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psychic functions is an outstanding
feature of the whole group". He
was not referring to a split per-
sonality in the sense of "Jekyll and
Hyde" in fiction, or multiple
personalities, such as "The Four
Faces of Eve", but to a split bet-
ween emotions and thought
content. A gross example of this
would be the patient who com-
plains that a malign force is
directing atomic rays at him from
outer space in mildly aggrieved
tones to a doctor instead of in more
dramatic fashion to the appropriate
authority.
Bleuler argued that all the
characteristics could be interpreted
in terms of fundamental disorders
of affect, that is emotion, and
thinking. Patients with schizo-
phrenia show emotional flattening
and a thought disorder based on
loosening of associations. Other
characteristics, such as delusions
and hallucinations, were regarded
by him as secondary.
In more recent times specific
criteria for the diagnosis of schizo-
phrenia have been laid down in
official systems of nomenclature.
The best known and probably most
widely accepted for research
purposes is that of the American
Psychiatric Association in its
Diagnostic and Statistical Manual
of Mental Disorders, usually
referred to as "D.S.M.3".
Recognition & Diagnosis
Little is known about the causes of
schizophrenia and in our present
state of knowledge our criteria for
diagnosis can only be the
occurrence of certain typical
clinical features. Kurt Schneider
made the most influential attempt
at a phenomenological definition by
describing a number of symptoms
which he regarded as being of
"first rank" importance in dif-
ferentiating schizophrenia from
other conditions.
He maintained that in the ab-
sence of epilepsy, drug intoxication
or gross cerebral damage, these
symptoms most frequently corre-
lated with a diagnosis of schizo-
phrenia. These "first rank"
symptoms are:
(a) Auditory hallucinations of a
specific type. They may be
audible thoughts, voices
repeating or anticipating the
patient's thoughts out loud,
two or more voices discussing
the patient in the third person
or voices commenting on the
patient's behaviour.
(b) Thought disorders of a
specific type, that is thought
withdrawal, or thought in-
sertion by some external
agency, thought broadcast-
ing, so that the thoughts are
conveyed to others.
(c) Feelings, impulses or acts
experienced as under external
control are also regarded as
first rank symptoms.
Typically thought insertion is
described by the patient in terms of
. . . in our present stete of
knowl edge our criterie for
d i egnos is c en only be the
occurrence of certein typical
clinical features."
some causal idea, such as a radio
implanted in the brain or rays
directed from another planet or
telepathy. Delusions of control are
often elaborated, the patient
believing that someone else's
words are coming out using his
voice or that his hand writing is not
his own, or that he is a zombie or
a robot, as every movement is
determined by some alien power.
Schizophrenia manifests itself in
various forms. It often starts with
an acute episode, although there
may have been premonitory sym-
ptoms, for example social with-
drawal, undue introspection, over-
sensitivity and so on. As the
patient becomes more acutely ill he
may manifest delusions, hear
voices and show the "first rank"
symptoms mentioned above. With
treatment, or even as a normal
progression of the illness, these
symptoms may abate but the
chronic condition may ensue.
There are two main groups of
chronic symptoms whichmay be of
varying degrees of severity from
mild to crippling. The first is a
syndrome of negative traits, such
as emotional apathy, slowness of
thought and movement, under-
activity, lack of drive, poverty of
speech and social withdrawal.
These obviously severely impair the
patient's functioning and present
obstacles to rehabilitation.
The second group of intrinsic
impairments can be even more
severely disabling. There may be
incoherence of speech and unpre-
dictability of associations, long
standing delusions and hallucina-
tions, with accompanying mani-
festations and behaviour. The
individual does not seemto be able
to think to a purpose but goes off
at a tangent owing to some un-
usual associations to a chance
stimulus and thus gives the
impression of vagueness, con-
fusion and incoherence. Occasion-
ally this may give the impression of
creativity but usually the syndrome
is constricting and handicapping.
Most of the creative people who
have been afflicted with schizo-
phrenia have had their creativity
diminished, not enhanced.
There is always a liability to
further relapse with acute sym-
ptoms of the kind that we have
considered already. Once an attack
has occurred there remains a
definite vulnerability to further
breakdowns of a similar kind.
Nevertheless, about half of the
people first admitted to hospital
with clearcut acute schizophrenic
syndrome suffer no further relapse
over the following five years. In
about a quarter of the cases there
is a relapsing course and in the
remaining quarter a condition of
chronic disablement is reached.
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