Which is the schizophrenia with worst prognosis?
1. Hebephrenic schizophrenia
2. Simple schizophrenia
Well, this seemingly simple question was asked by drani (RxPG Nick) in the shout-box yesterday. According to this RxPG member the standard books and the usual half baked PG entrance guides are confusing her more. Well, as we said this question looks extremely simple, but there is much more to it than that meet the eyes. Read on...
Well, before we look at the reason for the existing confusion, let us first see what these two types of schizophrenia mean.
At the turn of 20th century, in a landmark paper Kraepelin divided dementia praecox (older name for schizophrenia) into these four subtypes: paranoid, hebephrenic, catatonic, and simple. This classification stood the test of time and some test of validity till late 1960s. "Hebephrenic" is the term given to disorganised schizophrenia. It is characterised by marked positive symptoms and has only a minimal difference from paranoid schizophrenia i.e. in the intensity of persecutory delusions. On the other hand simple schizophrenia is not that simple. It is marked by strong negative symptoms and have a gradual and insiduos onset. The prognosis of both these type is poor. Now which one to choose for PG entrance exams? Well you can choose any one of them depending upon the exam you are undertaking. Confused? OK, lets read a little bit about the history of diagnostic classifications in psychiatry to understand this complex issue...
In 70's, with the advent of diagnostic classification systems, a classification derived from the original Kraeplin's classification was adopted by WHO. in 1973, Carpenter et al analysed the data from the massive International Pilot Study of Schizophrenia (famously known as IPSS) and develpoed the classification of schizophrenia which was later adopted by WHO's diagnostic classification system - ICD. Well, ICD is supposed to be an internationally valid classification and is accepted as preferred classification in most of the countries including India. The only major country where ICD psychiatric classifications are not preferred is USA as they have their own classification system - DSM. In 80's DSM incorporated a similar classification of schizophrenia and included both hebephrenic and simple schizophrenias as subtypes under the diagnositic heading of schizophrenia. But at the peak of cold war, during one of the revisions of DSM, it was felt that the term simple schizophrenia can be associated with politically volatile soviet classification of sluggish schizophrenia. So, the Americans decided to rename simple schizophrenia as "Simple Deteriorative Disorder" and classify it under the category - "Psychosis Not Otherwise Specified". In simple terms, they excluded simple schizophrenia from the group of schizophrenia i.e. simple schizophrenia was no more a schizophrenia subtype in DSM (even in latest edition DSM-IV-TR). If we compare head to head, the prognosis of simple schizophrenia is always poorer than any other type of schizophrenia including hebephrenic subtype. It is understandable due to delayed, insiduous and gradual onset and predominance of negative symptoms in simple schizophrenia. But as it does not exist as a schizophrenia type in DSM, U.S. accepts hebephrenic schizophrenia as the one with poorest prognosis. In countries where ICD-10 is accepted, simple schizophrenia is the schizophrenia with poorest prognosis. As one of the major participating centers for WHO's IPSS study, India accepts the ICD 10 classification and hence the term simple schizophrenia.
So, as you can understand (and perhaps can now explain to few of the confused authors as well), for Indian PG entrances Simple schizophrenia is the schizophrenia with poorest prognosis. For USMLE, obviously, Hebephrenic schizophrenia is the one with poorest prognosis. The dominance of US textbooks (eg. Kaplan & Saddok) in India usually leads to this innocent but extremely important confusion.
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