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This article throws light upon the nine important clinical types of schizophrenia. The types are: 1. Simple Schizophrenia 2. Hebephrenic Type 3. Paranoid Type 4. Catatonic Type 5. Childhood Schizophrenia 6. Affective Schizophrenia 7. Acute Undifferentiated Schizophrenia 8. Chronic Undifferentiated Schizophrenia 9. Residual Schizophrenia.
Type # 1. Simple Schizophrenia:
This is the beginning stage in which the individual shows apathy, indifference and general loss of ambition, emotional indifference. Gradually this sort of tendency goes on increasing and he becomes lazy, apathetic and is not able to concentrate, talks less, shows least interest with the opposite sex. However, there is no difficulty so far as mental function is concerned and it in-fact remains intact.
Such people always want to remain in lonely places. They do not show any interest in personal reputation or family welfare. Because of these symptoms sometimes they are mistaken as mentally retarded and intellectually impaired, though psychological tests show that they are not mentally retarded.
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Similarly they are sometimes mistaken of having inadequate personality, though there is a difference between simple hebephrenic and inadequate personality types.
Those with inadequate personality types may appear to try to function effectively while schizophrenics do not try at all. Many simple schizophrenics do not need hospitalization at all. They cannot stick to a particular place or job and often shift from one place to another.
Simple schizophrenia has therefore been defined as a form which is characterized by insidious development over some years of oddities of conduct, difficulties in social contact, unreasonableness, extreme intolerance of relations and friends who seek to induce the patient to conform to their own interests and to the demand of the society and decline in total performance.
Consequently, “Social derailment occurs and the patient sinks into vagrancy.” An analysis of the family history of simple schizophrenics by Kant (1973) indicates that most of the simple schizophrenics come from unhappy families, broken foster homes, having a very unsatisfactory, in secured and unhappy childhood.
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The onset of the disease began sometimes between puberty and early middle age. Before the occurrence of the symptoms most of them were reported to have made very poor sexual adjustment and have been very submissive, shy and hypersensitive. There are reports of many simple schizophrenics being maladjusted, leading a life of delinquency, prostitution etc.
In the simple type, the symptoms are mild and the patients have a touch with the reality and contact with the environment. There is emotional apathy and indifference without serious loss of contact with reality.
However, because of their antisocial and delinquent problems, they create law and order problems, disobey the rules and regulations and hence not only create problems for the society, but for themselves also.
In this connection Coleman (1974) remarks “one cannot help but be impressed by the need for love and affection almost pathetically evident in many of these patients lacking as they are inadequate means of expression and apparently very much inhibited by fear.
Type # 2. Hebephrenic Type:
The term “Hebephrenic” is derived from a Greek word meaning youthful mind as it was presumed that the type of behaviour disorder occurs at an early age and develops gradually.
Thus Coleman comments, “Hebephrenic reactions usually occur at an early age and represent a more severe disintegration of personality than the other types,” Commenting on the typical characteristics of a hebephrenic schizophrenic Duke and Nowicki have further remarked, “He is a bundle of energy characterized by primitive, dis-organised and regressive behaviour.”
They are thus very untidy, lack personal hygiene and are incoherent in speech. Thinking and language is distorted.
Their behaviour is characterized by silliness and absurdity as well as excitability. With the progress in the disease the patient becomes emotionally more indifferent and infantile in his reactions. A hebephrenic bothers and broods about trivial matters and occupies his time with religious and philosophical discussions.
He is rather more preoccupied with his fantasies. Lack of clear response to initial question and a special type of thinking distortion called ‘Clang’ is observed. Duke and Nowicki hold “In clanging the person speaks in rhymes, new thoughts or topics emerge as a result of rhyming relationship with the previous thought.
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Thus, knees leading to nephew (probably via niece) is an example of a clang association, an association made on the basis of sound rather than content.” Symbolic gestures and postures, laughing and crying without any obvious reason and irrational behaviour etc. are also notable among the hebephrenic.
Over and above all these characteristics of a hebephrenic, delusions, hallucinations and illusions are found. Hallucinations of auditory nature in particular and delusions of sexual, religious, hypochondriacally and persecutory nature are more prominent.
Sometimes they feel they are great men, king or wife of a star or a famous international cricket player. Once a patient came to the author claimed that he is the famous cricket player Gavaskar.
Another said, she is “Ma Kali”. Still another said she is the Prime Minister of India. Not only they verbally claim to be so, such great personalities, they strangely and interestingly exactly imitate such people. Their delusions and hallucinations are very fantastic and highly imaginative.
A patient for instance once claimed that there was a bee in his stomach which is talking to him. Another strongly felt that a vampire has sucked all her blood and she is now virtually a skeleton.
Viewing on a hebephrenic, Page (1947) comments…………………….. “As the disease progresses, they exhibit such pronounced deterioration of intellect, judgment of speech and social habits as to justify the statement that they no longer resemble human beings.”
Summing up the characteristics of a hebephrenic, Coleman says, “The overall picture of hebephrenic reactions is that of a young person who has retreated from the stresses of life by regressing to a silly, childish level of behaviour and by withdrawing into a fantasy world of his own with accompanying emotional distortion and blunting.”
Type # 3. Paranoid Type:
While the hebephrenic shows major affective disorders, the paranoid schizophrenic is characterized by strong delusions of persecution, influence or grandeur. Actually the patient’s behaviour is centred around those delusions and hallucinations.
This subsequently leads to loss of critical judgment and erratic, somewhat unpredictable behaviour. They more often than not develop ideas of reference. If some people are talking, the paranoid type overhears them, thinks that they are talking about or against him.
Thus, he becomes egoistic, extremely sensitive, shy and suspicious. They often face difficulty in relating to people and having interpersonal relationship. In reports of newspaper, television coverage’s or radio broadcasts, they think they are being referred.
An old lady of 80 developed a paranoid fear that policemen would come and arrest her and her daughter. All the while she complained that they would definitely harm them. Some paranoid types also believe that all are plotting against them, going to murder them.
They hear the voice of their enemies calling them. They see their faces in night and are terribly horrified. A paranoid patient suffering from delusion of grandeur really feels that because he is wealthy and intelligent others are envious of him.
Commenting on the symptoms of paranoid schizophrenics Shanmugam (1981) remarks, “Paranoid schizophrenics are generally alert, agitated, talkative, aggressive but also confused and afraid. They do not show signs of regression. However, compared to other types of schizophrenia, they show less extreme withdrawal from reality.”
Paranoid schizophrenia is most commonly found and usually develops between the ages of 25 to 40. The presence of homosexual conflicts in all paranoid conditions has been supported by the findings of a study where over 33 per cent had shown homosexual behaviour prior to their psychiatric breakdown.
It is said that people having strong homosexual tendency, as a defence see their enemies in hallucination. So male patients see male enemies and females see female enemies.
Paranoids are more intelligent and manifest a healthier life than other subtypes. 50 per cent of all schizophrenics first admission to mental hospital are diagnosed as paranoids and so it is said to be the most common type of all schizophrenics.
Type # 4. Catatonic Type:
Catatonia refers to lessened muscle tone. So the most prominent and marked symptoms of catatonic schizophrenic are motor disturbance, under activity, general inhibition manifested by catatonic stupor, mutism, regression etc. The catatonic patient sits or stands in a particular posture or position for hours and days together, does not listen, talk or pay attention to or reply to anything that is told to him.
He develops utter negativism. He seems completely out of touch with the reality and at times “there is automatic obedience where the patient follows all instructions.” He might be knowing what is happening, but he does not care to respond to the ordinary stimulation of his environment.
In a cyclic order sometimes he gets extremely excited and at time shows immobility. Extreme rigidity as well as flexibility of muscles is found. In the immobile stage the limbs may become stiff and swollen.
Keeping in view these symptoms the American Psychiatric Association has classified it as excited and withdrawn. In the excited stage he manifests wild uncontrollable verbal behaviour and very destructive motor behaviour while in the withdrawn stage extreme immobility and rigidity in behaviour is noticed.
Analysis of the behaviour patterns of most cationic reveal that there is a background of eccentric behaviour coupled with withdrawal from reality. Lack of capacity for decision is another visible characteristic of a catatonic type.
Catatonic schizophrenia is the least serious of all the types and its prognosis is not so difficult. Most surprising as well as interesting about the catatonic type is that after some months either the patient becomes normal or becomes very excited. Schizophrenia has also been divided to some other types by some experts in the area. They are discussed as follows.
Type # 5. Childhood Schizophrenia:
As a behaviour and disorder occurring during early childhood schizophrenia shows symptoms such as lack of relatedness to others, an obsessive desire for sameness, dis-organisation of thought process, unclear and distorted body image and extremely low degree of frustration tolerance.
Childhood schizophrenics also demonstrate severe disturbances in language function, such as mutism, delayed onset of speech and little desire to communicate with others. Obsessions for stereotyped motor behaviour are often found.
Studying 6 hundred schizophrenic children of 2—13 years age group, Bender (1953, 1955, 1961) emphasised retarded and irregular development. She noted the schizophrenic child having difficulty in developing a sense of self identity, becomes unable to make suitable identification with parental and other role models, lacks adequate development of ego defences and deals successfully with anxiety and structured view of reality.
Weil (1953) besides supporting Bender’s finding also noted that “the schizophrenic children show disturbances in eating, sleeping and other habit patterns and the anxiety and rigidity, typical of threatened persons.” Pollack (1960), Colbert and Koegler (1961), Kaufman (1962) Meyers and Goldflarb (1962) have also reported differences, between schizophrenic reactions in childhood adolescence and young, adulthood.
Type # 6. Affective Schizophrenia:
In this type of schizophrenia the main symptoms of the patient centre around the affective reactions like elations and depressions of the extreme degree. In some cases also the thinking of the schizophrenic is distorted and dis-organised and his behaviour may show signs of bizarreness.
Type # 7. Acute Undifferentiated Schizophrenia:
A sudden appearance of numerous varieties of schizophrenic symptoms come under this category, often they appear without sufficient and reasonable precipitating stress. These symptoms may subside within a few weeks. But with all probability they may reappear again or may shift to some other types of schizophrenia.
Type # 8. Chronic Undifferentiated Schizophrenia:
This reaction type consists of mixed symptoms. But the symptoms persist for a long period and this is why it is named as chronic. Coleman opines that “This category includes the so called latent incipient and prepsychic schizophrenic reactions in which the individual shows mild schizophrenic thought, affect and behaviour but may not be able to make a marginal adjustment.”
Type # 9. Residual Schizophrenia:
It refers to those schizophrenic patients who after treatment have improved substantially but who continue to show mild schizophrenic symptoms. Besides the above categories, experts in the field of psychiatry also use the terms such as ambulatory schizophrenia, Pseudo neurotic schizophrenia and Pseudo psychopathic schizophrenia.
An Evaluation:
Acute vs. chronic dimension seems to be the most widely accepted and practiced but research is more advanced on the process reactive dimension.
However, in-spite of other categories of classification DSM II seems strongly entrenched with those using diagnostic categories.
Duke and Nowicki (1979) have reported that some experts have offered the controversial idea schizophrenia may not even exist. For example, Van Praag (1975) has said, “I believe that the schizophrenia concept no longer meets any of the criteria of the disease entity.
In-fact, the term signifies hardly anything more than psychoses. I consider the concept to be absolute. The term should either be re-operationalized or dropped altogether.”
According to Lehmann, (1975), “the world renowned psychiatrist Karl Menninger has long protested the use of the term schizophrenia calling such a diagnosis a twentieth century version of witch craft”
Experimental studies on schizophrenia:
Experimental studies on schizophrenia reviewed by Yates (1975), Frith (1975) and Pyane (1964, 1975) suggest that a lot of experimental work has been done to measure the different mental process and psycho motor abilities of schizophrenic patients.
More specifically, scientific work has been conducted to measure the psychomotor abilities, perceptual processes, motivation, disorders of memory, intelligence and conceptual abilities of schizophrenic patients.
Analysing the studies conducted using reaction time and tapping, Yates drew the following conclusion:
(i) Undifferentiated schizophrenics are significantly lower than depressives and neurotics.
(ii) Chronic schizophrenics are significantly slower in reaction time and tapping than acute schizophrenics, depressives and neurotics.
Experimental work using tests of perception like estimation of size etc., show that wide range of stimuli are perceived by paranoid and reactive schizophrenics in comparison to process schizophrenics who perceive an unusually narrow range of stimuli.
Similarly in acute and chronic cases of schizophrenia, unlike paranoid Schizophrenia, abnormal distractibility was found. It is viewed that since cortical activation is considered to be in high level in the case of paranoid schizophrenic in comparison to other types, it obviously differs significantly from the other kinds.
Tests of immediate memory, short term and long term memory, conducted to assess the disorders of memory of schizophrenics indicate that in schizophrenia short term, long term memories were affected in comparison to neurotics and normal. Inability to form concreteness may be one of the reasons of memory disorders in schizophrenics. This is also found in brain damaged patients.
Experimental findings also reveal a complex relationship between motivational variables and schizophrenia. High drive levels are noticed in acute and paranoid schizophrenics having similar effects on the behaviour of severe anxiety neurotics.
On the contrary, non-paranoid and chronic schizophrenia show symptoms of apathy, indifference and withdrawal indicating low drive levels, but they appear to be defensive reactions to a state of abnormally high drive.
A large number of experiments have also been done on conceptualization especially the one by Payne (1962) are worth mentioning. By and large, the findings indicate the schizophrenics are characterized by over inclusive thinking in comparison to the clinical groups.
Studies on the I.Q. of different schizophrenic groups reveal that schizophrenics have a low I.Q. level in comparison to other clinical groups. Findings further suggest that there are also differences in the I.Q. level among the different schizophrenic types. Paranoid schizophrenics have a higher I.Q. than hebephrenic and simple schizophrenics have a higher I.Q. than catatonics.
Among all the investigations conducted to find out the relationship between low I.Q. and schizophrenia, only Mason’s study (1956) supports the view that those with low I.Q. develop schizophrenia. Experimental findings on rigidity and persistence of schizophrenia in comparison to normal and other clinical groups reveal significant difference. Also differences exist among various schizophrenic groups.