Meyer, who introduced the “psychobiologic approach” to psychiatry, sought the origins of schizophrenia, as well as other psychiatric syndromes, in the personal and medical history of patients, emphasizing particularly their habitual reactions to life events. Freud viewed schizophrenia as a manifestation of a “weak ego” and an inability to control anxiety and instinctual forces—the result of a fixation of libido at an early (“narcissistic”) stage of psychosexual development. None of these theories has been corroborated, and none ever gained wide acceptance, particularly as the biological disease model of schizophrenia, propelled by successful pharmacologic treatment, defined a disease and not a psychological disorder.
A contemporary approach to schizophrenia, summarized below, has involved the isolation of its many pervasive mental and behavioral features into three clusters: (1) negative symptoms of diminished psychomotor activity (poverty of speech and spontaneous movement, flatness of affect); (2) a “disorganization” syndrome, or thought disorder (fragmentation of ideas, loosening of associations, tangentiality, and inappropriate emotional expression); and (3) reality distortion, comprising hallucinations and delusions, or positive symptoms (see Liddle). The separation of behaviors into “positive” and “negative” symptoms was believed to be useful in distinguishing among the types of schizophrenias and perhaps to align the mental status with conventional physiologic analysis, but this view is an oversimplification, as pointed out by Andreasen. Although there is disagreement as to whether each of these features is primary or secondary, positive or negative, they have the value of lending themselves to objective study.
Clinical Syndrome of Schizophrenia
The central abnormalities in schizophrenia are hallucinations, mainly auditory, and a special disorder in the perception of one’s self in relation to the external world. It is unlike the condition that prevails in delirium and other confusional states, dementia, and depression. Some patients with chronic schizophrenia, before the onset of a flagrant psychosis or when in remission, show none of the usual symptoms and—during brief testing of mental status—might even pass for normal. But on longer observation, they are vague and preoccupied with their own thoughts. They seem unable to think in the abstract, to understand fully figurative statements, or are unable to separate relevant from irrelevant data. There is what has been called a circumstantiality and tangentiality about their thinking and remarks. They fail to communicate their ideas clearly. Their thinking no longer respects the logical limits of time and space so that parts of ideas are confused with the whole or are clustered together or condensed in an illogical way. In an analysis of a problem or a situation, there is a tendency to be overinclusive rather than underinclusive (as happens in dementia). In conversation and in writing, the trend of an argument or thought sequence is often interrupted abruptly, with a resulting disorder of verbal communication. Such disorders of thinking are reflected in the patient’s behavior. Over time there is a general deterioration in functioning, social withdrawal and bizarre actions, self-absorption, and aimlessness.
In more severely affected schizophrenic patients, thinking is even more disintegrated. They appear to be totally preoccupied with their inner psychic life (thus the early use of the term autism) and may do no more than utter a series of meaningless phrases or neologisms, or their speech may be reduced to a nonsensical “word salad.” They are unable to attend to any task or to concentrate, and their performance is interrupted by sudden “blocking” or by insertion of some extraneous idea or inexplicable act, somewhat like that observed in a severely confused or delirious patient. At times these patients are talkative and exhibit odd behavior; at other times they are quiet and idle. In the extreme, the patients are mute or assume and maintain imposed postures or remain immobile (catalepsy). With remission, they may remember much of what has happened or may have only fragmentary memories of events that occurred.