HM, aged 47, was a plump, pleasant woman, with an easy social manner. One year before her admission she had begun divorce proceedings, but her husband died before these plans came to fruition. The proceedings were prompted by HM developing the idea that a colleague from work had an interest in her, and that this man had enlisted the aid of groups of people who observed her. He also organised radio personalities to make reference to their liaison. HM described this surveillance as due to both paranormal and physical forces and believed it to be protective; but she had at times been fearful and was concemed that a carving knife was missing from her home and that she was followed by private detectives. These ideas had continued unabated despite having no contact with the man concerned for the preceding year. HM was admitted and rapidly transferred to day care. She clung to her ideas and was still in day care eight months later.
Case 1.4
Prior to her illness, CR, aged 20, had left home and was contemplating marriage. The most striking feature at interview was CR’s disorganised behaviour. She would sit for only moments in a chair and then wander round the room, picking up articles and occasionally sitting on the floor. Her limited spontaneous speech consisted often of abrupt commands to be given something. It was almost impossible to gain her attention. She repeatedly removed her dressing gown and made highly inappropriate sexual advances to the male staff, and then tore bits off a picture of a swan. She appeared neither depressed nor elated and moved slowly. She said that God talked to her, saying “Shut up and get out of here”. When replying to an enquiry as to interference with her thinking the patient said, “The thoughts go back to the swan. I want the cross to keep it for ever and ever. It depends on the soldier Marcus the nurse”.
After 6 months in hospital, CR returned to her mother’s home, and 14 months after her first admission remains there attending a day centre. She is now extremely lethargic with affective flattening and some incongruity.
Many epidemiological studies have been conducted using classification schemes of this type (see Hare, 1982 for a review). These studies show that schizophrenia is a surprisingly common illness with a life-time risk of approximately 1 in 100 people. This risk seems to be largely independent of culture and socio-economic status. In men the most likely age of onset is in the mid-20s, but the illness can occur in children as young as eight, and typical schizophrenic symptoms can occur for the first time in the elderly. The illness is equally common in women, but the average age of onset is a few years later than in men, that is in the early 30s.
The cause of schizophrenia remains unknown (for a review see Cutting, 1985), but it is generally assumed that it has an organic basis. There is strong evidence for a genetic component and some evidence that risk is increased by birth injury and by viral infection during pregnancy. There is no evidence that psychosocial factors can “cause” schizophrenia, except, possibly, in individuals already at risk.
In order to be diagnosed as schizophrenic the patient must report particular kinds of bizarre experiences and beliefs. Many of the symptoms involve hearing voices (hallucinations). These voices are described as, “discussing my actions”, “talking to me”, “repeating my thoughts”. Commonly found bizarre beliefs (delusions) are that “others can read my thoughts”, that “alien forces are controlling my actions”, that “famous people are communicating with me”, that “my actions somehow affect world events”. Table 1.2 lists these symptoms, which are often called “positive” because they are abnormal by their presence.
More rarely the patient’s speech becomes extremely difficult to understand and is described as incoherent. On the next page is an example of such speech recorded by Til Wykes from a psychiatric interview. I shall look more closely at language disorders in schizophrenia in Chapter 6.
We only know about the bizarre experiences and beliefs because the patient tells us about them (symptoms). In addition there are abnormalities in behaviour that we can observe (signs). For instance, the patient may show a reduction in spontaneous behaviour in many areas, resulting in poverty of speech, poverty of ideas, poverty of action, and social withdrawal (Table 1.3). These signs are called “negati...
