Schizophrenia

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Abstract

Schizophrenia SIR,-In your leading article "Epilepsy and Schizophrenia" (June 15, p. 1557) you report that recent research permits a distinction to be made between idiopathic and symptomatic cases of schizophrenia, and that in the second group some of the causal factors are known (e.g., cerebral disease, amphetamine intoxication; or, in the aged, personality deviation, deafness, and social isolation). You suggest that further exploration of some of these known factors in the causation of symptomatic schizophrenia may help us to understand those operating in the idiopathic disease, and that we may have reached a turning-point after more than 50 years of disappointing research. However, before taking this turning we should look back and reflect. In a paper read to the Psychiatric Section of the Royal Society of Medicine Professor Manfred Bleuler recently (on June 11) and eloquently reminded us that schizophrenic modes of experiencing and thinking occurred in mentally healthy people, but only in dreams and fantasies. Whenever they interfere with a person's dealing with reality matters, we speak of illness. I would like to saggest that, following an eruption of *schizophrenic phenomena into full awareness, the different types of schizophrenic illness may be understood in terms of the amount of reality-orientated psychic functioning remaining intact. A complete " take-over" is seen in the chronic or frequently recurring and crippling schizophrenias of early life. Here, hereditary factors are often present, and oftendescribed harmful interactions with the deviant personalities of mothers and fathers as well as with other persons (e.g., sexual trauma) may be held to bring out schizophrenic forms of experiencing, thinking, and behaving. Schizophrenic illnesses arising later in life are usually characterized by less complete syndromes: paranoid beliefs, passivity phenomena, and hallucinatory experiences, but no or only minimal changes of affective functioning, catatonic features, or disruption of thinking processes. In these patients there has been an incomplete displacement of reality-adjusted psychological functioning, and it is suggested that in these paranoid schizophrenias a more normal personality development has been allowed to occur. As was demonstrated by Slater and his colleagues' for epileptic schizophrenics, and for elderly schizophrenics by other workers,24 the clinical features of these " symptomatic " illnesses are indistinguishable from those of paranoid schizophrenia; dilapidation of the personality occurred rarely, and in many ways the patients remained adjusted to the demands of reality. Suppression of delusions and hallucinations by phenothiazine drugs frequently is tantamount to producing a remission of the illness, while in younger schizophrenics changes of affect and drive may persist and prove crippling. It is suggested that we should speak of " complete" rather than of " idiopathic " schizophrenias. The term "partial " schizophrenia should be substituted for "symptomatic " as well as for " paranoid " schizophrenia. Both are characterized by a limited number of schizophrenic modes of psychological functioning breaking surface in the wake of later-life experiences or of relatively mild or focalized cerebral disorders (e.g., toxic states, epilepsy, remitted G.P.I., or old age). By looking upon schizophrenic illnesses as more or less complete or as partial, the concept of a continuum and of gradation are introduced. Acceptance of this concept may be of heuristic value. It would lead to deploying future research in two directions: (1) Towards the discovery of factors which lead to a complete breakthrough of schizophrenic functioning in early life; and (2) towards the more difficult and fundamental task of elucidating the nature and somatic correlates of the normally hidden schizophrenic components of the human psyche. Divide et impera.-I am, etc.,