CLINICAL HANDBOOK OF SCHIZOPHRENIA

9. Psychopathology 83ations; changes of speech resulting from the thought disorder, such as incoherence; lackof insight and judgment; delusions; emotional blunting; negativism; and stereotypy. Thesesymptoms had to occur in the presence of a clear consciousness. Kraepelin’s description isimportant because it has historically shaped the way schizophrenia is conceptualized.Many of his symptom descriptions and schizophrenia subtypes have served as a foundationfor Diagnostic and Statistical Manual of Mental Disorders (DSM) and InternationalClassification of Diseases (ICD) descriptors and classification. One of the essential elementsof Kraepelin’s nosology was the association between symptomatology and a poorprognosis, although it is often forgotten that he did recognize that recovery, albeit rare,could occur with the disorder.In his original work, Eugen Bleuler used the phrase group of schizophrenias as synonymouswith dementia praecox. One of Bleuler’s aims was to apply Freud’s ideas to reexaminethe psychopathology in the disorder. Although the term schizophrenia did not carry thesame negative prognosis as dementia praecox, Bleuler indicated that restitution of functiondid not occur. Bleuler viewed schizophrenia as a splitting of psychic functions. Thus, psychiccomplexes did not combine in a unified form, as in healthy persons. Rather, the personalityseemed to lose its unity, so that different ideas and drives were split off. For example, processesof association became mere fragments of ideas and concepts, thinking stopped in themiddle of a thought, and the intensity of emotional reactions was not consistent with thevarious events that caused the reaction (i.e., an excessive or inadequate response).Bleuler’s main contribution was his effort to separate the “primary” or core symptomsof schizophrenia (i.e., those related to the splitting) from “secondary” symptoms, whichrepresented psychological reactions to the primary symptoms. The primary symptoms compriseddisturbances in association, thought disorder, changes in affectivity, a tendency toprefer fantasy to reality and to seclude oneself from reality, and autism. Secondary symptomsincluded hallucinations, delusions, catatonic symptoms, and various behavioral abnormalities.In response to those conceptions of schizophrenia that were etiologically driven,Kurt Schneider (1887–1967) proposed to define schizophrenia in purely symptomaticterms. Like Karl Jaspers (1883–1969), he championed diagnosis based on the form ratherthan the content of a sign or symptom. For example, he maintained that delusions shouldnot be diagnosed by the content of the belief, but by the way in which a belief is held. Hedistinguished “first-rank” symptoms, which, rather than being conceived in any theoreticalway, were seen as being primary or basic symptoms (i.e., of greatest diagnostic importance).His classification scheme played a strong role in the formation of DSM-III andICD classifications. Schneider’s first-rank symptoms may be summarized as follows:• Special auditory hallucinations. This includes hearing one’s own thoughts echoedby the voices, hearing two or more voices arguing or discussing a topic, or a voicecommenting on the person’s activities as they occur.• Special delusions. This two-stage phenomenon comprises a normal perception followedby a delusional interpretation of it as having a special and highly personalizedsignificance.• Passivity experiences. These include somatic passivity or sensations imposed by anoutside agency passivity of affect or emotions imposed by an external agency thatare not the person’s own, passivity of impulse or wishes that are not the person’sown, and passivity of volition, in which a person’s motor activity is controlled byan external agency.• Alienation of thought. This includes thought withdrawal, thought insertion, andthought broadcasting.