British Journal of Psychiatry 112: 225-251 (1966)
 
 

The Early Symptoms of Schizophrenia

By JAMES CHAPMAN

(Based on an M.D. thesis submitted to Glasgow University)
 
 

Introduction


 


Since Bleuler introduced his concept of schizophrenia in 1911, there has been a steady growth of clinical and experimental data relating to this disease. However, the literature dealing with early diagnosis is sparse and as yet there is no general agreement as to what symptomatology constitutes the early clinical picture. Older texts (Kraepelin, 1919; Bleuler, 1911) do not elaborate early diagnosis, dwelling more on distinguishing schizophrenia from other disease entities. Likewise, more recent texts tend to refer to the early stages very briefly in rather vague terms, signifying the development of the disease over the first few years from its onset. Although practice varies, the diagnosis of schizophrenia is often reserved until Bleuler’s primary symptoms of disordered volition, thinking and affect appear overtly, by which time there may be also some evidence of deterioration. It is recognized, however, that these symptoms may take years to appear (Gillies, 1949) so that early diagnosis cannot readily be made by using these criteria.

There are a number of reports which deal indirectly with the early stages of schizophrenia, but these tend to focus on the similarity between the early stages of the disease and other, particularly neurotic, states. Such reports are prone to compare and contrast the early stages of schizophrenia with a variety of neurotic clinical pictures and often merely emphasize the difficulty in early diagnosis, eventually labelling cases where the diagnosis is in doubt and where the disease is not established, as latent (Bleuler, 1911; Forer, 1950), pseudo-neurotic (Hoch and Polatin, 1949), abortive (Mayer, 1950), ambulatory (Zilboorg, 1956), masked (Kiesler, 1952), sub-clinical (Peterson, 1954), and borderline (Wolburg, 1952; Knight, 1953; Axel, 1955; Shenken 1956) schizophrenia.

The views of American psychiatrists are quoted by Bellak (1958), who states that the diagnosis of schizophrenia is essentially phenomenological, based on the degree of disturbance of ego functions and also on the pathological nature of the defences appearing in the disease. According to Bellak, the concept of the ego is best understood by reference to its functions, which include the individual’s relation to reality, drive regulation, object relationships, thought processes, defences, autonomous functions, and synthetic functions. With this ego-psychological approach, Bellak describes the "borderline" schizophrenic as an individual whose thinking, affective control, perceptual reliability and object relationships are weakened, but who does not show signs of deterioration. Bellak goes on to say, "If this same picture of dubious functioning is present, but accompanied by signs of increasing lability of mood, progressive inability of impulse control, increasing emergence of the primary processes and increasing crumbling of the defences, with deja vu experiences, feelings of unreality, impaired sleeping, impaired appetite and a rising anxiety level, then we are dealing with incipient schizophrenia, and steps might be taken to avoid its further progress". Here again the early clinical picture is expressed in somewhat vague and general terms. Bellak admits that symptoms related to the breakdown of ego functions are not specific to schizophrenia and may be present in a wide variety of other conditions.

Gillies (1949, 1958) is one of the few authorities who have attempted to describe the early clinical picture in a more specific manner. Gillies places emphasis on Bleuler’s primary symptoms of disordered thinking, affect and volition, and autistic withdrawal. He considers these symptoms pathognomonic, but points out that they may not appear overtly for a long time. Gillies’ approach was to study case records for the earliest subjective complaints made by schizophrenic patients and to arrange these non-specific symptoms according to their derivation from the primary symptoms. Such symptomatic changes included vagueness in thinking, bodily preoccupations, seclusiveness, lack of interest, and a wide variety of neurotic symptoms. Gillies stresses the importance of assessing the overall picture and also the patient’s attitude to his symptoms.

Some insight into how a proportion of Scottish psychiatrists approach the diagnosis of early schizophrenia was obtained in a survey made by Timbury and Mowbray (1964). In carrying out this survey, these authors first consulted seven British textbooks in general use (Curran and Partridge, 1955; Gillies, 1958; Henderson and Gillespie, 1950; Lewis, 1950; Mayer-Gross, Slater and Roth, 1960; Skottowe, 1953; Valentine, 1955). From these seven sources an objective composite description of the diagnostic features of early schizophrenia was obtained, using the comparative matching technique described by Raven (1950). This was done by analysing the frequency with which discrete statements about the diagnosis of schizophrenia appeared in the above texts. By removing recurring and synonymous statements, a final list of 106 such items was obtained, and these were then sorted by experienced observers until an agreed classification, under seven main headings, was reached. This list of items was then used to construct a questionnaire which was presented to members of the Royal Medico-Psychological Association in Scotland, of whom 95 (nearly 60 per cent.) responded. Analysis of the results showed that considerable differences existed between psychiatrists in the criteria used for diagnosis. The most characteristic items which senior psychiatrists used in early diagnosis, were, briefly, vagueness in thinking, emotional blunting and incongruity of affect, lack of spontaneity in speech, preoccupations, perplexity, withdrawal, and change in the experience of self. The authors of the survey concluded that the lack of uniformity in the approach to diagnosis was partly dependent on the lack of agreed operational definitions of the terms used.

In the present study, in the follow-up of young patients over a period of a few years, the observation was confirmed that profound changes in cognitive function are subjectively experienced by schizophrenics long before the overt appearance of signs of established disease. This led the author to continue the approach which bears some resemblance to that described by Gillies (1958), of making a detailed assessment of the subjective complaints of schizophrenic patients. However, whereas the latter author used a retrospective study of case records, it was decided that possibly more detailed clinical data might be obtained in a prospective study, by interviewing patients at an early stage of their psychosis and encouraging them to describe their subjective experiences.

The purpose of the present paper is to present clinical data in the form of symptomatic changes in subjective experience reported by a group of 40 schizophrenic patients who were in the main studied from an early stage in the disease, and to discuss their significance and possible application to early diagnosis.
 


Method


 


The subjects were selected from young inpatients at Gartnavel Royal Hospital, Glasgow, and later, more extensively, at the Dundee Liff Hospital. Patients were included in the study if the diagnosis of schizophrenia had been confirmed by the consultant psychiatrist in charge of the case, if the duration of illness did not exceed three years, and if the diagnosis was confirmed on follow-up. Most of the patients examined were still in the relatively early stages of the disease and had not yet lost the capacity to communicate their subjective experiences. Forty patients co-operated in the study. Details of age, occupation, marital status, sex distribution, and duration of illness at the time of examination, are listed in Table I. The age range was 17 to 32 years, giving a mean age of 24.6 years. Although the sex of the patient was not a criterion for selection, only two patients out of the whole group were female. The duration of illness, as measured from the time when the patient first became noticeably ill, varied from one to 33 months, the mean duration being 11 months. The majority of patients (85 per cent.) were unmarried. Every patient was examined in a short series of interviews, numbering from two to twelve, each of which lasted approximately one hour. The interview was structured in order to provide a full assessment of changes in subjective experience collected under categories which reflected disturbances in attention, perception, memory, motility, thinking and speech.

Since this involved a set of direct questions being put to the patient, this method is not without possible fallacies, arising particularly in the area of the patient’s suggestibility and from the possibility that the patients were producing memory illusions or falsifications. Precautions were taken as far as possible to avoid such contamination of the results by limiting the number of questions, presenting them in a set way and in the simplest and briefest form to act as cues for the patient to describe his experiences. Additional questions were avoided, and the patient was encouraged to project his difficulties on to the examiner while the latter remained silent. It was considered that the experiences reported by the patients were not due to illusions of memory, because in relation to each category of altered subjective experience the report of the patient was not regarded as having any validity unless he had experienced the same anomaly on numerous occasions, in different situations and in relation to different aspects of his environment. Each interview was recorded on tape and transferred later to type. The resulting data were then collected in a systematic fashion.

Although very valuable in a phenomenological study of this kind, the use of a tape recorder is not without its disadvantages, because the transfer to type may be influenced by the examiner. The patients’ quotations presented in this paper have been edited to the extent that the length of sentences and minor grammatical details were based on the author’s impression of each patient’s style, as heard on playback of the tape. Interjections, such as "eh", "um" etc., were removed. In a few cases, words spoken by the patient in a local Scottish dialect were altered to the basic English equivalent. With these qualifications in respect of modification in form, the contents of the quotations are otherwise faithful reproductions of the contents of the patients’ accounts.
 


Interview Technique


 


In an initial study of a few young schizophrenic patients, it was apparent that, although the disease was not advanced, the patients nevertheless had difficulty in communicating their subjective experiences and that interviewing by question and answer was likely to provide only a limited amount of information. It was concluded that some change in the formal aspects of communicating with the patient was .necessary.

The technique which was devised by the author was suggested by several observations of schizophrenic behaviour. Firstly, chronic schizophrenic patients occasionally speak about themselves in the third person. Secondly, it was noted that patients who could not communicate spontaneously in an individual interview could talk more readily when observed in a small group by referring to behaviour perceived in other members of the group. Occasionally a patient would engage in a monologue, which appeared to be a projection of his own experience on to another patient. Thirdly, some catatonic patients, after persistent questioning were unable to give any account or reason for their behaviour, but when the observer imitated their motor behaviour and repeated the same question, they were often able to give rational replies. Fourthly, with less deteriorated patients in individual interviews it was noted that the patient could describe his disturbance in motility much more spontaneously if referred to movements and actions made by the observer, i.e. when the patient utilized the observer as a concrete model. Finally, a few young schizophrenics reported spontaneously that they could describe their difficulties more easily if they referred to someone apart from themselves. For example, one patient (Case 25) stated, "It would be easier if we talked of a notional third person. I could more easily understand if we described this illness on a third person. Then I could understand it. I can’t understand it when it is applied to myself."

On the basis of these observations, it was decided to modify the form, as distinct from the structured content, of the interview. The patients were therefore encouraged to project their experiences and difficulties on to the examiner or an imaginary third person. 

In addition observations of the attentive behaviour of schizophrenic patients suggested that communication might be improved if extraneous stimulation, in and outwith [outside of] the room, were reduced. The interview was therefore conducted in a quiet setting, the patient and the observer sitting squarely face to face. The observer remained relatively immobile, avoiding irrelevant movements which had been noted previously to have a distracting effect on the patient. The observer’s verbal output was kept at a minimum, and the patient was allowed as much time as he wished to express himself. The patient was not discouraged or distracted from staring while speaking, since it considered that this naturally reduced his perceptual intake, which might otherwise interfere with his performance.

With this method of interviewing, patients who in ordinary circumstances might have had difficulty in providing information, could speak more spontaneously and coherently of their experiences, and the method proved fruitful in collecting clinical data which might not otherwise have been obtained. It was often noted that after the patient started off projecting his ideas on to a third person, as the flow of talk became more spontaneous, he would then begin to speak in the first person. The technique had the additional advantage, as a clinical research method, that it reduced the possibility of contaminating the patient's information with statements from the observer.

This method of interviewing may have some bearing on the apparently good articulation of these patients. However, this degree of articulation was sustained only for very brief periods of time. In addition, it should be emphasized that the patients were examined from an early stage, in some cases before the diagnosis was confirmed, and in all cases, before deterioration occurred, with the development of delusions, hallucinations, and loss of affect and insight.
 


Clinical Data


 


The phenomena to be described below are related to different aspects of perceptual and cognitive dysfunction. The clinical data are therefore presented under several headings which refer to corresponding categories of altered experience as reported by schizophrenic patients. Since presentation of all the clinical data would take up too much space, only a few of the most coherent reports are selected from those obtained from the whole group Of 40 patients in order to illustrate each type of change in mental function. For the purposes of clarity, any relevant past work is reviewed, and each phenomenon is discussed separately in the appropriate section of clinical data presented before proceeding to a general discussion of the data as a whole.

I. Disturbances In Visual Perception

Visual adaptation to the environment is normally achieved by the individual developing the capacity to select, from the diffuse mass of visual stimuli impinging upon him, that information which is relevant and necessary for him to function efficiently. In this process, sensory information is automatically organized during the act of perception itself, prior to short-term storage and subsequent integration with previous learning and experience. The ability to process a great deal of information in this way reduces the load on short-term memory and allows the individual to perceive his environment in terms of meaningful wholes. The normal adult is also able to perceive objects as being stable and constant, even though he views them from different angles or at different distances in space, regardless of whether the alteration in distance results from his own movement or the object's movement. This is referred to as visual perceptual constancy. 

The following reports illustrate how visual perception may be disturbed in schizophrenia.

Case 15

"I was sitting listening to another person and suddenly the other person became smaller and then larger and then he seemed to get smaller again. He did not become a complete miniature. Then today with another person, I felt he was getting taller and taller. There is a brightness and clarity of outline of things around me. Last week I was with a girl and suddenly she seemed to get bigger and bigger, like a monster coming nearer and nearer. The situation becomes threatening and I shrink back and back. "

Case 29

"Things go too quick for my mind. Everything is too fast and too big for me—too quick to study. Things get blurred and it's like being blind. I can't make them out clearly. It's as if you were seeing one picture one minute and another picture the next. I just stop and watch my feet. If I move, everything alters every minute and I have no control over my legs. My. legs are too quick for the top half of my body-it's my head that's weak. I followed the sun and it seemed to drive me along. The sun seemed too big for me and it was coming closer. Everything else seemed to be coming closer and bigger all the time. I tried to make the air turn back. It was frightening. That was a long time ago-last year."

"Everything I see is split up. It's like a photograph that's torn in bits and put together again. If somebody moves or speaks, everything I see disappears quickly and I have to put it together again."

Case 22

"I have to put things together in my head. If I look at my watch I see the watch, watchstrap, face, hands and so on, then I have got to put them together to get it into one piece."

This appeared to apply to this patient's perception of memory images as well as the external environment. For example, he stated, "I have to build up a picture of someone. If something interrupts me, the picture is not finished. You did it just now. You spoke while I was building up the picture. I was trying to hold on to it and listen to you at the same time. I lost it. You spoke and it faded away."

Case 25

"I see things flat. Whenever there is a sudden change I see it flat. That's why I'm reluctant to go forward. It's as if there were a wall there and I would walk into it. There's no depth, but if I take time to look at things I can pick out the pieces like a jigsaw puzzle, then I know what the wall is made of. Moving is like a motion picture. If you move, the picture in front of you changes. The rate of change in the picture depends on the speed of walking. If you run you receive the signals at a faster rate. The picture I see is literally made up of hundreds of pieces. Until I see into things I don't know what distance they are away."

It would appear from these and other reports that schizophrenic patients experience from time to time transient but severe disturbances in visual perception. At these times, perceptual stability appears to be lost and the patients are unable to reduce, organize, and interpret visual information in a normal fashion. The patient's attention is diverted to inspection of different parts of a whole, instead of being free to interpret and assimilate the whole itself. As illustrated in some of the reports (Cases 29, 22, 25), this may mean that they are unable to interpret the whole, as a meaningful gestalt, until they have taken sufficient time to co-ordinate its different elements, and this has to be done in a conscious deliberate fashion. As illustrated in two reports (Cases 29, 22), this latter activity may be interrupted by auditory or other visual stimuli occurring in the environment, thus delaying recognition of the initial stimulus. Also, the alteration in visual perception relates not only to the external environment but also to the conjuring up of visual images, a phenomenon which Critchley (1953) terms defective revisualization. There also appears to be an intricate relationship between disturbance in visual perception and motility but this will be discussed in more detail in another part of this paper.

Thus, the phenomena experienced by schizophrenic patients include alterations in the size, distance and shape of objects (metamorphopsia), alterations in colour or brightness/contrast, loss of stereoscopic vision, defective revisualization, and illusory acceleration of moving objects. Similar phenomena are known to occur with organic disease of the parietal lobes (Critchty, 1953), and some of them, also, as ictal phenomena in temporal lobe epilepsy (Penfield and Jasper, 1954; Lennox, 1960). Investigation of these phenomena in schizophrenia has begun only in recent years and has been experimental rather than clinical. The results from experiments carried out so far confirm that there is a reduction in size, shape, and distance constancy in schizophrenia (Crookes, 1957; Weckowicz et at., 1957, 1958, 1964; Hamilton, 1963). These experimental studies have been carried further to demonstrate a positive correlation between disturbed visual perceptual constancy and abnormal concept formation (Weckowicz and Blewett, 1959).

So far, there has been no attempt at a clinical correlation of disturbances in visual perception and the course of the illness. It will be shown below that there is a tendency for the illness to take a malignant course in those patients who report experiencing such phenomena at an early stage.

II. Blocking Phenomena

Bleuler (1911) stated that the Kraepelinian concept of blocking was of fundamental significance in the symptomatology and diagnosis of schizophrenia. This view has since been endorsed in some of the literature on schizophrenia, but the concept appears to have become limited to the sudden occurrence of stoppages in the flow of thinking. The phenomenon, so defined, has been likened to petit-mal epileptic seizures (Mayer-Gross, Slater and Roth, 1960) and has also been considered to be unrelated to any environmental influences (Henderson and Gillespie, 1950). This narrowing of the concept to sudden pauses in thinking is not wholly in accord with Bleuler's original observations on this particular feature of schizophrenia. Bleuler described how the phenomenon could develop rapidly, in a "capricious" manner, and occur in transitory episodes of varying duration, with blocking not only of the stream of thought but sometimes of the entire psyche, involving the processes of attention, perception, memory, speech and motility. Although he noted that attention could be blocked, Bleuler did not appear to link this phenomenon with the disorder of attention which he also described. Bleuler observed episodic changes in the selective and inhibitory functions of attention, so that at times the schizophrenic appeared to be bombarded by sensory stimuli from the environment, and he noted that—"almost everything is recorded that reaches the senses", while at other times the opposite conditions prevailed, the patient exhibiting short periods of inattention in which —"the most powerful stimuli are incapable of influencing their train of thought or of arousing their attention".

In the present study, earlier clinical observations had suggested that possibly environmental stimulation exerted some influence in the development of blocking phenomena and also that there might be a link between an apparent disturbance of selective attention and the episodic changes in mental function reported by schizophrenic patients. This question will be discussed after presenting a number of subjective accounts of "blank" spells reported by schizophrenic patients.

(A) Subjective Experiences:

The changes in subjective experience now to be reported were most often described by the patients as "trances", but different patients referred to "blank spells", "attacks", "stoppages of the- mind", "dazes", etc. The frequency and duration of the phenomenon varied with the individual patient, but in most cases it occurred several times every day, and many patients said that they had experienced these changes on a countless number of occasions. 

Case 10

"It’s like a temporary blackout—with my brain not working properly—like being in a vacuum. I just get cut off from outside things and go into another world. This happens when the tension starts to mount until it bursts in my brain. It has to do with what is going on around me —taking in too much of my surroundings—vital not to miss anything. I can't shut things out of my mind and everything closes in on me. It stops me thinking and then the mind goes a blank and everything gets switched off. I can't pick things up to memorize because I am absorbing everything around me and take in too much so that I can't retain anything for any length of time—only a few seconds, and I can't do simple habits like walking or cleaning my teeth. I have to use all my mind to do these things and sometimes I find myself moving and doing things without knowing it and I'm not controlling it. When this starts I find myself having to use tremendous control to direct my feet and force myself round a corner as if I'm on a bicycle. I want to move and the message goes from my brain down to my legs and they will not move the right way. What I'm worried about is that I might get myself so controlled that I will cease to be a person. I find it difficult to cope with these situations that get out of control and I can't differentiate myself from other people when this comes on. I can't control what's coming in and it stops me thinking with the mind a blank."

Case 25

"I don't like dividing my attention at any time because it leads to confusion and I don't know where I am or who I am. When this starts I just go into a trance and I just turn off all my senses and I don't see anything and I don't hear anything. Things going on around me don't affect me but when I come out of it all these things are turned on again. If I have to think a lot about everything I'm seeing around me and carry on a conversation at the same time, then the blank spell will come on and might be longer. It affects my actions as well. It's all right if it's just one thing at a time but I am virtually blind at these times and can't move property because there are so many things coming into my eyes that I don't know what's what, I'm like a robot that somebody else can work but I can't work myself I know what to do but I can't do it. When I'm in this state of confusion I can't relate past experience to what is happening now. I can't keep things in mind long enough."

Case 15

"At times there is nothing to hold the mind and this is when I go into a trance. When the mind stops receiving messages from things around me I don't react to anything that happens. When coming out of a trance something must disturb me to waken me out of it for you don't recover straight away. You tend to linger in these trances and your mind goes dead to the world around you. You can very easily go into a trance-it goes on as soon as the mind stops and then you realize you are not actually seeing anything or hearing anything. It's a delight—you don't feel anxious until you come out of it. When you're in it, you tend to withdraw all your interests from everything around you. It's a condition of unity and I return from this unity and say-‘Oh Heavens, where was I there?’ The trance worries you obviously if you want to jump on a bus because you might move the wrong way. It's when you return and find yourself in union with something specific that you start to worry. I might be coming out of a trance and realize that I'm not sure where my feet are going. It takes time to wear off but until it does I can't do the simplest tasks."

This patient was able to describe more clearly than any of the others in the study, an impairment of identity experienced during each episode, if he happened to be looking at another person.

"When you feel in a trance, you tend to identify yourself with the other person, but that does not matter for if he moves you go back into a trance. You are dying from moment to moment and living from moment to moment and you're different each time. You don't know you're in it. When I look at somebody my own personality is in danger. I am undergoing a transformation and myself is beginning to disappear."

Case 12

"My mind goes blank when I listen to somebody speaking to me—telling me a story, and my eyes just stare and I'm not aware of anything. It happens when I'm watching television as well and my concentration drifts away and focuses on any point in the room and I can't pick anything up that is going on. I go into a daze because I can't concentrate long enough to keep up the conversation and something lifts up inside my head and puts me into a trance or something but I always wake up later." (How does it start?) "I get shaky in the knees and my chest is like a mountain in front of me, and my body actions are different. The arms and legs are apart and away from me and they go on their own. That's when I feel I am the other person and copy their movements, or else stop and stand like a statue. I have to stop to find out whether my hand is in my pocket or not. I'm frightened to move or turn my head. Sometimes the legs walk on by themselves or sometimes I let my arms roll to see where they will land. After I sit down my head clears again but I don't remember what happened when I was in the daze."

Case 29

"Nothing settles in my mind—not even for a second. It just comes in and then it's out. My mind goes away—too many things come into my head at once and I lose control. I get afraid of walking when this happens. My feet just walk away from me and I've no control over myself. I feel my body breaking up into bits. I get all mixed up so that I don't know myself. I feet like more than one person when this happens. I'm falling apart into bits. My mind is not right if I walk and speak. It's better to stay still and not say a word. I'm frightened to say a word in case everything goes fleeing from me so that there's nothing in my mind. It puts me into a trance that's worse than death. There's a kind of hypnotism going on."

(B) Clinical Observations

Apart from subjective reports obtained initially at interview, this type of change in attentive behaviour in young schizophrenics could be observed directly. It was noted that when the phenomenon did occur, it appeared to develop in a certain way which will now be described and which, apart from duration, appeared to be strikingly the same for different patients.

At the beginning of the interview the patient may be listening attentively or speaking relatively coherently. Then, if the observer talks a lot and particularly if the communication is abstract, the patient may become confused and so distracted by environmental events that he is unable to maintain any one line of thought and communication begins rapidly to break down, When this occurs, the patient loses his initial composure and appears to become increasingly alert. This change is nearly always accompanied by manifest anxiety and tension. Then there is often a slight but nevertheless perceptible increase in the pressure of the patient's talk. The patient nearly always continues or initiates talk at this point and shows a more noticeable break up in his thinking. It appears also characteristic of this stage that extraneous or irrelevant items or environmental events (e.g. a movement of the observer, a noise, etc.) tend to intrude into the patient's thought content. As this distractibility increases if the patient is still speaking there comes a sudden cessation in the flow of his talk. If, on, the other hand, the observer is speaking, the patient appears to have increasing difficulty in following the conversation, and after producing a few echolalic responses appears suddenly to cease to attend to what is being said. The duration of any episode of inattention could be timed, and it varied with different patients and at different times with the same patient. In most cases, within the first two years of the illness, it usually ranged from a few seconds to one or two minutes, but in those patients who had been ill for longer, and in patients with additional catatonic symptoms, the episodes sometimes lasted for two to three hours.

During the episode the patient does not move, speak, or respond to verbal stimulation Eye blinking is either infrequent or absent, and the patient looks fixedly at some point in the room, usually the floor. The observer may deliberately introduce new stimuli at this stage, such as questions, noises, movements, etc., but the patient fails to attend to them.

Sometimes recovery from the episode seems to occur spontaneously, but at other times it appears to be coincident in time with some new and sudden stimulus, such as a loud noise or a sudden movement by the observer. The patient then starts to pay attention again, but at this stage he shows difficulty in localizing any sounds and appears perplexed. Also at this stage he appears to be very hazy concerning events which occurred prior to the blocking. He often fails to recall what the examiner has been saying, or else, with great difficulty and deliberation, he may respond with a patchy recollection of the general line of conversation or he may repeat a few words of what has been said. If the patient himself was speaking when the episode occurred, he has the same difficulty in recalling what he said.

Examination of such clinical data suggests that schizophrenic patients suffer from paroxysmal episodes of dissolution in mental function in which their perceptual and cognitive processes are profoundly disturbed. Although brief in duration, these changes appear to be very complicated. It would appear that at one moment the patient's consciousness may be flooded with an excess of sensory data, different items of which appear to compete for retention in short-term memory. Then, within a brief space of time, the same patient may find himself almost completely cut off from sensory experience. The phenomenon appears to build up through stages which are characterized by increasing distractibility and impairment in short-term memory, progressive impairment in communication, severe disruption of body image and motility, together with impairment of identity, to reach an end point in the actual blocking itself. Some of the reports (e.g. Cases 10, 25, 12) suggest that environmental stimulation plays a part in the development of this phenomenon, although internal stimulation, in the form of crowding of thoughts, appears also to be important (Case 29). Perhaps it should be mentioned at this point that only one patient lit of the 40 (Case 14) had a history of epileptic seizures, grand mal in type. In addition, ten patients who reported the phenomenon most floridly were subjected to electroencephalographic (E.E.G.) examination, and no specific abnormality was found.

It may be important to note that the patient is to some extent aware of the disrupting process as it develops; and his subjective experience of his body "breaking up into bits," and the impairment of identity which he tends to interpret as an impending death of the self, are associated with very intense anxiety. It would seem that the patient experiences the effects associated with the phenomenon in such a state of consciousness that he can recall most of them. When blocking does occur, there appears to be a tendency for this to be prolonged until the patient is "wakened out of it" by a new stimulus. Thus, one of the schizophrenic patient's main difficulties seems to be in regulating and organizing sensory intake so that it is kept at the optimum required for assimilation at a given time. It would appear that this balance can sometimes be achieved but is readily lost, so that there is a continuous waxing and waning on either extreme of this optimum.

It is tempting to compare these blocking phenomena in schizophrenia with the alterations in consciousness which occur in epilepsy. The resemblance to petit mal seizures seems to be superficial. Petit mal attacks appear to be more abrupt in onset, shorter in duration, and characterized by a more rapid shut-down of perception and cognition. There is, perhaps, a slightly greater degree of resemblance to temporal lobe seizures, in that the latter are slower to build up in time and may be associated with a variety of "positive" symptoms of perceptual disturbance, such as illusions and hallucinations. However, there do not appear to be any reports in the literature of epilepsy (e.g. Penfield and Jasper, 1954; Slater, Beard and Glithero, 1963; Karagulla and Robertson, 1955; Lennox, 1960; Marchand and Ajuriaguerra, 1948) which describe the occurrence of these phenomena experienced by schizophrenic patients. In addition, study of the small number of temporal lobe epileptic patients in the present investigation has failed to reveal the presence of such phenomena. Certainly, thought blocking, defined simply as a sudden pause in thinking, is known to occur in epilepsy, including the psychoses associated with temporal lobe epilepsy (Slater et al., 1963), but this symptom in schizophrenia is only one aspect of a very complex series of changes which may occur within a very brief space of time. The term "blocking phenomena" is therefore unsatisfactory, but rather than coin a new one this term has been used here because the changes in mental function described correspond to the wider concept of blocking as understood by Kraepelin and Bleuler. Although temporal lobe epileptic patients may produce symptoms of disturbed body image and motility, they do not appear to experience these disturbances with the same degree of severity as schizophrenic patients. Another point of difference appears to be that in the build up of these phenomena, before the block occurs, the schizophrenic has particular difficulty in coordinating motor sequences for simple actions, the nature of which he understands; in other words he suffers from ideokinetic dyspraxia. Further, although temporal lobe epileptic patients may at times feel detached from their own personalities, or express delusions of identity, they do not appear to suffer the same transient confusions of identity described in more detail elsewhere (Chapman and McGhie 1964) that schizophrenic patients experience during these episodes of mental disintegration. Finally, these phenomena in schizophrenia occur in such a state of consciousness that they are less affected by an amnesic gap than is the case with epilepsy. Details of this clinical comparison between schizophrenia and epilepsy are illustrated in Table III.

This peculiar phenomenon in schizophrenia, although bearing some resemblance to temporal lobe seizures, is not then indistinguishable from the latter. However, both conditions appear to have a common denominator in terms of a paroxysmal impairment in consciousness. Consciousness has been said to depend largely upon the inter-relationship between the neural basis of the body schema and the perceptual organization of the environment, and also upon the capacity for memory storage of sensory data and the availability (recall) of stored information (Brain, 1963; Sherwood, 1957). Sherwood (1957) states-"Consciousness is thus a function of the volume of information which can he continuously and simultaneously processed." Much of the clinical data obtained in the present study suggest that in schizophrenia the breakdown in perceptual functioning results in an increase in the volume of information with which the patient has to deal but which he is unable to process, and at times this may reach such a peak that consciousness is disturbed.

III. Disturbances In Speech Production

There have been many studies of the disturbed communication which is recognized to be one of the cardinal features of this disease. Different approaches, neurological, psychoanalytical, and experimental psychological, have emphasized one or other aspect of the physiological and psychical process which governs thinking and language behaviour. Such past studies have been dealt with recently by Payne (1961) and Fish (1962). Although thinking and speech are interdependent, in recent years the trend has been to swing away from clinical study of schizophrenic speech and to approach the problem by experimental investigation or different aspects of schizophrenic thought disorder. Possibly, as the findings accumulate and become coordinated, we shall achieve a better understanding of the mechanisms underlying schizophrenic thought disorder. At present, however, there still appears to be room for clinical study of the formal aspects of schizophrenic speech, especially in the early stages of the disease.

Two studies which may be mentioned at this point refer to the controversy which prevails concerning the abstract-concrete dichotomy in schizophrenic language. Goldstein (1939) described an impairment in abstract attitude, so that the schizophrenic's thinking and speech become more concrete. In contrast, Cameron (1938, 1939) described schizophrenic thinking as being "overinclusive". Overinclusion was defined as an inability to preserve conceptual boundaries, so that irrelevant items become incorporated in concepts, rendering the patient's thinking less precise and more abstract.

Clinical observation of young patients suggests that the disturbance in the schizophrenic's thinking and speech varies in severity. This dynamic fluctuation in cognitive function, which may occur within a very brief space of time, has been mentioned above. The following reports illustrate the disturbances of speech production which have been found to be associated with these paroxysmal episodes of mental disintegration in schizophrenic patients.

It was of considerable interest that a number of temporal lobe epileptic patients in the study (Table II) produced reports which contained some similarities and differences when compared with the reports of the schizophrenic patients and it may be worth while briefly mentioning the results of this comparison.

Case 22

"Often I have to go through two or three things in my head before I find the thought I want—words I don’t want come out—not the correct words—not the words I wanted for the meaning I wanted to give. I have to pick out thoughts and put them together. I can't control them actual thoughts I want. I can't compare it with my speech. I think something but I say it different. Thought, just come out—all kinds of things come out together. People listening might hear something different from what I mean. Sometimes I do not say anything because of this. I keep the words in me. Yesterday a chap came along and spoke to me. I knew what I wanted to say back. I had the impression of what I wanted to say in speech but I couldn't get the words I needed—words that weren't correct came out. I could not get the words that were correct to make up a sentence and I knew I was not saying the right thing. I listen to everything that I say. I don't like to say something and not hear it myself. I like to remember everything I say to somebody and make sure it's correct."

Case 36

"I am not conscious about what I have been speaking about. Other people might think I am not speaking any sense. I have to recheck it, but many a time it's just that quick, that if I was speaking, my mind goes a blank and I say the wrong words. My mind has gone blank many times and I have to take time to get the speaking right. You get your subconscious speaking differently to you. When I am speaking words just go back through the subconscious and irritate the subconscious and words go out that are sometimes the wrong words. Sometimes it's the right word but if it's the wrong word I have to check it I keep it in-just not let it out. Sometimes I don't get time to check it and I just have to say it."

Case 12

"The worst thing has been my face and my speech. The words wouldn't come out right. I know how to explain myself but the way it comes out of my mouth isn't right. My thoughts run too fast and I can't stop the train at the right point to make them go the right way. Big magnified thoughts come into my head when I am speaking and put away the words I wanted to say, and make me stray away from what was in my mind. Things I am speaking just fade away and my head gets very heavy and I can't place what I wanted to say. I've got a lot to say but I can't focus the words to come out so they come out jumbled up. A barrier inside my head stops me from speaking properly and the mind goes blank. I try to concentrate but nothing comes out. Sometimes I find a word to replace what I wanted to say." (Why can't you get the word you want?) "Something else comes in, something else keeps interfering in my mind. Maybe the word that comes in is a bit silly compared with what I would have said—but it puts out the right word and makes me say it instead. I listen to myself to make sure it's right. You've got an instinct as well you know. If you know something's wrong then it's wrong. Sometimes I don't speak and turn away, but sometimes I just say these other words to see if they will go away."

Case 23

"I can't control my thoughts. I can't keep thoughts out. It comes on automatically. It happens at most peculiar times—not just when I'm talking but when I'm listening as well. I lose control in conversation then I sweat and shake all over. If somebody is speaking I just let them continue until they are finished—I can't comprehend what they are saying, It's trying to think what they are talking about when they are speaking because I'm concentrating so much and trying to listen to what they are saying and I lose track of the conversation." (Can you hear them ?) "I can hear what they are saying all right, it's remembering what they have said in the next second that’s difficult-it just goes out of my mind. I'm concentrating so much on little things I have difficulty in finding an answer at the time—there's nothing there. The train of thought can be delayed for a time before I go back on to the train of thought. I am speaking but I'm not conscious of what I'm saying, that's the trouble with me, so I don't know what I'm talking about. I've got a rigmarole in my mind now for checking what I say in advance so if somebody speaks to me I get on my guard straight away so that I can make a sensible answer. I try to say something sensible and appropriate but it is a strain because I'm not speaking automatically and when the conversation is going on or when it is finished I don't know what they are talking about or what I was talking about. I keep talk to a minimum to prevent these attacks coming on."

The above clinical data on speech represent only a fraction of those obtained from the whole group of patients. Examination of all such data suggests that these disturbances in speech are closely related to the other changes in subjective experience reported by schizophrenic patients, which appear to occur in a paroxysmal fashion. The paroxysmal nature of these speech defects in the early stages seems worthy of mention because it does not appear to have been emphasized in the literature of schizophrenia, and, further, the disturbance bears some resemblance to the paroxysmal dysphasia reported to occur commonly in temporal lobe epilepsy.

The disturbances in speech may be briefly described by reference to a definition of paroxysmal dysphasia given by Serafetinides and Falconer (1963) in a study of 100 cases of temporal lobe epilepsy, namely—"an inability on the part of the patient to express himself by the correct words while he is still conscious and without obvious impairment of articulation or of hearing. The patient may or may not comprehend fully what is said to him, but his replies are such as to rule out confusion with disorientation or mere speech arrest". Two main types of paroxysmal dysphasia were recognized by these authors to occur in temporal lobe epilepsy, viz., (a) expressive, and (b) combined receptive and expressive, and they considered that a cardinal feature of paroxysmal dysphasia so defined was that it occurred during a period of awareness and could subsequently be recalled by the patient. In the present study, the disturbance, of speech in schizophrenic patients almost always involved both receptive and expressive aspects. If the paroxysmal nature of speech disturbances in schizophrenia is accepted, albeit provisionally, when we proceed to analyse the relevant reports from the patients included in the study certain common denominators appear to emerge, which may be summarized as follows: these disturbances may tentatively be related to (1) a defect in the automatic selection of appropriate words from memory storage so that frequently the patient is unable to use the correct word at the appropriate time; (2) an inability to screen out approximate or totally irrelevant words from entering short-term memory prior to the act of speaking. This may be associated with a difficulty in formulating grammatical sentences from individual words, the corresponding opposite of a similar defect in the perception of speech shown by these patients, which has been described elsewhere (Lawson, McGhie and Chapman, 1964); (3) a breakdown in the normally automatic process whereby the individual continuously criticizes and edits his own speech in order to make it intelligible to others; (4) a defect involving impairment in short-term memory which renders the patient unable to connect up different passages of verbal output in a logical sequence.

If we apply Hughlings Jackson's principle of physiological order to the dynamic variations in speech function exhibited by these schizophrenic patients, the many apparent contradictions in their performance and behaviour may become more understandable. In order to make this comparison it may be worth while giving a brief description of the development of speech. Russell Brain (1961) summarizes the various stages in the process, which include babbling in infancy, proceeding to echolalia which paves the way for verbal utterances. Gradually words are associated with the objects to which they refer, and this requires abstraction of the object from the rest of the environment. This begins with concrete objects and persons, but as development proceeds becomes increasingly abstract and refers to qualities, actions and relationships and ultimately highly abstract ideas. As speech develops, words are used in combination, grammar and syntax link them together, and their mutual modifications and temporal order in sentences make it possible to express more and more complex meanings. Piaget (1951) describes the process similarly, relating speech development to a functional continuity between sensory-motor activity and conceptual thought, whereby verbal schemas become detached from sensory-motor schemas and gradually acquire the function of representation. That is, initially a word is part of an action but later ceases to be so.

It is possible then to draw parallels between the fluctuation in speech function of schizophrenic patients and these gradations in speech development. One might expect schizophrenic speech to correspond at different times to any one of the three main stages of development, and clinical observation of young schizophrenic patients tends to bear this out. Thus the individual schizophrenic's speech may at one moment be abstract and relatively normal, while at his worst level he may be unable to separate the word from the object or action and thus gives a "concrete" response. With progressive dissolution of his mental state one would expect stages of a break-up in syntactical arrangements and temporal order, passing through a phase of echolalia and ending with babbling. Again, the argument here, in relation to the early stages of schizophrenia, is that this process of dissolution can occur, with rapid onset, but lasts only for a transient and brief space of time. It is therefore possible that the controversy which prevails concerning the abstract-concrete dichotomy in schizophrenic speech is irrelevant for the individual patient, whose thinking and speech may be both abstract and concrete within a very brief period. Likewise the same view can be applied to the concept of "overinclusion" in schizophrenia. At one moment the patient's consciousness may be flooded with irrelevant words or items and appear "overinclusive", but at another moment the opposite condition may prevail, the part experiencing a vacancy in thinking, unable to say anything.

As mentioned above, paroxysmal dysphasias are recognized to occur in temporal lobe epilepsy. Serafetinides and Falconer (1963) found speech disturbances in two-thirds of a total of 100 cases of temporal lobe epilepsy. In half of these (34 out of 67), the dysphasia was paroxysmal and occurred mostly in left temporal lobe epilepsy. Another interesting finding mentioned by these authors was that of the 34 cases with paroxysmal dysphasia three-quarters were also subject to grand mal seizures. These authors concluded that in cases with paroxysmal dysphasia the neuronal discharges were more widely-ranging than in cases who did not show this disturbance.

In the present study, details of the speech disturbances found in temporal lobe epileptic patients have not been presented, since they confirm the clinical findings reported by Serafetinides and Falconer in their study of a much larger group of such patients. However, it may be interesting to compare the reports given by temporal lobe epileptics with those produced by schizophrenic patient's. Very briefly, the similarities in disturbed speech between the two conditions appears to be related to (1) the paroxysmal nature of the disturbance, (2) the patient's awareness of the defect, (3) the difficulty in finding and using the correct words to express himself, and (4) a defect which makes the patient liable to wander off the point in spontaneous speech. On the other hand, of both types of report suggests two important differences between the epileptic and schizophrenic patients. These are that (a) schizophrenics appear to have a marked inability to screen out irrelevant words from entering consciousness and this exerts a much more catastrophic effect on their ability to express themselves; (b) schizophrenics find it necessary to monitor their own speech in a conscious and deliberate fashion.

IV. Gesture Language

The words gesture and pantomime are often used synonymously, but Critchley (1939) distinguishes the two, defining pantomime as that variety of dumb show which aims at expressing an idea, while gesture connotes those movements, particularly of the hands and face, which accompany speech for the purpose of emphasis. Critchley states that gesture is not only an important means of communicating ideas and emotions, but also serves as an important adjuvant to spoken speech. Pantomime movements are deliberately executed actions of a high propositional content. According to Critchley, pantomime is increased in cases of aphasia where the loss of speech is not complete and where the patient may be verbose but unintelligible.

Pantomime and gesture appear to have been neglected in clinical studies of schizophrenia. In the present study schizophrenic patients were repeatedly observed to utilize gesture or pantomime when they were having difficulty in communicating their ideas. The following few reports illustrate the subjective aspects of this activity.

Case 22

"I like talking to a person but not in audible words. I try to force my thoughts into someone. I concentrate on how they move. I think of a message and concentrate in my head. It's thought you're passing over. I send the messages by visual indication. Sometimes it's my foot, but it might be my arms, legs, sometimes the shoulder, Sometimes my whole body. I had the impression other people started this. They made movements first. I could contact back. They had a certain control over my body."

Case 35

"My brain is not working right—I can't speak properly —the words won't come and I've got to use my hands to speak like a dumb person."

Case 2

"It's difficult to speak in words—can't say anything— have to use my body to tell people anything."

Case 4

"If people talk to me about anything—say the weather —and my mind feels no response and I have difficulty in finding an answer at the time. There's nothing there and I can’t get the ideas quick enough. I can't speak it out so I reply by just moving my head or hands or something to indicate what I mean."

V. Disturbances In Motor Functions

During normal development, economy in mental function and adaptation to the environment are achieved in a process by which certain activities, after constant repetition, become more automatic so that they can be carried out spontaneously, with a minimum of conscious control. Attention is progressively less taken up with the activities themselves and is directed more towards their goals. Thus it is not just perceptual activity which has to be organized for efficient functioning, but also motor output. Movements are executed, not as a series of isolated units but as whole sequences, smaller units being bound together into larger units.

That schizophrenic patients suffer a loss of automation in mental function has already been suggested by some of the clinical data presented above. However, the following reports may serve to highlight this particular change.

Case 38

"None of my movements come automatically to me now. I've been thinking too much about them, even walking properly, talking properly and smoking—doing anything. Before they would be able to come automatically."

Case 22

"If I do something like going for a drink of water, I've to go over each detail-find cup, walk over, turn tap, fill cup, turn tap off, drink it. I keep building up a picture. I have to change the picture each time. I've got to make the old picture move. I can't concentrate. I can't hold things, Something else comes in, various things. It's easier if I stay still."

Case 40

"My brain is slowed up and when I'm talking to someone I don't know what to say back to them to keep it going. I think about it so much that I don't know what to say back. I don't seem to be relaxed when I'm walking. I'm thinking about it in case I might be doing it wrong and I'm trying to do it right by just trying to concentrate on every step I'm taking."

Case 16

"I find it very difficult to do things now, just everyday things like shaving, things that you do immediately you get up. just things I used to do without thinking, like hanging your coat up or taking your tea. I am very easily put off now-by noises or people speaking to me. It's trying to concentrate on two things. Sometimes I have just to cut everything short and sit down."

This, and additional clinical data which space does not allow to present, suggests that schizophrenic patients have an impairment of the ability to carry out purposeful activities which were previously self-regulative. They appear to have lost access to previous learning so that they are often unable to initiate an action simply by contemplating its goal. Instead, their attention seems to be taken up with the intermediate steps, which now require conscious co-ordination. There appears to be a loss of the organization normally inherent in motor activity. Much more detail has to be retained in immediate memory and consciously processed for the initiation and execution of simple actions, and the conscious co-ordination of motor sequences is vulnerable to distraction by other stimuli occurring simultaneously. The schizophrenic's psychomotor performance is consequently slow and deliberate and readily interfered with.

The patient's statements refer chiefly to the loss of spontaneity in moving and speaking. However, it can be inferred from clinical data presented above that this deficiency, which is associated with a heightened awareness of mental and bodily processes and flooding of consciousness with excess sensory data, applies also to auditory and visual perceptual tasks. Given sufficient time, the schizophrenic patient may be able to carry out a single task satisfactorily. However, when required to do two or more things at the same time, for example to move and speak or look and listen, this impairment in mental functioning becomes manifest.

VI. Emotional Reactions And Development Of Delusions

Two-fifths (40 per cent.) of the patients reported experiencing changes in visual perception, as described above. Although the time of onset of these changes could not be pinpointed, it emerged from the history-taking that in many cases these changes occurred long before admission to hospital, and before the patient became noticeably ill. The duration of illness given for each patient (Table 1) is therefore only approximate. Examination of the development of these changes suggested that the underlying process was an insidious one, even in the apparently acute cases. The clinical data also suggested that alteration in colour or sensory quality preceded the other disturbances in visual perception. Most of the patients who experienced this change reported that for a time everything around them looked fascinating, objects standing out vividly in contrast to the background. These initial changes in mental function were experienced as pleasant, and number of patients at this stage went through transient period of mild elation. Coincident with this alteration in perception, these patients appeared to regard everything with new significance, and there was a general tendency for their interest to be turned to ruminating about the world and life in general, and to religion, psychology, philosophy, art and literature.

However, as the breakdown in visual perception progressed, and as the other disturbances in perception and cognition developed, this early reaction changed to one of intense anxiety. The characteristic complaint at this stage, with regard to vision, was that the patient could no longer see objects standing out clearly from the background, and that instead they were looking at many irrelevant aspects of the environment and were less able to perceive objects as meaningful wholes. At this stage the patient's failure to adapt to his environment became more manifest, and he found it increasingly difficult to maintain his previous working performance. Short bouts of depression with suicidal ideation were common at this stage. However, none of the patients in the study committed suicide.

Many other reactions which gradually developed could be traced to the particular defects in perception and cognition described above. These secondary reactions appeared to have a common underlying aim, which was to reduce quantitatively the intake of sensory stimulation from the environment at any particular time and also to restrict motor output. For example, clinical observation and the patients' subjective reports suggested that they were attempting to reduce visual stimulation by voluntarily maintaining a fixed gaze. The disturbance in visual perceptual constancy (referring to size, shape and distance) could also be corrected by certain types of catatonic behaviour, which will be discussed below. There also was a general tendency to overcome difficulties in speech production and speech perception by avoiding conversation. This often meant that the patient had to avoid people. Thus social withdrawal was in part a voluntary activity carried out by the patient for his own protection. As the disease progressed, some of the patients attempted to reduce stimulation by more concrete methods such as plugging their ears, or keeping their eyes partly closed. These reactions appear to have the rational purpose of maintaining some degree of stability in mental function. However, as the various phenomena were continuously experienced, the patients gradually developed less rational and eventually floridly psychotic explanations to account for their experiences. Paranoid ideas and delusions of various kinds could be seen to develop in relation to the various categories of altered experience which have been described. In most cases the delusions were multiple and usually transient. Delusions expressed by individual patients could be traced to disturbances in visual perception, speech production, perception of speech, and blocking, with its associated phenomena of echopraxia, dyspraxia and confusion of identity.

For example, concerning visual perceptual disturbance, one patient (Case 3) came to the conclusion that other people were deliberately putting him to sleep and causing him to see things altering in size and shape. Another patient (Case 35), in relation to the same defect, expressed the delusion that he had the power to change the shape and size of people and objects.

Multiple delusions appeared to develop Simultaneously and be derived from the patient’s Continuing experience of blocking phenomena. Ten patients interpreted this change in terms of death and resurrection, and at the same time expressed delusions of identity, claiming to be Christ, a saint, or some other person. Six Patients, who at an earlier stage had blamed other people’s talk for producing their disturbed state of mind, later claimed that other people were making their minds go blank by using hypnotism. Seven patients were convinced that other people were doing it on purpose, but could not say by what means. Four patients attributed their blocking and other phenomena to unseen spirits or evil agencies taking control of their minds, and two patients blamed radio and television. Those patients who experienced and demonstrated echopractic phenomena expressed the delusion that the other person, whose gestures they copied, had control over their minds and bodies. The following is only one of many examples of how these particular patients, in the later stages of the illness, interpret blocking and echopractic phenomena. The patient (Case 7) after one year’s experience of these phenomena, said—"People are trying to control my brain and make my body work—trying to take over my body. It’s a medium of minds; everybody’s mind is connected up. They go into your body and take part of your body and put their parts in and make them move. The brain power gets taken away but I have always managed to get out of it."

Three patients (Cases 7, 8, 29) had a delusion, which appeared to be a projection of their echopractic experiences on to others, that they could control other people’s minds and bodies and make them move at will. Several patients, after repeated experience of echopraxia and pantomime, had the delusion that they could communicate with others without using words—merely transmitting ideas by a bodily movement. At an even later stage in the illness, these patients claimed that they did not even have to see the other person, but could transmit ideas over great distances by telepathy, and also that their thoughts could be read by others in the same way. Three patients, while conjuring up a memory image of a female, expressed the transient delusion that they had female bodies. With regard to difficulties in speech production, the patients tended to attribute the defect to the same source as their blocking experiences, expressing delusions of influence by other people using hypnotism, etc. Regarding deficiency in the perception of speech, which has been described elsewhere (Lawson, MeGhie and Chapman, 1964), the patients at an early stage recognized that the defect lay with themselves; later they blamed other people for their difficulty, and as the psychosis developed the defect became the source of delusional ideas. For example, one patient (Case 8) said-"It all boils down to the fact that people I was talking to started talking nonsense like babies. I thought I had driven them mad. Their talk was all jumbled up. I can will them to talk nonsense. I can control people through the ether and make them gibbering idiots who talk a lot of rubbish".

The disturbance in motility could also determine the content of delusions. For example, a patient (Case 10), who previously had some insight regarding his difficulty in moving, in the second year of his illness said—"They have been trying to put me off my feet; there is no doubt about it—it was my legs. I cannot make a movement anywhere unless it is with my legs. They can take away the power of my legs".

The conclusion suggested by this study is that many delusions develop insidiously and are preceded by a considerable period of time by profound disturbances in perception and cognition, although by no means is it implied that all delusions in schizophrenia develop on this basis. A point worth noting is that in these schizophrenic patients some delusions which appeared on superficial examination to be "primary", developing "out of the blue", could be traced to other defects as have been described, and the delusions in these cases appeared essentially to be attempts on the patient's part to explain what was for him a real experience. As isolated symptoms, these delusions probably do not have great diagnostic significance, and since they occur late they are probably irrelevant for early diagnostic purposes. However, where diagnosis is in doubt., it is possible to use such ideas or delusions as clues to underlying perceptual disturbances which characterize the schizophrenic psychosis. It is not so much the presence of a paranoid idea or a delusion itself which is important for diagnosis, but rather how it has developed and what it means for the patient.

VII. Cognitive Dysfunction And Catatonic Behaviour

Blocking phenomena characterized outwardly by a transient period of immobility, blank expression and fixed gaze, occurred in the majority (95 per cent.) of patients. This phenomenon has already been discussed above,

Transient periods of mutism were encountered in the later stages of the illness in 16 out of 40 patients. However, at an earlier stage some of these patients described that they often felt compelled to keep silent because of difficulties in speech production. They described how they had a fear of saying wrong words or speaking incoherently. The voluntary nature of this symptom is illustrated in several of the reports dealing with difficulties in speech production (Cases 22, 23, 36). A few hebephrenic patients at a later stage in their illnesses stated that they sometimes kept their hands in front of their mouths for the same reason, as one patient put it (Case 29) "to keep the words in".

Echolalia was frequently observed in the majority of patients and is considered to be secondary to the patient's difficulty in the perception of speech. Repetition of another person's words appears to give the patient time to organize them into a meaningful pattern.

Echopraxia occurring in young schizophrenics has been discussed elsewhere (Chapman and McGhie, 1964), and is likewise regarded as being associated with a breakdown in the perception of the environment.

Some bizarre actions or postures were found to be the result of abnormal perception of memory images. For example, two patients (Cases 12 and 29), while conjuring up a memory image of Christ being crucified, stood still with their arms outstretched sideways.

Some patients also gave an interesting account of why they carried out certain mannerisms and stereotypies. For example, one patient (Case 22) said—"Thoughts are still coming into my head that shouldn't come in. I frown or use my eyes just by blinking to get rid of these thoughts." A hebephrenic patient (Case 29) often showed a stereotypy of rubbing his forehead and scalp. When asked why he did this, he said, "It seems to help. Massaging my head seems to help to clear my head." A catatonic patient (Case 12) sometimes uttered isolated words, "to see if the words would go away." Another patient (Case 2) with a stereotypy of his hands said that he kept waving his hands, "to see if it would help to get the words I want to speak". Another patient (Case 14) shook his head rhythmically from side to side, and explained that too many thoughts were coming into his mind and he did this to try and shake them out. The majority of patients were negativistic, and explained their behaviour by saying that they were compelled to avoid people, especially in conversation, otherwise they would become mentally disturbed. At interview, patients were noticed to become increasingly negativistic if the observer spoke too quickly or if there happened to be a lot of extraneous stimulation.

The majority (75 per cent.) of patients experienced from time to time a difficulty in the co-ordination of movement. Their movements were slow, deliberate and restricted. This loss of automation with regard to motor output has already been referred to and appears to be associated with a heightened consciousness of bodily processes.

More overt and more prolonged catatonic behaviour was exhibited by a proportion (16 out of 40) of the patients who experienced a breakdown in visual perceptual constancy. These patients kept motionless for quite long periods, for several minutes at a time in the early stage, but as the disease progressed some did so for several hours at a time. The following reports relate to the subjective aspects of this behaviour.

Case 22

"Everything is all right when I stop. If I move everything I see keeps changing, everything I’m looking at gets broken up and I stop to put it together again."

Case 25

"If I try to keep moving, and at the same time try to pay attention to what I see, that’s when things become difficult. That’s what happens in emergencies. I don’t like it. I get into a panic. Normally it doesn’t happen because I stop. I stop to get the depth of things, else I get the feeling I might walk into a wall. I have got to slow down to see. Stopping obviates the flatness. If you keep going the flatness tends to continue. I stop to obviate the flatness because I know if I continued, the flatness will develop. You only see a still picture if you don’t move your head and eyes."

Case 12

"When I start walking I get a fast series of pictures in front of me. Everything seems to change and revolve Round me. Something goes wrong with my eyes and I’ve got to stop and stand still."

A few patients explained that they controlled all their movements because, just as many others had a fear of saying the wrong word when speaking, they had a fear of carrying out the wrong movement unless they controlled it consciously. This is illustrated in the following reports.

Case 25

"I am afraid to move without giving all my attention to it, because if I am doing something else, I might carry out the wrong movement. For instance, on going out of that door, if I paid attention to something else, I might stand on my head."

Case 10

"I try to empty my head of thoughts to enable me to stand still. If thoughts come through your head they are likely to be transmitted into action."

It may be concluded that some forms of catatonic behaviour are emotionally determined and voluntarily initiated, at least in the early stages. It is probable that, left unchecked, such behaviour may become more persistent. It would appear that many catatonic symptoms may be more purposeful than appears superficially. It is also suggested that many of these symptoms are related to particular defects in perception and communication rather than to any underlying psychogenic conflict. It may be possible to classify such catatonic symptoms by reference to the particular perceptual or cognitive function which is disturbed. Finally, there does not appear to be any sharp division, with regard to these symptoms, between cases categorized as hebephrenic and catatonic, since this type of behaviour was observed in both of these classical sub-groups. Of the 16 patients who showed prolonged catatonic behaviour, seven (Cases 3, 12, 14, 25, 27, 35, and 40) were diagnosed as catatonic, five (Cases 15, 21, 26, 29, and 38) were placed in the hebephrenic sub-group, and four (Cases 9, 22, 24, and 30) were difficult to classify. What these 16 patients had in common, apart from a tendency to behave in a catatonic fashion, was a gross disturbance in visual perception which appeared to be intricately connected with their motility. The other feature they had in common was a tendency for the illness to run a steadily downhill course. These two features differentiated these patients from the rest of the group. It may be that the end clinical picture is determined, in part, by how the individual patient reacts to his deficiencies in perception and cognition and what methods of self-help he employs, some electing to maintain a restriction of all motor activity including speech others deciding to relinquish such strategies at the price of performing in a disorganized fashion.

At any rate, it is apparent that individuals emotional and psychogenic factors play some part in the development of the clinical picture, and that some catatonic types of behaviour and habit deterioration may be checked by appropriate psychotherapeutic means. To be effective, the psychotherapy employed would have to take into consideration the patients’ difficulties in perception and cognition. Such an approach has been outlined elsewhere (Chapman and McGhie, 1963).
 


Discussion


 


The various phenomena described above have to some extent already been discussed. It remains to try and summarize these facets of schizophrenic experience and behaviour and to discuss the significance of the clinical data as a whole.

With regard to symptoms which the patient first reported to the doctor or which were first noticed by relatives, a list of some of these is given in Table IV. It may be seen that these symptoms and complaints are similar to those described in more detail by Gillies (1958). It was found on enquiry, however, that in individual patients such complaints were multiple. Taking the group as a whole, every kind of neurotic symptom was encountered in the early stages of the disease. This of course is in agreement with many other clinical studies, some of which have been cited above. In particular, tense anxiety reactions were almost invariable, occurring more frequently than depression. However, when a comparison was made between individual cases, although a few isolated symptoms of the same kind tended to crop up in different patients, yet if all the patients’ symptoms were considered, no common pattern emerged. One of the conclusions of the present study was that these presenting symptoms spontaneously complained of by the patients were superficial, and had more to do with the individual patient’s emotional reactions to his illness than to the underlying disease process itself.

In contrast, when the patient’s subjective experiences were examined in detail, a certain pattern did seem to emerge, although this was no means uniform. The group of anomalies which were found referred to disturbances in attention perception, memory, motility, thinking and speech. Although the reports of patients suggested that these disturbances did not occur evenly throughout the group, it was interesting that when any one of the phenomena did occur it was experienced by different patients in a relatively stereotyped way. It is suggested, then, that the disturbances which have been described have less to do with the patient’s personality reactions, but are more basic to the schizophrenic process itself. Also, these various anomalies, taken together, resemble defects found in organic cerebral disease more closely than neurotic disorders. The clinical findings in the present study therefore support the view that schizophrenia is an organic illness, and it is possible that those previous studies which have concentrated on comparing the onset of schizophrenia with that of neuroses have been rather misleading.

It is not the purpose of the present study to make a detailed comparison between schizophrenia and organic cerebral diseases as a whole. However, it is of interest that there appears to be a close resemblance between some of the subjective experiences described by schizophrenic patients and the ictal phenomena of temporal lobe epilepsy, although, as summarized in Table III, there also appear to be important differences, in respect of the degree of body image disturbance, ideokinetic dyspraxia, confusion of identity, echopraxia, attention disorder and the degree of disordered visual perception. Although there is an overlap between temporal lobe and parietal lobe symptomatology, the symptoms which have just been mentioned are more typical of parietal lobe disorders (Critchley, 1953).

It would appear that the alteration in perceptual and cognitive processes, which manifests itself as a loss of automation and economy in mental function together with a need for conscious voluntary control and co-ordination of sensory-motor activity, may place such a strain on the schizophrenic’s mental functioning that his performance of any task is very faulty and easily interfered with. Thus the schizophrenic’s difficulties appear to become maximal when he engages in any sensory-motor activity, particularly if he tries to do several things at the one time. It seems that the patient will be much less disturbed if he restricts all forms of sensory-motor activity, and it may be inferred from many of the patients’ statements that this is what they try to accomplish.

The clinical data also suggest that the perceptual and cognitive changes described contribute considerably to the psychopathology of the illness. Clearly, specific anomalies may in part determine the nature and content of some symptoms. When a schizophrenic complains that the world around him has changed he may be making a literal statement in terms of his own experience, and it is perhaps not surprising that he begins to ruminate and search for explanations to account for this change. Bizarre hypochondriacal ideas may likewise be derived from true disturbances in body image. Ideas of change of sex, or fears of homosexuality, are not necessarily derived from psychogenic conflict, but may develop as a result of abnormal perception of memory images of the opposite sex. If the observations made in this study are valid, then the schizophrenic is literally at the mercy of his environment. It is therefore understandable that the patient adopts a hostile attitude, and social withdrawal and negativism appear, at least in part, to be voluntarily initiated to protect himself from this environment. The most complex aspects of the schizophrenic’s environment appear to be social ones. Other symptoms, mutism and some forms of catatonic immobility, have also been seen to relate to particular aspects of the breakdown in perceptual and cognitive function; this applies also, as the psychosis develops, to delusions of all kinds, but particularly to delusions of influence and delusions referring to communication.

Concerning impairment of speech in schizophrenia, the conclusions which are suggested by the present study are not in accord with those expressed by Critchley (1964) in a brief discussion of psychotic speech. According to Critchley, in schizophrenia there is no true inaccessibility of words; speech impairment in schizophrenia is a product of the patient’s gradual withdrawal from the community; schizophrenics do not, like aphasic patients, while struggling to say a "yes", utter a "no", nor do they eke out their difficulties in speech by the use of gesture or pantomime; also,

the schizophrenic is less aware and less emotionally disturbed by his deficiency in speech Critchley infers from these various observations that schizophrenic speech impairment is not aphasic.

The clinical data obtained in this study conflict with all of these points mentioned by Critchley. It appears that schizophrenic patients do have a true difficulty in word finding, although it tends to be episodic in occurrence, and very similar to the paroxysmal dysphasias which occur in temporal lobe epilepsy. Further, the difficulty in speech relates to both expressive and receptive aspects of communication, the latter deficiency having been dealt with else. where (Lawson, McGhie and Chapman, 1964). Rather than difficulty in speaking being a product of social withdrawal, the clinical data illustrate that schizophrenics tend to avoid other people partly because of their defective capacity in communicating. Also, schizophrenics, particularly those with catatonic symptoms, were observed to give a negative reply when they really wished to say "yes", and then, with some embarrassment, correct themselves. These young schizophrenic patients were certainly aware of their defects in speech, and in the early stages expressed appropriate emotional reactions about it. Finally, as has been mentioned above, the patients in the present study quite frequently resorted to gesture and pantomime to facilitate transmitting their ideas to others. It is suggested here, then, that the disturbances both in production and perception of speech in schizophrenia indicate that a true aphasia is present intermittently. However, as in some other organic states, it tends to be paroxysmal occurrence and is not easily elicited unless specially looked for.

The present paper has attempted to focus on diagnosis and does not purport to outline the natural history of schizophrenia. However, since the follow-up study extended in many cases to over five years, it may be worth mentioning something of the outcome with regard to the presence of the various phenomena which have been described. The distribution of phenomena in question in relation to individual patients is listed in Table V, with a rough indication as to course and outcome. The data suggest that gross disturbance in visual perception on the whole is a bad prognostic symptom. The illness in patients who reported this symptom in the early stages took a downhill course, the end clinical picture being that of hebephrenia or deteriorated catatonia. As noted earlier, catatonic symptoms occurred in both of these subgroups of schizophrenia. Those patients classified as catatonic appeared to be reacting to their disturbed visual perception mainly by voluntarily controlling and restricting their own movements. Hebephrenic patients did the same, but more sporadically, and catatonic behaviour in their case was clouded over by a host of other positive symptoms, while in those classified as catatonic such behaviour was the prominent feature, the other symptoms being largely negative. In general, if the patient experienced all of the phenomena which have been described, the course of the illness tended to be malignant. In particular, apart from visual perceptual changes, the subjective experience of echopraxia appeared to be a bad prognostic sign.

With regard to early diagnosis, it is ‘not suggested here that any one of the phenomena which have been described, taken singly, is pathognomonic of schizophrenia. With the possible exception of the complex blocking phenomenon, it is evident that these defects may occur in other organic states. As with other approaches to the clinical diagnosis of schizophrenia, it is still the overall picture which should be considered. The main difference between the present approach and previous ones dealing with early diagnosis is that the pattern of symptoms considered important is organic in type. There is also more likelihood of agreement being obtained as to the operational definitions of the terms used in diagnosis. It is true that the schizophrenic psychosis may be masked by multiple neurotic symptoms, but there seems little doubt that schizophrenics experience the basic symptoms of the disease right from the outset.

However, as in many cases of cerebral disease, the phenomena in question tend to be episodic and fleeting. They are seldom reported spontaneously by the patient, but must be looked for. These phenomena are very readily missed in single interviews or even in a series of interviews, unless the examination is orientated towards eliciting organic changes in mental function. The difficulty in assessing such symptoms at an early stage lies in the fact that they occur in the realm of subjective experience and are not noticeable outwardly. From this point of view, it may be said that the schizophrenic is his own best observer, and since in most cases the patient has repeatedly experienced some or all of these changes long before he attends for examination, it is important to tap this wealth of changed experience, utilizing the patient’s memory resources. This can be done more easily, the more intelligent the patient. In suspected cases where the diagnosis is in doubt, neurotic symptoms should perhaps be disregarded, and the patient should be asked specific questions regarding his attention, perception, motility, memory and expressive and receptive aspects of speech. Any complaint, no matter how vague, of his mind going "blank", or being in a daze, trance, etc., should be actively pursued, since further examination may reveal the occurrence of blocking phenomena. Also, as mentioned in a previous paper dealing with echopraxia in young schizophrenic patients (Chapman and McGhie, 1964), one of the earliest changes in schizophrenic experience involves impairment in the process of empathy with other people. Here again, this change is subjectively experienced by the patient long before blunting of affect can be overtly noticed, and if asked he may be able to report this symptom. If the patient has difficulty in the spontaneous description of his experiences, it may be useful to use the projective interview technique which has been described.

If such phenomena are elicited from young patients, the illness may then be differentiated from neurosis and affective and paranoid psychoses. Using this approach, the most likely sources of difficulty will occur with cases of temporal lobe epilepsy and cases of cerebral tumour or other brain damage, particularly of the parietal lobe, but these are conditions which can be eliminated by history-taking and other physical methods of examination.

This approach to schizophrenia and the clinical findings obtained have much in common

with those of many other workers, particularly those German writers quoted by Jaspers (1942). A weakness of the present study is that the phenomenological method as described by Jaspers has not been used to the full, nor has any attempt been made to relate the present findings to the multiplicity of divergent approaches and interpretations to be found in the literature. The latter limitation is partly due to the amount of space which would be required, to linguistic barriers, and also partly to the fact that the present approach, in contrast to a purely psychoanalytical one, has been influenced considerably by experimental psychological methodology.

However, the clinical approach which has been outlined offers a tentative method which could possibly be developed for the purposes of classifying schizophrenic illnesses in a new way. For example, the clinical data suggest that those patients who experience a disturbance in visual perception may be separated out from the rest of the group. If such a clinical approach were combined with experimental psychological testing, it might be possible to introduce some scientific order into classification by increasing the precision with which more homogeneous groups may be delineated, which is a prerequisite of biochemical and other physical investigations of schizophrenic psychoses.
 


Summary


 


A clinical study of changes in mental function, subjectively experienced by a group of 40 young schizophrenic patients, is reported. Various phenomena related to disturbances in attention, perception, memory, motility and speech are described and discussed, with special reference to early diagnosis. It is suggested that these phenomena may be subjectively experienced by the patients long before signs of established disease appear overtly. It is argued that the clinical data presented support the view that schizophrenia is an organic psychosis, and also that the impairment in Speech in this disease is aphasic in nature. It is suggested that the alteration in the perceptual and psychomotor functions in schizophrenia results in a flooding of consciousness with Sensory data to a degree beyond the limits of normal experience. Blocking phenomena are regarded as transient disturbances in consciousness which develop in association with a failure to exclude irrelevant stimulation from internal and external sources. A clinical comparison is made between the latter phenomenon and epileptic disturbances of consciousness, the important differences being noted. Various emotional changes, catatonic symptoms and the development of delusions are discussed in relation to particular defects in perception and cognition. Finally, the tentative suggestion is made that the clinical approach outlined might be utilized, in conjunction with experimental psychological methods, for the purpose of classifying schizophrenic illnesses in a more specific manner.

[Accompanying tables, acknowledgments and references omitted]

Presented on the World Wide Web with the kind permission of the British Journal of Psychiatry, a publication of the Royal College of Psychiatrists.
 
 
 
 
 

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