2. Schizophrenia Symptoms

What are the positive symptoms of schizophrenia?

• Delusions: False, bizarre beliefs (e.g. being controlled by aliens/spies)

  • Can be paranoid (fear of being targeted) or grandiose (belief of being royalty/celebrity)

• Hallucinations: Delusional perceptions

  • Auditory: Hearing own thoughts or voices referring to them

  • Visual: Seeing lights, objects, faces

  • Olfactory: Strange smells

  • Tactile: Feeling bugs crawling under the skin

What are the negative symptoms of schizophrenia?

• Social withdrawal: Lack of emotion, expression, energy, motivation & activity

• Poor hygiene & grooming

• Catatonia: Immobility, remaining fixed in one position

• Waxy flexibility: Arms remain frozen in a position when moved

What is the active phase of schizophrenia?

When positive or negative symptoms are present.

What are the diagnostic criteria for schizophrenia?

• At least one symptom from these domains:

  • Positive psychotic symptoms

  • Negative symptoms

  • Reduced social/occupational functioning

• Symptoms must be clearly present for at least one month, or two present less clearly

• Exclusions:

  • Schizoaffective, depressive, or bipolar disorder with psychotic features

  • Drug abuse, medication, or medical conditions

  • Autism spectrum disorder (schizophrenia diagnosed only if prominent delusions or hallucinations are present)

What are some differential diagnosis of schizophrenia?

• Substance abuse (e.g. alcohol, stimulants, hallucinogens)

• Medical conditions (e.g. brain tumour, CNS infections, metabolic or endocrine causes)

• Mood disorders with psychotic features (usually mood-congruent)

• Delusional disorder (non-bizarre delusions without hallucinations or thought disorder)

• Schizotypal personality disorder (odd behaviour without clear delusions)

Dan is a 21 year-old male who recently completed his university degree and has returned to his parents’ home until he finds a job. Dan does not seem to be himself; spending long periods of time in his bedroom and making no attempt to interact with friends or family or to look for work. Furthermore, he has stopped paying attention to his appearance and personal hygiene. Dan’s mother is very concerned but when she questions Dan, he tells her that he is just tired and asks to be left alone.

Three weeks later, Dan throws his MP3 player and laptop out of his bedroom window. His parents manage to stop him throwing out a TV set but have to remove it from the room in order to calm him down. Dan explains that his thoughts are being controlled by aliens, via electromagnetic waves that come from these devices even when they are switched off. These aliens had initially wanted him to be their advocate on Earth, but now they are disappointed and want him to die.

Dan’s parents are sufficiently concerned that they take him to the local Accident and Emergency department.

Upon arrival at the hospital, Dan becomes very distressed by the presence of the screens and computers in the reception area. He is removed to a side room and the on-duty psychiatrist is called. A physical examination is carried out and Dan’s past medical history is obtained from his mother. Both are unremarkable. A mental state examination is performed. It becomes apparent that the ‘thought control’ began, intermittently, some months ago but has become almost constant in the past few days.

What supports a diagnosis of schizophrenia in Dan's case & which differentials were ruled out?

• Supports schizophrenia:

  • Gradual onset of negative symptoms: withdrawal, apathy, poor hygiene

  • Progression to positive symptoms: delusions of control, paranoia

  • Functional decline: not seeking work, isolating

  • Duration: symptoms present for ≥1 month

  • No medical or substance cause

• Key differentials ruled out:

  • Depression – no pervasive low mood

  • Substance misuse – no history or physical evidence

  • Delusional disorder – includes hallucinations & disorganised behaviour

  • Mood disorder with psychosis – no mood episode present

  • Normal stress response – symptoms are severe & persistent