Second edition

20.qxd 3/10/08 9:58 AM Page 609
of string or cloth may festoon jackets or shirts. Patients may
cut off their eyebrows or make deep gashes in their arms or
legs. Some seem almost analgesic: one patient bit out part of
his biceps muscle; another eviscerated himself, ‘just to see’
what was inside. In some cases the bizarre behavior may be
in response to delusions, as, for example, when a patient
wrapped his legs in aluminum foil to ‘keep the bugs off’.
NEGATIVE SYMPTOMS
‘Negative’, or ‘defect’, symptoms (Andreasen 1982;
Andreasen and Olson 1982; Andreasen et al. 1990a)
include flattening of affect, poverty of thought or speech,
and avolition.
Flattening of affect, also known as mere ‘blunting’ of
affect when less severe, is, as discussed further in Section
4.25, characterized by a lifeless and wooden facial expression
accompanied by a corresponding dearth or diminution
of all feelings.
Poverty of speech and poverty of thought are often
referred to collectively as ‘alogia’. Poverty of speech is said
to be present when patients, although speaking a normal
amount, seem to ‘say’ very little; there is a dearth of meaningful
content and speech is often composed of stock
phrases. In poverty of thought, by contrast, patients speak
little, essentially because there is a wide-ranging and farreaching
impoverishment of their entire thinking; patients
may complain that their heads are ‘empty’ and that, simply,
nothing comes to mind; there are no stirrings.
Avolition, referred to by Kraepelin as ‘annihilation of
the will’, is allied to poverty of thought in that avolitional
patients simply do not experience any impulses, desires,
stirrings or inclinations; if left undisturbed they may spend
hours or days in quietude, doing nothing.
MISCELLANEOUS SYMPTOMS
Of the miscellaneous symptoms seen in schizophrenia, perhaps
the most important are transient disturbances of
mood, which may tend toward depression, mania, or anxiety.
Patients may complain of depressive symptoms, such as
feeling depressed, being tired or having trouble sleeping;
some may demonstrate some euphoria and increased energy
and talkativeness, whereas others may complain of feeling
anxious and tremulous. Indeed, at first glance these symptoms
may seem to dominate the clinical picture; however,
on a closer and wider look one finds that they are transient,
lasting only hours or days, are mild overall, and, relative to
other symptoms, such as hallucinations and delusions, play
only a very minor role in the overall clinical picture.
Agitation may also be seen, and this may occur either as a
non-specific part of an exacerbation of the disease or as a
reaction to delusions of persecution or threatening voices.
SUBTYPES
Classifying patients as to subtype is useful not only because
the various subtypes pursue different courses with different
20.1 Schizophrenia 609
prognoses, as noted further below, but also because knowledge
of a patient’s subtype diagnosis may allow the clinician
to predict how the patient will act in any given situation.
After discussing the paranoid, catatonic, disorganized,
simple, and undifferentiated subtypes of schizophrenia,
some comments will also be offered on an alternative
mode of subdividing schizophrenia, namely into ‘reactive’
and ‘process’ types.
Paranoid schizophrenia tends to have a somewhat later
onset, sometimes as late as in middle years, and is characterized
primarily by hallucinations and delusions; disorganized
speech, catatonic or bizarre behavior, and
negative symptoms are either absent or relatively minor.
Hallucinations are generally auditory and delusions are
generally of persecution and reference. In paranoid schizophrenia,
more so than in any other subtype, the delusions
tend to be systematized and, on first glance, even plausible.
Voices may warn patients that their supervisors are plotting
against them. Patients may begin to suspect that people are
talking about them, perhaps laughing at them behind their
backs. Newspaper headlines pertain to them; the CIA may
be involved or perhaps the FBI. At times patients may
appeal to the authorities for help, but often they suffer their
persecutions in rigid silence; occasionally they may try to
escape, perhaps by moving to another area, or they may
turn on their supposed attackers, sometimes violently.
Often, allied with delusions of persecution, there may also
be delusions of grandeur. Patients believe that they are
being persecuted not for some trivial reason; they suspect
that others know that they have developed great inventions.
Rarely, grandiose delusions may be more prominent than
persecutory ones, and they may even dominate the clinical
picture. One patient believed himself to be the anointed of
God; he heard trumpets proclaiming his advent and was
prepared to announce himself to the world.
Catatonic schizophrenia, as the name obviously indicates,
is dominated by catatonic symptoms. As described in
Section 3.11, catatonia occurs in both stuporous and
excited forms and, although some patients with catatonic
schizophrenia may demonstrate only one form throughout
the course of the illness, in most cases, as noted earlier,
these two forms are seen to alternate in the same patient.
The duration of these forms is quite variable, ranging from
hours on one extreme to months or years on the other. The
transition from one form to another may be quite unpredictable
and, at times, quite sudden; in one case a chronically
stuporous patient, without any warning, suddenly
jumped from his bed, screamed incoherently, and paced
agitatedly from one wall to another, only to lapse into
immobility and muteness an hour later.
Disorganized schizophrenia, also known classically as
hebephrenic schizophrenia, tends to have an earlier onset
than the other subtypes and to develop very slowly.
Although hallucinations and delusions are present, they
generally play a minor role and the clinical picture is dominated
by disorganized speech and bizarre behavior. Overall,
the behavior of these patients seems at times to represent a