Hebephrenic
Schizophrenic Reactions
NORMAN Q. BRILL, MD, AND JOHN F. GLASS, MA, LOS ANGELES
Introduction
Considering the vast amount of research
in recent years dealing with schizophrenia, it
is surprising how little advance has been made
in problems of diagnosis and classification. The
work of Kraepelin and Bleuler on schizo-
phrenia done more than 50 years ago, apparently
still represents the major foundation for the
current classification of schizophrenic reactions.
This report will deal primarily with one major
subtype of schizophrenia, hebephrenic, which
although fairly common has been described as
the most difficult type to diagnose.1,6,8,14 It is
the type of schizophrenia with the most un-
favorable prognosis.10,15
Bleuler 4 about 50 years ago, pointed out that
catatonic and hebephrenic schizophrenics are
about equally represented in the hospital popu-
lation with the paranoid group somewhat less
common. A change in the relative incidence of
the various types of schizophrenia seems to have
occurred in the last few years. Until about two
decades ago there were relatively small differ-
ences in the incidence of the hebephrenic,
paranoid, and catatonic reactions, but now, ac-
cording to Arieti, many psychiatrists 1 feel that
the paranoid type is the most common. The
experience at the Neuropsychiatric Institute
would support this view.
The problem is complicated because the sys-
tem of classification of schizophrenic reactions
Submitted for publication Nov 30, 1964.
From the Department of Psychiatry and the Neuro-
psychiatric Institute, UCLA Medical Center. Profes-
sor and Chairman, Department of Psychiatry and
Medical Director, the Neuropsychiatric Institute (Dr.
Brill) and graduate student, Department of Sociology,
UCLA, and Assistant Social Research Analyst, the
Neuropsychiatric Institute (Mr. Glass).
Reprint requests to Department of Psychiatry,
UCLA, Los Angeles, Calif 90024 (Dr. Brill).
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at best and
according to types is approximate
because of the difficulties in diagnosing hebe¬
phrenic type symptoms which are not as easily
and clearly distinguishable, as current textbooks
suggest, from those of paranoid or catatonic
reactions.8,14
The criteria for the diagnosis of a schizo¬
phrenic reaction itself, without regard to type,
differ from doctor to doctor and hospital to hos¬
pital. The problem is compounded when the sub¬
type is categorized. Some hospital staffs
habitually call a greater percentage of cases
catatonic than do others, which are more partial
to the diagnosis of paranoid or hebephrenic
subtypes.
Infrequency of Diagnosis of
Hebephrenic Reactions
At the UCLA Neuropsychiatrie Institute, of
425 patients who have been diagnosed as schizo¬
phrenics, only four, or less than 1%, were diag¬
nosed as hebephrenic. Dr. John Frosch, in a
personal communication, states that at Bellevue
Hospital in New York, a diagnosis of hebe¬
phrenic reaction is rarely made. An occasional
case is seen of a fulminating psychosis in which
hebephrenic symptoms are seen from the be¬
ginning. Bellak3 believes that a certain per¬
centage of all cases probably progress from an
initial catatonic type to a later paranoid or
hebephrenic picture. Bleuler 4 recognized this a
long time ago and stated that changes in symp¬
toms are not at all rare : "Catatonic or paranoid
symptoms can disappear, so that an initially
catatonic or paranoid patient may later on
exhibit symptoms of simple hebephrenia."
of Diagnosis
History
Hebephrenia
of
The term "hebephrenia" (from the Greek:
hebe, youth; phrenia, mind), was first used by
 Hecker in 1871 to describe a disease which
"
in adolescence and progressed to a
began
chronic dementia. Hecker's concept of "hebe¬
phrenia" is not entirely comparable with the
present one which is based essentially on the
classification devised by Kraepelin and identi¬
fies hebephrenia as just one of the subtypes of
dementia praecox along with catatonia and
paranoia.
Kraepelin n described a form of hebephrenia
under the name of "silly dementia" which was
characterized by incoherence in thinking, feel¬
ing, and action. The development of the disease,
according to Kraepelin, was generally quite
gradual with the preliminary stages character¬
ized by nervous troubles, complaints of lassi¬
tude, headaches, feeling of giddiness, irritability,
and sleep disorders. This was followed by
absentmindedness, inability to collect thoughts,
silly and lazy behavior, and occupational diffi¬
culties. Hallucinations, delusions, and passing
states of depression were frequent. Some pa¬
tients exhibited exalted ideas, often of a re¬
ligious nature. The emotions of patients were for
the most part in harmony with the ideas that
they were expressing but they were not very
deep and showed sudden fluctuations. Patients
were observed to laugh and weep without
recognizable cause. Childish behavior often
occurred and a certain restlessness was observed
very frequently. The conduct of patients showed
many peculiarities. They were very changeable;
sometimes accessible, childlike, docile, and other
times repellent, inapproachable, and resistive.
Their mode of speech was described as manner-
istic and the substance of their conversation
confused. Sleep was frequently disturbed and
appetite irregular. Kraepelin points out that
in the great majority of cases he studied, the
progression of the disease "led to 'profound
dementia' in which for the most part, the
peculiarities of the previous morbid condition,
silly conduct, and incoherence of the train of
thought were still distinctly recognizable."
Eugene Bleuler4 accepted the essentials of
Kraepelin's system of classification but revised
the basic description of schizophrenia by es¬
tablishing two sets of symptoms, primary and
secondary. The primary, or fundamental
symptoms which are present in all forms of
schizophrenia, include disturbances of affect;
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disturbances of thought (association) and
ambivalence. Secondary, or accessory, symptoms
include those also frequently appearing in other
mental disorders such as delusions, hallucina¬
tions, ideas of depersonalization, catatonic symp¬
toms, etc. Bleuler considers hebephrenic
schizophrenia within his framework of basic
and accessory symptoms. He identifies hebe¬
phrenia as a subdivision of dementia praecox
where accessory symptoms (hallucinations, de¬
lusions, etc) appear, but do not dominate the
picture continually.
Hebephrenia, to Bleuler, includes the acutely
beginning, noncatatonic forms of schizophrenia
insofar as they do not pass over into chronic
paranoid or catatonic conditions, and all chronic
cases with accessory symptoms which do not
completely dominate the picture. He held that
there are no specific symptoms for hebephrenia
and includes under the term hebephrenic, what
used to be called secondary dementia with acute
onset of the psychoses and cases in which ex¬
citement and agitation first make their appear¬
ance after the onset of deterioration. Bleuler's
account of hebephrenia as a disease that has no
specific symptoms unfortunately is quite con¬
fusing.
Modern definitions of hebephrenic schizo¬
phrenia vary somewhat in the emphasis they
place on symptomatology and most refer to the
description of Kraepelin and Bleuler. Unlike
Bleuler, who lumped together under the
hebephrenia subgroup all cases not fitting into
one of the other three types—simple, catatonic,
and paranoid, Mayer-Gross et al13 prefer to
place under hebephrenic all cases of schizo¬
phrenia in which thought disorder is the leading
symptom; this being a large group comprising
the majority of schizophrenics whose illness
starts before the age of 10.
A recent book by Fish ß contains an excellent
chapter in the classification of schizophrenia
and describes in detail the classification system
of Leonhard based on the work of Kleist.
Leonhard divides schizophrenia into systematic
and nonsystematic types which correspond to
Kleist's typical and atypical forms. In the non-
systematic schizophrenias, the symptoms tend to
be polymorphous and because of their diversity
it is difficult to outline the clinical picture very
sharply.
 Leonhard believes that the diagnosis of sys¬
tematic schizophrenia, which depends on a char¬
acteristic combination of symptoms, is much
easier to classify since the symptomatology is
clear-cut, and sharply delimited clinical pictures
are found in the end states. He recognizes three
major systematic types of schizophrenia with
subtypes under each: Systematic Catatonia
(six subtypes); the Hebephrenics (four sub¬
types); and the Systematic Paraphrenias (six
subforms to designate all paranoid schizo¬
phrenias). The hebephrenic group, in which we
are primarily interested here, was described by
Leonhard as including: (1) Silly Hebephrenia;
(2) Eccentric Hebephrenia; (3) Shallow
Hebephrenia; (4) Autistic Hebephrenia.
Fish comments:
These (hebephrenic) forms are poor in symptoms
and this may lead to diagnostic difficulties especially
in mild cases. In the earlier stages the clinical picture
may be obscured by non-specific symptoms such as
depressive and euphoric mood states and states of
excitement or inhibition of a catatonic nature. Irritated
moods occur early in the illness and often continue
into the defect stage.
Silly hebephrenia is characterized by the silly
smiling and behavior discussed earlier.
Eccentric hebephrenia is characterized by
mannerisms and often begins with obsessive,
compulsive symptoms which are precursors of
the mannerisms. Fish says:
These patients appear rather cheerless and depressed,
but the main impression is one of severe affective
flattening The affective blunting is associated with
....
an ethical blunting,
which often leads to anti-social
behavior, so that these patients frequently become
beggars, tramps, and prostitutes.
Shallow hebephrenia is marked by flattening
of affect combined with a contrasting accessi¬
bility and ability to carry on a reasonable con¬
versation. "The mood state is one of indifferent
satisfaction, but is interrupted from time to
time by states of ill humor when the patient may
be anxious, irritated, or very rarely, euphoric.
In these mood states hallucinations and ideas of
reference occur and the patient may become ex¬
tremely excited and aggressive. ." "There is . .
a general lack of initiative in these patients."
Autistic hebephrenia, according to Fish, is
characterized by autism and a marked affective
blunting.
Ill humored states occur in which the
irritated, shouts threats or accusations
the environment, and may attack this
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states therefore differ from those in shallow hebe¬
phrenia in that here the aggression is directed against
a specific person. The mood, which is reminiscent of
eccentric hebephrenia, is one of rejection mixed with
discontent, so that it is in marked contrast to the
indifferent satisfaction of the silly and shallow hebe¬
phrenia.
Weiner le cites a study that supports Leon-
hard's four subcategories of hebephrenia. Fish *
reports that Leonhard's subgroups of hebe¬
phrenia have been ranked according to severity
of the clinical picture, from the mildest to the
most severe, as autistic, eccentric, shallow, and
silly.
Hinsie and Campbell9 define hebephrenic
schizophrenia as:
A chronic form of schizophrenia characterized by
marked disorders in thinking, incoherence, severe emo¬
tional disturbance, wild excitement alternating with
tearfulness and depression, vivid hallucinations, and
absurd, bizarre delusions which are prolific, fleeting,
frequently concerned with ideas of omnipotence, sex
change, cosmic identity, and rebirth ....
Onset is before age 20. They com¬
usually
ment that : "Others have depended upon the
presence of the silly inappropriate 'teenager'
symptoms to establish the diagnosis."
Most current textbook descriptions of hebe¬
phrenic schizophrenia mention shallow and
inappropriate affective reactions, silliness,
giggling, and inappropriate laughter, language
disorders, including incoherent speech, neol¬
ogisms, and word salads; dissociation of
thought and emotional processes; bizarre habits
and peculiar mannerisms, and hallucinations and
delusions.
Hebephrenic Symptoms—
A Manifestation ofRegression
We wondered if hebehprenics because of their
unfavorable outcome tend to accumulate in hos¬
pitals providing long-term care, or if in fact, pa¬
tients develop hebephrenic reactions as a result
of long confinement. We were interested in
learning if patients who were ultimately diag¬
nosed as hebephrenics, manifested hebephrenic
symptoms at the onset of their illness, or at some
later point in the course of their illness.
The case histories of the four patients diag¬
nosed as hebephrenic at the Neuropsychiatrie
Institute and of eight hebephrenic cases picked
patient is
very
at random from the Brentwood Veterans Ad¬
at someone in
person. These ministration Hospital files were reviewed in an
 attempt to obtain some answer to these ques¬
tions. The four hebephrenic from the
cases
Neuropsychiatrie Institute are briefly sum¬
marized below to show some of the patterns oc¬
curring in the onset of schizophrenic reactions
diagnosed as hebephrenic :
Report of Cases
Case 1.—A 20-year-old unemployed divorcee was
admitted to the hospital with symptoms of with¬
drawal, disinterest in her daily duties, delusions of a
vague plot by acquaintances to drug her and put her in
a white slave ring, auditory hallucinations, and inap¬
propriate comments, of several months duration—
coming on following her divorce. She had been a
somewhat withdrawn, seclusive individual all of her
life, but with no previous history of psychotic decom¬
pensation.
At the time of her admission to the hospital she
wore an almost constant grin which created an impres¬
sion of silliness. Periods with overt delusions alter¬
nated with periods of good reality orientation. After
three months of hospitalization and treatment with
chlorpromazine (Thorazine), group therapy, and occu¬
pational therapy, she improved markedly. The delu¬
sional system became isolated to a point where it did
not apparently affect the patient's behavior and the
hallucinations disappeared. The patient was discharged
with a diagnosis of "schizophrenic reaction, hebe¬
phrenic type."
HerAfter discharge,
behavior was the patient
grossly was followed
inappropriate andin her the
outpatient
thinking clinic. She After
disorganized. was readmitted
spending the
to the
next six
Neuro¬
psychiatrie Institute nine months was admitted
years in a variety of hospitals she later, having neg¬ to
UCLAlected withto take the chlorpromazine
catatonic symptoms. Herwhich thinking had wasbeen
prescribed
still greatly for her, with Her
disordered. increasing
diagnosis ideaswas "schizo¬
of reference,
motor restlessness,mixed
phrenic reaction, and hallucinations.
type, with a Atschizoid this timepre¬ the
patient'spersonality."
morbid facial expression vacillated between
After approximately a year she
a scowl
and a smile. She could not clearlysomewhat
was discharged from the hospital recall recent improved,
events
toand she states
continue treatment she felt strange,
elsewhere. suspicious, and was
uncertain to her sensory
She wasas readmitted years laterOver
sixexperiences. manifesting
the course
of hospitalization
"grossly inappropriate laughterthere was little
and behavior."
symptomatic
childlike im¬
Her provement. The patient
associations continued to
were markedly hear voices,
loosened and her was
negativistic,
verbal tendedwere
productions to be impulsive, and
disconnected between
idiosyncratic.
and varied
Her periods of appropriate
diagnosis was changed and toinappropriate
chronic hebephrenic behavior.
After a month
schizophrenic the patient went home for a week-end
reaction.
visit, and behaved
Comment.—In this highly
case, the so-called hebephrenic
inappropriately, smearing
feces overdidherself
symptoms while until
not appear at church.
about ten month after
A years later
the no improvement,
withonset upon her doctor's
of an acute schizophrenic illness.advice, the
patient
Case 3.—A 30-year-old a state hospital.
was committed to divorcee was originally seen
at aComment.—It
number of UCLA appearedMedical
that thisClinics for had
patient numerous
a life¬
and schizoid
longsometimes vague somatic
personality whichcomplaints. Three
decompensated years into a
franksheschizophrenic
later was referred to the atPsychiatric
reaction a time when she for
Clinic was
obtaining aThedivorce
evaluation. patientandwashaving described mountingas immature
financial
problems.
and Paranoid
dependent, marked were
withsymptoms at leastofas inade¬
feelings promi¬
nent as
quacy andhebephrenic
a markedones in this to
tendency intellectualization,
patient. It was the in¬
appropriate
denial, smilingformation.
and reaction and behavior Psychological
which prompted tests were the
diagnosis as showing
interpreted of hebephrenicpsychoneurotic
a reaction. disorder, with
Case 2.—A
hysterical single, independently
and obsessive-compulsive features.
wealthy female
became
After several psychotic
acutelymonths at age 18supportive
of outpatient psycho¬
after a sadomas¬
therapy
ochisticthe patient's condition
homosexual relationship appeared to deteriorate.
with another woman.
Her behavior became "increasingly inappropriate, bi¬
zarre and childlike." However, it was felt that she
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action. During his four months' stay at the Neuropsy¬
chiatrie Institute there was considerable improvement
in his condition; however, after a year the patient
was readmitted with a return of hallucinations, ideas
of grandiosity, persecutory, and somatic delusions. The
patient improved greatly with electroshock therapy but
his ideas of reference, periods of somatic delusions, and
inappropriate affect remained unchanged.
Several months later he was diagnosed as having a
hebephrenic schizophrenic reaction manifested by
"ritualistic behavior, obsessional thinking, ideas of
reference, word salad, neologisms, flight of ideas,
persecutory and grandiose delusions, hallucinations,
anorexia, and euphoria," and was transferred to a
state hospital for long-term care.
Comment.—This case illustrates the problem of dif¬
ferentiating between a diagnosis of paranoid and
hebephrenic reactions. The hebephrenic classification
seems to have been based on the regressive symptoms
and grossly inappropriate affect.
From these few cases no definite conclusions
can be drawn; the case histories of these pa¬
tients cover only a relatively short period of
time and information as to their current con¬
dition is not readily available. In three of the
four cases the diagnosis of hebephrenic reac¬
tion was not made until some time after the
onset of the acute phase of the illness. In one
case, that of case 2, the "hebephrenic" symp¬
toms apparently did not appear until much later
in the course of the illness. The adjectives in
these cases which were most often associated
with the diagnosis of "hebephrenia" were
"bizarre," "inappropriate," "childlike," and
"silly."
In order to
get more data, eight hebephrenic
schizophrenic casesfrom the Brentwood Vet¬
erans Administration Hospital in Los Angeles
were reviewed. These were cases that had
recently been terminated; six through death in
the hospital, and two by discharge. Seven of the
eight cases were World War I veterans, all
born in the 1890's. ( In all cases but two, initial
hospitalization was prior to the age of 26). Only
two of the eight cases were diagnosed as hebe¬
phrenic at the onset of hospitalization.
One was a chronic case with no improvement until
his death. The other was a Mexican-American World
War II veteran, 19 years old at the beginning of his
illness in 1946. His illness appeared quite acutely and
was characterized from the onset by silliness and fre¬
quent grinning. He appeared to regress and exhibited
catatonic symptoms at one point. After approximately
ten years of hospitalization with not much change,
some improvement was noted. Several years later the
patient made a remarkable recovery and was dis¬
charged after 17 years of hospitalization, obtained
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employment, married, and made a satisfactory adjust¬
ment to work and home life, although childlike be¬
havior was still noticable at times.
The second case that ended in a discharge was also a
Mexican-American who was first hospitalized at the
age of 56 with a diagnosis of involutional psychosis,
paranoid type, with no record of previous mental ill¬
ness, although it was stated that the patient had been
mentally disturbed for a few years before his admis¬
sion to the hospital. After two years in the hospital,
he exhibited "hebephrenic" symptoms and five years
later he was transferred to the Veterans Administra¬
tion Hospital, where he was diagnosed as having a hebe¬
phrenic schizophrenic reaction. He was discharged,
somewhat improved, after seven years at the Veterans
Administration Hospital.
The six cases which were not diagnosed as
hebephrenic at the onset of hospitalization in¬
cluded five of the cases which were terminated
by death in the hospital. A paranoid diagnosis
was given to four of the six cases before the
hebephrenic diagnosis was made. The other two
received prior diagnoses of "psychosis, dementia
praecox type" and "mental deficiency-moron,"
respectively. One case diagnosed as paranoid
initially, was diagnosed as hebephrenic 12 years
later, and catatonic ten years after that, and re¬
mained catatonic until his death.
The five hebephrenic illnesses which persisted
until death are similar in many respects. Upon
initial hospitalization all of them exhibited delu¬
sions and hallucinations and in addition each
showed one or more of the following symptoms :
confusion, lack of judgment and insight, in¬
coherent and irrelevant speech, indifference,
mannerisms, and flattened affect. All five cases
exhibited a progressive deterioration, or at least
no improvement, until the end.
Considering all 12 hebephrenic cases together,
in only two instances was a diagnosis of hebe¬
phrenia made at the onset of hospitalization. In
only one of the cases was the diagnosis changed
after a hebephrenic diagnosis had been made
(paranoid to hebephrenic to catatonic). Only 3
of the 12 cases improved enough to be dis¬
charged from the hospital, and the possibility
exists that even these may have been later hos¬
pitalized elsewhere with chronic conditions.
Comment
It appears from the cases studied that there is
evidence to suggest that symptoms which are
called hebephrenic often become apparent only
after long hospitalization and are not readily
 evident at the onset of schizophrenic illness.
Paranoid symptoms frequently appear initially
in cases later diagnosed as hebephrenic. It is
difficult to ascertain at precisely what point in
the course of illness of the patients studied the
hebephrenic diagnosis occurred, because of the
difficulties in diagnosis mentioned earlier, but a
very rough indication might be gained from the
fact that in half the cases studied the hebe¬
phrenic diagnosis came only after five or more
years after initial hospitalization.
That a hebephrenic reaction is a serious condi¬
tion with poor chances of recovery seems borne
out by our data which suggest that in all but
possibly two or three exceptions, the disorder
was chronic and associated with gradual de¬
terioration. According to Chase and Silverman 5
most statistical reports agree that the catatonic
type of schizophrenia offers the best prognosis
and paranoid the worst, with simple and hebe¬
phrenic subtypes in an intermediate position.
More recent data seems to suggest that the prog¬
nosis is worst for the hebephrenic type—if in¬
deed this is a type.
While the literature 8·14 stresses that "hebe¬
phrenia" appears early in life, in fact, earlier
than the paranoid or catatonic forms, our data
would suggest the reverse. In only four of our
cases was the initial diagnosis of hebephrenia
made before the age of 30, while seven of the pa¬
tients were first hospitalized before the age of
30. The hebephrenic syndrome seems to repre¬
sent a regressed psychotic state that generally
results from a long-standing withdrawal from
reality in chronically hospitalized patients who
appear initially deluded and hallucinated and
who become more preoccupied and autistic so
that their behavior eventually approaches the
silly manneristic form called hebephrenia. In
some instances severe regression occurs early
and behavior from the beginning is grossly in¬
appropriate and bizarre. Hebephrenic symptoms
would appear to be indicative of greater severity
of a schizophrenic illness rather than of a special
subtype.
This possibility receives support from at
least two recent writers. Arieti1 suggests that a
decline in the number of diagnoses of hebe¬
phrenia may be due to the fact that many cases
diagnosed in the past as hebephrenic were
paranoid with rapid disintegration and that early
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intervention might have arrested them at a
paranoid level. Höfling10 points out that hebe¬
phrenia is the most malignant type and least
responsive to treatment. He states :
Before the advent of intensive milieu therapy and
of the tranquilizing drugs, it not infrequently hap¬
pened that, if a patient of one of the other schizo¬
phrenic sub-groups was quite unresponsive to existing
treatment measures and remained in the hospital for
an extended period of time, his symptom picture would
gradually assume hebephrenic features.
Conclusion
Most of the recent research in schizophrenia
has dealt with etiology, theory, and therapy, and
relatively little advance has been made in prob¬
lems of diagnosis and classification. The
definition of schizophrenia and its subtypes in
common use is still based essentially on the
pioneering work of Kraepelin and Bleuler.
Weiner 1ß refers to many other subclasses that
have been suggested for diagnosing schizo¬
some on a descriptive basis, others on
phrenia,
the basis of course, etiology, or age of onset, and
points out that the tendency to subdivide
dementia praecox into various subcategories
varies from country to country and from school
to school.
A classification system quite different from
the Kraepelinian one, for instance, was devel¬
oped by Beck 2 using a Q-technique for sorting
both clinical and corresponding Rorschach data.
Grinker, in the introduction to Beck's book
states :
The result was the delineation of six types of
schizophrenia, two of these occurring only in children
as impermanent or intransitive states. Two represent
advanced stages with marked intellectual disruption
and little phantasy ; these individuals apparently do not
recover. Three are identified only by the Rorschach
test and cannot be discriminated clinically. The six
schizophrenias have been labeled by letters and num¬
bers. We have strongly resisted the temptation to
translate these six numbered types of schizophrenia
into the current Kraepelinian classification. We feel
that the dynamic factors with which these schizo¬
phrenic types represent are well illustrated in the
descriptions of the clinical states which are appended
to these numbers. To bring them back into Kraepelin¬
ian classification or even to give them new names
would defeat our purpose of establishing a much more
dynamic concept of various types of schizophrenia.
Despite the work of Beck and others, the
Kraepelinian categories of schizophrenia out-
 lined more than 50 years ago are still currently
in common use. The evidence presented in this
paper suggests that the syndrome described in
the literature and diagnosed as hebephrenia is
in reality a severely regressed state which is
usually part of a later stage in a chronic schizo¬
Most of the hebephrenic cases we studied were
first diagnosed as some other type, usually
paranoid.
This study highlights the generally unsatis¬
factory classification of schizophrenic reactions
and the need for a nomenclature which is based
on more than just the most obvious symptom¬

phrenic process, but may occasionally be present atology.

early in the development of the illness. Because Generic and Trade Names of Drug
of this it generally has a poor "prognosis." Chlorpromazine—Thorazine.
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