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Phenomenology of Schizophrenia
D. Barberio, D.O.
August 2000

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 A’s
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
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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The patient experience his thoughts being withdrawn or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

IV. Positive and Negative Symptoms

+ Positive
Hallucinations
Delusions
Bizarre behaviors
Formal Thought Disorder

- Negative

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Affective flattening
Alogia
Avoliton-Apathy
Attention

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
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. 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
4. Echopraxia
5. Negativism
6. Somatic Symptoms

F. Disorders of Perception

1. Hallucinations
2. Unusual Perceptions
3. Delusions
4. Hypersensitivity

G. Sensorium

VI. Hallucinations

VII. Delusions

General Comments

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DSM IV Glossary of Culture-Bound Syndromes

Nash Article

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

Fisher(1969) suggests a raised level of arousal

Decreased central serotonin levels may lead to an increased

dopamine

Etiology

Psychological

Psycho-Physiological

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Neurochemical

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

PTSD

Post -resuscitation

Grief reactions

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

Benzodiazepines

also occur in withdrawal

Lithium

visual which go away with the treatment with naloxone

Central Stimulants

In one study 83% of chronic amphetamine users reported auditory

and visual hallucinations

Antiparkinsonian Drugs, Dopminergic and anticholinergic agents

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Amantadine, lisuride, levodopa, mesulergine, pergolide mesylate,

and bromocriptine

Atropine, benztropine, triheyphenidyl, scopolamine (mainly

auditory)

may occur in low dosage

organophosphorus insecticides

Antihistamines

more frequent in children

Analgesics and narcotics

meperidine toxicity

Stadol

Antiinflammatory Drugs

NSAID

Prednisone

Anticonvulsant

Dilantin

Other anticonvulsant - more common in increased level

Anaesthetic Agents

Ketamine hydrochloride - dose related

Cardiovascular Medications

Digoxin

Propranolol - vivid nightmares, hypnogogic

Clonidine - visual

Timolol - visual

Antineoplastic
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olfactory and gustatory

visual loss and hallucination in bone marrow transplant

visual hallucinations occur with cyclosporine

Antimicrobial Agents

Pen G, Amoxicillin, Sulfa

Miscellaneous Agents

Cimetidine

Baclofen

Hallucination Associated with Neurological Disorders

Epileptic Disorders

TLE

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

Negative hallucinations can occur

Occipital lobe

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

Brain tumors

They often resolve after the lesion is removed

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

680-681

Cerebrovascular Disease

Some interesting case reports

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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

Head Injuries

r/o PTSD

Narcolepsy
watch the movie My Private Idaho

Peduncular Hallucinosis

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.

Release hallucination

disruption of the geinculocalcarien pathways and are more common

with right sided than with left sided lesions

CNS infections

Other Disorders
MS, hydrocephalus,NPHS, lupus

Hallucinations associated with Eye Disease

Cataract

Retinal Disease and Glaucoma

Optic Neuritis

Charles Bonnet Syndrome

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

Entoptic Phenomena

floaters

Scheerer's phenomenon

Anton's Syndrome - denial of blindness

Phantom Vision

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Hallucinations associated with Ear Disease

Concept of Sensory Depravation

Psychiatric Disease

Schizophrenia

Most common is auditory, some culture variation has been

noted

Other types have been noted usually in association with

auditory

Usually complex

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

Bipolar

Similar to the hallucinations of schizophrenia

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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.

Depression

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.

Dissociative Disorder

Not uncommon

Question is if these are true hallucinations, like a

conversion symptoms

Negative hallucinations

PTSD

Experience auditory hallucinations most commonly, eg a voice

telling them to kill themselves.

Severe states of anxiety may be present with the hallucinations

Alcoholism

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

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Other physical illness increases the risk

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

Alcohol Hallucinosis

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.

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

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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

References
Hallucinations

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

General Information

1. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision,
2000, APA Press .

Delusions
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1. Spitzer, Manfred M.D., Ph.D. The Phenomenology of Delusions,

Psychiatric Annals, 2215 (May 1992), 252-259

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