CLINICAL HANDBOOK OF SCHIZOPHRENIA

9. Psychopathology 87or “loose associations”); answers to questions may be obliquely related or completely unrelated(“tangentiality”); and, rarely, speech may be so severely disorganized that it isnearly incomprehensible and resembles receptive aphasia in its linguistic disorganization(“incoherence” or “word salad”). Since mild disorganization of speech is common, thedisorganization in schizophrenia should be sufficiently severe to impair meaningful communication.DISORGANIZATION OF BEHAVIORAccording to DSM-IV-TR,Grossly disorganized behavior may manifest itself in a variety of ways, ranging from childlikesilliness to unpredictable agitation. Problems may be noted in any form of goal-directedbehavior, leading to difficulties in performing activities of daily living such as preparing ameal or maintaining hygiene. The person may appear markedly disheveled, may dress in anunusual manner (e.g., wearing multiple overcoats, scarves, and gloves on a hot day), or maydisplay clearly inappropriate sexual behavior (e.g., public masturbation) or unpredictableand untriggered agitation (e.g., shouting or swearing). (American Psychiatric Association,2000, p. 300)The manual also stresses the importance of clinical discretion in determining this. Milddisorganization of behavior may be present in a variety of clinical disorders, and as in thecase of thought disorganization, the importance of severity is emphasized.CATATONIA AND MOTOR SYMPTOMSAccording to DSM-IV-TR,Catatonic motor behaviors include a marked decrease in reactivity to the environment,sometimes reaching an extreme degree of complete unawareness (catatonic stupor), maintaininga rigid posture and resisting efforts to be moved (catatonic rigidity), active resistanceto instructions or attempts to be moved (catatonic negativism), the assumption ofinappropriate or bizarre postures (catatonic posturing), or purposeless and unstimulatedexcessive motor activity (catatonic excitement). (American Psychiatric Association, 2000,p. 300)Abnormalities of psychomotor activity such as pacing, rocking, apathetic immobility,or other stereotyped movements are also common in patients with schizophrenia. Grimacing,posturing, and odd ritualistic movements are often noted. Motor abnormalitiesare associated with the catatonic subtype of schizophrenia.Negative SymptomsThree negative symptoms—affective flattening, alogia, and avolition—are included in thedefinition of schizophrenia in DSM-IV-TR.• Affective flattening, described by DSM-IV-TR as being especially common, ischaracterized by facial immobility and unresponsiveness, with poor eye contact and reducedbody language. Although a person with affective flattening may smile and warmup occasionally, his or her range of emotional expressiveness is clearly diminished most ofthe time. DSM-IV-TR recommends observation of a person over a period of time, as wellas in interactions outside those with the clinician, to determine presence of affective flat-