Schizophrenia DSM-IV-TR.pdf

Schizophrenia (DSM-IV-TR #295.1–295.3, 295.90)

Schizophrenia is a chronic, more or less debilitating illness

characterized by perturbations in cognition, affect and

behavior, all of which have a bizarre aspect. Delusions, also

generally bizarre, and hallucinations, generally auditory in

type, also typically occur. The original name for this illness,

“dementia praecox,” was coined by Emil Kraepelin, a

German psychiatrist in the late nineteenth and early twentieth

century, whose description of the illness remains a guiding

force for modern investigators.

simple subtypes, with a large proportion of patients, however,

failing to clearly fit any subtype and being characterized as

having “undifferentiated” schizophrenia.

Hallucinations are very common in schizophrenia. Patients

may hear things, often voices, or they may see things;

hallucinations of taste, touch, and smell may also occur. But

of all these, the hearing of voices is most characteristic of

schizophrenia.

Schizophrenia is a relatively common disorder, with a

lifetime prevalence of about 1%. Although the overall sex

ratio is almost equal, males tend to have an earlier onset than

females, a finding accounted for by the later age of onset in

those females who lack a family history of the disease.

The voices may come from anywhere. They come from the

air; God or angels send them. They may come from the

television or radio; wiring may emanate the voices. Special

devices may be planted in the walls or furniture. Sometimes

they are in clothing; often they are localized to certain parts

of the body. They come from the bowels, the liver, from “just

behind the ear.” They may be male or female; the patient

may or may not be able to recognize the identity of the

speaker. It is a sibling, or a dead parent. Most often, though,

the voices are not recognized as belonging to anyone; they

are from strangers. They may be clear and easily understood;

sometimes they are deafening and compelling—“everything

else is shut out.” At other times they may be soft, “just a

mumbling,” indistinct and fading.

ONSET

Although most patients fall ill in late teenage or early adult

years, the range of age of onset is wide: childhood onset may

occur, and in some instances symptoms may not appear until

the sixties.

There may or may not be a prodrome before the actual onset

of symptoms. In some cases the “pre-morbid personality”

appears completely normal. In others, however, peculiarities

may have been apparent for years or even decades before the

onset. In cases where the prodrome began in childhood, the

history may reveal introversion and peculiar interests. In

cases where the prodrome began later, after the patient’s

personality was formed, family members may recall a stretch

of time wherein the patient “changed” and was no longer “the

same.” Prior interests and habits may have been abandoned

and replaced by a certain irritable seclusiveness, or perhaps

suspiciousness.

What the voices say is extremely varied: however, certain

themes are relatively common. Voices may comment on what

the patient is doing. Often two voices argue with one another

about the patient. Often the voice echoes or repeats what the

patient thought. Thoughts are “audible”; they are “heard out

loud”; they are repeated on the television.

At times “command hallucinations,” or voices that tell the

patient what to do, may be heard. At times these are

imperious and irresistible; at other times they are soft,

“suggestive only.” Sometimes they command innocuous

things; the patient may be directed to shave again. At other

times they may command the patient to commit suicide or to

hurt others. Usually the commands can be resisted, but not

always. Sometimes they are overwhelmingly compelling—

“they must be obeyed.”

The onset of symptoms per se may be acute or insidious.

Acute onsets tend to span a matter of weeks or months and

may be characterized by confusion or at times by depressive

symptoms. Patients may recognize that something is wrong,

and they may make some desperate attempts to bring some

order into the fragmenting experience of life. By contrast, in

cases with an insidious onset the patient may not be

particularly troubled at all. Over many months or a year or

more, evanescent changes may occur: fleeting whispers,

vague intimations, or strange occurrences.

The patients generally hear only short phrases, perhaps single

words. Only very rarely do the voices speak at length in a

coherent way. Often the patient is tortured by the voices.

Patients may hear threats of death, accusations of

unspeakable sins, or announcements that the gallows are

being erected.

CLINICAL FEATURES

Rarely patients are encouraged or comforted by the voices.

An angel’s voice may proclaim their divinity; seductive

voices may whisper enticement; their names may be praised.

Unutterable joys are set aside for them. Patients who hear

such voices may have a beatific countenance.

Although the clinical presentation of schizophrenia varies

widely among patients, certain signs and symptoms, though

present to different degrees, are consistently present, and

these include hallucinations, delusions, disorganized speech

and catatonic or bizarre behavior. “Negative” symptoms

(e.g., flattening of affect) are often also seen but in some

cases are quite mild. Generally, based on the constellation of

symptoms present, one may classify any given case of

schizophrenia into one of several subtypes, namely the

paranoid, catatonic, hebephrenic (“disorganized”) and

Most patients find the voices as real sounding as the voice of

any other person. They may talk back to them out loud or

may even argue with them. At times when the voices are

unpleasant, the patient may try to drown them out by

listening to music or to the television.

efforts with the local police. Plain-clothes officers follow the

patient. At times the surveillance is covert. Satellites are

used. Listening devices have been placed in the walls; the

telephone is tapped. The patient is followed by cars;

headlights blink on and off to indicate that capture is

imminent. The food is poisoned. Electrical currents are

passed through the body at night; internal organs are horribly

manipulated during sleep. Tortures are prepared; escape is

not possible. Sometimes patients may stoically endure their

persecution, and at other times they may fight back. To the

patient, this unprovoked assault may be a justifiable defense.

Other patients attempt to flee their persecutors and may move

to another state. For a time they may feel less insecure, but

eventually they see signs that they have been found and again

the persecution begins. Some patients attempt to protect

themselves against noxious influences by armoring

themselves or their apartments. One patient who believed that

persecutors sent electrical charges down through the ceiling

at night papered the entire ceiling with aluminum foil and for

a time felt protected.

In addition to hearing voices patients may also hear sounds,

such as a creaking or a rattling of chains. Footsteps or a

tapping on the windows is heard. Hissing and whistling also

may be heard. Sometimes a ringing of church bells or an

explosion is heard. Hammering means the gallows are being

constructed. Very rarely the patient may hear music.

Visual hallucinations, though common, play a relatively less

prominent part in the clinical picture of schizophrenia than do

auditory hallucinations. They may be poorly formed,

indistinct, seen only “out of the corner of the eye.” They

may, however, be vivid and compellingly realistic. Strange

people walk the halls; the devil in violent red appears in front

of the patient; heads float through the air. Reptilian forms

appear in the bath; things crawl in the food; a myriad of

insects appear in the bedding. The electric chair is made

ready; torturers approach; a chorus of sympathetic angels is

seen.

Grandiose delusions also occur frequently, often in

conjugation with delusions of persecution. Patients are

attacked by jealous enemies who seek to bar them from the

throne. They are to be exalted; the angel of the Lord has

visited them. Millions of dollars are kept secretly away from

them. They embark for Washington; the President wishes

their advice. Commonly most patients do not act on their

delusions; rather they seem content to be comforted and

sustained by them. Exceptions do occur, of course. One

patient announced a plan for world happiness in a full-page

newspaper ad; another sent a letter of advice to the Secretary

of State.

Hallucinations of smell and taste, though not common, may

be particularly compelling to the patient. Poison gas is

smelled; it seems to be coming from the heating ducts. The

patient smells putrefied flesh, so the corpses must be buried

nearby. At times inexpressibly beautiful perfumes are

appreciated, a seduction seems close at hand.

Tastes, often foul and bitter, may appear on the tongue “from

nowhere.” Often, however, something is detected in food or

drink. Patients detect something brackish, a poisonous or

medicinal taste. Patients may refuse all food and drink and

declare that they have had enough poison already.

Delusions of reference are intimately tied to delusions of

persecution or of grandeur. Here patients believe that

otherwise chance occurrences or random encounters have

special meaning for them. What was done refers to them; it

pertains to them. A busboy leaves a particle of food on the

table; it is an intentional offense to the patient. The street

lights blink on; it is a sign for the persecutors to close in for

the final attack. The television newscaster speaks in code; the

songs on the radio hold special meaning for the patient. There

are no more coincidences in life, no accidental happenings.

To the grandiose patient the events of creation are exalting;

to the persecuted patient, walking the streets can provoke a

terrifying self-consciousness. Everything is pregnant with

meaning.

Hallucinations of touch, also known as haptic or tactile

hallucinations, are relatively common. Something is crawling

on them; a pricking is coming from behind. At night all

manner of things are felt. Fluids are poured over the body; a

caressing is felt, as are lips on all parts. Electrical sensations

may be felt at any time. Sometimes patients may feel things

inside their bodies. Their intestines shrivel up; the ovaries

burst; the brain is pressed upon.

Delusions are almost universal in schizophrenia. The content

of the delusions is extremely varied: patients may feel

persecuted; they may have grandiose ideas; all manner of

things may refer and pertain to them; thoughts may be

broadcast, withdrawn, or inserted into them; they may feel

influenced and controlled by outside forces; bizarre,

loathsome events may occur. These beliefs may grow in the

patient slowly. At first there may be only an inkling, a

suspicion; only with time does conviction occur. Conversely,

sudden enlightenment may occur; all may be immediately

clear. Sometimes patients may have lingering doubts about

the truth of these beliefs, but for most they are as self-evident

as any other belief. Occasionally patients may argue with

those who disagree, but for the most part they do not press

their case on the unbeliever. Most often the delusions are

poorly coordinated with each other; typically they are

contradictory and poorly elaborated. Occasionally, however,

they may be systematized, and this is especially the case in

the paranoid subtype.

Some patients may develop some peculiarly bizarre beliefs

about thinking itself, known as thought broadcasting, thought

withdrawal, and thought insertion. In thought broadcasting

patients experience thoughts as being broadcast from their

heads, as if by electricity. “It is like radio broadcasting,”

explained one patient. These thoughts may then be picked up

by others. Some patients compare it to telepathy; some feel

they can receive others’ thoughts. “There is mind reading

going on,” commented one patient. Sometimes the television

may broadcast their thoughts back to them. In thought

withdrawal the patients’ thoughts are removed, taken from

them. The mind is left blank. “There are no thoughts

anymore,” complained one patient. Magnetic devices may be

used; the thoughts are never returned.

Patients who experience this symptom of thought withdrawal

may concurrently, if they happen to be speaking their

thoughts, display the sign known as “thought blocking.”

Here, patients in the middle of speaking abruptly cease

Delusions of persecution are particularly common. There is a

conspiracy against the patient; the FBI has coordinated its

talking, and this happens precisely because they abruptly find

themselves with no thoughts to express. In thought insertion,

a phenomenon opposite to that of thought withdrawal occurs.

Here patients experienced the insertion of thoughts into their

minds. The thoughts are alien, not their own; they were

placed there by some other agency. The thoughts are

transmitted toward them electrically; they can feel a tingling

as they enter their brain. They cannot rid themselves of them.

that meaning is private and inaccessible to the listener. When

one patient was offered a cup of coffee, the reply was, “Yes,

doctor, thank you. With bufkuf.” When asked the meaning of

“bufkuf,” the patient replied “Oh, you know,” and made no

further effort to define or explain it.

Catatonic symptoms include negativism, certain peculiar

disturbances of voluntary activity known as catalepsy,

posturing, stereotypies and echolalia or echopraxia.

Allied to the foregoing three delusions are what are known as

delusions of influence, or control. Patients experience their

thoughts, emotions, or actions to be directly controlled by

some outside force or agency. They are made to experience

or do these things; they are like robots or automatons,

without any independence of will. The influence may

emanate from the television broadcast tower; a spell may be

cast on them; a massive computer has merged its workings

into them. They are not themselves anymore.

Negativism is characterized by a mulish, automatic, almost

instinctual opposition to any course of action suggested,

demanded, or merely expected. In some cases this negativism

is passive: if food is placed in front of patients, they do not

eat; if their clothes are set out for them, they do not dress; if a

question is asked, they do not answer, and a bizarre scowl

may mar the facial expression. In more extreme cases the

negativism becomes active, and patients may do the exact

opposite of what is expected: if shown to their room, they

may enter another; if asked to open their mouths, they may

clamp shut; if asked to walk from a burning room, they may

walk back in. Such active negativism seems neither thought

out nor done for a purpose; rather it appears instinctual, as if

the patients themselves had no choice but to do the opposite.

Remarkably, in some patients one may see the exact opposite

of negativism in the symptom known as “automatic

obedience.” Here, patients do whatever they are told to do,

regardless of what it is. In the nineteenth century, one way to

test for this symptom was to tell a patient that you wished

him to stick the tongue out so that it might be pierced with a

needle. Patients would protrude their tongues and not flinch

when pierced by the needle.

Other delusions may occur. In fact any imaginable belief may

be held, no matter how fantastic. Angels live in the patient’s

nose; sulphur is cast on the body during sleep; parents have

risen from their graves; all fluids have evaporated from the

body. Another delusion is the delusion of doubles, also

known as the “Capgras phenomenon,” or the delusion of

impostors. Here the patient believes that someone, or

something, has occupied the body of another. Although the

body looks the same and the voice is the same, indeed, for all

intents and purposes, it is the same person, yet the patient

knows without doubt that it is an impostor. The patient may

see subtle signs of it elsewhere; it is part of the conspiracy.

The senses cannot be trusted anymore; appearances must be

doubted. Doubles may be used for one’s spouse or children;

no one is immune. The patient must be on guard at all times.

Catalepsy, or, as it is also known, waxy flexibility, is

characterized by a state of continual and most unusual

muscular tension. If one attempts to bend the patient’s arm, it

is as if one were bending a length of thick metal wire, like

soldering wire. Definite resistance, though not great enough

to hinder movement, is nevertheless present. The remarkable

aspect here is that, as in bending the wire, the patient retains

whatever position the limb, or for that matter, the body, is

placed in. This happens regardless of whether the patient is

instructed to maintain the position or not. In this way the

most uncomfortable, grotesque, and strenuous positions may

be maintained for hours. This symptom, rarely seen in

modern times, was common before the advent of

antipsychotic medicines in the middle of the twentieth

century. The back wards of state hospitals housed many

catatonic patients who held their bodies in positions

throughout each nursing shift, day in and day out.

Disorganized speech is the next symptom to consider. Here,

we are concerned not so much with the content of the

patient’s speech, that is to say with delusions, but rather with

the form of speech. This “formal thought disorder” is most

often characterized as “loosening of associations”; less

frequently it is referred to as incoherence or “derailment.”

The patient’s speech becomes illogical; ideas are juxtaposed

that have no conceivable connection. A family member may

say that the patient “doesn’t make sense.” At its extreme,

loosening of associations may present as a veritable “word

salad.” An example of loosening of associations follows. A

patient was asked to report the previous day’s activities; the

patient replied, in part, “The sun bestrides the mouse doctor.

In the morning, if you wish. Twenty-five dollars is a lot of

money! Large faces and eyes. Terrible smells. Rat in the

socket. Can there be darkness? Oh, if you only knew!” Here

any inner connection among the various ideas and concepts is

lost; it is as if they came at random. Or to put it another way

the thoughts are no longer “goal-directed”; they no longer

cohere in pursuit of a common purpose. If patients are

pressed to explain what they mean, they are unable to offer a

satisfactory reply. The question may be responded to, but

only with another incoherent utterance. Interestingly, also,

these patients seem little concerned about their incoherence.

They seem oblivious to it and make little if any effort to

clarify what they say.

Posturing is said to occur when the patient, for no discernible

reason, assumes and maintains a bizarre posture. One may

keep the arms cocked; another stood bent at the waist to the

side.

Stereotypies are constituted by bizarre, perseverated

behaviors. A patient may march back and forth along the

same line for hours; another may repeatedly dress and

undress. Other persons may be approached again and again,

each time being asked the same question. The same piece of

paper may be folded and unfolded until it disintegrates. Most

patients can offer no reason for their senseless activity. When

asked, a patient replied, “it must be so.”

Allied to loosening of associations are neologisms. These are

words that occur in the normal course of the patient’s speech

and that the patient treats as an integral part of it, but that

convey no more meaning to the listener than if they were

from a long-dead foreign language. To the patient, however,

they have as much meaning and status as any other word, but

Echolalia and echopraxia are said to occur when the patient’s

behavior mirrors that of the other person, and, importantly,

when this happens automatically, and in the absence of any

request. If asked a question the echolalic patient will simply

repeat it, sometimes over and over again. The echopraxic

patient may clumsily mirror the gestures and posture of the

interviewer and, as in echolalia, may continue to do this long

after the other person has left, as if uncontrollably compelled

to maintain the same activity. Here it as if the ability to will

something independent of the environment has been lost, and

the patient is thus left enslaved in a mimicry of whatever is

close at hand.

Negative symptoms include flattening of affect, alogia (also

commonly known as poverty of speech and thought), and

avolition.

Flattening of affect, also known, when less severe, as

“blunting” of affect, is characterized by a lifeless and wooden

facial expression accompanied by an absence or diminution

of all feelings. This is quite different from a depressed

appearance. In depression patients appear drained or

weighted down; there is a definite sense of something there.

In flattening, however, patients seem to have nothing to

express; they are simply devoid of emotion. They appear

unmoved, wooden, and almost at times as if they were

machines.

Bizarre behavior may manifest as mannerisms, bizarre affect

or an overall disorganization and deterioration of behavior.

Mannerisms are bizarre or odd caricatures of gestures,

speech, or behavior. In manneristic gesturing patients may

offer their hands to shake with the fingers splayed out, or the

fingers may writhe in a peculiar, contorted way. In

manneristic speech, cadence, modulation, or volume are

erratic and dysmodulated. One patient may speak in a sing-

song voice, another in a telegraphic style, and yet another

with pompous accenting of random syllables. Overall

behavior may become manneristic. Rather than walking,

some patients may march in bizarre, stiff-legged fashion.

Poverty of speech is said to occur when patients, though

perhaps talking a normal amount, seem to “say” very little.

There is a dearth of meaningful content to what they say and

speech is often composed of stock phrases and repetitions.

Poverty of thought is characterized by a far-reaching

impoverishment of the entire thinking of the patient. The

patient may complain of having “no thoughts,” that “the head

is empty,” that there are no “stirrings.” Of its own accord

nothing “comes to mind.” If pressed by a question the patient

may offer a sparse reply, then fail to say anything else.

Bizarre affect appears to represent a distortion of the normal

connection between felt emotion and affective expression.

Often, facial expression appears theatrical, wooden, or under

a peculiar constraint. Patients may report feeling joy, yet the

rapturous facial expression may appear brittle and tenuous.

Conversely patients may report grief, and indeed tears may

be present, yet the emotion lacks depth, as if patients were

merely wearing a mask of grief that might disappear at any

moment. Inappropriate affect may also be seen. Here the

connection between the patient’s ideas and affect seems

completely severed. A young patient, grief stricken at a

parent’s funeral, was seen to snicker; another patient, relating

the infernal tortures suffered just the night before, smiled

beatifically.

Avolition, referred to by Kraepelin as “annihilation of the

will,” is said to be present when patients have lost the

capacity to embark on almost any goal-directed activity. Bills

are not paid; the house is not cleaned; infants are neither

changed nor fed. This is not because patients feel inhibited,

lack interest, or suffer from fatigue, but rather because the

ability to will an action has become deficient.

Before leaving this discussion of the individual signs and

symptoms of schizophrenia and proceeding to a discussion of

subtypes, two other symptoms, neither of which fit neatly

into the categories employed above, should be mentioned,

namely ambivalence and “double bookkeeping.”

Another, very important form of bizarre affect is unprovoked

and mirthless laughter. For no apparent reason patients may

break into bizarre and unrestrainable laughter. Though

appearing neither happy nor amused, the laughter continues.

Some patients report that they were unable to not laugh, that

the laughter moved itself no matter how they felt.

Ambivalence may render patients incapable of almost any

volitional activity. Here, patients experience two opposed

courses of action at the same time, and for lack of ability to

decide between them, do nothing. One patient stood at the

washstand for hours unable to decide whether to shave or to

use the toothbrush. This “paralysis of will,” however, may at

times be easily removed if another person gives directions. In

this case an aide simply told the patient to brush his teeth and

then put the toothbrush in the patient’s hand. Immediately

and with peculiar alacrity the patient then set to brushing his

teeth. This kind of ambivalence found in schizophrenia is to

be distinguished from the indecisiveness seen at times in

depression and the “normal” ambivalence that anyone may

experience. The depressed patient’s inability to embark on

decision-making stems more from a lack of energy and

initiative; unlike the patient with schizophrenia, the

depressed patient generally is not able to act when others

make the decision. In normal circumstances competing

desires may leave the patient unable to decide. With time,

however, a normal person makes a decision because the

capacity to do so is not lost. In schizophrenia, however, it is

this very capacity that is no longer present.

The overall deterioration of behavior in schizophrenia is what

often makes these patients “stand out” in public. Patients

become untidy and may neglect to bathe or wash their

clothes; the fingernails may become very long. Dress and

grooming may become bizarre. Several layers of clothing are

often worn, even during the summer. Bits of string or cloth

may festoon the patient’s hair or garments; makeup may be

smeared on. Not uncommonly, paranoid patients shave their

heads, and this often reliably predicts an oncoming

exacerbation of illness, and also some form of self-

mutilation. Patients may pluck out their eyelashes or cut deep

gouges in their legs. Some seem to be almost completely

analgesic: an eye may be plucked out; pieces of flesh may be

bitten off; in extreme cases, self-evisceration may occur,

“just to see” what the intestines look like. Although most

often no purpose seems to drive this bizarre behavior, at

times the patient may offer a reason. One patient wallpapered

the walls, ceiling, and floors with aluminum foil “to keep the

rays out”; another kept cotton in the ears “to keep the voices

away.”

“Double bookkeeping,” a phenomenon first identified by

Bleuler, refers to the patient’s ability to, as it were, live in

two worlds at the same time. On the one hand is the world of

voices, visions, and delusions, and on the other hand, and

quite coincident with this psychotic world, is the world as

perceived by others. To the patient both worlds seem quite

real. For example, a patient may hear a voice as clearly as the

voice of the physician and believe it just as real, yet at the

same time acknowledge that the physician does not hear it.

Or the grandiose patient who fully believed that a coronation

was imminent may yet continue to work at a janitor’s job and

go on doing so, living in two worlds, and feeling little if any

conflict between them. A variant of double bookkeeping,

known as “double orientation,” or “delusional

disorientation,” may at times mislead the interviewer into

thinking that the patient is disoriented. For example, a

grandiose patient believed that he was John F. Kennedy, and

when asked what year it was replied 1962. Later on,

however, when filling out a form, he put down the correct

year.

negativism, mutism, posturing, and waxy flexibility. One

patient curled into a rigid ball and lay on the bed, unspeaking,

for days, moving neither for defecation nor urination, and

catheterization was eventually required. Saliva drooled from

the mouth, and as there was no chewing, food simply lay in

the oral cavity and there was danger of aspiration. Another

patient stood praying in a corner, mumbling very softly. A

degree of waxy flexibility was present, and the patient’s arm

would, for a time, remain in any position it was placed, only

eventually to slowly return to the position of prayer.

In the excited form of catatonia one may see purposeless,

senseless, frenzied activity, multiple stereotypies, and at

times extreme impulsivity. Patients may scream, howl, beat

their sides repeatedly, jump up, hop about, or skitter back and

forth. A patient leaped up and attacked a bystander for no

reason, then immediately returned to a corner and restlessly

marched in place, squeaking loudly. Often speech is

extremely stereotyped and bizarre. Patients may shout,

declaim, preach, and pontificate in an incoherent fashion.

Words and phrases may be repeated hundreds of times.

Typically, despite their extreme activity, these patients

remain for the most part withdrawn. They often make little or

no effort to interact with others; they keep their excitation to

themselves, perhaps in a corner, perhaps under a bed. Rarely

Stauder’s lethal catatonia may occur. Here, as the excitation

mounts over days or weeks, autonomic changes occur with

hyperpyrexia, followed by coma and cardiovascular collapse.

Subtypes of schizophrenia are characterized by particular

constellations of symptoms and include the following:

paranoid, catatonic, hebephrenic (or “disorganized”), and

simple (which has also been referred to as “simple

deteriorative disorder”). Patients whose illness does not fall

into any of these subtypes are said to have an

“undifferentiated” subtype. Subtype diagnosing is not an

academic exercise, for, as discussed under Course, the

different subtypes may have different prognoses.

Furthermore, knowing the subtype allows one to predict with

better confidence how any given patient might react in any

specific situation.

Although some patients with catatonic schizophrenia may

display only one of these two forms, in most cases they are

seen to alternate in the same patient. In some cases a form

may last days, weeks, or longer, before passing through to the

other. In other cases, however, a rapid and unpredictable

oscillation from one form to another may occur. A stuporous

patient suddenly, without warning, jumped from his bed,

screamed incoherently, and paced agitatedly from one wall of

the room to another. Then, in less than an hour, the patient

again rapidly fell into mute immobility.

Paranoid schizophrenia , which tends to have a later onset

than the other subtypes, is characterized primarily by

hallucinations and delusions. Other symptoms, such as

loosening of associations, bizarre behavior, or flattened or

inappropriate affect, are either absent or relatively minor. The

hallucinations are generally auditory and typically hostile or

threatening. The delusions are generally persecutory and

referential. Voices warn patients that their supervisors plot

against them. They begin to suspect that their co-workers talk

about them behind their backs and laugh quietly as they pass

by. Newspaper headlines pertain to them; the CIA is

involved; meal portions at the factory cafeteria are secretly

poisoned, and patients may refuse to eat at work. At times

these patients may appeal to the police for help, or they may

suffer their slights in rigid silence. Their attitude becomes

one of intense, constrained anger and suspiciousness.

Occasionally they may move away to escape their

persecutors, yet eventually they are “followed.” At times they

may turn on their supposed attackers, and violent outbursts

may be seen.

Hebephrenic schizophrenia tends to have an earlier onset

than the other subtypes and tends to develop very insidiously.

Although delusions and hallucinations are present, they are

relatively minor, and the clinical picture is dominated by

bizarre behavior, loosened associations, and bizarre and

inappropriate affect. Overall the behavior of these patients

seems at times a caricature of childish silliness. Senselessly

they may busy themselves first with this, then with that,

generally to no purpose, and often with silly, shallow

laughter. At other times they may be withdrawn and

inaccessible. Delusions, when they occur, are unsystematized

and often hypochondriacal in nature. Some may display very

marked loosening of associations to the point of a fatuous,

almost driveling incoherence.

In paranoid schizophrenia, more so than in the other

subtypes, the delusions may be somewhat systematized, even

plausible. In most cases, however, inconsistencies appear,

which, however, have no impact on the patients. Often, along

with persecutory delusions, one may also see some grandiose

delusions. Patients believe themselves persecuted not for a

trivial reason; others now know that the patient recently

acquired a controlling interest in the company. Rarely,

grandiose delusions may be more prominent than persecutory

ones and may dominate the entire clinical picture. A patient

may believe herself anointed with holy oil; trumpets blared

forth her appearance as a prophet. She has a message that

will save the world, and sets about spreading it.

Simple schizophrenia has perhaps the earliest age of onset,

often first beginning in childhood, and shows very gradual

and insidious progression over many years. Delusions,

hallucinations, and loosening of associations are sparse, and

indeed are for the most part absent. Rather the clinical picture

is dominated by the annihilation of the will, impoverishment

of thought, and flattening of affect. Gradually over the years

these patients fall away from their former goals and often

become cold and distant with their former acquaintances.

They may appear shiftless, and some are accused of laziness.

Few thoughts disturb their days, and they may seem quite

content to lie in bed or sit in a darkened room all day.

Occasionally some bizarre behavior or a fragmentary

Catatonic schizophrenia manifests in one of two forms:

stuporous catatonia or excited catatonia. In the stuporous

form one sees varying combinations of immobility,

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