Schizophrenia- Delusions and Hallucinations

Schizophrenia- Delusions and Hallucinations

While schizophrenia is considered a chronic illness, the course of the illness appears to follow several stages (often classified according to the particular point of view or theoretical orientation of the clinician). Of course, the DSM-IV is considered non-theoretical as to diagnosis and etiology. The DSM-IV is empirically based and is organized into diagnostic categories according to symptoms. In classifying schizophrenia, the DSM speaks of active-phase and residual to refer to acute psychosis versus more chronic and long standing symptoms. It uses Residual as a Subtype classification. This means that most people diagnosed with Schizophrenia will move between Subtypes as their illness progresses. Others refer to acute, sub- acute and chronic phase patterns of symptoms. Whatever the theoretical considerations, for the purpose of communication and third party reimbursement, the DSM the most widely utilized tool for mental disorders. With that said, let’s look further at the acute symptom as they may manifest in the clinical situation.

We discussed disturbance of thought form last time. Now we move to Disturbance of thought content (delusions) and Disturbance of Perceptions (Hallucinations). In the organization of the DSM-IV, these symptoms give further clues as to diagnosing schizophrenia and choosing a Subtype classification.

Delusions are fixed false beliefs that are usually incredible and beyond belief. The may be bizarre or “nonbizarre” (nonbizzare delusions are a characteristic of Delusional Disorder-which will be touched on in later articles). Usually, the more acute the illness at the time of the assessment, the more disorganized and bizarre are the delusions. The following are some of the types of delusions that might be seen:

1. Bizarre and confused delusions with no systematic content

2. Persecutory delusions that are also relatively without systematic form

3. Delusions of Grandeur- “I am the second coming of Christ; I am the president”

4. Delusions of Influence- “I have powers of mind control and can make you stand on your head if I want”

5. Ideas of Reference- Casual events of others are seen as being directed toward the individual

6. Thought insertion- “The FBI is transmitting thoughts into my mind”

7. Thought Broadcasting- “The Government has been listening to my thoughts for years. (So, the individual covers her head and entire apartment with aluminum foil to block the transmission).

Most Delusions have a paranoid flavor. Hence, preoccupation with delusions is considered a characteristic of the Paranoid Subtype in the DSM-IV. The other criteria for Paranoid Type include prominent hallucinations as well as a lack of “prominent” disorganized speech, catatonic or disorganized behavior, or flat or inappropriate affect (which are criteria for other subtypes).

Perceptual disturbances (hallucinations) can be Auditory, Visual, Olfactory, and Tactile. Auditory hallucination may be just running commentary, negative or threatening statements, or directives for action (command hallucinations- often to hurt or kill oneself or others. Illusions (misperceptions of real objects) are also possible as are derealization (the world seems unreal) and depersonalizations (feels like observing self from outside). Note the latter is different from dissociation. (See Glossary, pg. 766 DSM-IV)

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