European Description

The ICD-10 Classification of Mental and Behavioural Disorders
World Health Organization, Geneva, 1992


F20 Schizophrenia

The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted affect. Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits may evolve in the course of time. The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-direction. The most intimate thoughts, feelings, and acts are often felt to be known to or shared by others, and explanatory delusions may develop, to the effect that natural or supernatural forces are at work to influence the afflicted individual's thoughts and actions in ways that are often bizarre. The individual may see himself or herself as the pivot of all that happens. Hallucinations, especially auditory, are common and may comment on the individual's behaviour or thoughts. Perception is frequently disturbed in other ways: colours or sounds may seem unduly vivid or altered in quality, and irrelevant features of ordinary things may appear more important than the whole object or situation. Perplexity is also common early on and frequently leads to a belief that everyday situations possess a special, usually sinister, meaning intended uniquely for the individual. In the characteristic schizophrenic disturbance of thinking, peripheral and irrelevant features of a total concept, which are inhibited in normal directed mental activity, are brought to the fore and utilized in place of those that are relevant and appropriate to the situation. Thus thinking becomes vague, elleptical, and obscure, and its expression in speech sometimes incomprehensible. Breaks and interpolations in the train of thought are frequent, and thoughts may seem to be withdrawn by some outside agency. Mood is characteristically shallow, capricious, or incongruous. Ambivalence and disturbance of volition may appear as inertia, negativism, or stupor. Catatonia may be present. The onset may be acute, with seriously disturbed behaviour, or insidious, with a gradual development of odd ideas and conduct. The course of the disorder shows equally great variation and is by no means inevitably chronic or deteriorating (the course is specified by five-character categories). In a proportion of cases, which may vary in different cultures and populations, the outcome is complete, or nearly complete, recovery. The sexes are approximately equally affected by the onset tends to be later in women.

Although no strictly pathognomonic symptoms can be identified, for practical purposes it is useful to divide the above symptoms into groups that have special importance for the diagnosis and often occur together, such as:

(a) thought echo, thought insertion or withdrawal, and thought broadcasting;
(b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;
(c) hallucinatory voices giving a running commentary on the patient's behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;
(d) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world);
(e) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;
(f) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;
(g) catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;
(h) "negative" symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;
(i) a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.


Diagnostic Guidelines

The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed as (a) to (d) above, or symptoms from at least two of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more. Conditions meeting such symptomatic requirements but of duration less than 1 month (whether treated or not) should be diagnosed in the first instance as acute schizophrenia-like psychotic disorder and are classified as schizophrenia if the sumptoms persist for longer periods.

Viewed retrospectively, it may be clear that a prodromal phase in which symptoms and behaviour, such as loss of interest in work, social activities, and personal appearance and hygiene, together with generalized anxiety and mild degrees of depression and preoccupation, preceded the onset of psychotic symptoms by weeks or even months. Because of the difficulty in timing onset, the 1-month duration criterion applies only to the specific symptoms listed above and not to any prodromal nonpsychotic phase.

The diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbance. If both schizophrenic and affective symptoms develop together and are evenly balanced, the diagnosis of schizoaffective disorder should be made, even if the schizophrenic symptoms by themselves would have justified the diagnosis of schizophrenia. Schizophrenia should not be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal.


F20.0 Paranoid Schizophrenia

This is the commonest type of schizophrenia in most parts of the world. The clinical picture is 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 hallulcinations 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

The general criteria for a diagnosis of schizophrenia (see introduction to F20 above) must 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. The hallucinations will usually be of the kind described in (b) and (c) above. Delusions can be of almost any kind of delusions of control, influence, or passivity, and persecutory beliefs of various kinds are the most characteristic.

* paraphrenic schizophrenia

Differential diagnosis. It is important to exclude epileptic and drug-induced psychoses, and to remember that persecutory delusions might carry little diagnostic weight in people from certain countries or cultures.

* involutional paranoid state (F22.8)
* paranoia (F22.0)


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 inappropirate 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. There is a tendency to remain solitary, and behaviour seems empty of purpose and feeling. This form of schizphrenia 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 (see introduction to F20 above) must be satisified. 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.

* disorganized schizophrenia
* hebephrenia


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 dream-like (oneiroid) state with vivid scenic hallucinations.


Diagnostic Guidelines

The general criteria for a diagnosis of schizophrenia (see introduction to F20 above) must 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.

In uncommunicative patients with behavioural manifestations of catatonic disorder, the diagnosis of schizophrenia may have to be provisional until adequate evidence of the presence of other symptoms is obtained. It is also vital to appreciate that catatonic symptoms are not diagnostic of schizophrenia. A catatonic symptom or symptoms may also be provoked by brain disease, metabolic disturbances, or alcohol and drugs, and may also occur in mood disorders.

* catatonic stupor
* schizophrenic catalepsy
* schizophrenic catatonia
* schizophrenic flexibilitas cerea


F20.3 Undifferentiated Schizophrenia

Conditions meeting the general diagnostic criteria for schizophrenia (see introduction to F20 above) but not conforming to any of the above subtypes, 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 and post-schizophrenic depression 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 diagnostic criteria for schizophrenia;
(b) do not satisfy the criteria for the paranoid, hebephrenic, or catatonic subtypes;
(c) do not satisfy the criteria for residual schizophrenia or post-schizophrenic depression.

atypical schizophrenia


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, and 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 (see introduction to F20 above) 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, and havew been present for at least 2 weeks.

If the patient no longer has any schizophrenic symptoms, a depressive episode should be diagnosed. If schizophrenic symptoms are still florid and prominent, the diagnosis should remain that of the appropriate schizophrenic subtype.


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.


Diagnostic Guidelines

For a confident diagnosis, the following requirements should be met:

(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.

* chronic undifferentiated schizophrenia
* "Restzustand"
* schizophrenic residual state


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 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.

* schizophrenia simplex


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