CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 9PSYCHOPATHOLOGYIPSIT V. VAHIACARL I. COHENOver the course of the last century the conceptualization of schizophrenia has beensubject to considerable debate. Unlike most disorders in medicine, no known pathophysiologicalmechanism can be linked to the symptoms of schizophrenia. This means that thediagnosis and symptoms of schizophrenia must be based on observations, verbal reports,and inferences, thereby making it more difficult to reach a consensus about how to conceptualizeand define it. Thus, in this chapter, although we focus primarily on the symptomsof schizophrenia, we also illustrate how the cluster of symptoms thought to be associatedwith schizophrenia is dependent on how the disorder is conceptualized. These conceptsremain in flux and have been influenced by historical, social, and cultural tendencies.HISTORICAL BACKGROUNDEarly DevelopmentsSchizophrenia as a distinct clinical entity has existed for slightly over 100 years. Prior tothat time, the existence of schizophrenia could only be inferred from case descriptions by17th- and 18th-century physicians, such as those of Philippe Pinel and John Haslam. ÉmilKraepelin (1856–1926) and Eugen Bleuler (1857–1939) have been recognized for establishingthe modern foundation for the concept of schizophrenia. Their primary contributionwas to bring unity to variety of overlapping symptom clusters by indicating whichsymptoms must be present to confirm the diagnosis. Although Karl Kahlbaum had proposeda longitudinal approach to schizophrenia prior to Kraepelin, it was Kraepelin’s insightthat a variety of psychotic entities could be combined into a single entity consistingof hebephrenia, paranoid deterioration, and catatonia subtypes. He used the term dementiapraecox (translated from the term demence precoce coined by French psychiatristBenedict Morel) to describe what he perceived as a deterioration process (dementia) withpremature onset. Whatever the subtype, Kraepelin regarded the following symptoms ascharacteristic of dementia praecox: hallucinations, usually of an auditory or tactile form;decreased attention to the outside world; lack of curiosity; disorders of thought, especiallyof the Zarfahrenheit (scatter) type, with unusual and partly comprehensible associ-82