Schizophrenia and delusional disorders are psychotic disorders in which there may be a lack of contact with reality, indicated by, for example, the presence of delusions, hallucinations and lack of insight. Schizoaffective disorders are psychotic disorders that have an intermediate position between schizophrenia and mood disorders.
SCHIZOPHRENIA
Clinical features
Characteristic features include one or more of the following:
• Changes in thinking
• Changes in perception
• Blunted or inappropriate affect
• A reduced level of social functioning.
Cognitive functions are usually intact in the early stages.
Schneiderian first-rank symptoms
In the absence of organic pathology the presence of any of these symptoms is indicative, though not pathognomonic, of schizophrenia:
• Auditory hallucinations: voices repeating thoughts out loud; voices discussing the subject in the third person; a running commentary
• Thought insertion
• Thought withdrawal
• Thought broadcasting
• Made feelings, impulses and actions
• Somatic passivity
• Delusional perception.
DSM-IV-TR criteria
A. Characteristic symptoms – at least two of the following, each present for a significant portion of time during a 1-month period (or less, if successfully treated):
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behaviour
• Negative symptoms (i.e. affective flattening, alogia, or avolition).
If the delusions are bizarre or the hallucinations consist of either a voice keeping up a running commentary on the patient’s behaviour or thoughts, or two or more voices conversing with each other, then Criterion A is sufficient to make a DSM-IV-TR diagnosis of schizophrenia. Otherwise, the following criteria are also required.
In the case of onset during childhood or adolescence, there is a failure to achieve the expected level of achievement in the following areas:
• Interpersonal
• Academic
• Occupational.
C. Duration – continuous signs of the disturbance persist for at least 6 months, including at least 1 month of symptoms (or less if successfully treated) that meet Criterion A and that may include periods of prodromal or residual symptoms.
D. Exclude schizoaffective disorder and mood disorder.
E. Exclude substance-related disorder and general medical conditions.
F. Relationship to a pervasive developmental disorder – if there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less, if successfully treated).
Classification
The classification of the World Health Organization includes a number of major ICD-10 subtypes. Based first on psychological studies (Liddle PF. The symptoms of chronic schizophrenia: a re-examination of the positive-negative dichotomy. Br J Psychiatry 1987; 151:145–151) and then neuroimaging with positron emission tomography (Liddle PF et al. Patterns of cerebral blood flow in schizophrenia. Br J Psychiatry 1992; 160:179–186), Liddle has classified schizophrenia into three dimensions that correspond to changed metabolic activity in different parts of the brain. A neurodevelopmental classification has been proposed based on the hypothesis that schizophrenia has a neurodevelopmental origin (Murray RM et al. A neurodevelopmental approach to the classification of schizophrenia. Schizophrenia Bull 1992; 8:319–333.)
ICD-10 subtypes
• Paranoid schizophrenia is dominated by the presence of paranoid symptoms, for example:
• Delusions of persecution
• Delusions of reference
• Delusions of exalted birth or of having a special mission
• Delusions of bodily change
• Delusions of jealousy
• Hallucinatory voices of a threatening nature, or that issue commands to the patient
• Non-verbal auditory hallucinations, e.g. laughing, whistling and humming
• Hallucinations in other modalities
• Hebephrenic schizophrenia is typified by:
• Irresponsible and unpredictable behaviour
• Rambling and incoherent speech
• Affective changes, including an incongruous affect and shallow mood, often with giggling and fatuousness
• Poorly organized delusions
• Fleeting and fragmentary hallucinations.
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