Appearance and behaviour

The patient may have a first presentation after contact with the criminal justice system or after failure to cope in a first job or at university, or may withdraw into their house or room. Deliberate self-harm and contact with drug and alcohol agencies are frequent.

Often the standard of self-care, as reflected in the appearance, may be reduced. In severe cases, where patients lose the ability to care for themselves, there may be self-neglect. More frequently, the patient's appearance will just be somewhat unusual. By saying this, of course, I do not mean that there is anything intrinsically unhealthy about the adoption of particular styles of appearance; it is just that clinical experience indicates that fairly outlandish styles of dress may be seen in newly presenting patients with schizophrenia. A misguided sense of 'political correctness' should not be permitted to lead one to ignore such matters. Tactful enquiry may therefore be necessary to find out the meaning to the patient, if, for example, they wear clothes of only one colour.

Presentations with abnormal movements and fixed posturing (catatonia) are classical, although now rare in developed countries. Catatonic features include mannerisms, stereotypies, imitation of the speech and behaviour of others (echo-lalia and echopraxia), negativism, mutism, stupor, hyperactivity, and prolonged maintenance of strange postures (waxy flexibility).

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