In Part One of this series the history of schizophrenia was briefly discussed (click here for part one). I now briefly discuss symptoms and diagnosis.
Current Diagnostic Issues with Schizophrenia
In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) schizophrenia has now been divided into five subcategories (APA, 2000). These subtypes are defined based on the presence of positive symptoms (excesses) or negative symptoms (deficits) of behavior in the presentation of the disorder.
Positive Symptoms
Positive symptoms are psychotic behaviors (a loss of touch with what is real). The positive symptoms in schizophrenia include (Cohen, 2003; Sadock & Sadock, 2007):
- Hallucinations are sensory distortions. Often the person will hear, see, smell, or feel things that others do not. Auditory hallucinations are the most common type of hallucination in schizophrenia, and these most often consist of hearing voices that no one else can hear. These voices might talk to the person, tell them things, order the person, talk to each other, etc. Other common types of schizophrenic hallucinations include seeing people or objects, smelling odors, or feeling things like bugs crawling on the skin or being touched by someone or something who is not there.
- Delusions are very strong “false” beliefs. Often the person will still adhere to the belief even after being shown that it is not true or it is illogical. People with schizophrenia will often express seemingly bizarre beliefs such as believing that aliens or the government can control their behavior through a television or other means. Other common delusions include the belief that people on television or the radio are directing messages to them or are broadcasting their thoughts aloud to others. Paranoid delusions or delusions of persecution include the belief that others are trying to harm them, cheat them, spy on them, harass them, or plot against them. Delusions of grandeur include the belief that one is an extremely important person like a messiah or that they are a famous historical figure.
- Thought disorders are dysfunctional ways of thinking. Several common forms of thought disorders are often seen in people with schizophrenia. Disorganized thinking occurs when the person cannot organize their thoughts or connect them in a logical and meaningful manner (sometimes called a flight of ideas). Thought disordered individuals often make up meaningless words (called neologisms). Thought blocking occurs when a person stops speaking abruptly in the middle of a sentence or in a specific train of thought. When asked why they stopped the person will often report that the thought had been removed from their head.
- Movement disorders can present as disorganized or repetitive agitated body movements.
Negative Symptoms
Negative symptoms consist of disruptions to one’s emotions and motivations. Often these types of symptoms are often mistaken for depression or other conditions. Negative symptoms include (Cohen, 2003; Sadock & Sadock, 2007):
- Flat affect: a person does not express emotion or she talks in a dull or monotone voice.
- Anhedonia: an inability to experience pleasure in one’s activities.
- Amotivation: an inability to begin, plan, and sustain activities.
- Poverty of thought: observed as a poverty of speech which is speaking very little or being mute even when the person is forced to interact with others.
- At the other end of the spectrum from agitation and hyperactive movements, catatonia occurs when the person does not move and does not respond. People may spend prolonged periods of time in odd stances. Catatonia is rare nowadays.
People with negative symptoms need help to complete everyday tasks and will often neglect basic personal hygiene. This may make appear lazy or unwilling to help themselves, but these problems are due to the symptoms of schizophrenia.
Cognitive issues in schizophrenia have to do with attention, executive functions, working memory, and other “frontal” brain issues.
DSM-IV-TR Diagnostic Categories
The five subtypes are schizophrenia are (APA, 2000):
(1) Paranoid schizophrenics fit the common conceptualization of schizophrenia with defining characteristic is the auditory (most often) or visual hallucinations. Paranoid schizophrenics tend to have hallucinations (alterations of perception) or delusions (alternations of beliefs) based upon common themes.
(2) Disorganized schizophrenics experience fewer hallucinations, but instead experience difficulty with everyday activities, personal hygiene, expressive language, and emotional regulation.
(3) Catatonic schizophrenics experience difficulties with immobility and muscular rigidity often remaining in the same position or displaying periods of hyperactivity.
(4) Undifferentiated schizophrenia has few specific defining characteristics that would allow patients to be diagnosed into one other specific category.
(5) Residual schizophrenics have experienced at least one psychotic episode, are in remission or the symptoms not florid enough to diagnose them in another category.
The paranoid type of schizophrenia is characterized by one or more delusions with frequent auditory hallucinations (other types of hallucinations are rare for schizophrenia).
Classically the delusions are characterized by feelings of persecution or grandeur, whereas the hallucinations are most often in the form of voices no one else can hear (APA, 2000). These are sometimes termed positive symptoms, whereas emotional blunting and poverty of speech observed in disorganized and catatonic schizophrenia are termed negative symptoms (Sadock & Sadock, 2007). Paranoid schizophrenics often experience a later onset of the disorder than do the other types; therefore, these patients may have established a social life that can help them through their illness. They may often be tense, reserved, guarded, or even hostile and aggressive but can occasionally respond appropriately in social situations. Areas of their intelligence or cognition not invaded by their psychosis tend to remain functional, unlike disorganized or catatonic patients who are less able to function during their episodes (Cohen, 2003). Other subtypes of schizophrenia may represent more serious manifestations of the disorder and may reflect more severe brain involvement. The paranoid type has the best prognosis if treated early (Cohen, 2003).
Left untreated schizophrenia may lead to very severe health problems as well as emotional, behavioral, financial, and legal problems. While not all homeless people have a mental illness there is six times the prevalence of schizophrenia in the homeless population compared to the general population (Cohen, 2003). The complications that can result from untreated alcohol or drug abuse, poverty, homelessness, incarceration, conflicts with family, and unemployment. Contrary to the depiction in the media paranoid schizophrenics or people with other forms of schizophrenia are not typically serial killers, in fact the crimes they most often are arrested for are vagrancy and trespassing (APA, 2000; Sadock & Sadock, 2007).
Next, Part Three: Proposed Causes of Schizophrenia (Click here for Part Three).
Rudy Hatfield - I am a clinical neuropsychologist with extensive experience in the assessment and treatment of neurological and psychiatric disorders. I ...
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