Phenomenology of Schizophrenia

(D. Barberio, D.O.)

I. Introduction
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 As
3. Gabriel Lanfeldt empirical
criteria
4. Kurt Schneider
II. DSMIV criteria
A. Characteristic symptoms
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or
catatonic behavior
5. Negative Symptoms
B. Social/occupational dysfunction
C. Duration
D. Schizoaffective and Mood exclusion
E. Substance/general medical
condition exclusion
F. Relationship to a Pervasive
Developmental Disorder
G. Longitudinal Course
H. Subtypes
1. Paranoid
2. Disorganized
3. Catatonic
4. Undifferentiated
5. Residual
III. Other Criteria
A. Bleulerian criteria
1. Autism: A tendency to
withdraw from reality into
idiosyncratic fantasy.
2. Associations: A loosening of
thoughts or
associations
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being withdrawn or taken out of his mind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

Second-rank Symptoms
1. Other disorders of perception
2. Sudden delusional ideas
3. Perplexity
4. Depressive and Euphoric Moods
5. Feeling of emotional improverishment

E. Disorders of Behaviors
1.
2.
3.
4.
5.
6.

Stereotyped behavior
Stuporous state
Eating Disorders
Echopraxia
Negativism
Somatic Symptoms

F. Disorders of Perception
IV. Positive and Negative Symptoms
+ Positive
Hallucinations
Delusions
Bizarre behaviors
Formal Thought Disorder

1.
2.
3.
4.

Hallucinations
Unusual Perceptions
Delusions
Hypersensitivity

G. Sensorium
VI. Hallucinations

- Negative

VII. Delusions

Affective flattening
Alogia
Avoliton-Apathy
Attention

General Comments

V. Mental Status Examination

Nash Article

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
5. Mutism
6. Neologisms
7. Stilted Language
8. Loss of ego boundaries
9. Inability to use abstract concepts
10. Echolalia
C. Disorders of Affect
1.
2.
3.
4.
5.

Flatten Affect
Reduced emotional responsiveness
Inappropriate responses
Bizarre emotions
Emotion sensitivity

D. Disorders of Ambivalence

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
Hallucinations
General Information
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

Phantom Limb - increased if depressive

symptoms
Culture and suggestion
Hallucinations Induced by
Pharmacological Agents
Psychotropic Medication
Antidepressants - often of the visual
modality
Case reports with buproion
MAO least likely

Fisher(1969) suggests a raised level of

arousal
Decreased central serotonin levels may
lead to an increased dopamine

Benzodiazepines
also occur in withdrawal
Lithium

Etiology

visual which go away with the treatment

with naloxone

Psychological
Psycho-Physiological
Neurochemical

Hallucinations in non-morbid states

Hypnagogic (falling) and Hypnapomic
(awakening)
Moore's lightning streaks

Central Stimulants
In one study 83% of chronic
amphetamine users reported auditory
and visual hallucinations

Antiparkinsonian Drugs, Dopminergic

and anticholinergic agents

Phosphenes occur with movements and

even noise

Amantadine, lisuride, levodopa,

mesulergine, pergolide mesylate, and
bromocriptine

Hallucinations secondary to sensory

deprivation

Atropine, benztropine, triheyphenidyl,

scopolamine (mainly auditory)

they get more complex as the

deprivation continues

may occur in low dosage

Sleep deprivation and jet lag

organophosphorus insecticides

PTSD
Post -resuscitation
Grief reactions

Antihistamines
more frequent in children

Analgesics and narcotics

meperidine toxicity
Stadol

Miscellaneous Agents
Cimetidine
Baclofen

Antiinflammatory Drugs
NSAID

Hallucination Associated with

Neurological Disorders

Prednisone

Epileptic Disorders
TLE

Anticonvulsant
Dilantin
Other anticonvulsant - more common in
increased level

generally the more posterior the lesion in

the temporal lobe the more complex the
hallucination
Visual are the most common
Olfactory uncus
Gustatory periinsular area

Anaesthetic Agents

Negative hallucinations can occur

Ketamine hydrochloride - dose related

Occipital lobe
Cardiovascular Medications
Digoxin

simple shapes, light flashes

the more anterior the more complex

Propranolol - vivid nightmares,

hypnogogic

sometimes seen in a blind field

Clonidine - visual

may experience transitory blindness

after the seizure

Timolol - visual

Palinacousis and palinopsia

Brain tumors

Antineoplastic
olfactory and gustatory

They often resolve after the lesion is

removed

visual loss and hallucination in bone

marrow transplant

NeuroOp interesting case report by Vike Ar of neurology 41, 680-681

visual hallucinations occur with

cyclosporine

Cerebrovascular Disease

Antimicrobial Agents
Pen G, Amoxicillin, Sulfa

Some interesting case reports

Extrapyramidal Syndromes

Huntington's
Parkinson
Fahr Disease - idiopathic basal ganglia
calcification , 50% with schizophrenic like
symptoms
Wilson's Disease,Sydenham's chorea or
rheumatic chorea

Anton's Syndrome - denial of blindness

Phantom Vision

Hallucinations associated with Ear

Disease

Head Injuries
r/o PTSD

Concept of Sensory Depravation

Narcolepsy
watch the movie My Private Idaho

Psychiatric Disease

Peduncular Hallucinosis

Schizophrenia

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.

Most common is auditory, some culture

variation has been noted

Release hallucination

Usually complex

disruption of the geinculocalcarien

pathways and are more common with
right sided than with left sided lesions

Simple types in paranoid schizophrenia "knocking"

CNS infections

Coming for inside the head vs outside

may reflect reality testing

Other Disorders
MS, hydrocephalus,NPHS, lupus

Hallucinations associated with Eye

Disease
Cataract
Retinal Disease and Glaucoma
Optic Neuritis

Other types have been noted usually in

association with auditory

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

Charles Bonnet Syndrome

First described by Charles Bonnet in
1769 and refers to vivid, elaborate and
well organized visual hallucination in the
elderly.

Hallucination become part of one's

delusional experience

Entoptic Phenomena

Cenesthetic hallucination refer to deep

visceral pain

floaters
Scheerer's phenomenon

Tactile and olfactory hallucinations may

be present- r/o organic causes

Visual hallucinations are often found in

association with auditory hallucination

Visual hallucinations may be simple or

complex

Severe states of anxiety may be present

with the hallucinations

Visual hallucinations of schizophrenia

less effected by environmental
manipulation
Alcoholism
Bipolar
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.

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.
Delirium Tremens
Other physical illness increases the risk

Depression
Most common are mood congruent
auditory hallucinations eg voices telling
them of sins they never committed or
commands to kill themselves.

Illusions become more prominent, spots

on wall becomes bugs
Objects and persons are reduced in size
Formication
Auditory are less frequent, commonly
persecutory or threatening

Brief Reactive Psychosis

Stressor related and symptoms less then
one month. Often visual and dreamlike.

Alcohol Hallucinosis
Average age of onset is 40 years
Follows 10 years of heavy drinking

Dissociative Disorder

Command hallucinations are common

Not uncommon

Most last only a few days, 10% for weeks

to months and some chronic.

Question is if these are true

hallucinations, like a conversion
symptoms
Negative hallucinations

Other psychotic symptoms may be

present, making the diagnosis difficult
from schizophrenia
Hallucination seem to respond to
neuroleptics and ECT.

PTSD
Experience auditory hallucinations most
commonly, eg a voice telling them to kill
themselves.

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

Kinesthetic hallucinations - perception of

sensation of movement when not
happening

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.

Pseudohallucinations - dissociative
disorder

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.
Visual Hallucinations
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

Hypnagogic hallucinations - falling

asleep and Hypnopompic - upon awaking
Negative hallucinations - dissociative
disorder, hypnosis

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
References
Hallucinations
1. Joel S. Glaser, M.D., Neuroophthalmology, 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
General Information
1. The Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text
Revision, 2000, APA Press .
Delusions
1. Spitzer, Manfred M.D., Ph.D. The
Phenomenology of Delusions, Psychiatric
Annals, 2215 (May 1992), 252-259