Suspicious and frightened, the victim fears he can trust neither his senses, nor the motives of other people…his skin prickles, his head seems to hum, and 'voices' annoy him. Unpleasant odours choke him, and bright and colourful visions pass before his eyes. When someone talks to him, he hears only disconnected words. When he tries to speak, his own words sound foreign to him.

SCHIZOPHRENIA SPECIFICATION

Classification of schizophrenia. Positive symptoms of schizophrenia include hallucinations and delusions. Negative symptoms of schizophrenia include speech poverty and avolition. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap.

DEMOGRAPHICS OF SCHIZOPHRENIA

• Schizophrenia ranks among the top 10 causes of disability in developed countries.

• Of all the disorders identified in ICD10 AND DSM V classification systems, schizophrenia is the most serious.

• At any one time, as many as 51 million people worldwide suffer from schizophrenia.

• It is slightly more commonly diagnosed in urban than rural areas.

• Schizophrenia overlaps with other psychiatric disorders, such as bipolar (manic type).

• The prevalence rate for developing schizophrenia without a biological relative with the condition is approximately 1.1% of the population over the age of 15. It is very unusual to get schizophrenia before the age of 15 (this, by the way, presents researchers with massive problems)

• There are small gender differences in the number of males and females who get schizophrenia. Slightly more males get schizophrenia and usually present with symptoms earlier. Females tend to get in middle age with less severe symptoms.

• Schizophrenia occurs between the ages of 15-60. The peak age incidence is in the early twenties for males and in the mid-forties for females.

• Schizophrenia occurs in all societies, regardless of class, colour, religion, and culture - however, there are some variations in terms of incidence and outcomes for different groups of people. For example, in individualistic countries, black people are diagnosed much more often than in collectivist countries.

• It is almost more common amongst the working class than in middle-class societies – although this could be blamed on the “Social Drift Hypothesis”.

• Suicide rates are high; as many as 50% will attempt, and 10% will succeed.

• Lifetime unemployment is 50-75%. 

• Life expectancy is ten years shorter. Heart disease/cancer increased risk.

• Substance-related disorders are high (over 50% smoke cigarettes regularly). They are also more likely to experience weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary disease. The combination of these factors may explain why people with schizophrenia die early compared to the general population.

• Schizophrenia treatment is still seen as “palliative”.

SCHIZOPHRENIA IS CO-MORBID WITH:

• Depression,

• Suicide

• Anxiety

• And excessive drug/tobacco/alcohol use

AFTER 10 YEARS, PEOPLE DIAGNOSED WITH SCHIZOPHRENIA:

• 25% Completely recover

• 25% Much Improved, relatively independent

• 25% Improved but require an extensive support network

• 15% Hospitalised, unimproved

• 10% Dead (Mostly Suicide)

WHERE ARE THE PEOPLE WITH SCHIZOPHRENIA?

APPROXIMATELY:

• 6% are homeless or live in shelters

• 6% are in prison

• 5% to 6% live in hospitals

• 10% live in nursing homes

• 25% live with a family member

• 28% are living independently

• 20% live in supervised housing (group homes, etc.)

THE COURSE OF SCHIZOPHRENIA

WIDE VARIATION OCCURS IN THE SYMPTOMS OF SCHIZ0PHRENIC PATIENTS

EPISODIC SCHIZOPHRENIA

• Some patients can have sudden symptoms, often after a stressful event. But every type of schizophrenia is variable, for example, at one end of the spectrum, a person can have a single psychotic episode of schizophrenia followed by complete recovery or a person can have many episodes of schizophrenia for an unspecified amount of time, e.g., periods where the illness might last weeks or months. This type of schizophrenia is known as “episodic schizophrenia.”

• With episodic schizophrenia, there is often a full remission in symptoms between each episode of schizophrenia, e.g., periods of relative normality, which can last from weeks to several months. Other persons, however, can have a fluctuating course in which symptoms are continuous but rise and fall in intensity.

CHRONIC ONSET SCHIZOPHRENIA

• Conversely, some patients can have a gradual onset over the years or months where symptoms are usually continuous and unrelenting, e.g., there is no remission and evidence of a steady decline over time.

• Other schizophrenics have relatively little variation in the symptoms of their illness over time.

• Recent research increasingly shows that the disease process of schizophrenia gradually and significantly damages the brain of the person.

BRIEF HISTORY OF SCHIZOPHRENIA?

The disorder was originally called Dementia Praecox (senility of youth) by Kraepelin, who believed that it occurred in young people only and was a disorder with progressive dementia-like symptoms. This was not long disputed by Bleuler (1911), who observed that the disorder often begins later and was not always characterised by progressive deterioration. Since then, schizophrenia as a construct has been through many metamorphoses from DSM-I to DSM-5 (1952-2013).

BLEULER COINED THE TERM SCHIZOPHRENIA.

Schizophrenia is a Greek word and means split mind (Schizein = to split and phren = mind). The media have popularly mistaken this term for many identities, such as in multi-personality disorder, where the patient presents with dual characters like Jekyll and Hyde or The Green Goblin in Spiderman. This is far from the truth.  Schizophrenia refers to a splitting in the functions of the mind and a disorder where the personality loses its unity.“Psychiatrists often refer to Schizophrenia as a royal disease because of the wealth of symptoms that accompany it. The syndromes are so diverse and complex that there has been disagreement on how they should be classified (Hunca-Bednarska, 1997).

WHAT IS SCHIZOPHRENIA?

Schizophrenia is a breakdown of perpetual filtering.

Although we are constantly bombarded by a great mass of incoming sensory information, we can ordinarily selectively attend to some bits and exclude most other sources of information. In this way, people can perceive their world in an orderly and meaningful way. For example, we are concentrating on what you are reading right now and excluding information about the sounds outside or the sensations of your feet.

Schizophrenics, by contrast, are unable to screen out distractions or to discriminate between relevant and irrelevant input. They are highly sensitive to stimuli of all kinds- from both internal and external sources- and cannot integrate their perceptions into a meaningful pattern, in other words, they can’t sustain focus, filter, or prioritise incoming and outgoing information. This leads to overwhelming and unintegrated ideas and sensations, affecting their concentration. As a result, schizophrenics are distracted by anything and everything. In turn, this is reflected in their language and their behaviour.

For the schizophrenic, then, their brain’s filtering system is effectively broken. For example, with the sentence “ I went outside to get some bread. “ a schizophrenic person may not be able to prioritise what’s important in that sentence; they might bypass the semantics (meaning) and focus on the individual words instead, thus the sound of the word bread might make them think of head? The word bread makes them think of breakfast, and then breakfast makes them think of Audrey Hepburn. And schizophrenics don’t know why this happens. They are confused about the things they think about, which leads to paranoia - imagine not knowing why you are suddenly thinking about a “head”! Schizophrenic individuals might then start to believe that their thoughts and feelings are so unusual they must have been inserted into their minds by somebody else and that their thoughts have been stolen.

When a neurotypical person’s conversation deviates from the subject matter, he/she can trace back the connections; schizophrenics cannot. The processes in their brain are not working in unison; they are fragmented. Therefore, sensations are felt but not identified as from the self. Most of us recognise our inner voice as our consciousness, but with the schizophrenic, the internal voice has disconnected from self-awareness. The world of the schizophrenic is, therefore, bewildering. This explains paranoid schizophrenia, where the person believes he/she hears voices in his/her head. As our culture designates supernatural experiences to a God, this could explain why many schizophrenics have deep connections to religions.

Individuals with schizophrenia cannot filter incoming stimuli and attend selectively when racing thoughts plague them or are 'locked in' on a theme and when their thoughts don't line up with their feelings. Not only does the disorganisation of thought and emotion involve the environment, but it also involves the self-structure. The self, which normally functions as the integrating core of the personality, becomes diffused, fragmented, and chaotic. Individuals may experience varying degrees of confusion concerning who and what they are, accompanied by some measure of depersonalisation. The loss of control over their thoughts and feelings, combined with the fragmentation of the self and a sense of depersonalisation, adds to acute panic.

POSITIVE & NEGATIVE SYMPTOMS

Clinicians distinguish two kinds of schizophrenia, one with Positive symptoms + and the other with Negative symptoms -

POSITIVE SYMPTOMS

POSITIVE SYMPTOMS are symptoms that reflect an excess or distortion of normal functions.

DISORGANISED SYMPTOMS: DISORGANISED SPEECH

There is a marked reduction in problem-solving and decision-making ability. Since cognitive processes strongly influence emotions, it is unsurprising that the disorganisation of thought is accompanied by distortions in affective (emotional) responses and language. Schizophrenics have difficulty concentrating, impaired ability to sort relevant from irrelevant stimuli and to maintain order in the association of thoughts and language; for example, when speaking a sentence, a schizophrenic is unable to follow the thread because he is distracted by words themselves, either the sounds they make or irrelevant associations to the conversation at hand.

• KNIGHTS MOVE THINKING: The classic disturbance in the form of Schizophrenic thought involves loose connections (also known as loose associations ). A new association emerges in which the individual shifts from one topic to another. As a result, a schizophrenic language is often rambling and disjointed. Very often one association seems to trigger an association with another.

• WORD SALAD: When associations become too loose, the result is incoherence or a word salad.

• CLANG ASSOCIATIONS: The word's sound may also trigger an association with a similar-sounding word.

• NEOLOGISMS: Made-up words or words used inappropriately.

• LANGUAGE: Verbosity, utterances are long, loud, emphatic, difficult to break into, and overloaded with details. Sentences are incomplete, agrammatical, incoherent texts within a single utterance. Numerous nouns to express aggression and mistrust

DISORGANISED BEHAVIOUR:

Disorganised behaviour can take many forms, but patients generally seem to lose their ability to conform to societal standards or cope with everyday life.

EXAMPLES INCLUDE

1. Dresses in unusual clothes

2. Fatuous behaviour (acting childishly)

3. Inexplicable bouts of aggression

4. Hoarding food

5. Collecting rubbish

6. Sexually inappropriate behaviour (e.g., masturbating in public )

DISTURBANCES OF AFFECT (EMOTION)

Disturbance in emotional responses and feelings is one of the hallmarks of the disorder.

FATUOUS AFFECT: The moods of a patient with fatuous affect resemble those of a child—often silly behaviour.

HALLUCINATIONS

Hallucinations are bizarre unreal sensory perceptions of the environment that can be from any sense modality but, in schizophrenics, are usually auditory (hearing voices in the third person, usually in the form of a running commentary on the patient’s behaviour that is derogatory) but maybe visual (seeing lights, objects or faces), olfactory (smelling things) or tactile (feeling bugs are crawling in or on the skin, feeling numb or disconnected from one’s body). Typically, voices are heard from outside the individual’s head and offer a running commentary on behaviour in the third person (such as ‘he is washing his hands, he is an idiot’. The voices often comment on the individual’s character, usually insultingly or give demands. Thus, they may hear voices telling them what to do, commenting on or criticising their actions. In some instances, the voices are ascribed to relatives or friends, in others to 'enemies', and in still other cases, the messages received "from God" or some organisation and told them of great powers that have been conferred on them or of their mission to save humanity.

• Somatosensory hallucinations involve changes in how the body feels. They may be described as burning or numb. They may also evoke a feeling of depersonalisation, e.g., a sense of being disconnected from one's own body.

• Anwesenheit Hallucination: Anwesenheit refers to the feeling of the presence of something or some person. It can be seen in normal grief reactions, schizophrenia and some emotionally arousing situations.

DELUSIONS

Delusions: Delusions are fake beliefs that persist even in the presence of evidence that contradicts them, e.g., beliefs maintained despite their logical absurdity or objective evidence showing they lack any foundation in reality.

Delusions are often overrepresentation of abstract and metaphysical ideas and verbal abuse of themes like death, power and hostility that have to do with the schizophrenic vision of the world.

TYPES OF DELUSIONS

• PARANOID DELUSIONS: Persecutory delusions are the most common type of delusions experienced by schizophrenic people, per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). These delusions are based on suspicions of being targeted by someone or something. Schizophrenic people with these types of delusions mistakenly believe that they are being followed, harmed, poisoned, or tormented. Delusions of persecution are suggestive of the paranoid type of schizophrenia.

• DELUSIONS OF CONTROL/ THOUGHT CONTROL: This delusion involves people believing that outside forces control their actions or thoughts. They may believe that certain people or groups put thoughts into their heads or "steal" thoughts away from them. They also may believe that a person or object makes them perform certain actions, and they are powerless to control their behaviour. Sometimes, the person may think their thoughts are being broadcast so others can hear them. Experiences of control – also include the person believing they are under the control of an alien force that’s invaded their mind and body.

• DELUSIONS OF THOUGHT BROADCAST: Patients may believe their thoughts are being broadcast to the outside world.

• DELUSIONS OF REFERENCE: Schizophrenics who believe ordinary events occur especially for them are suffering from delusions of reference, basically, ideas wherein seemingly random stimuli are thought to be referring to the individual. Schizophrenics with referential delusions believe that the gestures and words of others are specifically directed at them. They become convinced that they are the focus of song lyrics, books or comments made by someone on television. This delusion can manifest itself in a variety of ways. Some schizophrenics may believe that current events are happening "for" them or because of something they did. Others may believe that what strangers or celebrities do or say is meant as a message especially for them, even when they have never met or spoken to them. Another example is if a car beeps outside, the individual feels it was directed toward him or herself.

• DELUSIONS OF NIHILISM: The delusion that things (or everything, including the self-do not exist; a sense that everything is unreal.

• RELIGIOUS DELUSIONS: Religious delusions centre on misguided ideas about one's relationship with God. Schizophrenic people with this type of delusion may believe they have a special relationship with God or that God has given them special powers. They may profess an ability to speak directly to God or a responsibility to carry out God's plans. In some cases, these individuals may believe that they are God.

• AUTOCHTHONOUS DELUSION: Jaspers defined this as a delusion arising without apparent cause; for example, suddenly, without obvious cause, having the delusional belief that you are an alien.Typical

• GRANDIOSE DELUSIONS/DELUSIONS OF GRANDEUR: Those who believe they are famous, powerful or have extraordinary abilities when this is not true may suffer from delusions of grandeur. For example, some schizophrenics may believe th’re influential people from the past, such as Jesus Christ or Cleopatra, while others may think they can fly or become invisible. Even when presented with evidence that disproves their beliefs, these people will refuse to accept that they are not as powerful, magical, or famous as they think.

• SOMATIC DELUSIONS Are beliefs about the body that is untrue. For example, some schizophrenics may believe they have a deadly disease even when it has been proven that they do not or may believe that there are foreign objects inside of their bodies when there aren't.

PHYSICAL SYMPTOMS / BEHAVIOUR (POSITIVE)

• Hyperactive

• Suspicious

• Hostile

NEGATIVE SYMPTOMS

In contrast to positive symptoms, the negative symptoms of schizophrenia represent a relative absence of feelings, cognition and goal-directed behaviour, which has a detrimental effect on psychosocial functioning and quality of life, in short. Negative symptoms appear to reflect a lessening (reduction) or loss of normal functions.

NEGATIVE SYMPTOMS ARE GROUPED INTO TWO MAIN DOMAINS:

AVOLITION & APATHY: LACK OF MOTIVATION, ANHEDONIA & ASOCIALITY

• Anhedonia refers to a state of mind in which the subject finds no pleasure in anything. It is defined as the inability to experience pleasure from activities usually found enjoyable, such as hobbies, exercise, social interaction, or sexual activity.

• Apathy is a state of indifference or the suppression of emotions such as concern, excitement, motivation, and passion. An apathetic individual lacks interest in or concern about emotional, social, spiritual, philosophical, or physical life.

• Avolition/loss of volition: Reduction/inability to initiate and persist in goal-directed behaviour, usually because of a lack of energy and will. e.g. sitting in the house for hours every day, doing nothing. Patients may become inattentive to hygiene and grooming, e.g., sitting in dirty clothes and not washing. Movement is slowed down- staying in bed (in extreme cases, catatonia)

• Asociability: impairments in social relationships: poor social skills, few friends, little interest in being around others.

• Social withdrawal: Living a secluded life away from people

DIMINISHED EXPRESSIVENESS AND AFFECT ( VERBAL & NONVERBAL )

• Blunted affects: Blunting is the scientific term describing a marked reduction in the range and intensity of emotional expression and reactivity, including facial expression, voice tone, eye contact and body language. It manifests as a failure to express feelings verbally or non-verbally, even when talking about issues that would normally be expected to engage the emotions—a blank, vacant facial expression. An inability to smile or express emotion through the face is so characteristic of the disease.

• Flattened affect (e.g., flat or no emotion to even sad events): As the disease progresses, virtually no stimulus can elicit an emotional expression.

• A blank, vacant facial expression. An inability to smile or express emotion through the face is so characteristic of the disease that it was named affective flattening or a blunt affect.

LANGUAGE PROBLEMS (NEGATIVE)

Typical language change with negative symptoms

POVERTY OF SPEECH: Speech where little is conveyed or communicated although grammatically correct. Characterised by brief and empty replies to questions. It should not be confused with shyness or reluctance to talk. The patient exhibits many of the following.

• Becomes monosyllabic,

• Limits the use of their words

• Speak hesitatingly,

• Suddenly become mute,

• They never relate anything to their own initiative. For example, they never begin a conversation with anyone (they ask no questions, make no complaints, and never pass on the news - not even to close relatives.

• Allows all their responses to be laboriously pushed out of them.

• ALOGIA Literally means "not having words." It is characterized by lessening speech fluency and productivity, thought to reflect slowing or blocked thoughts. This may be seen in advanced dementia, too.

• THOUGHT AND SPEECH BLOCKING: Stopping in the middle of a word or sentence. Interruption of a train of speech before completion. e.g. "Am I early?" "No, you're just about on..."(silence).  To an extreme degree, the speaker does not recall the topic he or she was discussing after blocking occurs. True blocking is a common sign of schizophrenia. Lack of speech spontaneity Incoherence and disfluency of utterances showing and fluency, among other things - rare conjunctivitis and anaphoric and idiosyncratic pauses

• NEOLOGISMS AND OTHER PECULIARITIES IN SPEECH: Neologism perseverance; rare use of retreat group pronouns and animate nouns; very poor use of adjectives, especially emotive ones, which makes the utterances sound “cool and colourless”.

PHYSICAL SYMPTOMS (NEGATIVE)

• Staring, while in deep thought, with infrequent blinking.

• Clumsy, inexact motor skills

• Sleep disturbances- insomnia or excessive sleeping

• Parkinsonian-type symptoms- rigidity, tremor, jerking arm movements, or involuntary movements of the limbs

• An awkward gait (how you walk)

• Eye movements- difficulty focusing on slow-moving objects

• Unusual gestures or postures

TYPE 1 & TYPE 2 SCHIZOPHRENIA

Some clinicians distinguish between the following two subtypes of schizophrenia.

TYPE 1 SCHIZOPHRENIA

• ACUTE Sudden onset often after a stressful event.

• EPISODIC. It usually occurs in episodes, and there can be periods of remission in between—e.g., periods of relative normality between episodes for several months.

• CHARACTERISED BY: Hallucinations, delusions, and thought control;

TYPE 2 SCHIZOPHRENIA

• GRADUAL ONSET: Over years or months, there is evidence of a steady decline over time.

• CHRONIC: Symptoms are usually continuous and unrelenting; there is no remission).

• CHARACTERISED BY: Negative symptoms: alogia, avolition, and flattened affect;

Some patients experience both type-one and type-two symptoms; this is when the categorisation system seems flawed.

SUBTYPES OF SCHIZOPHRENIA

Some psychologists classify schizophrenia in terms of sub-types, although some classification systems have now omitted these.

THE SUBTYPES ARE

• DSM’s five subtypes were Paranoid, Disorganised, Catatonic, Undifferentiated or Residual schizophrenia.

• ICD’s seven subtypes were Paranoid, Hebephrenic, Catatonic, Undifferentiated, Simple Schizophrenia Residual, Simple and Post-schizophrenic depression

  By the way, simple schizophrenia and post-schizophrenic depression were not ever in the DSM, and Disorganised and Hebephrenic are the same subtypes. Just named differently in DSM and ICD.

THE ERADICATION OF THE SCHIZOPHRENIA SUBTYPES IN ICD AND DSM

Schizophrenia subtypes have been omitted from DSM-5 because of their “limited diagnostic stability, low reliability, and poor validity,” according to the American Psychology Association (APA). The APA also justified the removal of schizophrenia subtypes from the DSM-5 because they didn’t appear to help with providing better-targeted treatment or predicting treatment response.

Psychologists are now supposed to refer to the condition as schizophrenia without reference to subtypes.

• DSM-V contains no sub-classifications of schizophrenia: Schizophrenia is now known as a spectrum disorder with a variety of symptoms and causes. According to the DSM-5, a schizophrenia diagnosis requires the following: At least two of five main symptoms. The symptoms explained above are delusions, hallucinations, disorganized or incoherent speaking, disorganized or unusual movements and negative symptoms.

• ICD-11 contains no sub-classifications of schizophrenia: For an ICD-11 diagnosis of schizophrenia, at least two symptoms must be present, including positive, negative, depressive, manic, psychomotor, and cognitive symptoms. Of the two symptoms, one core symptom needs to be present, such as delusions, thought insertion, thought withdrawal, hallucinations, or thought disorder.

DSM V SCHIZOPHRENIA

• DSM states that “no single symptom is pathognomonic of [schizophrenia]”, and it is a “heterogeneous clinical syndrome”. Two people with people diagnosed with schizophrenia may look and behave nothing like each other.

• DSM V acknowledges that any risk factor for developing schizophrenia will combine biology and the environment. Therefore, the aetiology is no longer a fight between nature and nurture. A mixed explanation like this is known as a diathesis-stress model (DS).

• The addition of the term “spectrum” and the less stringent guidelines show that the DSM 5 is acknowledging that it sees schizophrenia as an umbrella term.

Many researchers still question why schizophrenia has been labelled a spectrum disorder, as most patients fall into either a negative symptomology with hypo dopamine function or a positive symptomology with hyper dopamine function.

BIOGRAPHY OF A SCHIZOPHRENIC

“Carl was twenty-seven years old when he was first admitted to a psychiatric facility; gangling and intensely shy, he was so incommunicative at the outset that his family had to supply initial information about him. It seemed they had been unhappy and uncomfortable about him for quite some time. His father dated the trouble some time back in high school. He reported. “Carl turned inwards, spent a lot of time in his room alone, he had no friends and did no schoolwork.” His mother was especially troubled by his untidiness. He really was an embarrassment to us, and things have not improved since. “You could never take him anywhere without an argument about washing or changing his clothes. And once he was there, he wouldn’t speak to anyone” His parents further reported that after living away from home for three years, Carl moved back. Disagreements between Carl and his family became frequent and intense. He became more reclusive, bizarre, and sloppy. His parents became more isolating and irritable. Finally, they could take it no longer and took him to hospital. He went without resistance. After ten days in the hospital, Carl told the psychiatrist working with him. “I am an unreal person. I am made of stone or else I am made of glass. I am wired precisely wrong. But you will not find the key to me. I have tried to lose the key to me. You can look closely if you want, but you will see more from far away. Shortly after that, the psychiatrist noticed that Carl “…. smiles when he is uncomfortable and smiles more when he is in pain. He cries during television comedies, seems angry that justice is done and is scared when someone compliments him. He roared with laughter on hearing that a child had tragically been burnt. He grimaces often. He eats very little but always carries away food. After two weeks, the psychiatrist said to him,” You hide a lot. As you say, you are wired precisely wrong. But why won’t you let me see the diagram?” Carl answered, “Never will you find the external lever that will sever me forever with my real, seal, deal heel. It is not on my shoe, not even on my sole. It walks away.”

HOW DO YOU DEFINE SCHIZOPHRENIA CONCISELY FOR AN ESSAY QUESTION?

Below is a very concise definition of schizophrenia—good for a quick essay outline. Remember, unless specifically asked, you do not need to describe schizophrenia.

In other words, if you are answering a question about what causes schizophrenia or the best way to treat it, you do not need to describe it. If you do, you will not receive marks for the description.

You may now be asking yourself why I have gone to such lengths to describe schizophrenia if learning this is not often required in exams. The reason YOU need to know the symptoms well is so that you can evaluate theories on cause and treatment effectively. If you don’t know what schizophrenia is, then you certainly won’t be able to judge theories that explain or treat it.

ESSAY QUESTION: “OUTLINE THE CLASSIFICATION OF SCHIZOPHRENIA” (6 MARKS = A01)

Schizophrenia (SZ) is an extremely difficult disorder to classify, as each individual can have different characteristics of the illness. It is a condition with disordered and disorganised thought processes manifesting in the patient’s language and behaviour. There is also a loss of contact with reality and a disturbance of form and thought content. Schizophrenia affects the mood of the person and their sense of self about the external world. The behaviour of schizophrenics may be purposeless, and they can distort reality and withdraw from society. Some types of schizophrenia develop slowly and insidiously, and the absence of emotion, language and self-initiation may dominate the early clinical picture. Yet other kinds of schizophrenia are dominated by auditory hallucinations, paranoid delusions, and excessive behaviours. As a result, schizophrenia is now classified as a spectrum disorder.