12 - ICD 10 schizophrenia

ICD-10 schizophrenia

© SPMM Course of onset of psychosis o Onset of illness prior to age 40

ICD-10 schizophrenia ICD 10 description of schizophrenia is largely based on Schneider’s  first-rank symptoms. Kurt Schneider described a number of symptoms which he believed were of first-rank importance in differentiating schizophrenia from related illnesses. According to the International Pilot Study of Schizophrenia, 58% of patients with acute schizophrenia exhibited at least one first rank symptom. However, at least 20% of schizophrenic never exhibit a first rank symptom while almost 10% of non-schizophrenic patients exhibit them. Duration criteria in ICD: ICD10 rejects the assumption that schizophrenia is an illness of necessarily long duration. Accordingly, acute psychotic episodes are diagnosed for up to one month; if schizophrenic features are continuous, the diagnosis is reclassified as schizophrenia after a month. If not, a diagnosis of the acute psychotic episode is valid for up to 3 months, after which other diagnoses such as a persistent delusional disorder may be entertained. Prodromal symptoms of schizophrenia are not included in the 1-month criteria for schizophrenia. Subtypes of schizophrenia Subtype Most prominent symptoms Less prominent (may or may not be present) Paranoid (commonest, with onset usually at a later age compared to hebephrenia and catatonia) Delusions or auditory hallucinations

Disorganized speech or behaviour Flat or inappropriate affect Catatonic behaviour Hebephrenic or disorganised (poorest prognosis) Disorganized speech or behaviour and flat or inappropriate affect. Markedly impaired social and occupational functioning; poor self-care, poor hygiene, extreme social behaviour and disorganised behaviour Catatonic behaviour

Catatonic (more common in developing nations; usually acute onset with episodic course and complete symptom remission) x Motoric immobility (i.e., catalepsy or stupor) x Excessive motor activity x Extreme negativism or mutism x Posturing, or stereotypy, mannerisms, grimacing x Echolalia or echopraxia (Minimum 2 of the above needed) Oneiroid (dream like) state can occur, and patients may experience visual hallucination. Transient catatonic features can be seen in all schizophrenia types

© SPMM Course Residual Evidence of full blown acute episode in the past Currently negative symptoms or attenuated forms of 2 or more generic symptoms (i.e. odd beliefs instead of delusions, unusual perceptual experience instead of fully formed hallucinations) Absence of delusions, hallucinations, disorganized speech or behaviour, catatonia

Simple Insidious development of negative symptoms without evidence of positive symptoms.  Very  rare.  Appears  as  if  one’s  personality  is  gradually  deteriorating   with increasing emotional bluntness; Occasional brief psychotic episodes may support the diagnosis. Undifferentiated Generic symptoms but not falling in other categories ‘Chronic  schizophrenia.' Persistent disability for two years or longer (not a subtype but a descriptive term)

Catatonic schizophrenia is characterised by marked disturbance of motor behaviour and can present in three clinical forms; (1) excited catatonia (2) stuporous catatonia and (3) catatonia alternating between excitement and stupor. Hebephrenic schizophrenia is characterised by marked thought disorder and severe loosening of associations, emotional disturbances described by inappropriate affect, blunted affect or senseless giggling, abnormal mannerisms like mirror gazing. ICD 10 recommends a period of 2-3 months of continuous observation for a confident diagnosis. Hypochondriacal complaints may be seen in some cases. Philosophical, religious and abstract preoccupations may be seen along with a preference for solitariness. The onset of hebephrenic schizophrenia is insidious, usually in the early second decade (15 to 25 years). The course in many patients is relentlessly downhill. Severe deterioration without remissions often occurs over time. The recovery from the episode classically never occurs. The term ‘disorganised schizophrenia’ is used to denote hebephrenia in DSM-IV. Simple schizophrenia is characterised by an early onset (usually in the second decade), very insidious and progressive course, and presence of characteristic negative symptoms like marked social withdrawal, loss of initiative and drive or shallow emotional response. People with this condition drift down the social ladder quickly, living shabbily and wandering aimlessly. Delusions and hallucinations are usually absent if present they are short lasting and poorly systematised. The prognosis is usually very poor. Note that for simple schizophrenia – duration criteria is one year, not one month (ICD-10). Residual schizophrenia consists of long-term but not necessarily irreversible negative symptoms. Delusions and hallucinations must have been minimally intense or reduced for at least one year period. The positive symptoms are gradually replaced by negative symptoms. According to the ICD 10 diagnosis “residual schizophrenia is characterised by the following features in additional to the general guidelines of schizophrenia which includes prominent negative schizophrenic symptoms, evidence in the past of at least one clear-cut psychotic episode meeting the diagnostic criteria for schizophrenia, a period of at least one year during which the intensity and frequency of