29th January 2024

Presentation

Schizophrenia typically presents as a syndrome across 4 main symptom domains: Positive symptoms, negative symptoms, cognitive impairment and mood and anxiety symptoms. Each individual will have a unique combination that varies in onset, duration and severity.

Positive symptoms 

Positive symptoms are those that distort the perception of reality. These include:

• Hallucinations: These can affect any of the five senses (auditory, visual, olfactory, gustatory or tactile). Auditory hallucinations are the most common form in schizophrenia and seem to respond the most to antipsychotics. Often, they present as voices, but they can also be sounds. Olfactory, tactile and visual hallucinations are less common and are more likely to be associated with organic pathology, which requires further investigations.
• Delusions: This is defined as a fixed, false belief that is unexplained by cultural norms and that which is unshakeable in the face of strong contradiction. Delusions can be bizarre or non-bizarre. A bizarre delusion could be that an individual believes that they are a shaman that transports spirits across different realms, whereas a non-bizarre delusion may be that an individual believes that HMRC is spying on them for not paying their taxes. Delusions can be further categorised as:
  • Ideas of reference: Individual believes that there is a personal significance behind coincidental or innocuous events, e.g. certain words or songs on TV are relaying a message to the individual
  • Grandiose: Individual believes that they have some sort of special significance, skill or power; e.g. they believe that they are related to the Queen of England
  • Paranoid: Individual believes that they are vulnerable and being targeted. This often leads to forensic issues such as carrying weapons and unpredictable, violent behaviour. Alternatively, it may lead to self-isolation or ‘going off the grid.’ Paranoia can lead to significant issues with treatment compliance and poor contact with services due to fear of being manipulated or poisoned.
  • Nihilistic: Individual believes that they are dead, rotting or have lost their internal organs
  • Delusion of thought interference: Thought insertion, withdrawal, and broadcast
  • Delusions of passivity: Belief that an external source is controlling their body and mind
• Thought disorder: Individuals demonstrate disorganised thinking, which can be observed through abnormal behaviour, speech, and written language.
  • Thought blocking: disruption in the train of thought such that the individual suddenly stops midway through talking
  • Flight of ideas: rapid speech that digresses from one topic to another before completion
  • Tangential speech: digressing off-topic and never returning to the initial conversation
  • Circumstantial speech: Individual offers a lot of irrelevant details and wanders off topic, but eventually, they are able to answer the question in a ’roundabout’ way
  • Neologisms: Creation of new words
  • Word salad: a jumble of random, incoherent words

Negative symptoms 

Negative symptoms are those that withdraw the individual from normal social functioning. These include:

• Anhedonia: loss of interest in previously enjoyable activities and relationships
• Unable to maintain personal hygiene or activities of daily living
• Social withdrawal: not going out or speaking to anyone
• Lack of energy, motivation and excessive sleeping
• Flat affect: restricted range of emotional expressions
• Thought poverty: slowness in thinking, reactivity and speech

Cognitive impairment

Studies have shown that individuals with schizophrenia demonstrate impaired cognitive performance across several cognitive domains. This includes a reduction in:

• Speed of processing information
• Attention and vigilance
• Working memory
• Reasoning and problem-solving
• Verbal comprehension
• Social cognition and awareness

Mood and Anxiety Symptoms

Mood and anxiety symptoms occur at high rates in schizophrenic patients compared to the general population.

Depression

Depression can present in Schizophrenic patients during the acute psychotic phase or after as a distinct depressive episode. It is associated with poorer outcomes such as prolonged hospital admission, re-hospitalisation, severe cognitive impairment, significant decline in social functioning, poorer response to pharmacological treatments and increased attempted and completed suicides.

Depression can sometimes be mistaken as negative symptoms of schizophrenia; however, the distinction can be made when you consider the fact that depression will likely present with cognitive symptoms of depression such as guilt, shame, worthlessness and tearfulness. In some individuals, a ‘depressive prodrome’ precedes a Schizophrenic relapse; this can be anticipated in patients who have had similar episodes.

Anxiety

Individuals with schizophrenia can either experience anxiety as part of their schizophrenia syndrome (this is called secondary anxiety) or as an additional disorder. An example of this is when an individual develops anxiety due to terrifying hallucinations or paranoid delusions.

First Rank Symptoms

These are a group of symptoms identified by German psychiatrist Kurt Schneider as being characteristic of schizophrenia, henceforth known as ‘Schneider’s first rank symptoms’. In practice, first-rank symptoms can often overlap with other disorders and, therefore, are not strictly pathognomonic of schizophrenia. Nonetheless, they are useful as a screening tool to prompt further evaluation of each symptom domain in schizophrenia. These are:

1. Auditory hallucinations: third person running commentary or thought echo (hearing thoughts spoken aloud)
2. Somatic hallucinations: bodily sensations experiences such as crawling insects
3. Delusion of thought interference: Thought insertion, withdrawal, and broadcast
4. Delusions of control or passivity phenomenon: the belief that an external source is controlling the individual

References

• World Health Organisation (WHO). ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research [internet]. World Health Organisation (WHO); 1993 [cited 2022 July 8]. Available from: https://icd.who.int/browse10/2016/en#/F20-F29
• UpToDate. Schizophrenia in adults: Clinical manifestations, course, assessment, and diagnosis [internet]. 2022 [cited 2022 July 10]. Available from: https://www.uptodate.com/contents/schizophrenia-in-adults-clinical-manifestations-course-assessment-and-diagnosis?search=schizophrenia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
• Mitchell A. First-rank symptoms: a first-rank diagnostic test? BJPsych [internet]. 2018 [cited 2022 July 12]; 21(3). Available from: https://www.cambridge.org/core/journals/bjpsych-advances/article/firstrank-symptoms-a-firstrank-diagnostic-test/BFE8808B3A673E5B9558C17EBFBE9B35