History and exam
Key diagnostic factors
common
auditory hallucinations
delusions
Persecutory, grandiose, nihilistic, somatic, or religious delusions are fixed false beliefs not belonging to the patient's cultural background.[1] They are not amenable to change in light of conflicting evidence.[1] Delusions commonly present at the onset of illness. Delusions typically change theme during the prodromal and early phase of the disease; over time, delusions tend to become crystallized.
Thought insertion or thought withdrawal delusions are positive symptoms and are types of thought control delusion. Experienced as someone placing thoughts in one's brain or removing thoughts from one's brain.
Thought broadcasting is another delusion, in which the patient believes that his/her thoughts are being broadcast out loud and can be perceived by others.
Ideas of reference are a milder form of thought control delusion in which a patient infers that common events refer to them directly (e.g., personal messages from television and newspapers).
Identifying delusions may be more challenging than identifying hallucinations, because the patient's beliefs are embedded into real-life situations and may form part of the patient’s cultural norms. Patients consider the delusions as real, and in time develop very elaborate connections. If indicated, psychosis should be assessed through interpreters or in a second or third language to avoid the misunderstanding of unfamiliar metaphors as delusions.[1]
A positive symptom.[1]
avolition
Decreased motivation to self-initiate purposeful activities (e.g., the patient may sit for long periods of time and show little interest in participating in work or social activities).[1]
anhedonia
asocial behavior
affective blunting
alogia
cognitive deficits
Schizophrenia affects all cognitive domains. Patients may experience problems with attention, language, memory, executive function, and processing speed.[1]
Executive function describes a set of higher-level cognitive processes that are utilized for control and coordination of cognitive and behavioral abilities. Among these are the abilities to start and stop actions, anticipate outcomes, adapt to new situations, and plan future behaviors in novel scenarios. The ability to think abstractly is often considered a part of executive functioning.
Cognitive symptoms are typically the first symptoms to appear and are one of the predominant features of the prodromal period. Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments.[1] Some people with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind).[1]
somatization
Somatization results from psychological stress that is subconsciously expressed somatically and is represented by physical symptoms that are persistent and can affect any organ system.
Common examples include pain, gastrointestinal symptoms, and "pseudoneurologic" symptoms (symptoms arising from any neurologic impairment for which there is no medical explanation).
Other diagnostic factors
common
lack of insight (anosognosia)
Some patients with psychosis may lack insight or awareness of their disorder (i.e., anosognosia). This symptom is the most common predictor of nonadherence to treatment, and it predicts higher relapse rates, increased number of involuntary treatments, poorer psychosocial functioning, aggression, and an unfavorable course of illness.[1]
bizarre or disorganized behavior
A positive symptom.[1]
tangentiality and looseness of association (derailment)
Tangentiality refers to an inability to stay on topic, jumping from one subject to another with minimal connection.
Looseness of association (derailment) refers to the complete incoherence that occurs when tangentiality is extreme. A positive symptom.[1]
circumstantiality
Inability to give a concise answer due to over-inclusion of unnecessary details. A positive symptom.[1]
pressured speech
A positive symptom, referring to rushed intense speech.[1]
distractible speech
Refers to an inability to maintain attention. The patient shifts from one topic to another with minimal provocation or is distracted too frequently by unimportant or irrelevant external stimuli. A positive symptom.[1]
depression
Most common immediately following an acute psychotic exacerbation; this may be because depression is more easily recognized once positive symptoms have subsided. However, depression may occur at any time during the illness course, including during the at-risk or prodromal period
suicidality
Suicidal ideation is one of the most dangerous complications of the disease.[69] The risk of suicide is highest at the onset of the illness. Approximately 20% of patients with schizophrenia attempt suicide at least once and many more have significant suicidal ideation.[1] Approximately 5% to 6% of patients with schizophrenia die by suicide.[1][70][71][72]
anxiety
Can occur at any time during the illness course, including during the at-risk or prodromal period.
elation
Occurs following psychosis.
incongruent affect
Refers to disconnect between thought and speech content (e.g., laughing in the absence of an appropriate stimulus).
verbigeration
A repetition of words in the absence of a stimulus; contrasted with perseveration, which is a repetition of the same response (e.g., word or phrase) to different stimuli. A positive symptom.[1]
perseveration
A repetition of the same response (e.g., word or phrase) to different stimuli; contrasted with verbigeration, a repetition of words in the absence of a stimulus. A positive symptom.[1]
word salad
A speech form in which no connection between words is found. A positive symptom.[1]
uncommon
derealization
Refers to an altered perception of the external world as strange or unreal.
If prominent, other pathologies (e.g., PTSD) should be considered. A positive symptom.[1]
nonauditory hallucinations
Visual, olfactory, and gustatory hallucinations are uncommon (exacerbated by unpleasant taste and smell). Tactile hallucinations (i.e., electrical pulses, crawling sensation) rarely present in schizophrenia (rule out drug-induced). Cenesthetic hallucinations are unfounded somatic sensations, such as a burning sensation in the brain, cutting pain in bone marrow, or a pushing feeling in the blood vessels. A positive symptom.[1]
déjà-vu
A paramnesia in which patients experience the sensation or illusion that they are seeing something that they have seen before.
If prominent, other pathologies should be considered. A positive symptom.[1]
stilted goal-directed behaviors
Stereotypies are stilted goal-directed behaviors that manifest as uniformly repetitive movements.
Includes parakinesias (grimacing, twitching, and jerking), echopraxia (repetition of movements seen in others), automatic obedience (automatic execution of directions), waxy flexibility (the ability to maintain imposed positions for long periods of time).
A negative symptom.[1]
catatonic symptoms
Typically a negative symptom.
Catatonic stupor: may present with either loss or excess of motor activity; associated with a decreased response to surroundings, immobility, and mutism; the most severe type of catatonia.
Catatonic rigidity: immobility and resistance to movement.
Catatonic negativism: refusal of all instructions.
Catatonic excitement: an overall increase in purposeless and excessive motor activity without obvious cause (this could be considered as a positive symptom).
"soft" neurologic deficits
Neurologic examination usually does not reveal gross deficits. "Soft" deficits are minor neurologic findings found in over half of patients with schizophrenia.[73][74]
These include motor coordination deficits, a smooth pursuit eye movement deficit, a sensory integration deficit, and right-left disorientation.[1]
The clinical value of these findings is very limited, although there is limited evidence that their presence may be associated with a worse prognosis.[75][76] One study suggests the presence of primary motor coordination dysfunction at initial presentation may be associated with a more severe nonremitting course.[77]
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