Disorganized, or hebephrenic, schizophrenia was believed by Kraepelin to be a particularly malignant form. It tended to occur at an earlier age than the other varieties, hence the prefix hebe (“youth”). The thought disorder is pronounced—there is a striking incoherence of ideas and a grossly inappropriate affect; the frequent occurrence of hallucinations and delusions leaves little doubt that the patient is psychotic. Kraepelin remarked on the changeable, fantastic, and bizarre character of the delusions. Motor symptoms, in the form of grimacing, stereotyped mannerisms, and other oddities of behavior, are prominent. In hebephrenic patients, since early life, there is likely to have been a history of tantrums and of being overly pious, shy, fearful, solitary, conscientious, and idealistic—traits that may have marked these individuals as odd. This latter state corresponds to what was referred to earlier on as a schizoid personality but could just as well represent the early phase of the disease itself (see Chap. 47).
Paranoid schizophrenia is still one of the most frequent and well-circumscribed types, even if now unattached from schizophrenia in the DSM-5 diagnostic criteria. The mean age of onset is in the early forties, much later than that of the preceding types (Winokur). The central feature is the preoccupation with one or more delusions related to a single or to a limited ensemble of themes, accompanied by auditory hallucinations. More often than not, the delusional hallucinatory content is persecutory, but it may also be religious, depressive, grandiose, or bizarrely hypochondriacal in nature. Delusional jealousy may be added. Many such patients settle into a chronic hallucinatory psychosis with disorders of thinking featuring mistrust and suspiciousness. They appear cold, aloof, and indifferent. Some European psychiatrists, impressed with the lack of schizoid traits in the premorbid period and late onset, insisted that paranoid schizophrenia is a separate disease. The studies of Rosenthal and colleagues and the clinical and family studies of Winokur tend to bear them out in that simple, catatonic, and hebephrenic types have different characteristics from paranoid schizophrenia. Therefore, modern classifications consider it to not be aligned with schizophrenia and instead to characterize an isolated paranoid-delusional disorder described in a later section. There is, in addition, a special form of delusional disorder in which the individual is consumed by a single persecutory, grandiose, or amorous delusional system without any other disorder of thinking. An exotic form is known as folie à deux, in which 2 closely related persons share a delusional system. These types of delusions are discussed further on in this chapter.
Course of Schizophrenia
Some schizophrenic patients are subject to periodic exacerbations of their illness, sometimes at regular intervals, as if the process was a metabolic disorder. Remissions that allow some degree of functioning in society are more frequent and lasting when medication is given and prolonged institutionalization is avoided. A small proportion of patients (approximately 10 percent), after an acute schizophrenic episode, have a long-lasting and fairly complete remission before lapsing into a chronic form of the illness. Unfortunately, these latter patients, at the time of their acute psychosis, cannot be distinguished from those few who will have a permanent remission.
Modern therapeutic programs have vastly reduced the number of patients in mental hospitals. However, readmission rates have also risen (revolving-door phenomenon) and the total number of very young and very old patients in hospitals has even increased slightly. The life expectancy of schizophrenic patients is somewhat reduced, possibly because of the malnutrition, neglect, and exposure to infections that occur in some public institutions and from living on the streets or in marginal circumstances. Most of these aspects of the disease were elucidated many decades ago by Langfeldt (1937 and 1969).