While the Feighner criteria are so strict as to exclude certain patients with a schizophrenic illness, those patients who are included will be found to constitute a fairly homogeneous group. Morrison and colleagues, who used these criteria, noted that after a 10-year period there was practically no need to change the diagnosis to another category of mental disease; in other words, they had reliably separated schizophrenia from schizophreniform psychosis (in which only the acute delusional-hallucinatory syndrome was present), and from bipolar psychosis.
The newer diagnostic criteria are no less refined but achieve clarity by stating that a patient must have at least one of the symptoms of delusions, hallucinations, and disorganized speech (not thinking). Also updated in DSM-5 is the removal of the necessity for delusions to be “bizarre” and for there to be some elements of Schneiderian first-rank symptoms, namely an auditory experience of 2 or more voices conversing.
Subtypes of Schizophrenia
Psychiatrists had in the past separated a number of subtypes of schizophrenia, although the usefulness of these distinctions has been questioned in recent decades and the newest edition of DSM-5 eliminates them entirely because they have proved to have limited clinical and therapeutic importance. Indeed, the various types may overlap or change during the course of the illness. And there are many cases that do not conform entirely to the conventional subtypes or that display characteristics of more than one type (referred to as undifferentiated or mixed types). They are briefly reviewed here for their historical interest and because their elimination in modern work signals a willingness of the field to move ahead with classification of mental disease on the basis of demonstrated biologic and therapeutic distinctions. However, they do allow an explication of the more interesting symptoms and signs of schizophrenia that are entirely descriptive but are still instructive and retain clinical interest.
In what had been called simple schizophrenia, the least florid form, the patient exhibits thought disorder, bland affect, social withdrawal, and reduction in speech and movement, all of which impair work performance. Poverty of psychomotor activity is the dominant feature and hallucinations and delusions are absent. These patients may attract notice in middle and high school because they behave in an odd manner, tending to remain by themselves (“loners”), making no effort to adjust to a social group at school or to find work, have dates, or later, to establish a family.
Catatonic schizophrenia is still the most readily identifiable type because of the striking syndrome of catatonia, and while still distinctive, it is now, for unclear reasons, found to be quite infrequent. In most cases the onset is relatively acute. In others, after a long prodrome of slackening interest, apathy, and dreamy preoccupation, a state of dull stupor supervenes, with mutism, inactivity, refusal of food, and a tendency to maintain one position “like a mummy” (catalepsy). Like other forms of catatonia, this type of schizophrenia was the one most characterized by the retention of a posture: if a limb is lifted by the examiner, it will be held in that position for hours (flexibilitas cerea). The patient may require tube-feeding (or will eat mechanically) and has to be dressed and undressed. Pinprick or pinch induces no reaction. Extreme “negativism,” every command being resisted, characterizes some cases. Yet these patients may be fully aware of what is said to them or happening around them and will reproduce much of this information during a later spontaneous remission or one induced by intravenous sodium amytal or midazolam. Even if untreated, the patient, after weeks or months in this state, begins to talk and act more normally and there is then rapid recovery. In certain phases of catatonia there may be a period of excitement and impulsivity, during which the patient may be suicidal or homicidal. Catatonia is currently recognized to be a feature of other mental illnesses and is more frequent in severe involutional depression than in schizophrenia (the catatonic state is further discussed in Chap. 16 on Coma and Related Disorders of Consciousness).