Symptoms in Schizophrenia

by Ulrika Kahl, PhD

Schizophrenia is a severe and major psychotic disorder with significant impairment in mental functioning and loss of contact with reality. Besides the patient his/herself, there are also devastating consequences for the patient’s family and close surrounding.
The age of onset tends to be in late adolescence or early adulthood. Since this most often is a period in life which is associated with considerable personal, academic and professional change and challenges, individuals who develop schizophrenia may be placed at social and economic risk.


Risk factors

The lifetime risk of developing schizophrenia is about 1 per cent. Approximately equal numbers of men and women are affected, but there is normally an earlier onset in men.
According to epidemiological studies there is no significant geographical variation, but there is a slight tendency towards an increased risk for babies which are born during the spring and winter months. Environmental pathogens such as viruses may contribute to developing schizophrenia, as do obstetric complications. In addition a hereditary linkage for the disease has been proven. Psychosocial influences from traumatic life events and interactions within the family also appear to be of importance.

Behavioral Symptoms

The psychological symptoms seen in different cases of schizophrenia are similar but may vary in form, severity, and persistence. Certain symptoms may be expressed in one patient, but absent in another. The interference of the disease with the individual’s daily life may be either light enough to lead a fairly normal life, or in some cases the patient needs to be hospitalized. This heterogeneity sometimes contributes to diagnostic problems. There are however rules for the diagnosis and definition of the symptoms seen in schizophrenic patients. Below is a list of the most common groups of symptoms.

Thought disorder
Loosening of the structure and coherence of thought
Lack of logical connections between topics when speaking, which makes it hard for the listener to follow the conversation
Blocking, slowing or poverty of thought, which that may lead to reduction of speech

Abnormal thought content, beliefs or delusions
Delusions of persecution where the patient believes he or she is followed or the subject of elaborate plots
Delusions of reference and control, where commonplace events and situations are of individual significance and take place in relation to the individual
Delusions about the possession of thought, which may include the belief that the patients thoughts are not under his or her control, that thoughts do not originate from the self and that others can pick up or insert thoughts in the patients mind

Abnormal experiences or perceptual disturbances
Often in the form of hallucinations, where the patient hears or sees things that are not real
Auditory hallucinations, which are most commonly associated with schizophrenia, with the patient’s own thought spoken out loud or others commenting on the patients actions
Visual, olfactory and tactile hallucinations

Mood disorders
Mood alterations
Depression, anxiety, aggressiveness, excitement and facile euphoria
Disconnection between mood and other aspects of functioning, which may result in expression of different moods inappropriately, for instance laughter when telling an obviously sad story
Blunting or flattening of affect (the outward expression of mood)

Motor alterations
Increased motor function with restlessness or over-activity
Reduced function resulting in immobility of the patient
Stereotypic repetitive movement or bizarre gesturing

Changes in social function
Isolation, gradual withdrawal from social interaction, which often affect work or study performance
Poor self-care
Permanent change in underlying personality

Diagnosis

The “Diagnostic and Statistical Manual of Mental Disorders” of the American Psychiatry Association (DSM-II-R) lists the criteria necessary for making the diagnosis of schizophrenia (see separate table).

DSM-III-R Criteria for Diagnosis of Schizophrenia

There are five different main subtypes of schizophrenia presented in DSM-II-R:

The catatonic type
Marked by severe motor disturbance showing as stupor, rigidity, excitement and posturing
The disorganized type
Characterized by incoherence, disorganized behavior and flat inappropriate affect
The paranoid type
Includes systemized delusions or auditory hallucinations
The undifferentiated type
Noted for pronounced psychotic symptoms which may not fit in any other specific category or more than one
The residual type
Where the patient has had at least one period of persistent signs of illness, but without major psychotic features

Positive and Negative Symptoms

Another way of classifying behavioral manifestations of brain damage is to divide them into positive and negative categories. Symptoms like delusions, thought disorder, perceptual disturbances, incongruous mood, and increased motor function are referred to as positive symptoms, due to their supranormal nature. Instead, poverty of speech, loss of emotional responsiveness, lack of initiation and motivation, reduced motor function and social withdrawal are referred to as negative symptoms because they represent deficits in normal function. Negative symptoms are further believed to be associated with anatomic changes related to loss of brain tissue, and it has also been shown that true negative symptoms are less responsive to medications than are positive symptoms.

Based on these criteria, two types of schizophrenia have has been postulated. Type I is represented by mostly positive symptoms and no brain atrophy, whereas type II is characterized by predominantly negative symptoms and disturbed brain anatomy.

Onset of Schizophrenia

At the onset of schizophrenia there is an acute period with predominantly positive symptoms in some patients, whereas others may have mostly negative symptoms in form of chronic long-term illness. Like indicated earlier, there are many variations and combinations of symptoms in different patients, with one or other predominant symptom, either negative or positive. The active, psychotic phase is usually preceded by a period of gradual, insidious deterioration of functioning that affects all spheres of life; personal appearance, interests and social relations. This phase is often hard to identify when it is happening, but can usually be easily pointed out in hindsight. Like mentioned earlier, in most cases the initial development of schizophrenia occurs in an otherwise active period of life, and the signs of disorder are usually interpreted as normal changes in personality due to altered circumstances in life.

Recovery

Recovery from the active phase of schizophrenia is variable. Only 15-25 per cent of the affected individuals returns to the previous level of functioning. 25-35 per cent go on to have a chronic form of the illness, which requires long-term care and treatment The remaining half are patients with residual impairment that typically suffer from fluctuating periods of illness over many years.