SUB-TYPES OF SCHIZOPHRENIA

CLINICAL FEATURES AND DIAGNOSIS Presented by Dr Pavan kumar Chaired by Dr Safeekh A.T

INTRODUCTION Kraepelin in 1899 classified dementia praecox into hebephrenic, catatonic, and paranoid groups. E. Bleuler (1911) added simple schizophrenia as 4th group. Cameron (1947) classified in accordance with behavioristic concepts into 3 main groups: the aggressive, the submissive, and the detached.

 Each of 3 groups subdivided, the aggressive group into persecuted, grandiose, and selfpunitive, the submissive group into compliant, dedicated, and transformed, the detached group into avoidant and adient. Cameron seems to have dispensed with simple schizophrenia and to have renamed paranoid, aggressive catatonic, as submissive and hebephrenic, detached forms .

 C. Schneider(1942) described three symptom-complexes in schizophrenia as disorder of complexes of functions in CNS. These syndromes are - the thought withdrawal syndrome experience of alienation of ones own acts and Gedankenlautwerden ( thoughts becoming loud) - the desultory syndrome disorders of social feeling and bodily hallucination and - the drivelling syndrome primary delusions.

Thought withdrawal syndrome Thought withdrawal associated with fragmentation of thought, verbal derailment, and blocking. Inspirations or sudden delusional ideas which appear to come from natural sources are also a part of this syndrome. Patients have cosmic, universal, or religious experiences. The experience of loss of personal control over ones actions frequently occurs so that the patients experience their own actions as being made or forced upon them from outside. The outstanding affective disorder in this syndrome is perplexity (confusion).

Desultory syndrome Characterized by desultory (disconnected) thinking, i.e. thought makes jumps and therefore proceeds in an irregular way. Lack of inner drive, unable to react quickly and adequately to environmental changes. Affect is flattened Patients are unable to feel happy or sad, but may pass into states of anger, anxiety, whining, or despair. Feel changed in themselves and have bodily hallucinations.

Drivelling syndrome Vague drivelling (silly) thinking No gross grammatical disorder Although speech and thinking are superficially integrated, the content is drivel. Delusions of significance and primary delusional experiences Affect is inadequate Lack of interest in real things and values.

 Kleist from Frankfurt school regards schizophrenia as a disease of nervous system which may be confined to one neurological system or which may affect different systems within neurological system. Typical schizophrenia made up of many subgroups which are due to different neurological system illnesses. More insidious in onset, more steadily progressive Atypical schizophrenia due to disorders of many different neurological systems More episodic, marked remissions Greater genetic loading than typical.

 He divides schizophrenia into 4 major groups Paranoid, catatonic, hebephrenic and confused Confused schizophrenia - severe disorder of speech or thought which gives rise to grossly muddled expressions. He divided Paranoid into 7 typical and one atypical form, catatonia into 7 typical and one atypical form, confused into 3 typical and 2 atypical forms and Hebephrenia - into 4 typical forms

 Leonard (1936) who studied chronic schizophrenia classified systematic and non-systematic types which correspond to Kleist's typical and atypical forms. Like Kleist, he separated from schizophrenia a group of nonaffective functional psychoses having favorable outcome called cycloid psychoses The Cycloid Psychosis Anxiety-Elation Psychosis Exited-Inhibited Confused Psychosis Hyperkinetic- Akinetic Motility Psychosis He considers non-systemic schizophrenias more closely related to cycloid psychoses than to systemic psychoses.

 The Unsystematic Schizophrenias

Affective Paraphrenia Cataphasia (Schizophasia) Periodic Catatonia

The Systematic Schizophrenias

Simple Systematic Schizophrenias
Catatonic Forms Parakinetic Catatonia Manneristic Catatonia Proskinetic Catatonia Negativistic Catatonia Speech-Prompt Catatonia Sluggish Catatonia

 Hebephrenic Forms Foolish Hebephrenia Eccentric Hebephrenia Shallow Hebephrenia Autistic Hebephrenia Paranoid Forms Hypochondrical Paraphrenia Phonemic Paraphrenia Incoherrent Paraphrenia Fantastic Paraphrenia Confabulatory Paraphrenia Expansive Paraphrenia

Combined Systematic Schizophrenias

Combined Systematic Catatonias Combined Systematic Hebephrenias Combined Systematic Paraphrenias

Clinical Syndromes in chronic schizophrenia Positive and Negative symptoms (Andreasen et al. 1983)
Positive symptoms hallucinations, delusions, formal thought disorder, bizarre behaviour Negative symptoms Avolition Affective blunting, Alogia (impoverished thinking and speech), Asociality Apathy, Anhedonia, disturbance of attention

 Positive, Negative, and disorganization syndromes (Liddle, 1987) Reality Distortion Syndrome delusions, hallucinations Psychomotor Poverty Syndrome poverty of speech, decreased spontaneous movement, unchanging facial expression, paucity of expressive gesture, lack of affective responsiveness, lack of vocal inflection Disorganization syndrome disorganization: inappropriate affect, incoherent speech, poverty of content of speech
syndromes are validated by recent factor-analytic and neuroimaging studies (Liddle et al. 1992)

 Deficit syndrome (Carpenter et al. 1988) Primary, enduring negative symptoms reflect a distinct neural substrate emphasis on distinguishing primary from secondary negative symptoms (e.g.Parkinsonism, depressed mood)

Continuum of psychosis (Crow, 1990; Greisinger, 1870) single psychosis, with schizophrenia most severe, affective disorders least severe, schizoaffective disorders occupy intermediate position.

 Crow classified schizophrenia patients into Type 1 and type 2 On basis of presence or absence of positive(productive) and negative (deficit) symptoms.
Type I Type II

positive symptoms, good response to treatment,

negative symptoms, poorer response to treatment,

relatively better outcome

relatively poor outcome,

MRI changes.

 Neurodevelopmental classification (Murray et al. 1992)

Congenital schizophrenia abnormality is present at birth more likely to involve minor physical abnormalities, abnormal personality, or social impairment in childhood more likely to be male and have a poor outcome
Adult-onset schizophrenia more likely to exhibit positive and affective symptoms may have a genetic predisposition to manifest symptomatology anywhere along a continuum from bipolar disorder, schizoaffective disorder, to schizophrenia

Late-onset schizophrenia presents after the age of 60 good premorbid functioning more common in females often associated with auditory and visual sensory deprivation organic brain dysfunction is often present

ICD 10

ICD 9

ICD 8

Paranoid schizophrenia Commonest type dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances. Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent.

 Examples of the most common paranoid symptoms are: (a)delusions of persecution, reference, exalted birth, special mission, bodily change, or jealousy; (b)hallucinatory voices that threaten the patient or give commands, or auditory hallucinations without verbal form, such as whistling, humming, or laughing; (c)hallucinations of smell or taste, or of sexual or other bodily sensations; visual hallucinations may occur but are rarely predominant.

 Thought disorder may be obvious in acute states, but if so it does not prevent the typical delusions or hallucinations from being described clearly. Affect is usually less blunted than in other varieties of schizophrenia, but a minor degree of incongruity is common, as are mood disturbances such as irritability, sudden anger, fearfulness, and suspicion.

 "Negative symptoms such as blunting of affect and impaired volition are often present but do not dominate the clinical picture. The course of paranoid schizophrenia may be episodic, with partial or complete remissions, or chronic. In chronic cases, the florid symptoms persist over years and it is difficult to distinguish discrete episodes. The onset tends to be later than in the hebephrenic and catatonic forms.

Diagnostic guidelines general criteria for diagnosis of schizophrenia be satisfied. In addition, hallucinations and/or delusions must be prominent, and disturbances of affect, volition and speech, and catatonic symptoms must be relatively inconspicuous. Delusions can be of almost any kind but delusions of control, influence, or passivity, and persecutory beliefs of various kinds are the most characteristic. Includes: paraphrenic schizophrenia

 Differential diagnosis. exclude epileptic and drug-induced psychoses, and to remember that persecutory delusions might carry little diagnostic weight in people from certain countries or cultures. Excludes: involutional paranoid state (F22.8), paranoia (F22.0)

DCR 10 F20.0 Paranoid schizophrenia A. The general criteria for Schizophrenia must be met. B. 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). C. 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.

DSM IV TR 295.30 Paranoid Type A type of Schizophrenia in which the following criteria are met: A. Preoccupation with one or more delusions or frequent auditory hallucinations. B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Paranoid schizophrenia
ICD 10 uses prominent and DSM 4 TR uses preoccupied

DSM-IV-TR diagnostic criteria for paranoid schizophrenia include a preoccupation with one or more paranoid delusions, which may be systematized, or frequent auditory hallucinations along with no prominent symptoms of disorganized speech, disorganized behavior, or flat/inappropriate affect.

ICD-10 diagnostic criteria are similar to those of the DSM-IV-TR but exclude paranoia and involutional paranoid state.

F20.1 Hebephrenic schizophrenia A form of schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate and often accompanied by giggling or self-satisfied, self-absorbed smiling, or by a lofty manner, grimaces, mannerisms, pranks, hypochondriacal complaints, and reiterated phrases.

Thought is disorganized and speech rambling and incoherent. tendency to remain solitary, and behaviour seems empty of purpose and feeling. This form of schizophrenia usually starts between the ages of 15 and 25 years and tends to have a poor prognosis because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition.

 In addition, disturbances of affect and volition, and thought disorder are usually prominent. Hallucinations and delusions may be present but are not usually prominent. Drive and determination are lost and goals abandoned, so that the patient's behaviour becomes characteristically aimless and empty of purpose. A superficial and manneristic preoccupation with religion, philosophy, and other abstract themes may add to the listener's difficulty in following the train of thought.

Diagnostic guidelines The general criteria for a diagnosis of schizophrenia must be satisfied. Hebephrenia should normally be diagnosed for the first time only in adolescents or young adults. The premorbid personality is characteristically, but not necessarily, rather shy and solitary. For a confident diagnosis of hebephrenia, a period of 2 or 3 months of continuous observation is usually necessary, in order to ensure that the characteristic behaviours described above are sustained. Includes: disorganized schizophrenia hebephrenia

DCR 10 F20.1 Hebephrenic schizophrenia A. The general criteria for Schizophrenia above must be met. B. Either (1) or (2): (1) Definite and sustained flattening or shallowness of affect; (2) Definite and sustained incongruity or inappropriateness of affect. C. Either (1) or (2): (1) Behaviour which is aimless and disjointed rather than goal-directed; (2) Definite thought disorder, manifesting as speech which is disjointed, rambling or incoherent. D. Hallucinations or delusions must not dominate the clinical picture, although they may be present to a mild degree.

DSM IV TR Diagnostic criteria for 295.10 Disorganized Type A type of Schizophrenia in which the following criteria are met: A. All of the following are prominent: (1 ) disorganized speech (2) disorganized behavior (3) flat or inappropriate affect B. The criteria are not met for Catatonic Type.

Disorganized or hebephrenic schizophrenia

ICD 10 requires flat or inappropriate affect AND either disorganized speech OR disorganized behavior DSM 4 tr def is more severe in that disorganized speech, disorganized behavior AND flat or inappropriate affect are all required.

DSM-IV-TR diagnostic criteria include disorganized speech, disorganized behavior, and flat/inappropriate affect and exclude catatonia and delusions and hallucinations that are systematized into a lucid theme.

ICD-10 criteria are similar to DSM-IV-TR criteria but add that the disorganized/hebephrenic subtype should normally be diagnosed for the first time only in adolescents or young adults, with a period of 23 months of observation ensuring sustained characteristic features. ICD-10 also indicates that the premorbid personality of these individuals includes timid and solitary behavior.

ICD 10 F20.2 Catatonic schizophrenia Prominent psychomotor disturbances are essential and dominant features and may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods. Episodes of violent excitement may be a striking feature of the condition. For reasons that are poorly understood, catatonic schizophrenia is now rarely seen in industrial countries, though it remains common elsewhere. These catatonic phenomena may be combined with a dreamlike (oneiroid) state with vivid scenic hallucinations.

Diagnostic guidelines general criteria for diagnosis of schizophrenia be satisfied. Transitory and isolated catatonic symptoms may occur in the context of any other subtype of schizophrenia, but for a diagnosis of catatonic schizophrenia one or more of the following behaviours should dominate the clinical picture: (a)stupor (marked decrease in reactivity to the environment and in spontaneous movements and activity) or mutism; (b)excitement (apparently purposeless motor activity, not influenced by external stimuli); (c)posturing (voluntary assumption and maintenance of inappropriate or bizarre postures);

 (d)negativism (an apparently motiveless resistance to all instructions or attempts to be moved, or movement in the opposite direction); (e)rigidity (maintenance of a rigid posture against efforts to be moved); (f) waxy flexibility (maintenance of limbs and body in externally imposed positions); and (g)other symptoms such as command automatism (automatic compliance with instructions),and perseveration of words and phrases. Includes: catatonic stupor schizophrenic catalepsy schizophrenic catatonia schizophrenic flexibilitas cerea

DCR 10 F20.2 Catatonic schizophrenia A. The general criteria for Schizophrenia must eventually be met, though this may not be possible initially if the patient is uncommunicative. B. For a period of at least two weeks one or more of the following catatonic behaviours must be prominent: (1) Stupor or mutism; (2) Excitement (3) Posturing (4) Negativism

(5) Rigidity (6) Waxy flexibility (7) Command automatism C. Other possible precipitants of catatonic behaviour, including brain disease and metabolic disturbances, have been excluded.

Diagnostic criteria for 295.20 Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following: (1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor (2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli) (3) extreme negativism or mutism (4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing (5) echolalia or echopraxia

Catatonic schizophrenia
ICD 10 one ore more predominating DSM 4 TR minimum of 2 Share most features in common except for echolalia and echopraxia (in DSM 4 TR) and command automatism (only in ICD 10)

DSM-IV-TR diagnosis includes two or more and ICD-10 specifies at least one of the following behaviors: stupor (marked reduction or suspended sensibility) or mutism, excitement not influenced by external stimuli, bizarre postures, meaningless resistance toward instructions or attempts to be moved, rigidity, waxy flexibility, and echolalia or echopraxia.
Differential diagnosis includes brain disease, metabolic instability, substance abuse, or mood disorderssuch as bipolar disorder.

F20.3 Undifferentiated schizophrenia Conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the above subtypes (F20.0-F20.2), or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics. This rubric should be used only for psychotic conditions (i.e. residual schizophrenia, F20.5, and post-schizophrenic depression, F20.4, are excluded) and after an attempt has been made to classify the condition into one of the three preceding categories.

Diagnostic guidelines This category should be reserved for disorders that: (a)meet the general criteria for schizophrenia; (b)either without sufficient symptoms to meet the criteria for only one of the subtypes F20.0, F20.1, F20.2, F20.4, or F20.5, or with so many symptoms that the criteria for more than one of the paranoid (F20.0), hebephrenic (F20.1), or catatonic (F20.2) subtypes are met. Includes: atypical schizophrenia

DCR 10 F20.3 Undifferentiated schizophrenia A. The general criteria for Schizophrenia above must be met. B. Either (1) or (2): (1) There are insufficient symptoms to meet the criteria of any of the sub-types F20.0, .1, .4, or .5; (2) There are so many symptoms that the criteria for more than one of the subtypes listed in B(1) above are met.

DSM IVTR Diagnostic criteria for 295.90 Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Undifferentiated schizophrenia
ICD 10 either insufficient symptoms or more than one of the subtype DSM 4TR- cases that dont meet criteria any of other subtype

Individuals should meet criterion A of DSM-IV-TR (APA 2000) and should not have symptoms of catatonia or paranoid and disorganized schizophrenia.

ICD-10, although following DSM-IV-TR criteria, includes the stipulation that undifferentiated schizophrenia should not satisfy the criteria for residual schizophrenia or Post-schizophrenia depression.

 F20.4 Post-schizophrenic depression A depressive episode, which may be prolonged, arising in the aftermath of a schizophrenic illness. Some schizophrenic symptoms must still be present but no longer dominate the clinical picture. These persisting schizophrenic symptoms may be "positive" or "negative, though the latter are more common.

 It is uncertain, and immaterial to the diagnosis, to what extent the depressive symptoms have merely been uncovered by the resolution of earlier psychotic symptoms (rather than being a new development) or are an intrinsic part of schizophrenia rather than a psychological reaction to it. They are rarely sufficiently severe or extensive to meet criteria for a severe depressive episode (F32.2 and F32.3), it is often difficult to decide which of the patient's symptoms are due to depression and which to neuroleptic medication or to the impaired volition and affective flattening of schizophrenia itself. This depressive disorder is associated with an increased risk of suicide.

 Diagnostic guidelines The diagnosis should be made only if: (a)the patient has had a schizophrenic illness meeting the general criteria for schizophrenia within the past 12 months; (b)some schizophrenic symptoms are still present; and (c)the depressive symptoms are prominent and distressing, fulfilling at least the criteria for a depressive episode (F32.-), and have been present for at least 2 weeks. If the patient no longer has any schizophrenic symptoms, a depressive episode should be diagnosed (F32.-). If schizophrenic symptoms are still florid and prominent, the diagnosis should remain that of the appropriate schizophrenic subtype (F20.0, F20.1, F20.2, or F20.3).

 F20.4 Post-schizophrenic depression A. The general criteria for schizophrenia (F20.0 - F20.3 above) must have been met within the past twelve months, but are not met at the present time. B. One of F20 G1.2 e, f, g or h must still be present. C. The depressive symptoms must be sufficiently prolonged, severe and extensive to meet criteria for at least a mild depressive episode (F32.0).

 Research criteria for postpsychotic depressive disorder of Schizophrenia A. Criteria are met for a Major Depressive Episode. Note: The Major Depressive Episode must include Criterion Al : depressed mood. Do not include symptoms that are better accounted for as medication side effects or negative symptoms of Schizophrenia. B. The Major Depressive Episode is superimposed on and occurs only during the residual phase of Schizophrenia. C. The Major Depressive Episode is not due to the direct physiological effects of a substance or a general medical condition.

 F20.5 Residual schizophrenia A chronic stage in the development of a schizophrenic disorder in which there has been a clear progression from an early stage (comprising one or more episodes with psychotic symptoms meeting the general criteria for schizophrenia described above) to a later stage characterized by long-term, though not necessarily irreversible, "negative" symptoms.

diagnosis (a)prominent "negative" schizophrenic symptoms, i.e. psychomotor slowing, underactivity, blunting of affect, passivity and lack of initiative, poverty of quantity or content of speech, poor nonverbal communication by facial expression, eye contact, voice modulation, and posture, poor self-care and social performance; (b)evidence in the past of at least one clear-cut psychotic episode meeting the diagnostic criteria for schizophrenia;

 (c)a period of at least 1 year during which the intensity and frequency of florid symptoms such as delusions and hallucinations have been minimal or substantially reduced and the "negative" schizophrenic syndrome has been present; (d)absence of dementia or other organic brain disease or disorder, and of chronic depression or institutionalism sufficient to explain the negative impairments.

 If adequate information about the patient's previous history cannot be obtained, and it therefore cannot be established that criteria for schizophrenia have been met at some time in the past, it may be necessary to make a provisional diagnosis of residual schizophrenia. Includes: chronic undifferentiated schizophrenia "Restzustand" schizophrenic residual state

DCR 10 F20.5 Residual schizophrenia A. The general criteria for Schizophrenia must have been met at some time in the past, but are not met at the present time. B. At least four of the following 'negative' symptoms have been present throughout the previous twelve months: (1) Psychomotor slowing or underactivity; (2) Definite blunting of affect; (3) Passivity and lack of initiative; (4) Poverty of either the quantity or the content of speech; (5) Poor non-verbal communication by facial expression, eye contact, voice modulation or posture; (6) Poor social performance or self-care.

DSM 4 TR Diagnostic criteria for 295.60 Residual Type A type of Schizophrenia in which the following criteria are met: A. Absence of prominent delusions, hall ucina tions, disorganized speech, and gross ly disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g ., odd beliefs, unusual perceptual experiences).

F20.6 Simple schizophrenia An uncommon disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. Delusions and hallucinations are not evident, and the disorder is less obviously psychotic than the hebephrenic, paranoid, and catatonic subtypes of schizophrenia. The characteristic "negative" features of residual schizophrenia (e.g. blunting of affect, loss of volition) develop without being preceded by any overt psychotic symptoms. With increasing social impoverishment, vagrancy may ensue and the individual may then become self-absorbed, idle, and aimless.

 Diagnostic guidelines Simple schizophrenia is a difficult diagnosis to make with any confidence because it depends on establishing the slowly progressive development of the characteristic "negative" symptoms of residual schizophrenia (see F20.5 above) without any history of hallucinations, delusions, or other manifestations of an earlier psychotic episode, and with significant changes in personal behaviour, manifest as a marked loss of interest, idleness, and social withdrawal over a period of at least one year. Includes: schizophrenia simplex

DCR 10 F20.6 Simple schizophrenia A. Slowly progressive development over a period of at least one year, of all three of the following: (1) 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. (2) 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 non-verbal communication (by facial expression, eye contact, voice modulation and posture). (3) Marked decline in social, scholastic, or occupational performance.

 B. Absence, at any time, of any symptoms referred to in G1 in F20.0 - F20.3, and of hallucinations or wellformed delusions of any kind, i.e. the subject must never have met the criteria for any other type of schizophrenia, or any other psychotic disorder. C. Absence of evidence of dementia or any other organic mental disorder listed in section F0.

DSM 4 TR Research criteria for simple deteriorative disorder (simple Schizophrenia) 771 A. Progressive development over a period of at least a year of all of the following: (1) marked decline in occupational or academic functioning (2) gradual appearance and deepening of negative symptoms such as affective flattening, alogia, and avolition (3) poor interpersonal rapport, social isolation, or social withdrawal

 B. Criterion A for Schizophrenia has never been met. e. The symptoms are not better accounted for by Schizotypal or Schizoid Personality Disorder, a Psychotic Disorder, a Mood Disorder, an Anxiety Disorder, a dementia, or Mental Retardation and are not due to the direct physiological effects of a substance or a general medical condition.

F20.8 Other schizophrenia Includes: cenesthopathic schizophrenia schizophreniform disorder NOS Excludes: acute schizophrenia-like disorder (F23.2) cyclic schizophrenia (F25.2) latent schizophrenia (F23.2) F20.9 Schizophrenia, unspecified

Schizophreniform Disorder 295.40 A. Criteria A, D, and E of Schizophrenia are met. B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as "Provisional.") Specify if: Without Good Prognostic Features With Good Prognostic Features: as evidenced by two (or more) of the following: (1) onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning (2) confusion or perplexity at the height of the psychotic episode

 (3) good pre morbid social and occupational functioning (4) absence of blunted or flat affect

DSM V Deletion of Subtypes. The current classic subtypes of schizophrenia provide a poor description of the heterogeneity of schizophrenia, have low diagnostic stability, do not exhibit distinctive patterns of treatment response or longitudinal course, and are not heritable. Except for the paranoid and undifferentiated subtypes, other subtypes are rarely diagnosed. As a result, it is proposed that these subtypes of schizophrenia be eliminated from DSM-5.

 Dimensions will be assessed on a 0-4 scale cross-sectionally, with severity assessment based on past month. There are distinct psychopathological domains in psychotic illnesses (most clearly noted in schizophrenia) with distinctive patterns of treatment-response, prognostic implications, and course. The relative severity of symptoms across these domains varies across the course of illness and among patients. This is a major change that will potentially be of great clinical value and will also be of additional research utility 0- Not Present 3- Present and moderate 1- Equivocal 4- Present and severe 2- Present, but mild

THANK U