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Schizophrenia:
clinical features
Dr David Middleton
ST4 in General Adult Psychiatry
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Introduction
Premorbid and prodromal features
Acute illness
Subtypes
Diagnostic criteria
Chronic illness
Exam questions
Introduction
• What is schizophrenia?
– a clinical syndrome involving disturbances of thought,
emotion, perception and behaviour
Premorbid and prodromal features
• Premorbid – before the disease process
• Prodromal – part of evolving disorder
Premorbid and prodromal features
1. Development
– National Child Development Survey from 1958 used by
Done et al (1994)
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Social behaviour aged 7 and 11
Boys: more anxiety, hostility and inconsequential behaviour
(restless, impulsive, short temper) in those who developed
schizophrenia
Girls: more withdrawn
NB those who developed affective psychosis
were not different from controls
Premorbid and prodromal features
– British National Survey of Health and Development 1946
used by Jones et al (1994)
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Delayed motor development (especially walking)
Speech problems
Preference for solitary play
Relatively low IQ
Premorbid and prodromal features
2. Personality
– Schizoid or schizotypal personality:
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‘odd’
Solitary, few friends
Suspicious
Abnormal speech patterns
– Leading to...
• Avoidance of social groups, team sports etc
• Prefererence for watching films, listening to music,
playing computer games
Premorbid and prodromal features
3. Prodromal symptoms
– Often only recognised after schizophrenia has been
diagnosed, may precede psychosis by 5-10 years
– Symptoms such as:
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Anxiety, depression
Perplexity, minor perceptual disturbances
Poor attention, reduced clarity of thought
Reduced sense of control
Somatic symptoms including headaches, back pain,
gastrointestinal problems
• Occupational, social or academic decline
Premorbid and prodromal features
– May be diagnosed with somatisation disorder,
malingering, ME etc
– Interests in abstract ideas, philosophy, religion may
develop
– Later, odd behaviour, altered affect, unusual ideas and
distorted perceptual experiences
Acute illness
• Onset
– Insidious (months)
– Acute
• Following stressor
• Unfamiliar environment (e.g. travelling, university)
• Drug use
Acute illness
Behaviour
• Agitated, unkempt, vocal, inappropriately dressed
• Withdrawn, immobile, silent
• Tics, stereotypies, mannerisms, echopraxia
Catatonia
• Automatic obedience
• Negativism
• Waxy flexibility
Acute illness
Affect
• Perplexity...which may become delusional mood
• Depressed, elated, angry
• Flattened (reduced range of emotional expression)
• Blunted (reduced sensitivity to others)
Affect may become incongruous
• e.g. Laughing when discussing unpleasant
experience
Acute illness
Thought
• Delusions are false, unshakeable beliefs out of keeping with the
patient’s social or cultural background
• Primary delusions (apophany)
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Delusional mood: something going on but unsure what
Sudden delusional idea: delusion appears suddenly, “autochthonous”
Delusional perception: new meaning attributed to a perceived object, not
arising from the patient’s affective state (c.f. Delusional misinterpretation)
Secondary delusions arise as a result of another
abnormality in mental state
Acute illness
• Theme of delusions
– Reference, persecution, grandiosity, religion, hypochondriasis
• Passivity phenomena
– Made actions, feelings, impulses
• Thought insertion, withdrawal, broadcast
Acute illness
• Thought disorder: loss of normal flow of thinking
– characteristic of schizophrenia (but rare!)
– unsatisfactory and ill-defined
1. Incoherence: incomprehensible speech (word salad)
2. Derailment: spontaneous speech falls off the track
3. Tangentiality: oblique reply to question
4. Clanging: sound rather than meaning
5. Illogicality: false conclusions
6. Neologisms: new words or phrases
(Examples...p14)
Acute illness
Perception
• Auditory, visual, olfactory, gustatory, tactile hallucinations
– duration rather than content important
– may be reported as an experience between perception and
thought
– details may be vague due to embarrassment or commands
Acute illness
• Schneider’s ‘symptoms of the first rank’
– Auditory hallucinations:
1. Thoughts out loud (gedankenlautwerden or echo de la
pensee)
2. Third person
3. Running commentary
– Delusions of thought interference:
1. Insertion
2. Withdrawal
3. Broadcast
Examples...p28
Acute illness
– Delusions of control:
1. Passivity of affect
2. Passivity of impulse
3. Passivity of volitions
– Somatic passivity
– Delusional perception
Acute illness
• Bleuler’s fundamental symptoms: 4 A’s
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Loosening of Associations (thought disorder)
Blunt of incongruous Affect
Autism (social withdrawal)
Ambivalence (apathy)
Diagnostic criteria
DSM-IV
ICD-10
Symptoms
One of: bizarre delusions or
Schneiderian hallucinations
OR
Two of: delusions, hallucinations,
disorganised speech/behaviour,
negative features
One of: Schneiderian
delusions/hallucinations
OR
Two of: catatonic behaviour,
hallucinations, disorganised speech,
negative features
Dysfunction
Social/occupational
Not specified
Duration
> 6 months
> 1 month
Exclusions
Mood disorder, substance abuse,
pervasive developmental disorder
Mood disorder, substance abuse,
organic brain disorder
Schizophrenia subtypes
• Kraeplin described three subtypes:
1. Paranoid
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hallucinations and delusions prominent
personality well preserved
2. Catatonic
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motor abnormalities e.g. stupor, posturing
3. Hebephrenic
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early onset
insidious progression
thought disorder
affective disturbance
Schizophrenia subtypes
• Bleuler added two more:
1. Simple
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progressive deterioration
eccentricity
overt psychotic symptoms absent
2. Residual
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original psychotic symptoms reduced
apathy
emotional blunting
eccentricity
Example...p46
Chronic illness
• Initial symptoms (hallucinations/delusions) reduce in
intensity or influence behaviour less
• Greater frequency and duration of episodes leads to
‘defect state’:
– reduced drive, speech, socialisation
– more apathy and emotional blunting
– personality changes
• Recurrent episodes, depression etc
Chronic illness
• Crow’s syndromes
1. Type I ‘positive symptoms’
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delusions
hallucinations
thought disorder
2. Type II ‘negative symptoms’
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flat affect
apathy
poverty of speech
Chronic illness
• Liddle’s three syndromes
1. Psychomotor poverty
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poverty of speech
flat affect
decreased spontaneous movement
2. Disorganisation
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disorder of form of thought
inappropriate affect
3. Reality distortion
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delusions
hallucinations
Exam questions
References and further reading
• Companion to Psychiatric Studies (7th edition) Johnstone et
al (2004)
• Schizophrenia and Related Syndromes (2nd edition) P.J.
McKenna (2007)
• Fish’s Clinical Psychopathology (3rd edition) Casey and
Kelly (2007)
• Synopsis of Psychiatry (10th edition) Kaplan and Saddock