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PSYCHOBIOLOGY OF SCHIZOPHRENIA: A NEO-JACKSONIAN DETOUR ADAM SULKOWSKI* It ¿s possible and even probable that the relationship to reality is learned by way ofdetours . . . throughfantasy.—H. Hartmann [1] Introduction The history of psychiatry illustrates rather well the type of learning described by Hartmann. In no other field ofknowledge have the detours been so tortuous and so far reaching as to result in denial of the very existence of the object of study [2] and self-destructive gestures [S]. Recent developments in brain sciences, psychiatric nosology, and clinical research on schizophrenia strongly indicate that this regressive phase might soon be over. A new synthesis has begun to emerge that will bring us closer to reahty than ever before. The foundations of modern psychiatry were laid in the nineteenth century when many great physicians realized that what was called "insanity " consisted of many identifiable syndromes. Each syndrome had a different mode of onset, clinical picture, course, and outcome. This descriptive psychiatry could not offer any effective preventive and therapeutic measures. The world would not wait, however, and psychiatry embarked on a "wild ride" in all directions: biological, psychodynamic, psychosocial, philosophical, and so on, disregarding the very often scientifically valid and clinically useful insights of the classics. The wild ride provided unprecedented opportunities for exploration and confrontation of different points of view. As a result, an enormous amount of data has accumulated and, in some areas of psychiatry, an arduous task of integration has been partially accomplished. The new nosology of schizophrenia is one of these achievements [4]. ?Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, Massachusetts 01730; and Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118.© 1983 by The University of Chicago. AU rights reserved. 0031-5982/83/2602-0338$01.00 Perspectives inBiology andMediane, 26, 2 · Winter 1983 | 205 The most remarkable feature of these developments is that they represent a return to the classic nosology of Kraepelin and Bleuler. Could it be that there are more treasures in the ashes of the past? I beUeve so and feel that the time has arrived for a psychobiological detour integrating research and clinical data on schizophrenia. The detour will take us as far as the end of the nineteenth century to the work ofJ. H. Jackson. From the selective overview of recent developments in neuropsychiatry of schizophrenia and related fields of the neurosciences , it will become apparent that his theory ofevolution-dissolution of the central nervous system (CNS) provides an attractive framework for reconciUation of seemingly contradictory points of view. Its potential heuristic value lies in suggesting new approaches to scientific investigations of the disease. Clinical Features Advances in clinical psychiatry, epidemiology, and genetics have led to a growing consensus that schizophrenia is a chronic psychiatric illness affecting the entire personality, that is, the thinking, feeling, and behavior of its victims. Disorganization of thought processes, impoverishment ofemotional life, and bizarre behavior are the cardinal signs in the absence of which no diagnosis of schizophrenia should be made. The chronic and malignant course is interrupted by acute exacerbations in the form of catatonic, hebephrenic, and paranoid syndromes. These syndromes are characterized by florid psychiatric symptoms (agitation , stupor, hallucinations, delusions) and maladaptive regressive behavior . The cardinal signs of the disease are detectable regardless of what form an acute episode takes, and they persist or become more obvious when the acute symptoms disappear. They lead to psychosocial disability, which becomes more severe as the disease progresses. It expresses itself in gradual withdrawal from reality and permanent dependence on others or marginal social adjustment. In simple ("undifferentiated ") form only the cardinal features are present. Many follow-up studies [5] have documented the clinical impression that the long-term prognosis for this "Kraepelinian" schizophrenia is poor. Careful clinical observation of chronic "institutionalized" schizophrenic patients [6] shows that crippling cognitive deficits with poverty of affect and volition are probably due to schizophrenia itself rather than pharmacological treatments or chronic hospitalization. The maHgnant nature of these deficits suggests organic etiology. An infrequently asked but very relevant question is, What regions of the brain are involved? Clinical neurology textbooks discuss only one organic syndrome that resembles simple schizophrenia: "the frontal lobe syndrome." While it...


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