SCHIZOPHRENIA. The symptoms that characterise schizophrenia cause dysfunctions in various basic areas of psychological functioning: thought, perception and attention, motor behaviour, an individual’s emotional state and various other spheres of the patient’s existence. The range of problems encountered by a patient diagnosed with schizophrenia can be quite extensive, although typically such patients present with only some of these problems. The DSM-IV-TR describes three types of schizophrenia, which correspond with the different sets of symptoms generally found in these patients. These are the Disorganised, Catatonic and Paranoid Schizophrenia types. As the effects of the disorder are so varied and fall within a broad spectrum of mental states, it was also necessary to further subdivide its symptoms into what are referred to as the ‘positive’ and ‘negative’ types. A further, ‘mixed’ category comprises presentations and effects that cannot be easily assigned to either of these two areas.

The positive symptoms include profound disruptions in cognition, emotion and behaviour, such as disorganized speech, hallucinations, bizarre behaviour and delusions. Disorganized speech - also referred to as formal thought disorder (FTD) - refers to the incapacity to organize ideas and speak in a manner that will allow a person listening to comprehend what the patient is saying. The speech of a schizophrenic is incoherent, fragments of thought and images are disconnected and it is difficult to understand exactly what the person wants to communicate. A schizophrenic’s speech is sometimes characterised by a loosening or loss of associative links or derailment and therefore the person is incapable of remaining focused on a single topic. He or she will be constantly drifting here and there in the wake of a series of associations perhaps evoked by an idea from the past. Schizophrenic patients often refer that to some extent the world seems ‘different’ to them or even unreal. Some patients suffering from this disorder speak in terms of changes in the way they ‘feel’ their body: the phenomenon of depersonalization (see Dissociative Disorders) can be so strong that the individual’s body is even perceived as if it were a machine.

The most dramatic distortions in the way a schizophrenic sees and experiences the world take place in the form of hallucinations and sensory phenomena occurring in the absence of any related environmental stimulus. Hallucinations of the auditory type are much more frequent than those of the visual type. The most common auditory hallucinations are those in which a voice can be heard repeating the patient’s thoughts or those in which the individual can hear voices arguing with each other. Delusions are convictions which contradict the substance of reality. Schizophrenics may suffer from this anomaly as they are not conscious of their condition. They seem totally oblivious to what is happening to them or around them and they believe that it is all quite normal (Amador et al., 1994). They may be convinced that they have fallen prey to some external agent that causes them to experience certain sensations or that their thoughts may be broadcast or can emanate outwards and that other people can become aware of this.

The negative symptoms include behavioural deficits such as avolition and abulia (an impairment of the will or ability to perform voluntary actions or make decisions and a marked reduction in emotional reactivity and speech), alogia (complete absence of speech), anhedonia (the inability to experience pleasure), the flattening of affectivity and asocial behaviour. Abulia - or apathy - is generally characterised by a lack of energy and an apparent lack of interest in what would be seen as customary day-to-day activities. Schizophrenic patients neglect their attire and personal cleanliness, their hair will be left uncombed, their finger nails dirty and their teeth not cleaned. They also reveal great difficulty in carrying out occupational, scholastic or domestic activities and spend much of their time sitting around doing absolutely nothing. Alogia is a ‘negative’ language disorder that can assume various forms. When there is poverty of speech, the quantity of language produced is greatly reduced. When patients present poverty of content, the quantity of speech may be adequate but little information is conveyed and this will tend to be vague and repetitive. Anhedonia is a loss of interest in the world or a restricted capacity to experience pleasure. The condition manifests as a lack of interest in recreational activities, an incapacity to develop close relationships with people and an absence of interest in sexual activities.

Schizophrenics that present affective flattening react to practically no external stimuli. Their look and gaze are empty, their facial muscles totally inexpressive and their eyes convey the sensation of lifelessness. When someone speaks to them, they respond with a dull, colourless tone of voice. The concept of a dulling or flattening of affectivity however refers only to the external expression of the emotions and not to the patient’s internal experiences, which sometimes may not be impoverished at all. Some schizophrenic patients also present a severe impairment of their social relations: these types will tend to have few friends, mediocre social skills and show very little interest in being with other people.

Disorganized Schizophrenia is characterised by disorganized speech, which makes it difficult for a listener to follow the patient’s ideas and train of thought. The patient may invent new words, may laugh for no apparent reason or suddenly start crying. His or her behaviour will be generally disorganized and reveal no distinct purpose. For example, such patients may tie a ribbon around their big toe or move incessantly, pointing at objects for no apparent reason. Nor do they bother about their appearance in any way at all: they do not wash, comb their hair or clean their teeth.

In Catatonic Schizophrenia the most evident symptoms are those pertaining to the sphere of motor activity. Catatonic patients present alternating states of physical immobility and episodes of extreme excitement and agitation but the motor symptoms of one or the other state may predominate. Catatonic subjects moreover resist acting when they are given instructions and orders and often repeat (echolalia) a word or a sentence which another person has just said. The limbs of a catatonic patient in a state of immobility may present rigidity and swelling. Despite an apparent state of total oblivion, the  patient will sometimes be able to refer everything that happened during an episode of catatonic stupor. In the phase of catatonic excitement, he or she may shout and talk incessantly and incoherently, in the meantime continuing to walk up and down in a state of extreme agitation.

In Paranoid Schizophrenia the crucial element is the presence of delusions. Delusions of persecution are the most frequent, but delusions of grandeur, in which a subject will outwardly project an exaggerated sense of his or her importance, power, knowledge and identity, are also common. Some patients are tormented by delusions of jealousy, i.e., the groundless  conviction that their sexual partner is being unfaithful. Delusions may also be accompanied by vivid auditory hallucinations. It also frequently occurs that these subjects develop delusions of reference. They will incorporate ordinary events within their delusional system and read a personal meaning into even the most common types of action performed by others. For example, they might think that fragments of conversation picked up purely by chance in fact refer to them, that the frequent presence of a certain person on a street they habitually walk along means that they are being spied on, and that what they see on television or read in a magazine somehow refers to them. Paranoid Schizophrenics are agitated, polemical, irascible and occasionally violent.

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Bibliographical references:

Amador, X.F., Flaum, M., Andreasen, N.C., Strauss, D.H., Yale, S.A., e altri (1994). Awarness of illness in schizophrenia ans schizoaffective and mood disorder. Archives of General Psychiatry, 51, 826-836.