What is the clinical picture of schizophrenia?

Schizophrenic disorders could develop slowly and insidiously. This early clinical picture may be dominated by seclusiveness, gradual lack of interest in the surrounding world, excessive daydreaming, blunting of affect and mildly appropriate responses. This is known as process schizophrenia and the outcome is considered generally unfavourable partly because the need for treatment is usually not recognized until the behavior pattern has become more entrenched.

Schizophrenia may have a sudden onset,typically marked by intense emotional turmoil and a nightmarish sense of confusion. The symptoms of this reactive schizophrenia usually clear up in a matter of weeks although in some cases an acute episode is the prelude to a more chronic pattern.

This process-reactive distinction should not be viewed as a dichotomy but rather as a continuum. However, there is relatively few patients falling at either the process or reactive extremes as most of them fall somewhere in the middle.

In both process and reactive schizophrenia specific symptoms are vast and vary greatly from one individual to another as well as the time it is manifested. However, the basic experience in schizophrenia seems to be one of disorganization in perception, thought and emotion.

Disorganization of a previous level of functioning

This is probably the most significant indicator of schizophrenic breakdown and it distinguishes the schizophrenias from various developmental anomalies like infantile autism in which the patient never attained a suitable degree of integrated bahavioural functioning. The impairment always affects daily functioning, such as work, social relations and self-care.

Disturbance of language and communication

Also known as “formal thought disorder” and considered to be a prime indicator of the presence of a schizophrenic disorder. There is typically a failure to conform to the semantic and syntactic rules governing verbal communication in the individual’s known language which is not attributed to lower intelligence,poor education and cultural deprivation. This process is also known as one of “cognitive slippage” or “derailment of associations”

Content of thought

These disturbances usually involve certain standard types delusion and typical examples include false beliefs that one’s thoughts, feelings or activities are being controlled by external agents, that one’s private thoughts are being broadcast indiscriminately to others, that thoughts are being inserted involuntarily by alien forces or that some mysterious agency has removed their thoughts. Other absurd delusions include those of grotesque bodily changes.

Perception

The breakdown in perpetual filtering is frequent as the patient becomes overwhelmed by the influx of sensory information. The patient evidently do not have the resources for appropriate information processing.

Perceptual phenomena may include hallucinations, perceptions for which there are no discernible external stimuli. Although hallucinations in the schizophrenias are normally in the auditory mode they may be visual and even olfactory as well. These patients would usually hear a voice or voices that constantly run commentary on the individual’s behavior which are often accusatory.

Affect

There is usually an element of clearly inappropriate emotion of affect. In extreme case an emotional shallowness or “blunting” becomes evident and the patient appears to be incapable of expressing any emotion and dramatic events may produce at most an intellectual recognition of what is happening. In cases of acute phases, the patient may show very strong affect, but the reaction is discordant with the situation or with their thoughts. For example, the patient may laugh uproariously upon receipt of the news of a parent’s death.

Sense of self

The schizophrenic person is perplexed about themes such as identity, including gender identity and is frequently concerned about the boundaries separating the self from the rest of the world. These boundaries are often associated with frightening “cosmic” and “oceanic” feelings of being somehow intimately tied up with universal powers and appears to be related to ideas of external control and similar delusions.

Volition

Disruption of goal directed activity initiated by the patient occurs, whether in apparent motivation or the inability to carry through a course of action. For example, the patient may be blatantly unable to maintain minimum standards of personal hygiene.

Relationship to the external world

The withdrawal from the external world of reality may be nearly complete in certain cases. This detachment is accompanied by the elaboration of an inner world in which the patient develops illogical and fantastic idealogical constructions which has no relationship with reality as perceived by others.

Motor behavior

Various peculiarities of movement are sometimes observed in the schizophrenias which is the chief and defining characteristic of the catatonic subtype of schizophrenia. These range from from an excited sort of hyperactivity to a marked decrease in all movement or an apparent motor clumsiness. Further examples of bizarre behavior are various forms of rigid posturing, ritualistic mannerisms and unpredictable grimacing.

Associated features

Various other primary features have also been ascribed to schizophrenic disorders including anhedonia. This is a marked, widespread and refractory defect in pleasure capacity which, once identified is one of the consistent and dramatic behavioural signs of the disease. There is also profound ambivalence with conflicting motives, thoughts and feelings.