The Schizophrenias: Medical Diagnosis and Treatment by the Family Physician Patrick T. Donlon, MD Sacramento, California About one percent of the population will develop schizo­ phrenic symptoms sometime during their life. Etiologies are poorly understood and the course is highly variable. The dif­ ferential diagnosis and medical treatment of the schizophrenias are discussed. Neuroleptic drugs are the most effective single treatment, for they allow most patients to be treated on an ambulatory basis, under the care of community physicians. Adverse effects of neuroleptic agents are common and often subjectively annoying. They may be prevented or minimized by agent selection, dosage schedules, or contra-active treat­ ment. The prevalence of schizophrenia has probably physician practical guidelines for the differential remained unchanged over the past 100 years and is diagnosis and medical management of the schizo­ still approximately one percent of the adult popu­ phrenic patient. lation.1 Although the incidence of the illness remains unaltered, the treatment of schizophrenia has changed dramatically. Until the middle 1950s Diagnosis the treatment was primarily supportive and cus­ The schizophrenias represent a clinical syn­ todial, but with the introduction of neuroleptics, drome of poorly understood etiologies. Schizo­ ambulatory treatment became possible. phrenics are a seemingly heterogeneous popula­ Neuroleptics, though not curative, greatly reduce tion, all having a relatively similar endstate. No the signs and symptoms and modify the course of pathognomonic biologic signs have been iden­ schizophrenia, allowing for most patients to func­ tified, and the thought disorder remains the unique tion on an ambulatory basis. Some patients may diagnostic sign. Thus, the schizophrenias remain recover completely and may not require continued classified as “functional psychosis.” care, but most patients require close monitoring for years. The following review offers the primary Early Signs Nevertheless, there are some vague signs of a predisposition toward schizophrenia. A schizo­ phrenic person often has a family history of schiz­ From the Department of Psychiatry, University of California at Davis, Sacramento, California. Requests for reprints ophrenia and chronic family communication dis­ should be addressed to Dr. Patrick T. Donlon, Department turbances. As children, many preschizophrenic of Psychiatry, University of California at Davis, 2252 45th Street, Sacramento, CA 95817. individuals have asocial development, poor peer THE JOURNAL OF FAMILY PRACTICE, VOL 6, NO. 1, 1978 71 DIAGNOSIS AND TREATMENT OF SCHIZOPHRENIAS relationships, and emotional eccentricity leading phase, reality testing breaks down and thinking to scapegoating.2 Neurologic soft signs and ill processes become uncontrollable, leading to the health are frequently present. As adolescents, un­ cognitive and perceptual disorganization typically socialized aggressiveness among males and over­ found in schizophrenia.7 Because this process is inhibited hyperconformity among females may subjectively distressing, it often is associated with prevail.3 autonomic signs of mydriasis, tachycardia, in­ creased systolic blood pressure, and sweating. Notably, once the illness has fully developed, the schizophrenic individual is less likely than the nonschizophrenic individual to have psychosoma­ tic illness.8 Somatic delusions and preoccupations, nonetheless, may remain and make diagnosis of developing medical problems more difficult. For Psychotic Decompensation example, it may be difficult to consider the diag­ Although psychosis may present at any age, the nosis of peptic ulcer or gall bladder disease in a age of highest risk is with young adults. Emotional chronic delusional patient who fantasizes an elec­ and biological events may antecede psychotic de­ tronic device transmitting radio messages from his compensation in the vulnerable individual. Fre­ abdomen. quently, a personal or family emotional crisis will precede the onset of symptoms, although a direct causal relationship between emotional stress and psychosis remains unclear.4 Often the stress rep­ resents an actual or fantasized loss (death, separa­ tion, etc),5 or a failure in reaching an important Schizophrenia Diagnosis goal or mastering a developmental stage.5 Medical procedures, such as childbirth and surgery, may The diagnosis of schizophrenia should be made immediately predate decompensation; drug abuse only when psychosis presents. There is no exact or administration (sympathomimetics, hal- diagnostic scheme, and the diagnosis rests on the lucinogenics) may also precipitate schizophrenia clinical evaluation of the course and in those who are biologically predisposed. symptomatology. The diagnostic systems of Unfortunately, it remains impossible to predict Bleuler9 and Schnieder10 are listed in Table 1. Ac­ which individuals will ultimately develop schizo­ cording to Bleuler, the four A’s are characteristic phrenia. No valid biologic marker or clinical of schizophrenia and are present under no other profile has yet been identified. Thus the premorbid conditions. Schnieder concludes the same about characteristics are usually documented retrospec­ his First Rank Symptoms. The secondary tively and treatment is predominantly ipso facto symptoms of Bleuler are frequently seen with rather than preventative. other psychotic disorders but may be absent in The signs and symptoms of schizophrenic de­ schizophrenia. Although the primary care physi­ compensation may present insidiously or acutely. cian will find these schemes useful, recent study Although acute symptoms may appear within has documented that neither of them are unique to hours, a careful history usually reveals that schizophrenia and neither has prognostic value.3 psychotic symptoms had been developing for days or weeks. Some of the symptoms are: cognitive and perceptual changes, anxiety and depression, somatic preoccupation, emotional and behavioral changes, physiologic responses to stress, and so­ cial withdrawal. The somatic complaints may be vague or may represent developing psy- Schizophrenic Types chophysiologic symptoms, and are often diag­ Schizophrenia is divided into various clinical nosed as neurasthenia, neurosis, or malingering. types (Table 2). These types are distinguished by With the transition to the overt psychotic presenting form, course, and age of onset. Such 72 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 1, 1978 DIAGNOSIS AND TREATMENT OF SCHIZOPHRENIAS typing is of limited value to the physician because, many patients present with mixed symptoms, and the form may change with subsequent exacerba­ Table 1. Diagnostic Criteria tions. Nevertheless, correctly diagnosing a type facilitates treatment and helps to insure as quick a 1. Bleuier's Primary and Secondary Symptoms* A. Primary Symptoms: Bleuier's four A's, which remission as possible. may not be evident early in the disorder: All 11 types involve a pathology of the total 1) Disturbances in affect, either inappropriate personality, manifested as disorganized and illogi­ or flattened. 2) Loose associations, wandering from topic cal thinking, inadequate or inappropriate emo­ to topic with little relevancy. tional responses to people or events, heightened 3) Autistic thinking, or involvement in fantasy material, often completely absorbed in emotional sensitivity, impaired volition and judg­ ideas of reference to self. ment, idiosyncratic belief systems (eg, delusions), 4) Ambivalence, often not quickly apparent but characterized by conflicting and simul­ and perceptual distortions (illusions and halluci­ taneously positive and negative feelings nations). toward another person. The simple type is characterized chiefly by a B. Secondary Symptoms: slow and insidious onset plus emotional detach­ 1) Erratic behavior, often day-night reversal. ment and apathy. The hebephrenic type is associ­ 2) Anhedonia, or inability to experience gratification or immersion in life experi­ ated with the fragmentation of thinking processes, ences. silliness, and regressive mannerisms in behavior. 3) Anger and frustration, often in reaction to inability to function. The catatonic type consists of two subtypes: ex­ 4) Dependence, a part of the boundary prob­ cited and withdrawn. The excited subtype is as­ lem and the reality problem of being un­ able to handle the exigencies of life. sociated with excessive and sometimes violent 5) Depression, with occasional suicide at­ motor behavior and emotions; the withdrawn sub- tempts. 6) Pathologic coping devices, or attempts to type with stupor, mutism, negativism, and waxy "e xplain" what is happening (eg, delu­ flexibility. The paranoid type is characterized sions, hallucinations, preoccupations, and depersonalizations). primarily by the presence of grandiose and perse­ 7) "Boundary" problems, or inability to dif­ cutory delusions, often associated with hallucina­ ferentiate oneself (both self and body) as distinct from others. tions. Excessive religiosity, blaming, aggressive­ 8) Feelings of markedly enhanced or muted ness, and hostile behavior are also common. sensory awareness. 9) Reports of "racing thoughts." However, personality disorganization is less 10) Mental exhaustion. common with this type than with the hebephrenic 11) Deficits in focusing attention and concen­ tration. and catatonic schizophrenias. 12) Disturbances in speech perception and Besides the simple, hebephrenic, catatonic, and word meanings. paranoid, there are seven additional types.