Phenomenology of Schizophrenia
D. Barberio, D.O.
A. What is the phenomenology of Schizophrenia?
The symptoms cluster.
The subjective schizophrenic experience
Need for empathy and understanding
The gathering of information
B. History and Important Names
1. Emil Kraepelin- 1896 "dementia praecox"
2. Eugen Bleuler "schizophrenia", four A’s
3. Gabriel Lanfeldt empirical criteria
4. Kurt Schneider
II. DSMIV criteria
A. Characteristic symptoms
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative Symptoms
B. Social/occupational dysfunction
D. Schizoaffective and Mood exclusion
E. Substance/general medical condition exclusion
F. Relationship to a Pervasive Developmental Disorder
G. Longitudinal Course
III. Other Criteria
A. Bleulerian criteria
1. Autism: A tendency to withdraw from reality into
2. Associations: A loosening of thoughts or
3. Affect: Affects or feelings tend to be split off or
exhibit inappropriate to the situation at hand.
4. Ambivalence: Profoundly mixed or contradictory
feelings or attitudes tend to preoccupy the
patient, sometimes to the point of immobility.
B. Schneiderian Criteria
First Ranked Criteria
1. Audible Thoughts
The patient experiences hallucinatory voices that echo or speak his thoughts aloud.
2. Voices Debating or Disagreeing
The patient experiences hallucinatory voices engaged in debate or argument, frequent about himself.
3. Voices Commentating
The patient experiences hallucinatory voices that comment on his action.
4. Somatic Passivity
The patient believes that sensation are being imposed upon his body by an outside force.
5. Thought Withdrawal
The patient experience his thoughts being withdrawn or taken out of his mind by an outside force.
6. Thought Broadcasting
The patient experience his thoughts being disseminated to the world around him.
7. Thought Insertion
The patient experience thoughts being placed in his mind by an outside force.
8. "Made" Feeling
The patient has the experience that his feelings are not his own, they have been imposed upon him.
9. Made" Impulses
The patient experiences and generally acts upon a compelling impulse which he believes is not his own.
10. "Made" Acts
The patient experiences his action and his will to be under the control of an outside force.
11. Delusional Persecution
The patient takes a precept and ascribes an idiosyncratic value to it. The perceptions evolve into delusions.
B. Schneiderian Criteria
1. Other disorders of perception
2. Sudden delusional ideas
4. Depressive and Euphoric Moods
5. Feeling of emotional improverishment
IV. Positive and Negative Symptoms
Formal Thought Disorder
V. Mental Status Examination
A. General Appearance
1. Deteriorated appearance and manner
2. Social Isolation
3. Lack of Motivation
B. Disorders of Thought and Speech
1. Loosening of associations
2. Disorganization and incomprehensibility
3. Thought Blocking
4. Poverty of Content
7. Stilted Language
8. Loss of ego boundaries
9. Inability to use abstract concepts
C. Disorders of Affect
1. Flatten Affect
2. Reduced emotional responsiveness
3. Inappropriate responses
4. Bizarre emotions
5. Emotion sensitivity
D. Disorders of Ambivalence
E. Disorders of Behaviors
1. Stereotyped behavior
2. Stuporous state
3. Eating Disorders
6. Somatic Symptoms
F. Disorders of Perception
2. Unusual Perceptions
DSM IV Glossary of Culture-Bound Syndromes
VIII. Cognitive Symptoms
Important therapy implications
Has been important for a long time but interesting new developments
IX. Speech Patterns
X. Boundaries of Schizophrenia
Disturbances of Perception
Life like perceptions is a balance. Humans operate in at an average expectable environment for which the nervous system is primed. Too much or little sensory stimulation may lead to distortions in perception.
More common then mentioned in the press.
Do a thoughtful mental status examination
Unformed and Complex
Unverifiable and have to associate with behavior
Esquirol (1772-1840) explored the concept in his textbook Des Maladies Mentales (1837) - separated illusion and hallucination
Reflects a problem with reality testing
Association with dreams since early history and furthered by Freud
EEG notes "pontine-geniculate-occipital" waves in REM
Fisher(1969) suggests a raised level of arousal
Decreased central serotonin levels may lead to an increased dopamine
Hallucinations in non-morbid states
Hypnagogic (falling) and Hypnapomic (awakening)
Moore's lightning streaks
Phosphenes occur with movements and even noise
Hallucinations secondary to sensory deprivation
they get more complex as the deprivation continues
Sleep deprivation and jet lag
Phantom Limb - increased if depressive symptoms
Culture and suggestion
Hallucinations Induced by Pharmacological Agents
Antidepressants - often of the visual modality
Case reports with buproion
MAO least likely
also occur in withdrawal
visual which go away with the treatment with naloxone
In one study 83% of chronic amphetamine users reported auditory and visual hallucinations
Antiparkinsonian Drugs, Dopminergic and anticholinergic agents
Amantadine, lisuride, levodopa, mesulergine, pergolide mesylate, and bromocriptine
Atropine, benztropine, triheyphenidyl, scopolamine (mainly auditory)
may occur in low dosage
more frequent in children
Analgesics and narcotics
Other anticonvulsant - more common in increased level
Ketamine hydrochloride - dose related
Propranolol - vivid nightmares, hypnogogic
Clonidine - visual
Timolol - visual
olfactory and gustatory
visual loss and hallucination in bone marrow transplant
visual hallucinations occur with cyclosporine
Pen G, Amoxicillin, Sulfa
Hallucination Associated with Neurological Disorders
generally the more posterior the lesion in the temporal lobe the more complex the hallucination
Visual are the most common
Gustatory periinsular area
Negative hallucinations can occur
simple shapes, light flashes
the more anterior the more complex
sometimes seen in a blind field
may experience transitory blindness after the seizure
Palinacousis and palinopsia
They often resolve after the lesion is removed
NeuroOp interesting case report by Vike - Ar of neurology 41, 680-681
Some interesting case reports
Fahr Disease - idiopathic basal ganglia calcification , 50% with schizophrenic like symptoms
Wilson's Disease,Sydenham's chorea or rheumatic chorea
watch the movie My Private Idaho
damage to the midbrain or pons
typically occur in the evening and consist of geometric patterns, flower, birds animals or people. The pt. may react with amusement or astonishment.
disruption of the geinculocalcarien pathways and are more common with right sided than with left sided lesions
MS, hydrocephalus,NPHS, lupus
Hallucinations associated with Eye Disease
Retinal Disease and Glaucoma
Charles Bonnet Syndrome
First described by Charles Bonnet in 1769 and refers to vivid, elaborate and well organized visual hallucination in the elderly.
Anton's Syndrome - denial of blindness
Hallucinations associated with Ear Disease
Concept of Sensory Depravation
Most common is auditory, some culture variation has been noted
Other types have been noted usually in association with auditory
Simple types in paranoid schizophrenia - "knocking"
Coming for inside the head vs outside may reflect reality testing
No "scientific" proof that those with command hallucination are more likely to do harm, but don't take any chances
Interesting, some report right sided vs. left sided; those with right sided are often significantly more depressed.
Content sometime provides a clue to psychodynamic issues
May be seen at times as psychotic projection
Hallucination become part of one's delusional experience
Tactile and olfactory hallucinations may be present- r/o organic causes
Cenesthetic hallucination refer to deep visceral pain
Visual hallucinations are often found in association with auditory hallucination
Visual hallucinations may be simple or complex
Visual hallucinations of schizophrenia less effected by environmental manipulation
Similar to the hallucinations of schizophrenia
Auditory is the most common, generally transient in nature and confined to the acute state.
More often related to mood.
Sensory amplification and hallucination may be a prodrome to manic episode.
Most common are mood congruent auditory hallucinations eg voices telling them of sins they never committed or commands to kill themselves.
Brief Reactive Psychosis
Stressor related and symptoms less then one month. Often visual and dreamlike.
Question is if these are true hallucinations, like a conversion symptoms
Experience auditory hallucinations most commonly, eg a voice telling them to kill themselves.
Severe states of anxiety may be present with the hallucinations
Occur in chronic use states, withdrawal and as a result of nutritional deficiencies.
Pardes postulates that contraction of inner ear muscle may make some sound during withdrawal but not supported by other literature.
Strong association between the reticular formation and hallucination in alcohol withdrawal.
Other physical illness increases the risk
Illusions become more prominent, spots on wall becomes bugs
Objects and persons are reduced in size
Auditory are less frequent, commonly persecutory or threatening
Average age of onset is 40 years
Follows 10 years of heavy drinking
Command hallucinations are common
Most last only a few days, 10% for weeks to months and some chronic.
Other psychotic symptoms may be present, making the diagnosis difficult from schizophrenia
Hallucination seem to respond to neuroleptics and ECT.
Disturbances of Perception
Perception is the awareness of objects and relation in the surrounding environment in response to the stimulation of peripheral sense organs as distinct from the awareness that results from memory. Impairments in perceptual apparatus set the stage for delusions, hallucination, illusions and misinterpretations of reality
Illusions - perceptual distortion in the estimation of size, shape and spatial relations of objects. Pareidolia - eg clouds, fire, those playful controlled illusions. Trailing - drug intoxication or side effect.
Hallucinations are generally defined as perceptions that occur in the absence of corresponding external stimuli.
Auditory Hallucinations - second person, command, third person - between two parties, audible thoughts.
Flashbacks are spontaneous recurrences of visual hallucinations and illusions that occur in some people with a history of repeated drug usage.
Lilliputian hallucinations are visual hallucinations in which the patient experiences seeing people who appear greatly reduced in size. Associated with atropine and other anticholinergics
Autoscopic phenomena refer to hallucinatory experiences in which all or part of the person own body is perceived as appearing in a mirror.
Tactile hallucinations (Haptic) are false perceptions of touch. Formication
Olfactory hallucination - smell and Gustatory -taste, reported in TLE and uncinate gyrus fits
Cenesthetic hallucinations eg "my brain is on fire"
Synesthetic hallucination - change in sensory modality eg bright light changes to auditory
Kinesthetic hallucinations - perception of sensation of movement when not happening
Hypnagogic hallucinations - falling asleep and Hypnopompic - upon awaking
Negative hallucinations - dissociative disorder, hypnosis
Pseudohallucinations - dissociative disorder
Extracampine - located outside of the visual field, eg - behind the head
Functional - those demonstrated only under a specific external stimulation.
Mirganinous - those with migraines
Micropsia and macropsia - distortion of size
Hallucinosis - state of active hallucination in alert state
1. Joel S. Glaser, M.D., Neuro-ophthalmology, Second Edition, 1990, J.B. Lippincott pages 230 - 238
2. Ghazi Asaad, M.D., Hallucinations in Clinical Psychiatry, 1990, Brunner/Maxel Inc.
3. William Lishmann, Organic Psychiatry, 1980, Blackwell Scientific Publications
4. Jerry L. Carter, M.D., Visual, Somatosensory, Olfactory and Gustatroy Hallucinations, The Psychiatric Clinics of North America, June 92, Saunders
1. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000, APA Press .
1. Spitzer, Manfred M.D., Ph.D. The Phenomenology of Delusions, Psychiatric Annals, 2215 (May 1992), 252-259