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Schizophrenia

1. Be able to describe the clinical symptoms of schizophrenia, including positive, negative, and disorganized
symptoms.
2. Be able to differentiate the genetic factors, both behavioral and molecular, in the etiology of schizophrenia.
3. Be able to discuss how the brain has been implicated in schizophrenia, both in studies of etiology and in
treatment.
4. Be able to describe the role of stress and other psychosocial factors in the etiology and relapse of
schizophrenia.
5. Be able to distinguish the medication treatments and psychological treatments for schizophrenia.

A
ll of a sudden things weren't going so well. I began to lose control of my life and, most of all, myself. I couldn't
concentrate on my schoolwork, I couldn't sleep, and when I did sleep, I had dreams about dying. I was afraid to
go to class, imagined that people were talking about me, and on top of that I heard voices. I called my mother in
Pittsburgh and asked for her advice. She told me to move off campus into an apartment with my sister.
After I moved in with my sister, things got worse. I was afraid to go outside and when I looked out of the
window, it seemed that everyone outside was yelling, "Kill her, kill her." My sister forced me to go to school. I
would go out of the house until I knew she had gone to work; then I would return home. Things continued to get
worse. I imagined that I had a foul body odor and I sometimes took up to 6 showers a day. I recall going to the
grocery store one day, and I imagined that the people in the store were saying, "Get saved, Jesus is the answer."
Things worsened-I couldn't remember a thing. I had a notebook full of reminders telling me what to do on that
particular day. I couldn't remember my schoolwork, and I
would study from 6:00 P.M. until 4:00 A.M. but never had the courage to go to class on the following day. I tried to
tell my sister about it, but she didn't understand. She suggested that I see a psychiatrist, but I was afraid to go
out of the house to see him.
One day I decided that I couldn't take this trauma anymore, so I took an overdose of 35 Darvon pills. At the
same moment, a voice inside me said, "What did you do that for? Now you won't go to heaven." At that instant I
realized that I didn't really want to die. I wanted to live, and I was afraid. I got on the phone and called the
psychiatrist whom my sister had recommended. I told him I had taken an overdose of Darvon and that I was
afraid. He told me to take a taxi to the hospital. When I arrived at the hospital, I began vomiting, but I didn't pass
out. Somehow, I just coutdn't accept the fact ltJat I was really going to see a psychiatrist. I thought that
psychiatrists were only for crazy people, and I definitely didn't think I was crazy. As a result, I did not admit myself
right away. As a matter of fact I left the hospital and ended up meeting my sister on the way home. She told me to
turn right back around because I was definitely going to be admitted. We then called my mother, and she said
she would fly down the following day. (O'Neil, 1984, pp. 109-110)

T
he young woman described in this case study was diagnosed as having schizophrenia. The diagnosis of
schizophrenia has existed now for over a century, and this serious mental disorder has spawned more research
than any other, but we are far from understanding it.
Schizophrenia is a disorder characterized by disturbances in thought, emotion, and behavior-disordered
thinking, in which ideas are not logically related; faulty perception and attention; a lack of emotional
expressiveness or at times, inappropriate expressions; and disturbances in movement and behavior, such as a
shuffling gait or a disheveled appearance. Patients with schizophrenia may withdraw from people and from
everyday reality, often into a life of odd beliefs (delusions) and hallucinations. Given that schizophrenia is
associated with such widespread disruptions in the person's life, we should not be surprised that it has proved
difficult to uncover the causes of the disorder and develop methods to treat it. We still have a long way to go
before we fully understand the multiple factors that trigger schizophrenia and have treatments that are both
effective and free of unpleasant side effects.
The symptoms of schizophrenia have a profound effect not just on patients' lives, but also on the lives of
families and friends. Delusions and hallucinations may cause considerable distress, both to patients and others,
compounded by the fact that hopes and dreams have been shattered. Other symptoms make stable employment
difficult, often leading to impoverishment and homelessness. Strange behavior and social skills deficits lead to
loss of friends, a solitary existence, and sometimes ridicule and persecution. Substance-abuse rates are high
(Fowler et aI., 1998), perhaps reflecting an attempt to achieve some relief from negative emotions (Blanchard et
aI., 1999). Little wonder, then, that the suicide rate among patients with schizophrenia is high.
Schizophrenia is one of the most severe psychopathologies we will describe in this book. Its lifetime
prevalence is slightly less than 1 percent, and it affects men and women about equally. Schizophrenia is
diagnosed more frequently among some groups, such as African Americans, though it remains unclear whether
this reflects an actual difference among groups or bias among clinicians (USDHHS, 200 1a). Schizophrenia
sometimes begins in childhood, but it usually appears in late adolescence or early adulthood, and usually
somewhat earlier in men than in women. Age of onset appears to have been decreasing over recent last decades
(DiMaggio, Martinez, & Menard, 2001). People with schizophrenia typically have a number of acute episodes of
their symptoms and less severe but still very debilitating symptoms between episodes. Comorbid substance
abuse occurs in about 50 percent of patients with schizophrenia and so it is a major problem (Kosten & Ziedonis,
1997)
In this chapter, we first describe the clinical features of schizophrenia followed by discussions of the
etiology of schizophrenia and treatments for the disorder.
Clinical Descriptions of Schizophrenia
The range of symptoms in the diagnosis of
schizophrenia is extensive, although patients typically
have only some of these problems at any given time.
The DSM determines for the diagnostician how many
problems must be present, in what degree, and for
what duration to justify the diagnosis (see DSM -IV-
TR criteria)
No single essential symptom must be present for a
diagnosis of schizophrenia. Thus, patients with
schizophrenia can differ from one another quite a bit.
The heterogeneity of schizophrenia suggests that it
may be appropriate to subdivide p~tients into types that
manifest particular constellations of problems, and we
examine sev'eral recognized types later in this chapter.
But first we present the main categories of symptoms
of schizophrenia.
About 30 years ago, symptoms were divided into
two categories called positive and negative (Crow,
1980; Strauss, Carpenter, & Bartko, 1974).
Subsequently, the original category of positive
symptoms was divided into two categories-positive
(hallucinations and delusions) and disorganized
(disorganized speech and behavior) (Lenzenwenger,
Dworkin,
Positive Symptoms
Positive symptoms comprise excesses and distortions, such as hallucinations and delusions. For the most part,
acute episodes of schizophrenia are characterized by positive symptoms.
&Wethington, 1991). The distinction between positive, negative, and disorganized symptoms has been very
useful in research on etiology and treatment of schizophrenia-even more useful than the DSM-1V- TR subtypes
that we describe later. Table 11.1 shows the symptoms that comprise these categories.
In the following sections, we describe in some detail the individual symptoms that make up the positive,
negative, and disorganized categories. We also describe some symptoms that do not fit neatly into these three
categories.

Delusions, hallucinations

Avolition (apathy), alogia (poverty of speech, poverty of content of speech), anhedonia, flat affect, asociality

Disorganized behavior, disorganized speech


·1 DSM-IV- TR Criteria for Schizophrenia
·2 Two or more of the following symptoms for a significant portion of time for at least 1 month: delusions,
hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms
·3 Social and occupational functioning have declined since onset
·4 Signs of disturbance for at least 6 months; at least 1 month duration for the symptoms in the first bullet;
during the remaining time either negative symptoms or other symptoms from the first bullet in attenuated form

Delusions No doubt all of us at one time or another have been concerned


because we believed that others thought ill of us. Some of the time this
belief may be justified After all, who is universally loved? Consider,
though, the anguish that you would feel if you were firmly convinced that
many people did not like you-indeed, that they disliked you so much that
they were plotting against you. Imagine that your persecutors have
sophisticated listening devices that let them tune in on your most private
conversations and gather evidence in a plot to discredit you. Those around
you, including your loved ones, are unable to reassure you that people are
not spying on you. Even your closest friends are gradually joining forces
with your tormentor. Anxious and angry, you begin taking counteractions
against the persecutors. You carefully check any new room you enter for
listening devices. When you meet people for the first time, you question
them at great length to determine whether they are part of the plot against
you.
Such delusions, which are beliefs held contrary to reality and
firmly held in spite of disconfirming evidence, are common positive
symptoms of schizophrenia. Persecutory delusions such as those just
related were found in 65 percent of a large, cross-national sample of
people diagnosed with schizophrenia (Sartorius, Shapiro, &. Jablonsky,
1974). Delusions may take several other forms as well, which were
described by the German psychiatrist Kurt Schneider (959). The
follOwing descriptions of these delusions are drawn from Mellor
(970):

·5 The patient may believe that thoughts that are not his or her
own have been placed in his or her mind by an external source.

A twenty-nine-year-old housewife said, "] look out oj the window


and I think the garden looks nice and the grass loohs cool, but the
thoughts oj Eamonn Andrews come into my mind. There are no
other thoughts there, only his. He treats my mind like a screen
and flashes his thoughts on it like you flash a pictu re." (p. ] 7)

·6 Patients may believe tha~ their though~s are broadcast or


transmitted, so that others
know what they are thinking. .

A twenty-one-year-old student (found that], "As] think, my


tho~lghts leave my head on a-.type oj mental ticker-tape.
Evelyone around has only to pass the tape through their mind
and they hnow my thoughts." (p. 17)

·7 Patients may think their thoughts are being stolen from them, suddenly and unexpectedly, by an
external force.
A twenty-two-year-old woman [described such an experience}. "1 am thinking about my mother, and
suddenly my thoughts are sucked out of my mind by a phrenological vacuum extractOl; and there is
nothing in my mind, it is empty." (pp 16-1 7)

A twenty-nine-year-old shorthand typist described her [simplest] actions as follows' "When 1 reach my
hand for the comb it is my hand and arm which move, and my fingers pick up the pen, but 1 don't control
them. 1 sit there watching them move, and they are quite independent, what they do is nothing to do with
me. 1 am just a puppet who is manipulated by cosmic strings. When the strings are pulled my body moves
and 1 cannot prevent it." (p. 17)

Although delusions are found among more than half of people with schizophrenia, they are also found among
patients with other diagnoses, particularly bipolar disorder, depression with psychotic features, and
delusional disorder. In contrast to delusions among such patients, however, the delusions of patients with
schizophrenia are highly implausible, as shown by the descriptions above Ounginger, Barker, &: Coe, 1992)

Hallucinations and Other Disturbances of Perception Patients with schizophrenia frequently report that
the world seems somehow different or even unreal to them. A patient may mention changes in how his or her
body feels, or the patient may become so depersonalized that his or her body feels as though it is a machine.
As in the case at the beginning of this chapter, some people report difficulties in attending to what is
happening around them:

1 can't concentrate on television because 1 can't watch the screen and listen to what is being said at the
same time. 1 can't seem to take in two things like this at the same time especially when one of them means
watching and the other means listening. On the other hand 1 seem to be always taking in too much at the
one time, and then 1 can't handle it and can't make sense of it. (McGhie & Chapman, 1961, p. 106)

The most dramatic distortions of perception are hallucinations, sensory experiences in the absence of any
relevant stimulation from the environment. They are more often auditory than visual; 74 percent of one
sample of schizophrenia patients reported having auditory hallucinations (Sartorius et aI., 1974). Like
delusions, hallucinations can be very frightening experiences.
Some types of hallucinations are thought to be particularly important diagnostically because they occur
more often in patients with schizophrenia than in other psychotic patients. These types of hallucinations
include the following (taken from Mellor, 1970)

·8 Some patients with schizophrenia report hearing their own thoughts spoken by another voice.

[The] thirty-two-year-old housewife complained of a man's voice speaking in an intense whisper from a
point about two feet above her head. The voice would repeat almost all the patient's goal-directed
thinking-even the most banal thoughts. The patient would think, "1 must put the kettle on," and after a
pause of not more than one second the voice would say, "T must put the kettle on." It would often say the
opposite,"Don't put the kettle on." (p. 16)

-i"', ' A twenty-four-year-old male patient reported hearing voices comingfrom the nurse's office. One
voice, deep in pitch and roughly spoken, repeatedly said, "G. I is a bloody paradox," and another higher in
pitch said, "He is that, 'he should be locked up." A female voice occasionally interrupted, saying, "He is
not, he is a lovely man." (p. 16)
·9 Some patients hear voices commenting on their behavior.
A Jorty-one-year-old hOLlsewife heard a voice comingJrom a house across the road. The voice went on
incessantly in a flat monotone describing evelything she was doing with an admixture oj critical comments.
"She is peeling potatoes, got hold oj the peeler, she does not want that potato, she is putting it back, because
she thinks it has a knobble like a penis, she has a dirty mind, she is peeli ng potatoes, now she is washing
them." (p. 16)

For many patients, these hallucinations are experienced negatively. In one study of nearly 200 patients, those
who had hallucinations that were longer, louder, more frequent, and experienced in the third person found them
unpleasant. Hallucinations that were believed to come from a known person were experienced more positively
(Copolov, Mackinnon, & Trauer, 2004).
Recent ne~roimaging studies have examined what happens in the brain during auditory hallucinations. Some
theorists propose that patients misattribute their own voice as being someone else's voice. Behavioral studies
have shown that schizophrenia patients with hallucinations are more likely to misattribute recordings of their
own speech to a different source than are patients without hallucinations or nonpatient controls (Allen et a!.,
2004). Studies using brain-imaging methods have also found greater activity in Broca's area, the productive
language area of the brain, when patients hear voices (McGuire, Shah, & Murray, 1993) Why might patients
make this misattribution? Other studies suggest that there is a problem in the connections between the frontal
lobe areas that enable the production of speech and the temporal lobe areas that enable the understanding of
speech Studies using both psychophysiological (Ford et aL, 2002) and brain-imaging methods (McGuire,
Silbersweig, & Frith 1996; Shergill et aL, 2000) support this idea

Negative Symptoms
The negative symptoms of schizophrenia consist of behavioral defiCits, such as avolition, alogia, anhedonia,
flat affect, and asociality, all of which we describe below. These symptoms tend to endure beyond an acute
episode and have profound effects on the lives of patients with schizophrenia. They are also important
prognostically; the presence of many negative symptoms is a strong predictor of a poor quality of life (e.g.,
occupational impairment, few friends) 2 years following hospitalization (Ho et a!., 1998)
When assessing negative symptoms it is important to distinguish among those that are truly symptoms of
schizophrenia and those that are due to some other factor (Carpenter, Heinrichs, & Wagman, 1988). For
example, flat affect (a lack of emotional expressiveness) can be a side effect of antipsychotic medication.
Observing patients over extended time periods is probably the only way to address this issue.

Avolition Apathy, or avolition, refers to a lack of energy and a seeming absence of interest in or an inability to
persist in what are usually routine activities. Patients may become inattentive to grooming and personal hygiene,
with uncombed hair, dirty nails, unbrushed teeth, and disheveled clothes. They have difficulty persisting at
work, school, or household chores and may spend much of their time sitting around doing nothing.

Alogia Alogia can take several forms. In poverty oj speech, the sheer amount of speech is greatly reduced. In
poverty oj content oj speech, the amount of speech is adequate, but it conveys little information and tends to be
vague and repetitive as shown by the follOwing excerpt:
Interviewer: o.K. Why is it, do you think, that people believe in God?
Patient: Well,first oj all because, He is the person that is their personal savior He walks with me and talks
with me. And u}1, the understanding that I have, a lot oj peoples, they don't really know their personal self.
Because they ain't, theX all, just don't know their personal self. They don't know that He uh, see,ms to like me,
a lot oj them don't understand that He walks and talks with them. And uh, show 'em their way to go. I
understand also that, every man and every lady, is not

just pointed in the same direction. Some are pointed different. They go in their different ways. The way
tha1}esLls Chlist wanted 'em to go. Myself. I am pointed in the ways of uh, knowing right from wrong, and
doing it, I can't do any more, or not less than that. (Amelican Psychiatlic Association, 1987, pp. 403-404)

Anhedonia A loss of interest in or a reported lessening of the experience of pleasure is called anhedonia. When
asked about hypothetical situations or activities that are pleasurable to most people (e.g., good food, recreational
activities, sex) on an anhedonia questionnaire, schizophrenia patients report that they derive less pleasure from
these sorts of activities than people without schizophrenia. However, when patients are presented with actual
pleasant activities, such as amusing films, they report experiencing as much pleasure as do people without
schizophrenia (Kring & Earnst, 1999). How can patients report anhedonia yet still derive pleasure from positive
things7 One possibility is that patients do not anticipate that situations will be pleasurable. Thus, patients may
score low on anhedonia questionnaires that require them to estimate how much pleasure they would experience
in a variety of activities. But when in the presence of pleasurable things or situations, patients do get in-the-
moment pleasure (Kring, 1999).

Flat Affect In patients with flat affect virtually no stimulus can elicit an emotional expression. The patient may
stare vacantly, the muscles of the face flaccid, the eyes lifeless. When spoken to, the patient answers in a flat and
toneless voice. Flat affect was found in 66 percent of a large sample of patients with schizophrenia (Sartorius et
al., 1974).
The concept of flat affect refers only to the outward expression of emotion and not to the patient's inner
experience, which may not be impoverished at all. In one study, patients with schizophrenia and a control group
of people without schizophrenia watched excerpts from films while their facial reactions and skin conductance
were recorded (Kring &. Neale, 1996). After each film clip, participants self-reported on the emotions the films
had elicited. As expected, the patients were much less facially expressive than were the people without
schizophrenia, but they reported about the same amount of emotion and were even more physiologically aroused
(as measured by skin conductance).

Asociality Some patients with schizophrenia have severe impairments in social relationships, referred to as
asociality. They have few friends, poor social skills, and little interest in being with other people. Indeed, as will
be seen later, these manifestations of schizophrenia are often the first to appear, beginning in childhood before
the onset of other symptoms.

Disorganized Symptoms
Disorganized symptoms include disorganized speech and disorganized behavior.

Disorganized Speech Also known as formal thought disorder, disorganized speech refers to problems in
organizing ideas and in speaking so that a listener can understand.

Interviewer: Have you been nervous or tense lately? Patient: No, I


got a head of lettuce.
Interviewer: You got a head of lettuce? I don't understand. Patient: Well,
it's just a head of lettuce.
Interviewer: Tell me about lettuce. What do you mean?
Patient: Well ... lettuce is a transformation of a dead cougar that suffered a relapse on the lion's toe.
And he swallowed the lion and something happened. The ... see, the ... Glolia and Tommy, they're two heads and
theY'IT not whales. BLlt they escaped with herds of vomit, and things like that.
Interviewer: Who are Tommy and Glolia?
Patient: Uh, ... there's Joe DiMaggio, Tommy Henlich, Bill Dickey, Phil Rizzuto, John Esclavera, Del Crandell, Ted
Williams, Mickey Mantle, Roy Mantle, Ray Mantle, Bob Chance ...
Interviewer: WIlD are they? WIlD are those people?
Patient: Dead people ... they want to be fucked ... by this outlaw. Interviewer:
Wlwt does all that mean?
Patient: Well, you see, I have to leave the hospital. I'm supposed to have an operation on my legs, you know. And it
comes to be pretty sickly that I don't want to keep my legs. That's why I wish I could have an operation.
Interviewer: You want to have your legs taken off? Patient: It's
possible, you know.
Interviewer: WIlY would you want to do that?
Patient: I didn't have any legs to begin with So I would imagine that if I was a fast runner, I'd be scared to be a wife,
because I. had a splinter inside of my head of lettuce. (Neale & Oltmanns, 1980, pp. 103-104)

This excerpt illustrates the incoherence sometimes found in the conversation of individuals with schizophrenia.
Although the patient may make repeated references to central ideas or themes, the images and fragments of
thought are not connected; it is difficult to understand what the patient is trying to tell the interviewer.
Speech may also be disordered by what are called loose associations, or derailment, in which case the
patient may be more successful in communicating with a listener but has difficulty sticking to one topic.
Patients seem to drift off on a train of associations evoked by an idea from the past. Patients have themselves
provided descriptions of this state.

My thoughts get all jumbled up. I start thinking or talking about something but I never get there. Instead, 1
wander off in the wrong direction and get caught up with all sorts of different things that may be connected
with things I want to say but in a way I can't explain. People listening to me get more lost than I do. My
trouble is that I've got too many thoughts. You might think about something, let's say that ashtray and just
think, oh yes, that's for putting my cigarette in, bLlt I would think of it and then I would think of a dozen
different things connected with it at the same time. (McGhie & Chapman, 1961, p. 108)

Disturbances in speech were at one time regarded as the principal clinical symptom of schizophrenia, and they
remain one of the criteria for the diagnosis. But evidence indicates that the speech of many patients with
schizophrenia is not disorganized, and the presence of disorganized speech does not discriminate well between
schizophrenia and other disorders, such as some mood disorders (Andreasen, 1979). For example, patients in a
manic episode exhibit loose associations as much as do patients with schizophrenia.
It would seem logical to expect disorganized speech to be associated with problems in language production,
but this does not appear to be the case. Instead, disorganized speech is associated with problems in what is
called executive functioning-problem solving, planning, and making associations between thinking and
feeling. Disorganized speech is also related to the ability to perceive semantic information (i.e., the meaning of
words) (Kerns & Berenbaum, 2002, 2003).

Disorganized Behavior Disorganized behavior takes many forms. Patients may go into inexplicable bouts of
agitation, dress in unusual clothes, act in a childlike or silly manner, hoard food, collect garbage, or engage in
sexually inappropriate behavior such as masturbating in public. They seem to lose the ability to organize their
behavior and make it conform to community standards. They also have difficulty performing the tasks of
everyday living.

Other Symptoms
Several other symptoms of schizophrenia do not fit neatly into the categories we have just presented. Two
important symptoms of this kind are catatonia and inappropriate affect.

An 1894 photo showing a woman with catatonic schizophrenia. She held this unusual posture for long periods of
time. (The Burns Archive.)
Catatonia Several motor abnormalities define catatonia. Patients may gesture repeatedly, using peculiar and
sometimes complex se· quences of finger, hand, and arm movements, which often seem to be purposeful. Some
patients manifest an unusual increase in their over· all level of activity, including much excitement, wild flailing
of the limbs, and great expenditure of energy similar to that seen in mania. At the other end of the spectrum is
catatonic immobility: patients adopt unusual postures and maintain them for very long periods of time. A
patient may stand on one leg, with the other tucked up toward the buttocks, and remain in this position virtually
all day. Catatonic patients may also have waxy flexibility-another person can move the patient's limbs into
positions that the patient will then maintain for long periods of time.

Inappropriate Affect Some people with schizophrenia show in-


appropriate affect-their emotional responses are out of context.
Such a patient may laugh on hearing that his or her mother just died or become enraged when asked a simple
question about how a new garment fits. These patients are likely to shift rapidly from one emotional state to
another for no discernible reason. This symptom is quite rare, and it is relatively specific to schizophrenia.

Schizophrenia in DSM-IV- TR
The table in the margin (p. 351) presents the current diagnostic criteria for schizophrenia. In addition, DSM -IV-
TR requires at least 6 months of disturbance for the diagnosis. The 6-month period must include at least 1 month
of an acute episode, or active phase, defined by the presence of at least two of the following: delusions,
hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. (Only
one of these symptoms is required if the delusions are bizarre or if the hallucinations consist of voices
commenting or arguing.) The remaining time required for the diagnosis can occur either before the active phase
or after the active phase. This time criterion eliminates patients who have a brief psychotic episode and then
recover quickly.
Are the DSM-IV-TR diagnostic criteria applicable across cultures? Evidence bearing on this question was
collected in a World Health Organization study of both industrialized and developing countries (Jablonsky et aI.,
1994). The symptomatic criteria held up well crossculturally. However, for reasons not yet fully understood,
patients in developing countries have a more acute onset and a more favorable course than those in industrialized
societies (Susser &: Wanderling, 1994)
Categories of Schizophrenia in DSM-IV- TR Although schizophrenia is much less broadly characterized than
formerly (see Focus on Discovery 11.1), it continues to be a very heterogeneous disorder. The diverse array of
symptoms has given rise to proposals concerning subtypes of the disorder. Yet, as we shall see, the validity of
these subtypes is questionable.
Disorganized Schizophrenia The subtype called disorganized schizophrenia in DSMIV- TR is manifested by
speech that is disorganized and difficult for a listener to follow. Patients may speak incoherently, stringing
together similar-sounding words and even inventing new words, often accompanied by silliness or laughter. He
or she may have flat affect or experience constant shifts of emotion, breaking into inexplicable fits of laughter
and crying. The patient's behavior is also generally disorganized and not goal directed; for example, he or she
may tie a ribbon around a big toe or move incessantly, pointing at objects for no apparent reason.
Catatonic Schizophrenia The most obvious symptoms of catatonic schizophrenia are the catatonic symptoms
described earlier. Patients typically alternate between catatonic

History of the Concept of Schizophrenia


did not deteriorate, but he preferred to limit this diagnostic category to patients who had a poor prognosis. Bleuler's
work, in contrast, led to a broader concept of the disorder. He diagnosed some patients with a good prognosis as having
schizophrenia, and he also diagnosed schizophrenia
in many patients who would have received different diagnoses from other clinicians.
Two European psychiatrists, Emil Kraepelin and Eugen Bleuler, initially formulated the concept of schizophrenia.
Kraepelin first described dementia praecox, his term for what we now call schizophrenia, in 1898. He differentiated
two major groups of disorders that he asserted were
endogenous, or internally caused: manic-depressive illness and dementia praecox. Dementia
praecox included several diagnostic subtypes-clementia paranoides, catatonia, and hebephrenia-
that had been regarded as distinct entities by clinicians in the preI'ious few decades. Although
these disorders were symptomatically diverse, Kraepelin believed that they shared a common
core, and the term "dementia praecox" reflected what he believed was that core-an early onset
(praecox) and a progressive, inevitable intellectual deterioration (dementia). The dementia in
dementia praecox is not the same as the dementias we discuss in the chapter on late life (Chapter
15), which are defined principally by severe memory impairments. Kraepelin's term referred to a
general "mental enfeeblement."
Bleuler broke with Kraepelin's description on two major points: he believed that the disorder
did
not necessarily have an early onset, and he believed that it did not inevitably progress toward
dementia. Thus the label "dementia praecox" was no longer appropriate, and in 1908 Bleuler
proposed his own term, schizophrenia, from the Greek words schizein ("to split"), and phren
("mind"), capturing what he viewed as the essential nature of the condition.
With age of onset and deteriorating course no longer considered defining features of the
disorder, Bleuler faced a conceptual problem. The symptoms of
chizophrenia ould vary widely among pabents, so he had to provide some justification for
putting them into a single diagnostic ategory That is, he needed to specify some common denomi.nator,
or essential property, that would link the various disturbances. The metaphorical concept that he
adopted for this purpose was the "breaking of associative threads."
For Bleuler, associative threads joined not only words but also thoughts. Thus, goal-directed,
efficient thinking and communication were possible only when these hypothetical structures were
intact. The notion that associative threads were disrupted in patients with schizophrenia could then
be used to account for the range of other disturbances. Bleuler viewed attentional difficulties, for
example, as resulting from a loss of purposeful direction in thought, in turn causing passive
responses to objects and people in the immediate surroundings. In a similar vein, he viewed
blocking, the apparently total inability to hold a train of thought, as a complete disruption of the
person's associative threads.
Kraepelin had recognized that a small percentage of patients with symptoms of dementia
praecox
Emil Kraepelin (1856-1926), German pSYChiatrist, articulated descriptions of schizophrenia (then called dementia
praecox) that have proved remarkably durable in the light of contemporary research. (Hueton Archive Getty Images.)
Eugen Bleuler (1857-1939), Swiss psychiatrist, contributed to our conceptions of schizophrenia and coined the term.
(Corbis Bettmann.)
The Broadened U.S. Concept
Bleuler had a great influence on the concept of schizophrenia as it developed in the United States. Over the first part of
the twentieth century, the breadth of the diagnosis was extended considerably. In contrast, the concept of schizophrenia
prevalent in Europe remained narrower.
The reasons for the increase in the frequency of diagnoses of schizophrenia in the United States are easily
discerned. First of all, several prominent figures in U.S. psychiatry expanded Bleuler's already broad concept of
schizophrenia even more. For example, patients who had a combination of both schizophrenia and affective symptoms
were said to have a subtype of schizophrenia called schizoaffective psychosis in the DSM-I (1952) and DSM-Il (1968).
Also, U.S. clinicians tended to diagnose schizophrenia whenever delusions or hallucinations were present. Because
these symptoms, particularly delusions, occur also in mood disorders, many patients with a DSM-Il diagnosis of
schizophrenia might actually have been diagnosed with a mood disorder (Cooper et al., 1972). Similarly, patients
whom we would now d\.a%W0S~ as ha\lil\% a P~'iS'i)frd\iry dis'i)ro:er \t\'<.wab\y schizotypal, schizoid,
borderline, and paranoid per$onali ty disc>rder.<, $('e h:tptcr J 2) were c!i"snn.<('d
with schizophrenia.
Current Conceptions of Schizophrenia: A More Narrow Definition
Beginning with DSM-III (American Psychiatric Association, 1980) and continuing in DSM-IV (American Psychiatric
Association, 1994) and DSM-IV-TR (American Psychiatric Association, 2000), the U.S. concept of schizophrenia has
shifted considerably, narrowing the range of patients diagnosed with the disorder. This shift involved making the
diagnostic criteria more detailed and explicit, creating separate categories of disorder for some conditions formerly
considered subtypes of schizophrenia, and requiring at least 6 months of disturbance for a diagnosis (see the DSM-IV-
TR diagnostic criteria for schizophrenia in the margin).