History and exam
Key diagnostic factors
common
hallucinations
Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control.[3] Hallucinations are typically auditory but may involve any sensory modality. The patient may hear their own thoughts spoken aloud (thought echo) or hear voices referring to themself, typically in the third person or in the form of a commentary.
Tactile hallucinations involve the perception of a physical experience within the patient’s body (e.g., electrical pulses, crawling sensation).[77][78]
Less common hallucinations include visual, olfactory, and gustatory hallucinations.
You may observe the patient responding to hallucinations if these are present.
delusions
Delusions refer to fixed beliefs that are not reality-based and cannot be explained as part of the patient's cultural background.[3] They are not amenable to change in light of conflicting evidence.[3] The most characteristic delusion of schizophrenia is ‘delusional perception’, in which the delusion arises at the same time as, and apparently out of, a normal perception.[77]
Interpret delusional symptoms in the context of the patient’s culture and also what is normal for the patient.[67] Be aware that there can be significant differences in beliefs within a single culture; it is important to establish the patient’s previous beliefs. If indicated, psychosis should be assessed through interpreters or in a second or third language to avoid the misunderstanding of unfamiliar metaphors as delusions.[3]
passivity phenomena
The patient may feel that their thoughts or actions are controlled by an outside agency.
This can be experienced as removed (thought withdrawal), inserted (thought insertion), or known to others (thought broadcast).
Sudden pauses in the patient’s speech may indicate thought withdrawal.[79]
negative symptoms
These include flattened affect, apathy, anergia, social withdrawal, and anhedonia (these can be difficult to differentiate from comorbid depression - see Depression in adults).
Practical tip
Comorbid depression and anxiety are common in patients with schizophrenia but are commonly missed; always assess the patient’s mood.[81][82] See Depression in adults and Generalised anxiety disorder.
If a patient with acute psychosis has depression, seek advice from the mental health team to determine the best approach to treatment. An antidepressant may not be started initially because other treatments may be more appropriate and symptoms may resolve with antipsychotic treatment.[83]
disorganised thinking (formal thought disorder)
This includes:
Tangentiality
Loosening of association (derailment)
Circumstantiality
Distractible speech
Word salad.
uncommon
catatonia
Signs of catatonia include stupor, waxy flexibility, mutism, catalepsy, negativism, posturing, mannerisms, stereotypy, echolalia, and echopraxia.
Other diagnostic factors
common
agitation or distress
Sometimes, patients may understandably become very agitated or distressed by psychosis. They may use aggression as a defence against apparent persecutors, which can increase the risk of harm to themselves and others.
suicidal thoughts
Assess the patient’s suicide risk carefully and sensitively.[85] See Suicide risk mitigation.
Practical tip
Around 5% of patients with schizophrenia die by suicide.[86] However, poor physical health is the main cause of premature death in patients with schizophrenia.[87] Patients with auditory hallucinations, delusions, substance misuse, comorbid depression, or a history of suicide attempts are at higher risk for suicide.[86][88][89] Risk of suicide is highest in the year after the first presentation of psychosis.[88]
altered cognition
Schizophrenia affects all cognitive domains, including attention, language, memory, executive function, and processing speed.[3] Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments.[3] Some people with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind).[3] Consider using a formal test such as the Abbreviated Mental Test Score to assess this. Abbreviated Mental Test Score Opens in new window
loss of insight
Loss of insight is the most common predictor of non-adherence to treatment, and it predicts higher relapse rates, increased number of involuntary treatments, poorer psychosocial functioning, aggression, and an unfavourable course.[3] The patient’s insight (the extent of their understanding of their experience) should always be assessed.[66] Useful questions to ask include: What do you feel are your difficulties at the moment?’, ‘What do you think might be causing how you’re feeling?’, and ‘Do you think medical treatment or therapies would help?’
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