Dr Sarmad Nadeem
Consultant Psychiatrist
Northwestern School of Psychiatry MRCPsych Course
ICD-10 diagnosis
Course
Subtypes
Clinical features
Differential diagnosis
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The Schizophrenic disorders are characterised
in general by fundamental & characteristic
distortions of thinking, perception& affects
that are inappropriate or blunted
1 of the following
A)
B)
C)
D)
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)
2 of the following
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
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.
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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.
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Episodic with stable deficit
Persistent but non-progressive symptoms in
the intervals between psychotic episodes.
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Episodic remittent
Complete or virtually complete remissions
between psychotic episodes.
Incomplete remission
Complete remission
Other
Course uncertain, period of observation too
short
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Paranoid ( the commonest subtype)
Hebephrenic
Catatonic
Undifferentiated
Post-Schizophrenic depression
Residual schizophrenic depression
Residual Schizophrenia
Simple Schizophrenia
Other Schizophrenia
Schizophrenia ,unspecified
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Paranoid schizophrenia
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).
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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.
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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.
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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
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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;
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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);
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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).
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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.
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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.
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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;
 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.
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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 selfabsorbed attitude, and social withdrawal;
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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.
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Other schizophrenia
Schizophrenia, unspecified
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Delusions
◦ Firmly held beliefs
◦ Contrary to reality
◦ Resistant to
disconfirming
evidence
Persecutory
delusions common
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◦ Sensory experiences in
the absence of sensory
stimulation
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Other common
forms :
◦ Thought insertion
◦ Thought
broadcasting
◦ Grandiose delusions
◦ Ideas of reference
Types of hallucinations
◦ Audible thoughts
◦ Voices commenting
◦ Voices arguing
 “The CIA planted a
listening device in my
head”
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Hallucinations
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Increased levels of
activity in Broca’s area
during hallucinations
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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
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Negative symptoms
predict poor quality of
life posthospitalization
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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
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Catatonia
Motor abnormalities
Repetitive, complex gestures
Usually of the fingers or hands
Excitable, wild flailing of limbs
Catatonic immobility
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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
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Only Schizotypal PD is aetiologically related
to Schizophrenia
 Eccentricity
 Affect
constriction
 Excessive
social anxiety
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10% of patients commit suicide
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Early in illness
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Paranoid schizophrenics 3 times more likely
than non paranoid schizophrenic to commit
suicide
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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
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Wide
Initially a lot of uncertainty
In general
 Broader
range of psychotic symptoms
 Greater functional impairment
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Substance induced psychotic disorder
Psychotic disorder due to general medical
condition (Head injury, CNS infection, CNS
tumour, TLE, Epilepsy , Metabolic or
endocrine disorder)
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Mood disorder with psychotic features
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Delusional disorder
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Kaplan & Sadock’s synopsis of Psychiatry
Revision notes in Psychiatry
NICE Guidelines
Oxford Shorter text book in psychiatry
Oxford Handbook of Psychiatry
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Any questions
Thank you