Second edition

Idiopathic psychotic, mood, and anxiety disorders
20.1 Schizophrenia 606
20.2 Schizoaffective disorder 614
20.3 Delusional disorder 615
20.4 Post-partum psychosis 617
20.5 Bipolar disorder 618
20.6 Major depressive disorder 624
20.7 Premenstrual dysphoric disorder 629
20.8 Post-partum depression 630
20.9 Post-partum blues 631
20.1 SCHIZOPHRENIA
Schizophrenia is a chronic, more or less debilitating psychosis
that occurs in about 1 percent of the general population
and which is equally common in males and females.
This illness was first noted by Morel in 1860 (Anonymous
1954), who referred to it as démence précoce. A full description
of the disease, however, had to await the efforts of Emil
Kraepelin. Kraepelin, who latinized the name to dementia
praecox, was a German psychiatrist of the late nineteenth
and early twentieth centuries, whose work remains a guiding
force for modern psychiatry. The current name for the
disease, schizophrenia, was coined by Eugen Bleuler, a
Swiss psychiatrist who amplified Kraepelin’s original
descriptions. Another guiding light in the elucidation of the
disease was the German psychiatrist Kurt Schneider, who
isolated certain symptoms, now known as Schneiderian
first rank symptoms, which, although not pathognomonic
of the disease, are very, very suggestive.
Clinical features
The age of onset of schizophrenia, although generally
falling in the late teens or early twenties, may range from
late childhood to the seventh decade (Brodaty et al. 1999;
Grahame 1984). A prodrome may or may not be present; in
some cases the premorbid personality may have been completely
normal, whereas in others, peculiarities may have
been present for years or even decades (Walker and Lewine
1990). In cases in which the prodrome begins in childhood,
history may reveal introversion and peculiar interests. In
cases in which the prodrome appears in teenage years or
later, well after the patient’s personality has formed, family
20
20.10 Panic disorder 631
20.11 Agoraphobia 634
20.12 Specific (simple) phobia 635
20.13 Social phobia 636
20.14 Obsessive–compulsive disorder 638
20.15 Post-traumatic stress disorder 639
20.16 Generalized anxiety disorder 641
References 643
members may recall a stretch of time when the patient
‘changed’ and was no longer ‘himself’; prior interests and
hobbies may have been abandoned and replaced by a certain
irritable seclusiveness or perhaps suspiciousness.
The mode of onset ranges from acute to gradual. Acute
onsets occur over weeks or months and may be initially
marked by perplexity or depressive symptoms; patients
may recognize that something is going wrong, and some
may make desperate attempts to bring order and structure
into a life that is rapidly fragmenting. By contrast, gradual
onsets, which may span months or a year or more, may not
be particularly disturbing to the patient; there may be fleeting,
whispering auditory hallucinations, vague intimations,
or strange occurrences.
Although the symptomatology of schizophrenia may be
quite varied, in most cases one sees hallucinations, delusions,
disorganized speech, and catatonic or bizarre behavior.
Negative symptoms (e.g., flattening of affect) are also often
seen and, as with all typologies, there is also a category of miscellaneous
symptoms, the most important of which is transient
disturbances of mood. Generally, based on the overall
constellation of symptoms, one may classify any given case of
schizophrenia into one of several subtypes, namely paranoid,
catatonic, disorganized (also known as hebephrenic), or simple
schizophrenia; in a large minority, however, there
appears to be a mixture of these subtypes, and in such cases
one speaks of ‘undifferentiated’ schizophrenia. Each of these
symptoms and subtypes is now considered in some detail.
HALLUCINATIONS
Hallucinations may occur in the auditory, visual, gustatory,
olfactory, and tactile realms (Mueser et al. 1990).