The Gazette 1990

SEPTEMBER 1990

GAZETTE

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.

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

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