SCHIZOPHRENIA. - Under the term "dementia praecox" Kraepelin (1893) had grouped the forms of the so-called "catatonia" of Kahlbaum, the "hebephrenia" of Hecker and the "paranoid" forms, presenting as a common characteristic "a particular alteration of the intimate unity of the personality with disturbances prevailing in the affective and volitional life."
Bleuler, on the other hand, saw at the basis of the aforementioned psychopathy a loosening of the intrapsychic associations, almost a fissuring of consciousness, whence the name s. (1908; σχίζω = I separate, I divide and φρήν = spirit, mind), whereby constituents foreign to it would find easy entry to wedge themselves into consciousness, bringing about its dissociation. Such foreign constituents are seen by Bleuler, with a psychoanalytic approach, as psychic formations taking shape on the basis of intense affective experiences, especially sexual ones, or of psychic traumas occurring in childhood, which, repressed into the unconscious, could be reactivated in any circumstance through the recall of one of their constituent parts. Moreover, because of their intense affective tone, they influence the subject's conduct with such intrusion as to override all logical reflection.
Bumke regards the schizophrenic symptoms rather as a particular reactive form of the brain to exogenous agents or to various injuries.
The Heidelberg school, on the other hand, regards s. as a form of cerebral disease developing on the basis of a special hereditary disposition (dimeric-recessive) with a prevailing and progressive destruction of the subject's active social personality, and in which one could distinguish, though never sharply, heboid, hebephrenic, catatonic and paranoid forms.
Dide and Guiraud, instead, speak of "hebephrenia," which they characterize clinically as a "progressive and precocious weakening of the instinctive sources of mental life, which originate directly from the vegetative nervous system." And the clinical study of hebephrenics would indeed show that the weakening of vital drive, of interest, of affectivity represents the necessary and sufficient element to characterize the disease. This primitive defect is called by the same authors athymormie, thereby linking up with the concept of the horme of v. Monakov. The intellectual anomaly would for a long time consist in a disorder, a hitch, a contradictory orientation of the psychic processes without a definitive destruction of them, whereas true dementia would occur only in the terminal period, without being a necessary element of it.
U. Cerletti, with a similar approach and on the basis of the new data provided to clinical practice by shock therapies (v. SHOCK-TERAPIA) and especially by electroshock, invented by the same author, has gathered under the heading of "dysthymias" both s., which he considers an "athymia," and manic-depressive psychosis, which he considers a "hyperthymia." For Cerletti, therefore, at the basis of the schizophrenic process there would be a progressive and fatal decline of the emotive-affective sphere, whereby the whole volitional and intellectual activity of the subject, no longer sustained and coordinated by the affective or emotive moment, would assume that so peculiar appearance of bizarreness and dullness. To this failing of the nucleus of the personality could also be imputed the serious disorder of sensory activity, which would become an easy prey to the intrusion of anomalous mechanisms with the production of hallucinations and pseudo-hallucinations.
The symptomatic complex of s., according to the various authors, has been divided now into primary symptoms (sense of estrangement which then leads to autism) and secondary symptoms (delusions and hallucinations); now into essential symptoms (autism, weakening of the active social personality, especially in the volitional and affective sphere, psychic dissociation) and accessory symptoms (motor phenomena, delusions, illusions); now into characteristic symptoms (negativism, dyspraxic disturbances, such as mannerism, schizophasia) and non-specific symptoms (hallucinations, delusions, mental deficits).
I. CLINICAL PICTURE
Schizophrenia is a disease of youth and adolescence and generally appears between the ages of 15 and 25. At times it is more precocious (De Sanctis's dementia praecocissima), appearing at 10 or 12 years of age; at times it is more delayed, that is, between the ages of 30 and 35. The onset is polymorphous, being able to assume various aspects that have been distinguished clinically as the psychasthenic type, the neurasthenic type, the hysterical type, the manic type, the melancholic type.
1. Fundamental symptoms
Disinterest: whereas normal adolescence is the period of great hopes and of concerns for one's own individual and social future, patients instead become, little by little, indifferent to their own situation; interest ceases for studies, for play, for sport, and even for all important family and social events. Inertia: it is the consequence and the manifestation of disinterest, whereby the patient remains motionless and inactive for entire days; all initiative has vanished, as has the very sense of the struggle for life. Such inertia can extend even to the most elementary bodily needs, so that patients no longer take care of their personal cleanliness or their clothing, do not eat, do not drink, and go so far as to retain urine and feces or to soil themselves with them. Affective collapse: at first it can be masked beneath the appearances of good manners, but very soon acquaintances, friends and relatives become indifferent to the patient; at times, because of the feeling of estrangement that strikes him, he goes so far as to assume a hostile attitude toward the family in which he feels isolated. Such a state of affectlessness can reach "autism," inasmuch as these patients can hardly endure social life, which appears to them not only alien but hostile, and so they often isolate themselves for long periods in a room, leaving it only for indispensable necessities. Ambivalence: it is the tendency to experience psychological phenomena simultaneously under their positive and negative aspect. It can be considered in relation to disinterest, inasmuch as every thought, every action, every feeling appears without any value and therefore equally indifferent to its opposite. Painful feeling of estrangement: because of the weakening of the instinctual-affective tendencies there is a deficit in the intuition of the ego, in the feeling of one's own personality, whereby the patient is often led to continual self-checking, spending long hours before the mirror observing himself; for the same reason the sick have a painful feeling of unreality, not only for everything that surrounds them, but also for their own activity and above all for their own thought, which they feel to be illusory, cold and alien.
2. Accessory symptoms
They are for the most part a consequence of the symptoms described above and are above all traceable to disinterest and to the loss of affective value of every mental representation. In this way the disturbances of "self-conduct" (Toulouse and Mignard) appear. The external world is perceived correctly, orientation in time and space is often normal; but all this occurs without any personal interest, so that every activity is easily interrupted or diverted by parasitic ideas or by anomalous sensations.
Thus, as regards memory, facts unfold before the subject without his taking any interest in them whatsoever; therefore their fixation and their retention as mnemonic facts appear weak, and on the other hand their recall too, unsupported by any interest or affective moment, occurs with difficulty, but above all is disordered and with the strangest associations of the memories themselves. For the same reasons the course of ideation also occurs in a bizarre manner, translating the more or less clear randomness of associations, whereby verbalism and incoherence appear in speech.
Other anomalies of the course of thought are represented by the presence in speech of sudden arrests (barrage of the French authors) or by a "stagnation" of thought that gives rise to a verbal "diffluence," whereby speech lingers around one and the same idea with phrases that add nothing. At other times the fragility of ideation, unsupported by interest, causes speech to be diverted onto topics entirely different from those of its initial purpose; or there can even be a mingling of two different ideas whose expression occurs simultaneously and therefore in an incongruous and incomprehensible manner. Naturally, it is easy to understand how, along this path, the patient easily becomes prey, during speech, to verbal automatisms, such as: the enumeration of verbal series, like names of animals, of plants, etc.; verbal associations by contiguity or by assonance; verbal deformations and neologisms through perseverations or syllabic assonances; verbigerations, verbal stereotypies, word salad, echolalia.
On the basis of the feeling of estrangement and of dissolution of the physical and mental personality, the delusions of the schizophrenic originate, with the common character of a mysterious aggression against one's own physical and psychic personality: ideas of negation, of destruction of organs, of the introduction of alien persons or animals into the organism, of influencing of thought, of magnetism, of thought transmission.
As regards motor activity, in the catatonic form (v. CATATONIA) of schizophrenia one can observe disturbances characterized above all by immobility or delay in the execution of actions commanded or willed by the subject himself, which, once begun, can also be interrupted abruptly, at times as if by a counter-order (ambivalence), at times through a fading of the energy for executing the act (the patient's disinterest in the act itself). For the same reason there can occur so-called catalepsy (v.), whereby the patient long maintains attitudes passively imposed on him, even if entirely incongruous and uncomfortable. In this syndrome of motor arrest or torpor, so-called impulses (v. IMPULSIVITY) can suddenly appear, by which the subject, abruptly emerging from his inertia and without apparent reason, at times under the stimulus of an acoustic hallucination, strikes a neighbor with his fist, hurls an object, or tears his clothes, only then perhaps to return to the immobility of a few moments before.
Clinical practice has distinguished, besides De Sanctis's form of dementia praecocissima that affects children, the simple form (characterized above all by indifference and inertia, without delusions or motor disturbances), the catatonic form (with highly accentuated motor signs), the delusional or paranoid form (with a predominance of delusional phenomena), the heboidophrenic form (which would represent a fruste form of it, in which inertia and apathy affect only the desire to provide for one's own needs through regular and productive employment, and family and social affectivity; hence such patients live by expedients, terrorizing their own family in order to obtain money, or committing thefts or acts of violence).
Bibliography12 works
Lamberto Longhi
Per la cura della s., v. PSICOTERAPIA CHIRURGICA; SHOCKTERAPIA.
II. MORAL EVALUATION
From the moral point of view, full-blown schizophrenia, even more than any other mental illness (v.), because of the grave alterations it produces in the mind of the individual, depriving it of the faculty of understanding rightly and of willing according to reasonable motives, fully deprives the sick person of responsibility for his acts and of the validity of consent. In the initial stages of the illness, the partial disturbance of the mental faculties, at times not easily determinable by an examination that is not deeply specialized, can give the appearance of a full normality of thought and of acts; even in such a case, however, complete responsibility cannot be admitted; this must be considered particularly, in the light of subsequent episodes, in the historical judgment of the individual's acts, as already more or less impaired, in proportion to the degree in which the faculties were impaired and to the rapidity and gravity with which complete imbalance was reached.
In relation to the therapy applied, there may be in schizophrenia an arrest of the process and even a regression, to the point of the appearance of a full normality; in a high percentage of cases, however, the illness resumes its course, until it reaches, in the succession of its stages, the most complete disintegration of the personality. In the periods of pause and improvement of the illness, the judgment as to whether these are true returns to normality with full recovery of the mental faculties ("lucid intervals") or only periods of "larval quiet" and, correspondingly, the determination of the degree of moral responsibility and of the validity of consent of the sick person, represent often very difficult and controversial questions, entrusted to the work of experts. See, on this point, certain decisions of the S. Rota:
« Lucida intervalla non sunt confundenda cum "conspectu umbratae quietis"... neque cum plena et definitiva sanatione infirmi... Infirmi in lucidis intervallis actus humanos elicere et etiam matrimonium inire possunt » (Decisiones Rotales 1930, pp. 133-34); as likewise CIC, can. 754 on the Baptism of the « amentes et furiosi ».
Bibliography3 works
Giuseppe de Ninno