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Included in the early de nitions of the disease, both of Kraepelin and of Bleuler, were a characteristic premorbid personality, an insidious onset of the more agrant symptoms in adolescence or early adult life, and a chronic but uctuating course with a tendency to progressive deterioration Both regarded hallucinations and delusions as secondary or accessory symptoms that could be absent, as in their simple schizophrenia They emphasized the absence of primary disturbances of perception, orientation, memory, and other cognitive functions, which played such a large role in other cerebral diseases Embodied in both their de nitions was the concept of disease characterized by a poor prognosis and, as stated earlier, a unique constellation of symptoms different from those of delirium, confusion, depression, mania, dementia the other manifestations of brain diseases Attempts to apply these diagnostic criteria initially met with dif culty, especially when hallucinations and delusions were absent In order to overcome this, Schneider proposed that the distinction between primary and accessory manifestations be abandoned He attached more importance and reliability to the occurrence of auditory hallucinations, perceptual delusions (misinterpretation of what the patient hears and feels), and disturbances of thinking, often re ected in the experience that one s thoughts and actions are being broadcast and are not one s own but are under the in uence of some outside agency (experiences of alienation and in uence) This constellation of symptoms, which was more precise and easy to recognize, came to be known as Schneider s rstrank symptoms of active schizophrenia Strict adherence to Schneider s diagnostic criteria, when applied to a group of patients admitted to the hospital with a diagnosis of schizophrenia, served to distinguish two groups of patients those with and those without rst-rank symptoms (Taylor) Those without hallucinations, delusions, and thought control or projection responded more poorly to treatment and required a more prolonged period in the hospital and higher doses of neuroleptic drugs than did those with these features The two groups correspond closely to two categories of schizophrenic disorders recognized by Robins and Guze on the basis of prognosis The Schneider-positive, poor-prognosis schizophrenia (also referred to in older literature as nuclear or process schizophrenia) corresponds closely to kraepelinian schizophrenia; many of the Schneider-negative patients with good prognosis are probably suffering from some other nonschizophrenic illness or schizophreniform illness, or manic-depressive disease (see Chap 57) Feighner and colleagues, who drew up a set of diagnostic criteria for research in the major psychiatric syndromes [which were subsequently incorporated in successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)], stated that the diagnosis of schizophrenia is tenable only in the presence of (1) a chronic illness of at least 6 months duration and a failure (after an acute episode) to return to the premorbid level of psychosocial adjustment, (2) delusions or hallucinations without signi cant confusion or disorientation (ie, without clouding of consciousness),
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THE SCHIZOPHRENIAS AND PARANOID STATES
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(3) verbal productions that are so illogical and confusing as to make communication dif cult (if the patient is mute, diagnosis should be deferred), and (4) at least three of the following manifestations: (a) among adults, the lack of a partner or spouse; (b) poor premorbid social adjustment or work history; (c) family history of schizophrenia; or (d) onset of illness prior to age of 40 years Important negatives include the absence of a family history of manic-depressive disease, absence of an earlier illness with depressive or manic symptoms, and absence of alcoholism, drug abuse, or other organic disease While the Feighner criteria are so strict as to exclude certain patients with a schizophrenic illness, those patients who are included will be found to constitute a fairly homogeneous group Morrison and colleagues, who used these criteria, noted that after a 10-year period there was practically no change in diagnosis; they had reliably separated schizophrenia from schizophreniform psychosis (in which only the acute delusional-hallucinatory syndrome was present), and from manic-depressive psychosis
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school or to nd work, have dates, or later, to establish a family unit If support and protection is not provided, such persons drift from one menial job to another, always shy, withdrawn, and relatively indifferent to their surroundings Catatonic Schizophrenia This, the most readily differentiated type of schizophrenia, is now quite rare Characterized by an extreme diminution in psychomotor activity, it was originally described by Kahlbaum and considered to be a mental disturbance sui generis until Kraepelin recognized it as another form of schizophrenia In about 60 percent of cases the onset is relatively acute In the remainder, after a long prodrome of slackening interest, apathy, and dreamy preoccupation, a state of dull stupor supervenes, with mutism, inactivity, refusal of food, and a tendency to maintain one position like a mummy (catalepsy) The facial expression is vacant, the lips are pursed; the patient lies supine without motion or sits for hours with hands on knees and head bowed (a form of catalepsy) If a limb is lifted by the examiner, it will sometimes be held in that position for hours ( exibilitas cerea) Urine and feces are retained or there is incontinence The patient may require tubefeeding (or will eat mechanically) and has to be dressed and undressed Pinprick or pinch induces no reaction Extreme negativism, every command being resisted, characterizes some cases Echolalia and echopraxia are observed occasionally Yet these patients may be fully aware of what is said to them or happening around them and will reproduce much of this information during a later spontaneous remission or one induced by intravenous sodium amytal or midazolam Even if untreated, the patient, after weeks or months in this state, begins to talk and act more normally, and there is then rapid recovery In certain phases of catatonia there may be a period of excitement and impulsivity, during which the patient may be suicidal or homicidal As mentioned, for reasons that are unclear, this form of schizophrenia is now seen infrequently, and there is increasing recognition of the fact that its catatonic features are often manifestations of a depressive illness rather than of schizophrenia Disorganized, or Hebephrenic, Schizophrenia This was believed by Kraepelin to be a particularly malignant form of the disease It tends to occur at an earlier age than the other varieties, hence the pre x hebe ( youth ) The thought disorder is pronounced there is a striking incoherence of ideas and a grossly inappropriate affect; the frequent occurrence of hallucinations and delusions leaves little doubt that the patient is psychotic The visual and auditory illusions and hallucinations are usually more in the nature of symbolic interpretations than abnormal perceptions Kraepelin remarked on the changeable, fantastic, and bizarre character of the delusions Motor symptoms, in the form of grimacing, stereotyped mannerisms, and other oddities of behavior, are prominent In hebephrenic patients, since early life, there is likely to have been a history of tantrums and of being overly pious, shy, fearful, solitary, conscientious, and idealistic traits that may have marked these individuals as odd This latter state corresponds to what was referred to earlier on as a schizoid personality but could just as well represent the early phase of the disease itself (see Chap 56) Paranoid Schizophrenia This is one of the most frequent and well-circumscribed types The mean age of onset is in the early forties, much later than that of the preceding types (Winokur) The central feature is the preoccupation with one or more delusions related to a single or to a limited ensemble of themes, accompanied
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