function in daily
life
• Holding a job
• Attending school
• Forming friendships
• Having intimate family
relationships
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Subdivision of Symptoms
into Three Dimensions
• Psychotic
Delusions
Hallucinations
• Disorganized
Disorganized speech
Disorganized behavior
Inappropriate affect
• Negative
Poverty of speech
Avolition
Affective Blunting
Anhedonia
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Types of
Hallucinations
• Auditory
• Visual
• Tactile
• Olfactory
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Types of Delusions
• Persecutory
• Grandiose
• Religious
• Jealous
• Somatic
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Historical Concepts
• Emil Kraepelin
• Eugen Bleuler
• Kurt Schneider
• Others (e.g.,
Leonhard, Kleist,
Langfeldt)
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Emil Kraepelin: Dementia Praecox
“Dementia praecox consists of
a series of states, the
common characteristic of
which is a peculiar
destruction of internal
connections of the psychic
personality....the majority of
the clinical pictures are the
expression of a single
morbid process, though
outwardly they often diverge
very far from one another.”
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Kraepelin: Course and
Outcome
• Split “dementia praecox” from
manic-depressive illness
• Early onset
• Marked deterioration
• Chronic course
• Diversity of signs and symptoms
• Importance of volition and affect
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Eugen Bleuler: Loosening
of Associations
“Of the thousands of
associative threads
that guide our
thinking, this disease
seems to interrupt,
quite haphazardly,
sometimes single
threads, sometimes a
whole group, and
sometimes whole
segments of them.”
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Bleuler: Fundamental
Symptoms
• Renamed the disorder “schizophrenia”
• Focused on the characteristic
symptoms
• Emphasized fragmenting of thinking
• Partial recovery possible
• No full “restitutio ad integrum”
• A broader concept
• Heterogeneity: the “group of
schizophrenias”
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Bleuler’s Fundamental
Symptoms
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Associations
Affective Blunting
Avolition
Autism
Ambivalence
Attention
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Bleuler’s Description of
Fundamental Symptoms
• Certain symptoms of schizophrenia are present in
every case and at every period of the illness even
though, as with every other disease symptom, they
must have attained a certain degree of intensity before
they can be recognized with any certainty…for
example, the peculiar association disturbance is
always present, but not each and every aspect of
it…besides these specific permanent or fundamental
symptoms, we can find a host of other, more accessory
manifestations such as delusions, hallucinations, or
catatonic symptoms…as far as we know, the
fundamental symptoms are characteristic of
schizophrenia, while the accessory symptoms
may also appear in other types of illnesses.
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Kurt Schneider
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Schneider: The
Psychotic Experience
• Interested in pathognomonic
symptoms
• “First Rank Symptoms” (FRS)
E.g., voices commenting
Voices arguing
Thought insertion
• Involve a loss of the sense of
autonomy of self, or “ego
boundaries”
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Importance of
Schneiderian Ideas
• Discrete phenomena—clearly
pathological or “bizarre”
• Discontinuous from
normality
• Potentially for good reliability
• Ideal for objective criterionbased systems
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Schneiderian Influences
on Diagnostic Systems
• Incorporated into Present State
Examination (PSE)
• Used in International Pilot Study of
Schizophrenia (IPSS)
• Influenced the International
Classification of Disease (ICD)
• Influenced the US Diagnostic and
Statistical Manual (DSM)
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Fundamental Questions
about Schizophrenia
• What are the characteristic
symptoms?
• What are the boundaries of the
concept?
• Is the disorder a single illness or
multiple disorders?
• If multiple, what are the subtypes?
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Characteristic Symptoms
• Schneider: specific types of
delusions and hallucinations
• Bleuler: fragmented thinking,
inability to relate to external
world
• Kraepelin: emotional dullness,
avolition, loss of inner unity
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Schizophrenia as a
“Polythetic Construct”
• No single characteristic symptom
• Many symptoms, all present in
some, not present in all
• Manifestations in thinking, emotion,
interpersonal relationships
• A multisystem disease
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What are the Characteristic
Symptoms of Schizophrenia?
• Depends upon whom you ask
• Depends upon theoretical
construct
• Depends upon what you mean by
characteristic
Common?
Specific?
Core?
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Kraepelin: The Borders
of Schizophrenia
…it is certainly possible that
its borders are drawn at
present in many directions
too narrow, in others perhaps
too wide.
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Boundaries of the Concept
• Schizoaffective Disorder
• Psychotic Mood Disorders
• Nonpsychotic disorders
Schizotypal Personality
Simple Schizophrenia
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“Good Prognosis
Schizophrenia”
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Prominent affective symptoms
Acute onset
Family history of affective disorder
Good premorbid function
Presence of insight
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Narrowing of Concept:
Rationale
• Risk of tardive dyskinesia
• Risk of erroneously treating
mood disorders with
neuroleptics
• Risk of self-fulfilling
prophesies of poor outcome
• Risk of political abuse
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Single or Multiple
Illnesses
• Whether dementia praecox in the
extent here delimited represents
one uniform disease, cannot be
decided at present with certainty.
-- Emil Kraepelin
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Heterogeneity:
Competing Models
• Single disease entity: multiple
sclerosis
• Multiple disease entities: mental
retardation
• Multiple domains of
psychopathology
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Single Disease Entity
• A single illness
• A single cause that produces
diverse manifestations
• Possible mechanism:
process producing multiple
brain lesions
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Multiple Disease Entities
• “The group of schizophrenias”
• Multiple causes
Purely genetic forms, e.g. phenylketonuria
Purely environmental forms, e.g. virally induced
Multifactorial forms
• Manifestations reflect site of injury
and time of the maturational
process
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Multiple Domains
• Multiple dimensions of
psychopathology
e.g., psychotic, disorganized, negative
• Different mechanism for each dimension
• Disease process A  dimension A
• Disease process B  dimension B
• Disease process C  dimension C
• Mixed clinical presentation due to
multiple disease processes
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Methods for Subtyping
• Traditional subtypes based
on clinical presentation
• Phenomenotype vs. biotype
• Positive vs. mixed vs.
negative
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Traditional Subtypes
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Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
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Traditional Subtypes
• Divide patients based on
their prominent presenting
symptoms
• Useful for prediction
Prognosis
Social and occupational function
Response to treatment
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Phenomenotype
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Types of symptoms
Severity of symptoms
Longitudinal course
Mode of onset
Cognitive function
Psychosocial adaptation
Response to treatment
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Biotype
• Genetic loading and linkage
• Birth and pregnancy
complications
• Viral risk factors
• Neurophysiological measures
• Neuropsychological measures
• Neuroimaging measures
• Neurochemical measures
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Positive vs. Negative
Positive
Negative
Poor premorbid
Acute onset
Psychotic symptoms
Intact cognition
Poor treatment response
Neurochemical mechanism
Reversible
Good premorbid
Insidious onset
Negative symptoms
Impaired cognition
Good treatment response
Structural mechanism
Irreversible
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DSM-IV Criteria for
Schizophrenia: The Basics
• Characteristic symptoms for one
month
• Social/Occupational Dysfunction
• Overall Duration > 6 months
• Not attributable to mood disorder
• Not attributable to substance use
or general medical condition
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Criterion A: Characteristic
Symptoms
• At least two of the following, each present for
a significant portion of time during a one
month period (or less if successfully treated):
• (1) delusions
• (2) hallucinations
• (3) disorganized speech (e.g., frequent
derailment or incoherence)
• (4) grossly disorganized or catatonic behavior
• (5) negative symptoms, I.e., affective
flattening, alogia, or avolition
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Criterion A:
Parenthetical Note
• [Note: Only one “A” symptom is
required if delusions are bizarre
or hallucinations consist of a
voice keeping up a running
commentary on the person’s
behavior or thoughts, or two or
more voices conversing with
each other.]
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Criterion B: Social/Occupational
Dysfunction
• For a significant portion of the time
since the onset of the disturbance, one
or more major areas of functioning such
as work, interpersonal relations or selfcare is markedly below the level
achieved prior to the onset
• OR when the onset is in childhood or
adolescence, failure to achieve expected
level of interpersonal, academic, or
occupational achievement
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Criterion C: Overall Duration
• Continuous signs of the disturbance persist for at
least six months
• This six-month period must include at least one
month of symptoms that meet criterion A (i.e., active
phase symptoms), and may include periods of
prodromal or residual symptoms
• During these prodromal or residual period, the signs
of the disturbance may be manifested by only
negative symptoms or two or more symptoms listed
in criterion A present in an attenuated form (e.g.
odd beliefs, unusual perceptual experiences)
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Criterion D: Schizoaffective
and Mood Disorder Exclusion
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Schizoaffective Disorder and Mood
Disorder with Psychotic Features have
been ruled out because of either:
(1) No major depressive or manic episodes have
occurred concurrently with the active phase
symptoms; or
(2) If mood episodes have occurred during active
phase symptoms, their total duration has been
brief relative to the duration of the active
and residual periods
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Criterion E: Substance /
General Medical Condition
Exclusion
The disturbance is not due to the
direct effects of a substance
(e.g., drugs of abuse,
medication) or a general medical
condition
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ICD 10 Criteria for
Schizophrenia: The Basics
• Characteristic symptoms for one
month
• If mood disorder is present, one
month of characteristic symptoms
must antedate it
• Not attributable to organic brain
disease or substance abuse
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ICD 10: Characteristic
Symptoms
•At least one of the following:
Thought echo, insertion, withdrawal, or
broadcasting
Delusions of control, influence, or passivity;
delusional percept
Voices commenting or discussing; voices
coming from some part of the body
Persistent delusions that are culturally
inappropriate and completely impossible, such
as religious or political identity, superhuman
powers
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ICD 10: Characteristic
Symptoms
•Or at least two of the following:
Persistent hallucinations in any modality
when accompanied by delusions
Neologisms, breaks or interpolations in
the train of thought, resulting in
incoherence or irrelevant speech
Catatonic behavior
“Negative” symptoms such as marked
apathy, paucity of speech, and blunting
or incongruity of emotional responses
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Similarities Between ICD
and DSM
• Both require one month of active
symptoms
• Both include references to
negative symptoms
• Both require presence of
delusions and hallucinations for
a diagnosis of schizophrenia
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Differences Between ICD
and DSM
• Characteristic symptoms (more
emphasis on FRS in ICD)
• Overall duration of symptoms
(one month for ICD vs. six
months for DSM)
• More specific and complex
symptom list in ICD
• Inclusion of Schizotypal Disorder
and Simple Schizophrenia in ICD
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ICD 10: Types of
Schizophrenia
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Paranoid
Hebephrenic
Catatonic
Undifferentiated
Post-schizophrenic depression
Simple schizophrenia
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ICD 10: Categories of
Psychosis
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Schizophrenia
Schizotypal Disorder
Persistent Delusional Disorders
Acute and Transient Psychotic
Disorders
• Induced Delusional Disorder
• Schizoaffective Disorders
• Other Nonorganic Psychotic
Disorders
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DSM IV: Subtypes
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Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
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DSM IV: Categories of
Psychosis
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Schizophreniform Disorder
Schizophrenia
Brief Psychotic Disorder
Schizoaffective Disorder
Delusional Disorder
Shared Psychotic Disorder
Psychotic Disorder due to a General Medical
Condition
• Substance-Induced Psychotic Disorder
• Psychotic Disorder Not Otherwise
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Specified
Differential Diagnosis
• Mood Disorders
• Nonpsychotic personality
disorders
• Substance-induced psychotic
disorders
• Psychotic disorders due to a
general medical condition (i.e.,
“organic” disorders)
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Drugs That May Induce
Psychosis
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Amphetamines
Marijuana
Hallucinogens
Cocaine
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Medical Conditions That May
Present with Psychosis
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Temporal lobe epilepsy
Tumor
Stroke
Trauma
Endocrine/metabolic abnormalities
Infections
Multiple Sclerosis
Autoimmune diseases
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Evaluating
Psychosocial
Function
• Premorbid
• Current
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Aspects of Psychosocial
Function
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Relationship to parents
Relationship to siblings
Relationship to peers
Sexual adjustment
Educational history
Work function
Recreational activities and
interests
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Laboratory Workup
• No standard set of laboratory
tests
• Test selected on basis of
clinical presentation, mode of
onset, and past history
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Some Common
Laboratory Tests
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Complete blood count
Urinalysis
Endocrine tests
Liver function tests
Electroencephalogram
Computerized Tomography
Magnetic Resonance Imaging
Neuropsychological tests
Projective tests
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Cross Cultural Issues:
Similarities Across Cultures
• Schizophrenia is found
throughout the world
• Some symptoms tend to be
identical worldwide
Negative symptoms
Thought Disorder
Cognitive Impairment
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Differences Across
Cultures
• Content of psychotic
symptoms
• Outcome
• Frequency of acute psychotic
episodes
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Reasons for
Frequency of Acute
Psychosis
• Infections
• Nutrition
• Delays in provision of
medical care
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Social Outcome in First Episode
Schizophrenia: Nagasaki
Follow-up
after 2 years
1981-1982
Follow-up
after 5
years 19841985
Follow-up
after 10
years 19891990
64
65
58
Good Outcome
34.4
44.6
36.2
Poor Outcome
24.4
35.4
35.5
Hospitalized
31.3
20.0
29.3
With good outcome
39.1
50.8
44.8
With poor outcome
60.9
49.2
55.2
Number of cases at follow-up
DAS overall evaluation (includes
cases in the hospital)
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Poor Outcome: Predictors
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Prominent negative symptoms
Early age of onset
Insidious onset
Poor premorbid adjustment
Low educational achievement
Low parental social class
Male gender
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Comparison of Course in Developed
and Developing Countries
Pattern of Course *
1
2
3
4
5
6
7
8
9
Developed Countries (n-604)
15.7
17.4
6.2
5.3
14.7
12.1
17.1
2.3
--
Developing Countries (n-474)
37.1
11.6
6.5
2.3
19.0
10.6
11.2
1.1
0.6
* 1. Single psychotic episode, complete remission
2. Single psychotic episode, incomplete remission
3. Single psychotic episode, non-psychotic episodes complete remission
4. Single psychotic episode, non-psychotic episodes incomplete remission
5. 2+ psychotic episodes, complete remission
6. 2+ psychotic episodes, incomplete remission
7. Continuous psychotic illness, no remission
8. Continuous non-psychotic illness
9. Not known
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Reasons for Better
Outcome in Developing
Countries
• Better social support from
extended families
• Less social pressure to achieve
occupationally
• Lower stress in rural
environments and small villages
• Less stigma toward mental
illness
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