Subtyping of schizophrenia

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Classification according to ICD-10
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
ICD-10 online (WHO version 2019)

The traditional subtypes of schizophrenia are the paranoid, hebephrenic, and catatonic forms . In ICD-10 they are listed, while the subgroup classification of schizophrenia in the DSM-5 has been completely abandoned.

This trisection was suggested by Emil Kraepelin , although the individual forms have already been described by other authors. The first description of hebephrenia goes back to Hecker and that of catatonia to Kahlbaum. In the modern diagnostic manuals , further subtypes are distinguished. In addition, there are two important classification schemes for the subdivision of schizophrenia: the dimensional approach according to Liddle and the differentiation between type I and type II schizophrenia according to Tim Crow and their assignment to the positive / negative symptoms according to Nancy Andreasen .

Traditional subtypes

Paranoid schizophrenia

Here the delusion and hallucinations are in the foreground of the disease. The most common forms of delusion are paranoia and megalomania. The hallucinations most common in paranoid-hallucinatory schizophrenia are audible hallucinations in the form of dialogic (patients hear people talking about them) and commentary (patients hear voices accompanying their actions). The visual hallucinations occasionally depicted in the media play a rather subordinate role. This form of schizophrenia is more likely to occur in patients who have a later onset of the disease.

Hebephrenic schizophrenia

Disturbances of affect , drive and thinking are in the foreground here. The patients are often "flattened" (little modulated) or inappropriately cheerful in their mood. The drive can switch between apathetic, restlessly driven or uninhibited. Thinking is not infrequently disordered (disorganized), so that patients are sometimes unable to do everyday things. This form of schizophrenia not infrequently occurs in younger patients and is then associated with more pronounced social disabilities.

Catatonic schizophrenia

Here expression and behavior are dominated by a psychomotor disorder. The patients sometimes show a pronounced lack of movement (freezing in one movement) or storms of movement (frenzied actions), one observes stereotypes of posture or language (always the same actions or ways of speaking) or a so-called waxy flexibility ( " Flexibilitas Cerea " : one can do that Move the patient like a jointed dummy and they remain in the assumed position).

Other subtypes

Undifferentiated schizophrenia

This is a diagnosis of exclusion in those cases in which a symptom cannot be assigned to another picture.

Post-schizophrenic depression

After an acute episode of illness, some patients experience a phase with pronounced sadness and an increased risk of suicide. Postschizophrenic depression is when a depressive episode (at least two weeks) occurs after schizophrenia (at least twelve months). There must still be some schizophrenic symptoms, but the clinical picture must be dominated by depression.

Schizophrenic residual

If patients show pronounced negative symptoms for at least one year after an acute episode of the disease and only a few positive symptoms are present, this is referred to as a residual.

Schizophrenia simplex

This term is used to describe a form of schizophrenia that is characterized by the fact that the patient shows pronounced negative symptoms without ever having had strong positive symptoms before. The course of the disease is not infrequently chronic and patients tend to continually deteriorate their condition.

rating

The differentiation of schizophrenia into subtypes has repeatedly been criticized and questioned. On the one hand, as we know from follow-up observations, the subtype assignments in the longitudinal section are not always stable. Only the paranoid form seems to show a certain stability. In addition, there are no differences in the genetics of the subtypes. The subtypes also do not allow any reliable conclusions to be drawn about the prognosis. Only the hebephrene form appears less favorable over time, the paranoid form tends to have a better prognosis.

The positive / negative concept

The idea that there are two fundamentally different types of schizophrenia goes back to a proposal by British psychiatrist Tim Crow in 1980. Crow suggested distinguishing between those patients who have predominantly positive symptoms (delusion, hallucinations, etc.) and those who show predominantly negative symptoms (flattening of affect, impoverishment of speech, social withdrawal, etc.).

Type concept according to Tim Crow.
Type symptom course CT findings NL response forecast

Type I
Type II

Positive symptoms
Negative symptoms

acute
chronic

normal
ventricular asymmetry

Responding well. Responding
badly

cheap
unfavorable

To test this concept, Nancy Andreasen and others have systematically examined the distinction between positive and negative symptoms. The negative symptoms were summarized under the keyword "six A":

The distinction between positive and negative symptoms is similar to Bleuler's distinction between basic and accessory symptoms . Numerous studies on this topic have shown that the distinction between positive and negative symptoms is not suitable for subtyping schizophrenia.

The dimensional approach

Based on a criticism of Crow's classification of schizophrenia into three subtypes, Peter F. Liddle has suggested distinguishing three syndrome clusters of schizophrenia:

  • Impoverishment of the psychomotor system
  • Disorganization
  • Distortion of reality

In numerous follow-up studies, Liddle et al. Tried to show that the syndrome clusters correspond to dysfunctions in different brain regions. The dimensional approach provides that there are no pure syndrome clusters in a specific patient, but these syndromes always only to a more or less pronounced extent.

Summary

Kraepelin's original differentiation of schizophrenia into primarily three subgroups is still valid in psychiatry. For about 20 years, however, further subtyping has been proposed in the course of the further development of the concept of disease in psychiatry and empirical studies on schizophrenia. The additional types in the ICD-10 sometimes only include progressive phenomena and options for classifying individual exclusion diagnoses. The dichotomization of schizophrenic disease proposed by Tim Crow and further developed by Nancy Andreasen has not led to a valid systematization. Peter Liddles dimensional approach to differentiate syndrome clusters appears more promising in relation to neurobiological research projects.

See also

Individual evidence

  1. ^ Mathias Berger: Mental Illnesses. Clinic and Therapy. Munich 2004, ISBN 3-437-22480-8 .
  2. ^ E. Kraepelin: Psychiatry. 4th edition. Abel (Meixner), Leipzig 1893.
  3. ↑ Hecker: The Hebephrenia. In: Archives for Pathology, Anatomy, Physiology and Clinical Medicine. 52 (1871), pp. 394-429.
  4. ↑ K. Kahlbaum: The catatonia or the tension madness. Hirschwald, Berlin 1874.
  5. ↑ Tim J. Crow: The molecular pathology of schizophrenia. More than one disease process. In: Br. Med. J.. 280: 66-68 (1980). PMID 6101544 .
  6. ^ NC Andreasen: The Diagnosis of Schizophrenia. In: Schizophrenia Bulletin. 13: 9-22 (1987). PMID 3496659
  7. ↑ NC Andreasen u. a .: Positive and negative symptoms. In: SR Hirsch u. a. (Ed.): Schizophrenia. Blackwell Science, Oxford 1995, pp. 28-45.
  8. ^ E. Bleuer: Dementia praecox or group of schizophrenias . Deuticke, Leipzig / Vienna 1911.
  9. ^ PF Liddle: The symptoms of chronic schizophrenia: a re-examination of the positive-negative dichotomy. In: British Journal of Psychiatry. 151, pp. 145-151 (1987). PMID 3690102 .