Subtypes of Schizophrenia

Classic Subtypes of Schizophrenia Disorder

There are five classic subtypes of schizophrenia disorder: paranoid schizophrenia, disorganized (hebephrenic) schizophrenia, undifferentiated schizophrenia, residual schizophrenia, and catatonic schizophrenia. The nosology of schizophrenia into subtypes can be credited to two psychiatrists: Emil Kraepelin and Eugen Bleuler.

Emil Kraepelin was a German psychiatrist who spent time working with the well-known psychologist Wilhelm Wundt and was the first to make the distinction between dementia praecox and manic depression.

Swiss-born psychiatrist Eugen Bleuler is responsible for changing the name to schizophrenia because he thought the disorder is better characterized by "split" psychic functions. The five classic subtypes of schizophrenia were born out of the ways in which Bleuler and Kraepelin classified symptoms of schizophrenia.

This remained the common method of classifying and diagnosing schizophrenia in the Diagnostic and Statistical Manual (DSM) until the DSM-5. This decision was made because the subtypes were believed to have low validity and reliability for diagnosis. However, the five subtypes of schizophrenia are still useful for understanding an individual's experience with schizophrenia and creating a treatment plan tailored for each person.

Subtypes of Schizophrenia Disorder

Let's begin by defining two of the most common subtypes of schizophrenia -- paranoid and disorganized schizophrenia.

Paranoid Schizophrenia

Paranoid schizophrenia is the most common type of schizophrenia and is characterized by delusions of persecution or delusions of grandeur.

Delusions of persecution, Freepik.com

These beliefs are clearly abnormal and most of us would be concerned about them. However, people who could be diagnosed with paranoid schizophrenia are often still capable of caring for themselves and all other cognitive and emotional functioning are likely intact.

For this reason, recognizing symptoms of paranoid schizophrenia can be difficult to do unless the patient is talking about the topic of their delusion. While paranoid schizophrenia has the highest recovery rate, it is also most commonly associated with aggressive behavior. It is also known to have the highest suicide rate of all schizophrenia subtypes.

Disorganized (Hebephrenic) Schizophrenia

Disorganized schizophrenia (also called hebephrenic schizophrenia) is characterized by disordered speech and behavior as well as inappropriate emotional responses. People with disorganized schizophrenia may have childlike behavior like giggling or silliness. They may also dress strangely, use obscene talk or speak incoherently. It can be very difficult to communicate with someone with disorganized schizophrenia.

Another feature of this subtype of schizophrenia is that their emotional responses often do not match the moment.

The onset of disorganized schizophrenia symptoms can occur gradually which could make it difficult to spot at first. It might be dismissed as simply a reaction to adjusting to adult life as the onset of schizophrenia for men is late teens to early 20s and for women, late 20s to early 30s. Treatment for disorganized schizophrenia usually includes a combination of medication and psychotherapy such as cognitive-behavioral therapy.

People with disorganized schizophrenia may be unable to function by themselves. For this reason, treatment might also include skills training to help people with this subtype of schizophrenia find and keep a job. Also, ensuring the person has support from family or loved ones can also be especially beneficial in treating disorganized schizophrenia.

Undifferentiated Schizophrenia

When the subtypes were used to diagnose schizophrenia, there would be times when someone didn't quite fit all the criteria for any one subtype. In this case, they were diagnosed with undifferentiated schizophrenia.

People who were diagnosed with undifferentiated schizophrenia still experienced psychiatric symptoms (delusions and hallucinations) but often had symptoms of more than one subtype of schizophrenia. Undifferentiated schizophrenia can also be characterized by:

• a reduction in relationships and interests

• a lack of emotional depth

• thinking becomes more simple and concrete

Catatonic Schizophrenia

One of the most severe subtypes of schizophrenia is catatonic schizophrenia. Catatonic schizophrenia is characterized by noticeable motor disturbances such as muscle rigidity or random and repetitive movements.

People with catatonic schizophrenia are unable to effectively care for themselves and likely require constant care. They usually alternate between a stuporous state and agitated excitement. During the stuporous state, they may seem unaware of reality or experience a symptom called wavy flexibility.

Other characteristics of catatonic schizophrenia include:

• Jerking movements

• Frozen facial expressions

• Mute

• Involuntarily speech

• Senseless repetition of words or phrases said by others

• Slowed movements

• Opposite response to requestions to move

• Mimic other people's motions

There are several theories used to explain the etiology of catatonic schizophrenia. One suggests that it is due to a disruption in GABAergic (gamma-aminobutyric acid) neurotransmitters which are responsible for regulating emotional and cognitive functions. It's also important for clinicians to rule out any potential influence from antipsychotic medication as catatonic symptoms can be a side effect.

People with catatonic schizophrenia often have a poor prognosis. It is key to begin treating catatonic schizophrenia as early as possible. Electroconvulsive therapy (ECT) is usually the treatment of choice for catatonic schizophrenia although many may relapse within a year. Benzodiazepines may also be used first, although ECT is shown to be the most effective.

Negative symptoms can resemble depression, Freepik.com

Residual Schizophrenia

Schizophrenia symptoms can be in one of two categories -- positive or negative symptoms. Positive symptoms include symptoms are any changes to thoughts or behavior like hallucinations or delusions. Negative symptoms might include flattened affect, alogia (poor speech), or anhedonia (inability to feel pleasure).

At some point, or during treatment, a person's symptoms may begin to subside.

Regardless of the subtype, anyone with schizophrenia can develop residual schizophrenia. Residual schizophrenia can be characterized by:

• Emotional withdraw
• Lack of judgment and insight
• Difficulty with abstract thinking
• Poor attention
• Anxiety
• Social withdraw
• Bluntness

Clinicians should also be careful in distinguishing symptoms of residual schizophrenia from potential symptoms of depression as they can look very similar. Distinguishing symptoms of depression include sleep disturbances, depressed mood, or loss of appetite.

When subtypes were used to diagnose schizophrenia, a residual schizophrenia diagnosis was meant to be temporary. At some point either the person's positive symptoms relapsed or their negative symptoms began to subside as well. Some medications used to treat schizophrenia may be designed to primarily reduce positive symptoms, leaving negative symptoms untreated and leaving someone with residual schizophrenia. Psychotherapy and psychosocial interventions have proven effective in reducing negative symptoms and are therefore the treatment of choice for residual schizophrenia.