Disorganized Schizophrenia (Hebephrenia) – What is it?

Previously, schizophrenia was categorized into five subtypes: paranoid, catatonic, disorganized, residual, and undifferentiated ^[1]. In the most recent publication of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ^[2], these five subtypes have been removed, due to concerns relating to the validity and stability of these diagnoses ^[3].

As such, disorganized schizophrenia is no longer a specific diagnosis, but the symptoms of disorganized schizophrenia and other types of schizophrenia are still used by physicians to form a diagnosis, based on the severity of the presenting symptoms.

What is disorganized schizophrenia?

Schizophrenia can present as a variety of symptoms, including:

• Positive symptoms: such as hallucinations, delusions, and thought disorders
• Negative symptoms: such as social withdrawal, loss of motivation, catatonia, and blunted emotions
• Cognitive symptoms: such as abnormal or disorganized speech and behavior, including incoherent sentences, difficulty following a train of thought, and odd or repeated movements.

According to the DSM-IV, for a diagnosis of disorganized schizophrenia, hallucinations and delusions may be present, but the primary symptoms would be disorganized speech and behavior ^[1]. This could include saying bizarre things, repeating words and phrases, shifting rapidly between topics during conversation, or often feeling confused about things.

Another common symptom of disorganized schizophrenia is flat affect, which means that the individual will present as expressionless and show inappropriate or unusual responses.

Symptoms of disorganized schizophrenia

Symptoms of disorganized schizophrenia may include hallucinations, meaning that you may see, hear, feel, smell, or taste things that are not there, such as hearing voices; or delusions, meaning that you have strongly held beliefs that are not correct or based on any evidence, such as believing that the television is sending messages, or that people can hear your thoughts ^[4].

While delusions and hallucinations may be present in disorganized schizophrenia, the primary presenting symptoms will be related to a clear impairment in cognition and daily functioning, usually seen as disorganized thoughts and behavior. Symptoms of disorganized schizophrenia include ^[5][6]:

• Using made up words
• Speaking in jumbled, incomprehensible sentences
• Repeating words or phrases
• Responding to questions with an unrelated answer
• Showing inappropriate emotional responses, such as laughing at bad news
• Displaying no emotion
• Unusual or inappropriate facial expressions
• Impaired memory
• Inability to concentrate
• Regularly losing or misplacing items
• Lack of impulse control
• Inability to make decisions or complete tasks
• Poor self-care
• Using illicit substances
• Suicidal thoughts
• Treatment noncompliance, such as forgetting or choosing not to take medication, or declining to attend appointments with professionals

Causes of disorganized schizophrenia

The cause of schizophrenia is not known, but it is thought to be related to several factors, such as:

Brain structure and function

Research suggests that schizophrenia may be caused by changes in neurotransmitter levels, particularly dopamine and glutamate ^[7].

There is also evidence to suggest that people with schizophrenia have differences in their brain structure, including a decreased amount of gray matter, suggesting that the condition could be caused by impaired development of the brain ^[8].

Similarly, traumatic brain injury could cause an onset of psychosis or schizophrenia, also suggesting that brain structure can contribute to the development of the condition ^[9].

Genetics

Studies indicate that schizophrenia is around six times more likely to occur in people who have a direct relative with the condition, than in those with no family history of schizophrenia ^[7]. Despite this, having a family history of schizophrenia does not always mean that the condition will develop in offspring.

Social and environmental influences

The risk of developing schizophrenia is thought to be increased by various social and environmental influences, including traumatic events in childhood, complications during pregnancy and childbirth, lack of social engagement, ethnicity, and socioeconomic status ^[10][11].

Alcohol and drugs

Substance use, in particular the use of cannabis, has been found to increase the risk of psychosis. This risk is significantly higher in those who use cannabis from a young age, in large and frequent doses ^[11][12].

Similarly, some research suggests that cocaine, amphetamines, and alcohol use can contribute to an increased risk of psychosis ^[11].

Treatment of disorganized schizophrenia

Medication

Antipsychotic medication is typically used in the treatment of all types of schizophrenia and can help alleviate most symptoms. Your doctor will initially prescribe a second-generation antipsychotic medication, such as olanzapine, aripiprazole, or risperidone.

People respond to medications differently, so what works for one person may not work for another. You may need to try more than one medication, or a combination of medications, before you find an effective treatment. Antidepressants and mood stabilizers may also be used to treat certain symptoms of schizophrenia.

If you have had limited success with two or more antipsychotic medications, you might be prescribed clozapine. It is a very effective medication for the treatment of schizophrenia, but can have severe side effects and risks associated, which is why it is not a first choice of medication, and requires careful monitoring, including regular blood tests ^[8].

Many antipsychotic medications can cause side effects of varying severity, which is one of the reasons that some people don’t take their medication regularly. Also, people with schizophrenia sometimes lack insight, meaning that they don’t think they are unwell, so don’t think they require medication. Medication noncompliance can cause a relapse of symptoms ^[13].

It is important that you take your medication exactly as prescribed, as taking too much, missing doses, or suddenly stopping your medication can cause adverse effects and can worsen your condition.

Therapy

There are various types of therapy that can be useful for the treatment of schizophrenia.

Cognitive behavioral therapy (CBT) can be helpful for adapting negative thoughts and behaviors, gaining insight about your condition, and preventing relapse ^[8].

Family therapy can be useful for some people, as it can help the family to better understand and manage their loved one’s condition, symptoms, and behavior ^[14].

Psychosocial treatments can help you to learn social skills, develop tools to manage your condition, understand the importance of your medication, and find support in others who have coped with similar experiences ^[7].

Self-care

• Avoid drugs and alcohol: Drugs and alcohol can have detrimental effects on your mental health, potentially causing a relapse. They may also interact with your medication, which could cause serious side effects and risks to your physical health ^[10].
• Attend all appointments: Ensure you attend all arranged appointments with your doctor, mental health nurse, and anyone else involved in your treatment, so that you continue to receive the proper care and treatment that is required for your recovery. It is also important that your treatment team is aware of any changes or improvements in your mental and physical health.
• Get enough sleep: Sleep is very important in improving or maintaining good physical and mental health, and a lack of sleep can contribute to a worsening of your symptoms. Try to develop a good routine for bedtime and get around 8 hours each night.
• Be active: Do things that you enjoy, as this can help prevent symptoms from worsening. Beneficial activities include exercise, meditation, walking, reading, games, and spending time with friends.

Other types of schizophrenia

Schizophrenia is no longer diagnosed as one of five specific subtypes, but the symptoms of each subtype are still used in formulating diagnoses. Along with disorganized schizophrenia, the other four previously used subtypes were ^[1]:

Paranoid schizophrenia

According to the DSM-IV ^[1], delusions and/or hallucinations must be present for a diagnosis of paranoid schizophrenia. The individual will be very focused on at least one specific delusion, which will typically be of a persecutory nature, causing the belief that someone or something is trying to cause them harm.

This could be a voice, or voices, telling them they are being followed, watched, or poisoned, or they may see or hear concerning messages. As such, people with a diagnosis of paranoid schizophrenia will typically be very suspicious and untrusting of others, which may result in expressions of anger, fear, or withdrawal ^[15].

For more information please see our article on persecutory delusions.

Catatonic schizophrenia

Catatonic schizophrenia involves abnormal psychomotor function. This can be an inability to move, excessive or hyperactive moments, or odd and unusual movements or postures ^[1].

A common symptom of catatonic schizophrenia is immobility, or stupor, which means that the person appears frozen in place, sometimes for hours or days, and can be in odd positions for long periods of time.

Other common symptoms are echolalia and echopraxia, which respectively mean mimicking other people’s words or mimicking other people’s actions ^[16].

Residual schizophrenia

People with a diagnosis of residual schizophrenia would have no prominent examples of positive symptoms, such as hallucinations, delusions, and disorganized speech, but there would be a clear disturbance in their cognition. They may experience negative symptoms and odd beliefs.

Undifferentiated schizophrenia

A diagnosis of undifferentiated schizophrenia was given when symptoms of schizophrenia were present, but the criteria for any of the other subtypes was not clearly met.