We have now come to the fourth, or last, stage of schizophrenia during which a new set of phenomena occurs. Some of the symptoms appear no longer as predominantly psychological but neurological. It seems as if the disorder has reached a level where psychology and neurology coalesce.

This chapter presents a general description of schizophrenia, and then discusses the various types.

In this chapter we discuss patients in whom a slow psychodynamic development that appeared directed toward a schizophrenic outcome was diverted, arrested, or slowed down.

The competency of the psychiatrist is often measured by his ability to rule out from the classification schizophrenia many patients who present a schizophrenic-like symptomatology. Although no one can be absolutely sure what course a given patient will follow, a certain group of symptoms and factors tend to occur more frequently in patients who recover; on the other hand, other symptoms and factors tend to occur in patients with a poor outcome.

In this part of the book we shall examine the mechanisms with which the patient attempts to envision life in a less frightening manner.

A psychodynamic understanding of any human being and, in our particular case, of a person who will eventually suffer from schizophrenia, requires that we study the following:

1. The world which the child meets.

2. The child’s way of experiencing that world, especially in its interpersonal aspects.

3. The way the child internalizes that world and the effects of such internalization.

4. The ways by which the sequence of later experiences weaken, reinforce, distort, neutralize, expand, or restrict the effects of the early experiences.

In many cases of schizophrenia the disorder does not manifest itself, at least in its initial stages, with obvious symptoms. Some cognitive alterations may appear to be within the normal range or not distinguishable from those occurring in neuroses and character disorders. Usual psychological tests may also fail to show evidence of cognitive impairment. However, people who knew the patient well can recognize the difference in him. His attitude toward life has changed.

Although primary process mechanisms continue to function in these children for a period of time longer than in normal circumstances, the primary process is eventually overcome and to a very large extent is replaced by secondary process mechanisms.

Because the early experiences have made the future patient awkward socially, clumsy in his activities, and somewhat inadequate in coping with life in general, his defects become more evident in adolescence and later, when he has to deal with a greater range of situations.

The fourth, psychotic, period of schizophrenia covers the whole psychosis, from its onset to termination.