Schizophrenia is a mental condition with a remitting, persistent, or deteriorating course, characterized by the continuity of certain underlying features. In its early stages, it is dominated by psychotic symptoms such as hallucinations and delusions (the “productive” phase), while in its advanced stages it is characterized by symptoms such as abulia (that is, reduced will and initiative), apathy (that is, the absence of inclination or desire for anything), and affective flattening and indifference (the impoverishment, or “deficit,” phase). At present, schizophrenia, compared with other conditions involving similar symptoms, should be defined by the persistence of symptoms during the first two years after onset, although at the current state of medical knowledge it is highly unlikely that no therapeutic intervention would alter the spontaneous course throughout this entire period. For the meaning of psychotic symptoms, see the article “Psychosis.”
Originally, schizophrenia was called dementia praecox (dementia of young age), because it was understood as a disorder with a dementing course, beginning at a young age and dominated by psychotic symptoms. It was contrasted with the other major disorder characterized by psychotic symptoms, manic-depressive illness or bipolar I disorder, precisely because of its course: persistent rather than cyclical. In other words, the person with schizophrenia does not return to “normal” once the acute phases have subsided, but instead develops a sort of increasing “deficiency” in social, productive, and self-care functions.
In fact, different forms have always been recognized, and these are not merely stages of progression but also variants. In the paranoid form, delusions and hallucinations predominate; in the disorganized form, there is a breakdown in the logic of behavior, with a loss of the harmonious association between the various components of mental life (intrapsychic ataxia); in the catatonic form, apathy, indifference, and inhibition of initiative predominate.
Psychiatry has nevertheless always attempted to identify a common thread that would define the nature of the illness through its essential features, shared by all its variants. This is reflected in the concept of schizoid personality, a term still used today to describe a personality pattern of the schizophrenic type and one that may occur as a pre-schizophrenic condition. Paranoid, schizotypal, and schizoid personalities have been described. They do not necessarily develop into schizophrenia, but they represent an attenuated and more stable version of the schizophrenic condition (particularly the schizoid type).
These personality types are collectively described as “odd,” meaning strange or bizarre, in the sense of being alienated, socially detached, and not centered on shared emotions. The schizoid type appears as an isolated individual who does not necessarily suffer because of this situation, but rather perceives others as a source of threat or anxiety and has few interests, often difficult to understand in terms of their underlying structure. The schizotypal type has a better capacity for relationships, but this is often limited by the logical bizarreness of their thinking. The paranoid type may be well adapted, but tends to develop logically unjustified beliefs and suspicions regarding other people, resulting in hostility and antagonism.
In the presence of a psychotic state, schizophrenia is therefore not currently diagnosed on the basis of specific symptoms, but rather on the basis of its course. In practice, however, most psychiatrists also rely on an impression based on the concept of “fundamental symptoms,” concerning the disorganization of the affective-volitional axis, detached indifference toward the environment, abnormally structured emotional relationships (an ambivalent judgment toward the same object without a recognizable affective position), and the un-derived or loosened nature of associative connections.
From this perspective, the dominant symptoms—hallucinations and delusions—are actually accessory and less specific symptoms, meaning that they are also common in other disorders.
It is less useful, on the other hand, to distinguish schizophrenia from manic-depressive illness on the basis of the characteristics of psychotic symptoms such as hallucinations and delusions, because these differences are particularly unreliable in contexts where “new” factors are present, such as substance use.
The impression of “schizophrenia” may sometimes also be based on a particular sensation experienced during interaction with the person being examined, described as a “dissonance of atmospheres between the two interlocutors.” This refers to a form of detachment perceived as uncomfortable or embarrassing, a silence that cannot be interpreted in terms of an identifiable emotional position or attitude, but rather as a breakdown in rational communication and emotional impenetrability. The person with schizophrenia therefore appears cold, not easily “provoked” within the interaction, and unable to understand the emotional position of the other person (absence of emotional resonance).
The prognosis of schizophrenia is characterized by chronicity of its fundamental symptoms, although the severity of the accessory symptoms and the progression toward a fully developed dementing condition are more variable. It is currently believed that the more benign forms are those with a “productive” onset, provided that they are treated promptly.
Even today, a person with a several-year history of schizophrenia, although stabilized and protected from the main symptoms through treatment, is generally recognizable because of the consequences of the underlying symptoms: isolation, distrust, or superficial interaction with the surrounding reality; reduced autonomy in productive activities and in organizing everyday life; and an absence or fragmentation of goals and initiatives.
The treatments initially available were developed to resolve the accessory symptoms, which were also the most problematic ones—hallucinations, delusions, and aggression. However, the overall side-effect profile of these medications partly reproduced the “negative” symptoms of schizophrenia, that is, those that become evident in the later stages or in the “deficit” forms. The impact of the first medications on these forms, or on people who had been ill for many years, was therefore more limited and, in some respects, actually worsened certain aspects of the condition.