SCHIZOPHRENIA (OTHER TYPES)

Many cases of schizophrenia cannot be classified into the four primary types (simple, paranoid, catatonic, hebephrenic) because the symptom picture is so mixed. Also, some cases have unique features which call for special descriptive terms. These additional types of schizophrenia have been receiving increasing emphasis in recent years. They fall into the following major categories:Acute Undifferentiated Type. Cases with a wide variety of symptoms that cut across the four major types. The symptoms manifest themselves suddenly and do not appear to be precipitated by external stress. During an attack the patient is thrown into a state of mental and emotional turmoil, and becomes confused and bewildered by what is happening to him. These cases may clear up in a few weeks, but frequently recur or progress to one of the other reaction types.Chronic Undifferentiated Type. Here, too, the clinical picture is mixed, but symptoms develop insidiously and there is no acute attack. The patient grows apathetic and appears to accept and “settle down” with his disorder. The category includes so-called “latent,” “incipient,” and “pre-psychotic” schizophrenic reactions in which there are relatively mild changes in thought, behavior, and affect. The condition is persistent, but many individuals succeed in living with it, although they are poorly adjusted.Schizo-Affective Type. This is a mixed reaction with both schizophrenic and manic-depressive features. The episodes are recurrent and of two general kinds: predominantly schizophrenic but accompanied by pronounced elation or depression; and predominantly affective but accompanied by schizophrenic thinking and bizarre behavior. The schizophrenic symptoms are usually of the paranoid type: the patient may have delusions, ideas of reference (others talking about him), and hallucinations, and yet at the same time manifest a depressed mood with ideas of guilt and self-accusation. Less frequently the delusions and hallucinations are accompanied by an elevated mood with grandiose overtones. The manic-depressive characteristics are usually more prominent at the beginning of the illness, but if the condition is not arrested, each new attack tends to be more schizophrenic until one of the classic forms is reached.Some authorities, notably Stanley Cobb, cite these mixed reactions as evidence that there is actually only one serious mental disease with many variations. They contend that the more schizophrenic disorders are at one end of a continuum, with the affective disorders at the other end, and the schizoaffective in between. Others claim that instead of being variables of one “disease,” these are simply different types of reactions or personality patterns.Residual Schizophrenia. This term is applied to patients who have suffered from any of the types of schizophrenia but show sufficient improvement to be discharged from the hospital and get along in the community, even though they continue to manifest mild schizophrenic disturbances of thought, affect, or behavior.Ambulatory Schizophrenia. As with residual schizophrenia, this is not a separate type in the sense of a special set of symptoms. The term refers, rather, to individuals who “walk around with” schizophrenia. They are usually untreated or insufficiently treated patients who are schizophrenic in their thinking, behavior, and emotional life but manage to stay out of the hospital and live in the community. They are marginally adjusted and often put an extreme burden on their families and associates. Some of them withdraw from practically all activities and social life, spending their time wandering aimlessly about. Others make peculiar grimaces, talk to themselves, and behave in a generally eccentric manner. Still others are hypersensitive and therefore easily hurt by the slightest criticism. Out of this sensitivity they may develop suspicious attitudes which may occasionally lead to destructive actions.Pseudoneurotic Schizophrenia. These patients are apparently afflicted with a severe, mixed neurosis, but careful examination reveals the presence of serious and disabling thought disturbances of a schizophrenic nature. According to Hoch and Polatin (1949), they suffer from “pan-anxiety,” “an all-pervading anxiety structure (that) does not leave any life-approach of the person free of tension,” and “pan-neurosis,” in which “all symptoms known in neurotic illness are often present at the same time.” The symptoms shift constantly and include hysterical disturbances, phobias, obsessions, compulsions, depression, and such psychosomatic symptoms as loss of appetite, poor sleep, vomiting, and palpitation. A latent or incipient psychosis lurks beneath this neurotic facade and first makes its appearance in the form of short psychotic episodes. About one third of these patients later develop frank schizophrenia, although it is not usually of an extreme character.Pseudopsychopathic Schizophrenia. In some patients the schizophrenic tendencies are masked or overlaid by delinquent or antisocial behavior. They exhibit typical and pervasive psychopathic (antisocial) personality traits, such as pathological lying, violent and uninhibited behavior, and sexual deviations. The existence of the pseudopsychopathic type of schizophrenia suggests that no strict line can be drawn between schizophrenia and character disorder, just as the pseudoneurotic type appears to bridge the gap between psychotic and psychoneurotic disturbances.Propfschizophrenia. A form of schizophrenia found in a small minority of metal retardates, generally at the mild or borderline level. “Propf” comes from the German word for “to graft” (pro- pfen); the disorder is therefore conceived to be engrafted, or superimposed, on the mental deficiency. It takes the form of paranoid episodes with delusions and hallucinations, which may be followed by gradual regression to infantile, deteriorated behavior.A distinction is frequently made between two general classes of schizophrenia which cut across both the major and minor types. The term process (or nuclear) schizophrenia is used to designate cases that begin early in life, develop gradually, and have a poor prognosis. These patients are withdrawn, socially inadequate, and indulge in excessive fantasies even though they have never been subjected to any special situations of stress. Some therapists view process schizophrenia as the basic or “true” form of the disorder, and believe it stems from a biological, constitutional predisposition. Many authorities, however, believe there is no concrete evidence for a constitutional basis. In reactive schizophrenia, on the other hand, the individual has a history of better adjustment and socialization in childhood. He has not been particularly isolated or introverted, has not experienced any special difficulties at school, and has usually shown an interest in the opposite sex during adolescence. Here the onset of the disorder is acute and appears to be a response to precipitating stress. The degree of regression is lower than in process schizophrenia and the prognosis is considerably more favorable. Some specialists apply the adjective “schizophreniform” to this illness, to indicate that it is not basically schizophrenic. Reactive schizophrenia is considered to be functional and environmental in origin, with no constitutional basis.Illustrative Case:Jane S. is a thirty-eight-year-old married woman who developed a sudden episode of violence in her home. She became so abusive and destructive that it became necessary to call the police. The patient barricaded herself in a room, and it required six police officers to subdue her after the door was broken open. The patient was brought to the hospital in a wildly excited state in which she hurled verbal abuse at the two officers who were accompanying her. When she arrived at the hospital she broke loose and tore up the admitting office, threatening to kill anyone who came near her. It was necessary to bring psychiatric aides from nearby wards to place her in restraint. The patient literally roared in a most frightening manner. It was necessary to keep her in mechanical restraint until the calming drugs took effect She was intermittently hostile, euphoric, tearful, and depressed. (Kisker, 1964).Dlustrative Case:Sylvia M. is a forty-five-year-old single woman who was admitted to the psychiatric hospital after a series of complaints by neighbors, the fire department and the Board of Health. The patient’s psychotic condition existed for at least four years, during which time she had been living alone. She hallucinated actively, talked to herself, and screamed at night. Neighbors reported she would scream from the window, “Get out of here, or I’ll kill you if you take the children. The patient has never been married and has no children. Her apartment was filthy, with thirty-seven large bags of garbage found in her apartment when she was hospitalized.The patient was an excellent student in school, and graduated from the university with honors in sociology. She was an active and well-liked member of a sorority, and following her graduation she took a position in the field of social work. She enjoyed a secure financial position, and was considered an attractive and well-dressed woman. Several young men wanted to marry her, but her father interfered each time.Sylvia’s mother died soon after the child was born, and the father became an alcoholic. The patient was adopted by relatives, although she did not know of her adoption until her adoptive mother died while the patient was in her late twenties. At that time she had an emotional disturbance which required hospitalization. Upon her recovery she returned home and took care of her father until his death a few years ago. Since that time she-' has been living alone, showing a steady deterioration of her personality.When seen at the hospital, the patient appeared somewhat older than her age of forty-five years. She was unkempt, disheveled, and gray-haired. When she entered the interview room she was suspicious, looked carefully at the walls and into the corners. She was tense and agitated, frequently rubbing her hands, and sometimes giggling and laughing inappropriately. She commented, “There doesn’t seem to be much the matter with me, just my nerves.” When asked why she was in the hospital, she replied that she had no idea except that the police brought her. At times she appeared puzzled and bewildered. She was oriented for time, place, and person, although her remote and recent memory were impaired. She showed much delusional material centering around her practice of “standing” as a part of some type of legal action involving her nonexistent children. She admitted that she did not understand it very well, but knew that the situation required that she stand up for long intervals, sometimes throughout the night (Kisker, 1964)"