Structural Aspects of a Case of Schizophrenia

The study of the case of H. is the first publication of a number of investigations of schizophrenia, in all of which I arrive at the conclusion that schizophrenia is not preceded by an infantile psychotic state; that in this respect a psychosis differs radically from a neurosis, for which there is always an infantile basis.

In almost all cases of schizophrenia a distinction can be made between a prepsychotic period and the psychosis proper. The study of the relationship between the prepsychotic and the psychotic symptoms enables us to gain insight into the structure of the delusion and its related phenomena.

Many times the beginning of the prepsychotic phase is marked sharply, as when symptoms appear which show that important parts of the personality have disappeared. Notwithstanding this disappearance, contact with reality is still maintained. The prepsychotic period is characterized not only by "dropping out" phenomena but also by mechanisms that try to ward off the danger of losing contact with reality; sometimes even attempts at recovery are made by remnants of the personality.

There are other cases of schizophrenia where the beginning of the prepsychotic period is less sharply marked and where symptoms seem to develop as an exacerbation of a situation already long in existence. In these cases it is not certain whether these exacerbations differ only quantitatively from the preceding state or whether a qualitative change has also taken place.

In addition, there are a number of borderline cases which show symptoms of a prepsychotic nature but which never develop into a real psychosis, for the patients still succeed in maintaining contact with reality. We know that puberty now and then takes a course which strongly resembles prepsychotic development; fortunately, however, such puberal development frequently takes a turn for the better.

The psychosis proper starts when contact with reality has been abandoned. The delusion and almost all of the other sc