Schizophrenia and Related Syndromes

P. J. McKenna, P. J. McKenna

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135843830
• Edition: 2
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

This new edition of Schizophrenia and Related Syndromes has been thoroughly updated and revised to provide an authoritative overview of the subject, including new chapters on the neurodevelopmental hypothesis, cognitive neuropsychology, and schizophrenia and personality.

Peter McKenna guides the reader through a vast amount of literature on schizophrenia plus related syndromes such as paranoia and schizoaffective disorder, providing detailed and in-depth, but highly readable, accounts of the key areas of research. The book describes the clinical features of schizophrenia and its causes and treatment, covering subjects such as:

• Aetiological factors in schizophrenia
• The neurodevelopmental theory of schizophrenia
• Neuroleptic drug treatment
• Paraphrenia and paranoia
• Childhood schizophrenia, autism and Asperger's syndrome

Schizophrenia and Related Syndromes will prove invaluable for psychiatrists and clinical psychologists in training and in practice. It willalsobe a useful guide for mental health professionals and researchers working in related fields.

1 The cardinal symptoms of schizophrenia

Schizophrenia confronts the clinician with an array of symptoms that is remarkably diverse and disconcertingly large. The symptoms themselves are often quite strange, sometimes extraordinary, and on occasion downright unbelievable. To make matters worse they vary greatly from patient to patient, and in the same patient at different times. In such circumstances their description and classification might be considered to present something of a daunting task.

To a considerable extent this task was accomplished by Kraepelin (1913a) and Bleuler (1911) in the two original accounts of schizophrenia. With an eloquence that has never been equalled, they delineated the full range of symptoms seen in the disorder, brought them to life with examples, and constructed a framework for classifying them that has governed all subsequent thinking. Succeeding decades saw only minor modifications to their scheme, the most important of which was the isolation by Schneider (1958) of a set of ‘first rank’ symptoms, which he considered to be pathognomonic of schizophrenia. Some further refinement has been achieved in the contemporary era of standardised methods of assessment. A particularly influential contribution in this area has been the rich and phenomenologically rigorous definitions of many schizophrenic symptoms provided in the glossary to a structured psychiatric interview, the Present State Examination of Wing et al. (1974), which far outstrips any of its competitors.

The symptoms detailed in this chapter consist of those that would be ordinarily regarded as psychotic rather than neurotic, and would be considered unexceptional in established schizophrenia, or, if they occurred in isolation, would raise the distinct possibility of schizophrenia being the diagnosis. These are divided in the time-honoured way into abnormal ideas; abnormal perceptions; formal thought disorder; motor, volitional, and behavioural disorders; and emotional disorders. Some members of each category have come to be regarded as prominent, striking, or especially characteristic of schizophrenia and therefore are singled out as cardinal symptoms. Other more minor or non-specific phenomena are grouped together as miscellaneous symptoms. Finally, there are the diagnostically important but otherwise motley collection of Schneiderian first rank symptoms, which are given a category of their own.

Abnormal ideas

The cardinal abnormal idea of schizophrenia is of course delusion. This is typically defined as a belief that is judged to be erroneous; is held with fixed, intense conviction; is incorrigible to argument; and is out of keeping with the individual’s social, educational and cultural background. Delusions are also usually fantastic, patently absurd or at least inherently unlikely (Feighner et al., 1972); typically they are also justified by the patient in a peculiarly illogical way (Sims, 2002). Abnormal ideas that are not delusions are undoubtedly also seen in schizophrenia, but are very much a mixed bag of individually uncommon phenomena.

Delusions

Always the hallmark of insanity, Kraepelin (1913a) drew attention to the extraordinary frequency with which delusions of many different types developed in schizophrenia, and to the fact that they could be either transitory or permanent. Bleuler (1911) made the point that schizophrenic delusions characteristically lacked systematisation and logical integration. In almost all cases, ideas that were obviously inconsistent with one another were simultaneously entertained; often there was a whole series of senseless and completely contradictory beliefs; occasionally this amounted to what could only be described as a ‘delusional chaos’. Both authors considered persecutory and grandiose delusions to be particularly common, but sexual, hypochondriacal, referential and guilty delusions could also be seen.

Contemporarily, delusions are accepted as forming a commonplace, though variable part of the clinical picture of schizophrenia. They may be florid, multiple, and shifting; or alternatively sparse and only elicited on questioning, but persisting in the background for years. The rich variety in the content of schizophrenic delusions continues to be noted (Fish, 1962/Hamilton, 1984); nevertheless it is striking how regularly particular themes recur. The most detailed classification of delusions according to content is that in the Present State Examination of Wing et al. (1974). This is reproduced in a slightly condensed form and with a few minor modifications below.

Delusional mood

Here the subject feels that his familiar surroundings have changed in a puzzling way which he may be unable to describe, but which seems to be especially significant for him. Everything feels odd, strange and uncanny, something suspicious is afoot, events are charged with new meaning. The state may be experienced as ominous or threatening, or there may simply be puzzlement. The state typically precedes the development of full delusions: the patient may fluctuate between acceptance and rejection of various delusional explanations, or the experience may suddenly crystallise into a clear, fully formed delusional idea.

Delusions of reference, misinterpretation, and misidentification

The central experience here is that all kinds of neutral events acquire special significance and refer to the patient personally, but in a more definite way than in delusional mood. What is said has a double meaning, someone makes a gesture that is construed as a deliberate message, the whole neighbourhood may be gossiping about the patient, far beyond the bounds of possibility. He may see references to himself on the television, on the radio, and in newspapers; or feel he is being followed; that his movements are observed; and that what he says is tape recorded. The same phenomenon can extend beyond gestures and words to many other aspects of the environment, so that situations appear to be created and people seem to be acting in ways that have a special meaning. Circumstances appear to the patient to be arranged to test him out, objects are placed in particular positions to convey a meaning to him, whole armies of people are deployed to discover what he is doing or to convey some information to him. The patient sees people he knew from the distant past planted in his way to remind him of something; there are people about in disguise; patients on the ward are not what they seem to be.

Delusions of persecution

Here the patient believes that someone, some organisation, some force or power is trying to harm him in some way, to damage his reputation, to cause him bodily injury, to drive him mad, and so on. The symptom may take many forms, from the simple belief that people are hunting him down, to complex and bizarre plots incorporating all kinds of science fiction. Delusions of assistance are a variant of the same phenomenon, where the patient believes the same forces, powers and organisations are endeavouring to help him in surreptitious ways – to direct his life, to enable him to become a better person, and so on.

Grandiose delusions

These are separated in the Present State Examination into delusions of grandiose ability, delusions of grandiose identity and religious delusions. In delusions of grandiose ability the subject thinks he has unusual talents, he is much cleverer than others, he has invented things, composed music or solved mathematical problems beyond most people’s comprehension. Because of these talents he may feel he has a special mission or that he is particularly suited to helping people. The patient with delusions of grandiose identity believes he is famous, rich, titled; he is royalty or some famous person, or is related to prominent people. Although not all religious delusions are grandiose, grandiose delusions commonly have a religious colouring: patients may believe they have a divine purpose, they are saints, prophets, angels, even God.

Hypochondriacal delusions

At its purest, this term is applied to an individual’s belief that his body is unhealthy, diseased or rotten. However, the bizarre complaints of bodily change and malfunction in schizophrenia frequently – almost characteristically – go far beyond the relatively unelaborated ideas seen, for example, in depression. Kraepelin described patients who believed that that their lungs were dried up, that their body was full of wax, or that their flesh was coming away from their bones. Contemporary examples in the same vein can be found in the Present State Examination, where Wing et al. gave as examples patients who stated that they had a metal nose, or that their liver was turned to lead by X-rays. One of Sims’ (2002) patients was convinced that his semen travelled up his vertebral column to his head, where it was laid out in sheets.

Sexual and fantastic delusions, delusional memory and delusional confabulation

Sometimes sexual delusions are intimately bound up with hallucinatory sensations, for example in the genitals; in other cases, however, there are beliefs of pregnancy, in a fantasy lover, or that one’s sex is changing, which cannot be attributed to abnormal perceptions. In fantastic delusions, the notable bizarre quality of schizophrenic delusions comes to violate common sense at its most elementary. Patients describe giving birth to thousands of children, walking all over the moon, having hundreds of people inside their body, and so on. One form of delusional memory consists of clearly recalled experiences of past events that equally clearly did not take place. These commonly have a fantastic quality, for instance a patient’s recollection that he came to earth on a silver star or that members of the Royal family were present at his birth. In other instances, genuine memories become distorted by delusional significance in much the same way as current events do in referential delusions; for example, a patient realised he was of royal descent when he remembered that the fork he had used as a child had a crown on it (Fish, 1962/Hamilton, 1984)). Delusional confabulation is a rare phenomenon in which delusions – invariably fantastic delusions and delusional memories – appear to be made up on the spot and shift, change and become more elaborate as the patient is questioned about them. An example is shown in Box 1.1.

Box 1.1 Delusional confabulation

Extract from an interview with a chronically hospitalised schizophrenic patient whose main symptoms were auditory hallucinations and mild-to-moderate catatonic phenomena. He was not thought to be currently deluded, but had alluded to ‘violent ideas’ while being tested by a psychologist.

Q:	The main thing I wanted to ask you about today was about what you were telling me on Wednesday about the Carlton brothers. Can you tell me again?
A:	OK I’ll tell you what happened. In 1978 I shot a man in the back of the head in a shop in Cambridge. I put one cartridge into him. My brother David put about eight into him. I shot a man in the leg called Conrad Carlton.
Q:	When was this?
A:	About 1978. I frogmarched him from St Neots right into the Midlands with a shotgun pointed at him. It was an empty shotgun.
Q:	Was this on foot?
A:	Yeah. Right into the Midlands, about 80-odd miles.
Q:	Both walking?
A:	Yeah, I did. I was on the television.
Q:	How did you end up on television?
A:	Because I had a shotgun pointed at him, you know. I was sort of notorious, you know, we had a bit of fame – well the wrong sort of fame – but, you know, we got into a sort of contest and he could have lost his life. If I had aimed a few inches higher I could have killed him.
Q:	Where did you shoot him?
A:	I shot him in the leg.
Q:	And you say this was a contest.
A:	Yes [laughs]. Only he lost it. In 1979 Richard, Conrad Carlton, Reg Walters and, um, Davis, shot my father in the head with a shotgun in a removal van in Papworth Everard hospital grounds.
Q:	What were the circumstances of that, then?
A:	Well, the Walters, Richard and Reg Walters and the Wilson brothers got together and they murdered my father in the back of a removal van in Papworth Everard hospital grounds. I think they shot him in the head with a shotgun and Reg and Richard smashed the back of his head with club hammers and axes. And Richard said bring the next one up and Conrad and Paul got hold of me and tried to get me in the back of the removal van and I said you are not going to get me into that and do what you did to my father.
Q:	Why were you aro...