Types of Schizophrenia
Key takeaways
The DSM-5 no longer recognizes schizophrenia subtypes as separate diagnostic categories. However, the five classical subtypes (paranoid, hebephrenic, undifferentiated, residual, and catatonic) can still be helpful as specifiers for treatment planning.
Schizophrenia affects approximately 1% of people in the United States, with men typically receiving a diagnosis in their late teens to early 20s and women typically receiving a diagnosis in their late 20s to early 30s.
When schizophrenia occurs in children (which is rare), symptoms in older children and teens can include social withdrawal, sleep disruptions, impaired school performance, irritability, irregular behavior, and substance use.
Schizophrenia is a chronic mental health disorder that affects:
emotions
the ability to think rationally and clearly
the ability to interact with and relate to others
The National Alliance on Mental Illness (NAMI) reports that research indicates that schizophrenia affects close to 1% of people in the United States. Men typically receive a schizophrenia diagnosis in their late teens to early 20s. Women typically receive a diagnosis in their late 20s to early 30s.
Episodes of the illness can come and go, similar to the process of remission. When there's an 'active' period, an individual might experience:
Current DSM-5 status
Diagnostic changes were made for several disorders in the new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, text revision (DSM-5-TR), including schizophrenia. In the past, an individual only had to have one of the symptoms to receive a confirmed diagnosis Now, a person must have at least two of the symptoms.
The DSM-5 also removed the subtypes as separate diagnostic categories, based on the presenting symptom. This was found to not be helpful, since many subtypes overlapped with one another and were thought to decrease the diagnostic validity, according to the American Psychiatric Association (APA).
Instead, these subtypes are now specifiers for the overarching diagnosis, to provide more detail for the clinician.
Subtypes of schizophrenia
Although the subtypes don't exist as separate clinical disorders anymore, they can still be helpful as specifiers and for treatment planning. There are five classical subtypes:
paranoid
hebephrenic
undifferentiated
residual
catatonic
Paranoid schizophrenia
In 2013, the APA determined that paranoia was a positive symptom of the disorder. Paranoid schizophrenia was no longer considered a separate condition.
However, the subtype description is still used because of how common this symptom is. Symptoms include:
delusions
hallucinations
disorganized speech (word salad, echolalia)
trouble concentrating
behavioral impairment (impulse control challenges, emotional lability)
flat affect
Hebephrenic (disorganized) schizophrenia
Hebephrenic or disorganized schizophrenia is still recognized by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), although it's been removed from the DSM-5-TR.
In this variation of schizophrenia, the individual does not have hallucinations or delusions. Instead, they experience disorganized behavior and speech. This can include:
flat affect (inability to display emotions)
speech disturbances
disorganized thinking
involuntary or unexpected emotions or facial reactions
trouble with daily activities
Undifferentiated schizophrenia
Undifferentiated schizophrenia was the term used to describe when an individual displayed behaviors that were applicable to more than one type of schizophrenia. For instance, an individual who had catatonic behavior but also had delusions or hallucinations and disorganized speech might have received a diagnosis of undifferentiated schizophrenia.
With the new diagnostic criteria, this merely signifies to the clinician that a variety of symptoms are present.
Residual schizophrenia
This 'subtype' is a bit tricky. It's been used when a person has a previous diagnosis of schizophrenia but no longer has any prominent symptoms of the disorder. The symptoms have generally lessened in intensity.
Residual schizophrenia usually includes more 'negative' than positive symptoms, such as:
flattened affect
psychomotor difficulties
slowed speech
limited attentiveness to personal hygiene
Many people with schizophrenia go through periods where their symptoms wax and wane (increase and decrease) and vary in frequency and intensity. Therefore, this designation is rarely used anymore.
Catatonic schizophrenia
Although catatonic schizophrenia had been listed as a subtype in the first Diagnostic and Statistical Manual of Mental Disorders first edition (1952) through the DSM-4 (1994), the DSM-5 removed it as a subtype. Catatonia is now considered a specifier. This is because it occurs in a variety of psychiatric and general medical conditions.
Catatonic schizophrenia typically presents itself as immobility, but it can also look like:
mimicking behavior
mutism (inability to speak)
a stupor-like condition (reduced responsiveness)
Childhood schizophrenia
Childhood schizophrenia isn't a subtype but rather an indicator of the time of diagnosis. A diagnosis in children is fairly uncommon.
When it does occur, it can be severe. Early onset schizophrenia typically occurs between ages 13 and 18 years. A diagnosis under age 13 years is considered very early onset and is extremely rare.
Symptoms in very young children are similar to those of developmental disorders, such as autism and attention deficit hyperactivity disorder (ADHD). These symptoms can include:
language delays
late or unusual crawling or walking
irregular motor movements
It's important to rule out developmental issues when considering a very early onset schizophrenia diagnosis.
Symptoms in older children and teens include:
social withdrawal
sleep disruptions
impaired school performance
irritability
irregular behavior
substance use
Younger individuals are less likely to have delusions, but they're more likely to have hallucinations. As teens get older, more typical symptoms of schizophrenia — like those seen in adults — usually emerge.
It's important to have a knowledgeable professional make a diagnosis of childhood schizophrenia because it's so rare. It's crucial to rule out any other condition, including substance use or an organic medical issue.
A child psychiatrist with experience in childhood schizophrenia should lead the treatment team and discussions about its plan. Treatment typically involves a combination approach that can include:
Conditions related to schizophrenia
Schizoaffective disorder
Schizoaffective disorder is a separate and different condition from schizophrenia, but sometimes it gets lumped in with it. This disorder has elements of both schizophrenia and mood disorders.
Psychosis, which involves a loss of connection with reality, is often a component. Mood disorders can include either mania or depression.
Schizoaffective disorder is further classified into subtypes based on whether a person has only depressive episodes or whether they also have manic episodes with or without depression. Symptoms can include:
paranoid thoughts
delusions or hallucinations
trouble concentrating
depression
hyperactivity or mania
limited attentiveness to personal hygiene
appetite disturbance
sleep disruptions
social withdrawal
disorganized thinking or behavior
Diagnosis is typically made through a thorough physical exam, interview, and psychiatric evaluation. It's important to rule out any medical conditions or any other mental illnesses like bipolar disorder. Treatments include:
medications
group or individual therapy
practical life skills training
Other related conditions
Other related conditions to schizophrenia include:
delusional disorder
brief psychotic disorder
schizophreniform disorder
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