Subtypes of Schizophrenia
Once a patient is diagnosed with schizophrenia, a clinician considers his or her symptoms and determines a subtype diagnosis.
There are four subtypes of schizophrenia. Each subtype is based upon the types of symptoms the patient experiences.
Paranoid Type. Although psychotic by definition, patients with paranoid type usually appear the most “normal.” That is, they are generally able to take care of themselves and their behavior and physical appearance often remains unaffected.
Patients with this type of schizophrenia may have intimate relationships with other people; it is not uncommon for them to marry and have children. Their primary symptoms include delusions and/or hallucinations. These patients do not experience any negative symptoms, meaning that they rarely lose the ability to talk clearly. Paranoid type generally develops later than other forms of schizophrenia and usually responds quite well to medication.
Disorganized Type. Patients with disorganized type are the most apparently psychotic. They are difficult to understand and their appearance makes them easy to identify. Someone with disorganized type schizophrenia might dress in weather-inappropriate clothing or appear disheveled and unkempt.
The disorganized type of schizophrenia was first recognized more than 100 years ago by a German psychiatrist, Ewald Hecker. In 1871, Hecker identified a group of patients who demonstrated extremely psychotic behaviors beginning in late adolescence or early adulthood. He called this pattern hebephrenia, originating from the Greek word hebe, meaning “youth.” Emilio, from the case study at the beginning of the chapter, appears to have schizophrenia, disorganized type.
Course and subtypes of schizophrenia
Both ICD-10 and DSM-IV provide broadly similar classifications of longitudinal course. The subtypes of schizophrenia included in both ICD-10 and DSM-IV are paranoid, catatonic, undifferentiated and residual schizophrenia. Hebephrenic schizophrenia is called disorganized type in DSM-IV. The requirement for the subtypes is similar in both classification systems, although they are more clearly operationalized in DSM-IV.
Common subtypes in ICD-10 and DSM-IV
- Hebephrenic (disorganized in DSM-IV)
Additional subtypes in ICD-10
- Postschizophrenic depression
ICD-10 clarifies retention of simple schizophrenia as a subtype of schizophrenia, with the requirement of certain described features for at least 2 years because of its continued use in some countries and because of the uncertainty about its nature, which will require additional information for resolution.
Catatonic Type. Patients with catatonic schizophrenia may have symptoms similar to patients with other subtypes of the disease but their physical movements make them different. Catatonic behavior is typically extremely slow, and these patients may appear as though they are moving in slow motion.
Sometimes these patients refuse to speak or even to acknowledge the presence of others. Such behaviors are called negativistic. Patients who have this form of schizophrenia may arrange their body in strange postures for extended periods of time.
They may lie curled up in a ball for hours, their muscles so tense that it is nearly impossible for other people to move them. They may involuntarily mimic the speech of others, a behavior called echolalia. Alternatively, these patients may involuntarily mimic the behaviors of others, a behavior called echopraxia. In very rare cases, a patient with schizophrenia, catatonic type, may display random hyperactivity, purposeless exhibitions of manic-like behavior.
Undifferentiated Type. Schizophrenia, undifferentiated type is a category used for patients who do not meet the criteria for any other subtype. That is, these patients may meet the general minimum criteria for schizophrenia but do not exhibit a pattern of symptoms that is consistent with any subtype.
Schizophrenia patients may have symptoms that are part of more than one subtype. For example, Emilio appears to have both paranoid and disorganized symptoms, in that he believes his mother is trying to poison him, he is dressed strangely, and he uses odd words and rhymes to express himself. One type of symptom, however, often trumps another.
For example, if a patient has any disorganized symptoms, even if he has a paranoid symptom, he will receive a diagnosis of schizophrenia, disorganized type. Similarly, if a patient has any symptoms of catatonia, even if he has disorganized or paranoid symptoms, he will receive a diagnosis of schizophrenia, catatonic type.
A leading academic journal in the area of schizophrenia
research frequently publishes first-person accounts of people
suffering from schizophrenia. The following text is adapted from
one of these accounts, by Valerie Fox:
“Having suffered from schizophrenia for the past 30 years—
including a period of homelessness—I know the complexity of
the illness. When I was a young woman in my twenties, working
for an airline and traveling throughout the world, my life was
wonderful, exciting. I was part of the theater scene in New York,
liked the fabulous restaurants there, and was thoroughly enjoy-
ing my life.
“One day, however, my life changed drastically. I was diag-
nosed with schizophrenia, hospitalized, and given medicine.
When I was healthy enough to leave the hospital, I was over-
whelmed. I could not believe the medicine was good for me,
because I had never felt so depressed and lethargic as I did
while taking the medicine. After a few months I decided to
stop taking the medicine, believing, as my psychiatrist did,
that I would be fine, that I had been struggling with the transi-
tion from teenager to young womanhood, and that my “break-
down” would probably never recur. This was the thinking in the
1960s. There was no talk then of body chemistry being involved
“I did go off my medicine about six months after my first
episode. I felt great: I had my alertness, my good sense of who I
was; I was not depressed; and I looked forward to working again.
Instead, within weeks I was again hospitalized. This time I was
sent to a long-term care facility, a state hospital. During this
time I decided to take charge of my life. I realized that when I
was taking the medicine I was able to stay in the community;
without the medicine, I was institutionalized. I determined I
would find a way to cope with taking the medicine, because I
did not want my life to be a revolving door from society to the
hospital and back again.
“While in remission I met a good man and discussed with my
doctor the feasibility of my getting married and having children.
I did marry and gave birth to two children. During the course of
the marriage, if we had an argument and I got angry, my hus-
band would say, “Valerie, are you getting ill?” I wasn’t getting
ill, but my illness was a controlling factor for my husband to
use over me. As this kept happening, I knew the marriage was
over for me and that I would leave it as soon as my daughters
were a little older. I did leave and retained custody of my two
daughters. For 14 years, I remained healthy and was not re-
hospitalized. I took my medicine and went to psychotherapy.
I had gained a relative peace, acceptance, and a good level
“Then came a dramatic schizophrenic episode. It started
when someone began harassing me in the middle of the night.
This harassment culminated with the person cutting my bed-
room screen. I was terrified that because I slept so soundly
as a result of the medicine, I would awaken one night with a
stranger in my apartment. I decided to stop taking my medicine
against the advice of my doctor. I had to do what I thought was
responsible, and that was to be semi-awake in case an intruder
entered my apartment. The police finally staked out my apart-
ment and apprehended the person who was harassing me, but
the damage was done. Because I was an adult and not acting
out, I was free from forced hospitalization. I did not know I
was ill. My ex-husband took our children, which I thought was
kidnapping. No one would help me have the children returned.
I must have been visibly ill, although I was not aware of it.
“I went deeper and deeper into schizophrenia, ending in
homelessness for a two-year period. During this period of
homelessness and mental illness, I faced the dangers of street
living, including being beaten and raped, almost freezing to
death, and being malnourished, but I was free. In that state,
freedom was what I wanted. This odyssey ended one day when
I decided to do whatever it took to have the good life I had
known. I still did not know I was ill, but I did associate taking
medicine and being hospitalized with living as I had previously,
“One day, I summoned every bit of strength I had and did not
back away from institutionalization. Fortunately, the psychiatrist
I saw during the admittance process treated me with empathy,
compassion, and respect. I trusted him, and, therefore, did
not back away from my decision to seek treatment. I remained
hospitalized for a six-month period, three months of which were
spent waiting for a bed in a housing program in the community.
Eventually, I reunited with my children and built another life for
myself. I still see a therapist and can call between visits if I am
very upset. I don’t abuse this arrangement, and it has served me very well.”
Table 1.4 DSM-IV diagnostic criteria for schizophrenia.
At least one of:
Third person auditory hallucinations
or two or more of:
Grossly disorganized behaviour
1 month of characteristic symptoms
With 6 months of social/occupational dysfunction
Schizoaffective or mood disorders
Direct consequence of substance use or general medical condition
Pervasive developmental disorders
Diagnosis of postpsychotic depression requires a clear diagnosis of schizophrenia within the past 12 months with the presence of some features of schizophrenia and predominant depressive symptoms, which meet a threshold of depressive episode, for 2 weeks.
In addition to a categorical description of schizophrenia subtypes, DSM-IV offers a dimensional alternative in its Appendix B:
- psychotic dimension;
- disorganized dimension; and
- negative dimension.
ICD-10 does not give a description of any dimensions yet as these are difficult to define.
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