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8.1 Clinical Presentation

Section Learning Objectives

  • Identify and describe the five symptoms of schizophrenia spectrum disorders.
  • Describe how schizophrenia presents itself.
  • Describe how schizophreniform disorder presents itself.
  • Describe how brief psychotic disorder presents itself.
  • Describe how schizoaffective disorder presents itself.
  • Describe how delusional disorder presents itself.
  • Be able to distinguish the five disorders from one another.

8.1.1 Symptoms of Schizophrenia Spectrum Disorders

Individuals diagnosed with a schizophrenia spectrum disorder experience psychosis, which is defined as a loss of contact with reality and is manifested by delusions and/or hallucinations. These episodes of psychosis can make it difficult for individuals to perceive and respond to environmental stimuli, which can cause significant disturbances in everyday functioning. While there are a number of symptoms displayed in schizophrenia spectrum disorders, presentation of symptoms varies greatly among individuals, as there are rarely two cases similar in presentation, triggers, course, or responsiveness to treatment (APA, 2013). We will now turn our attention to the five major symptoms associated with these disorders: delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms.

8.1.1.1 Delusions

Delusions are defined as “fixed beliefs that are not amenable to change in light of conflicting evidence” (APA, 2013, pp. 87). This means that despite evidence contradicting one’s thoughts, the individual is unable to distinguish them from reality. There are a variety of delusions that can present in many different ways:

  • Delusions of grandeur – beliefs they have exceptional abilities, wealth, or fame; the belief they are God or other religious saviors
  • Delusions of persecution – beliefs they are going to be harmed, harassed, plotted or discriminated against by either an individual or an institution
  • Delusions of reference – beliefs that specific gestures, comments, or even larger environmental cues (e.g., an ad in the newspaper, a terrorist attack) are directed at them
  • Delusions of control – beliefs that their thoughts/feelings/actions are controlled by others
  • Delusions of thought broadcasting – beliefs that one’s thoughts are transparent and everyone knows what they are thinking
  • Delusions of thought withdrawal – belief that one’s thoughts have been removed by another source

The most common delusion is delusions of persecution (APA, 2013). It is believed that the presentation of the delusion is largely related to the social, emotional, educational, and cultural background of the individual (Arango & Carpenter, 2010). For example, an individual with schizophrenia who comes from a highly religious family is more likely to experience religious delusions (e.g., delusions of grandeur) than another type of delusion.

8.1.1.2 Hallucinations 

Hallucinations can occur in any of the five senses including as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), touching (tactile hallucinations), or tasting (gustatory hallucinations). Additionally, they can occur in a single modality or present across a combination of modalities (i.e. experiencing both auditory and visual hallucinations). For the most part, individuals recognize that their hallucinations are not real and attempt to engage in normal behavior while simultaneously combating ongoing hallucinations.

According to various research studies, nearly half of all people with schizophrenia report auditory hallucinations, 15% report visual hallucinations, and 5% report tactile hallucinations (DeLeon, Cuesta, & Peralta, 1993). Among the most common types of auditory hallucinations are voices talking to the individual or various voices talking to one another. Generally, these hallucinations are not attributable to any one person that the individual knows. However, they are usually clear, objective, and definite (Arango & Carpenter, 2010). Additionally, the auditory hallucinations can be pleasurable, providing comfort to the individuals; however, in other individuals, the auditory hallucinations can be unsettling as they produce commands or have malicious intent.

8.1.1.3 Disorganized Speech

Among the most common cognitive impairments displayed in individuals with schizophrenia are disorganized speech, communication, and thoughts. More specifically, thoughts and speech patterns may appear to be circumstantial or tangential. For example, individuals with circumstantial speech may give unnecessary details in response to a question before they finally produce the desired response. While the question is eventually answered by individuals with circumstantial speech, those with tangential speech never reach the point or answer the question. Another common cognitive symptom is speech retardation where the individual may take a long period of time before answering a question. Derailment, or the illogical connection in a chain of thoughts, is another common type of disorganized thinking. The most severe form of disorganized speech is incoherence or word salad which is where speech is completely incomprehensible and meaningful sentences are not produced.

These type of distorted thought patterns are often related to concrete thinking. That is, the individual is focused on one aspect of a concept or thing, and neglects all other aspects. This type of thinking makes treatment difficult as individuals lack insight into their illness and symptoms (APA, 2013).

8.1.1.4 Disorganized Behavior

Psychomotor symptoms can also be observed in individuals with schizophrenia spectrum disorders. These behaviors may manifest as awkward movements or even ritualistic/repetitive behaviors. They are often unpredictable and overwhelming, severely impacting the ability to perform daily activities (APA, 2013). Catatonic behavior, or the decrease or even lack of reactivity to the environment, is among the most commonly seen disorganized motor behavior in schizophrenia spectrum disorders. These catatonic behaviors include:

  • Negativism – resistance to instruction
  • Mutism –  complete lack of verbal responses
  • Stupor – complete lack of motor responses
  • Rigidity maintaining a rigid or upright posture while resisting efforts to be moved
  • Posturing – holding odd, awkward postures for long periods of time

On the opposite side of the spectrum is catatonic excitement, where the individual experiences a hyperactivity of motor behavior. This can include echolalia (mimicking the speech of others) and echopraxia (mimicking the movement of others) but may also simply be manifested through excessive and/or purposeless motor behaviors.

8.1.1.5 Negative Symptoms

Up until this point, all the schizophrenia symptoms can be categorized as positive symptoms or symptoms that involve the presence of something that should not be there (e.g., hallucinations and delusions) or disorganized symptoms (disorganized speech and behavior). The final symptom included in the diagnostic criteria of several of the schizophrenia spectrum disorders is negative symptoms, which are defined as the inability, or decreased ability, to initiate actions, speech, express emotion, or to feel pleasure (Barch, 2013). Negative symptoms are typically present before positive symptoms and often remain once positive symptoms remit. They account for much of the morbidity in schizophrenia but not as prominent in the other spectrum disorders (indeed, as you will see, they are not included as a symptom in some of these other disorders). Because of their prevalence through the course of the schizophrenia, they are also more indicative of prognosis, with more negative symptoms suggestive of a poorer prognosis. The poorer prognosis may be explained by the lack of effect that traditional antipsychotic medications have in addressing negative symptoms (Kirkpatrick, Fenton, Carpenter, & Marder, 2006).

There are five main types of negative symptoms seen in individuals with schizophrenia:

  • Affective flattening – reduction in emotional expression (i.e., a reduced display of emotional expression)
  • Alogia  poverty of speech or speech content
  • Anhedonia  decreased ability to experience pleasure
  • Asociality lack of interest in social relationships
  • Avolition – lack of motivation of goal-directed behavior

8.1.2 Types of Schizophrenia Spectrum Disorders

8.1.2.1 Schizophrenia

As stated above, the hallmark symptoms of schizophrenia include the presence of at least two of the following symptoms for at least one month: delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, negative symptoms. These symptoms must create significant impairment in the individual’s ability to engage in normal daily functioning such as work, school, relationships with others, or self-care. It should be noted that presentation of schizophrenia varies greatly among individuals, as it is a heterogeneous clinical syndrome (APA, 2013).

While the presence of active phase symptoms must persist for a minimum of one month to meet criteria for a schizophrenia diagnosis, the total duration of symptoms must persist for at least six months before a diagnosis of schizophrenia can be made. This six month period can comprise a combination of active, prodromal, and residual phase symptoms. Active phase symptoms represent the “full-blown” symptoms previously described. Prodromal symptoms are “subthreshold” symptoms that precede the active phase of the disorder and residual symptoms are subthreshold symptoms that follow the active phase. These prodromal and residual symptoms are milder forms of symptoms that do not cause significant impairment in functioning, with the exception of negative symptoms (Lieberman et al., 2001). Due to the severity of psychotic symptoms, mood disorder symptoms are also common among individuals with schizophrenia; however, to diagnose schizophrenia either there must be no mood symptoms or if mood symptoms have occurred they must be present for only a minority of the total duration of the illness. The latter helps to distinguish schizophrenia from a mood disorder with psychotic features for which psychotic symptoms are limited to the context of the mood episodes and do not extend beyond those episodes.

8.1.2.2 Schizophreniform Disorder

Schizophreniform disorder is similar to schizophrenia with the exception of the length of presentation of symptoms and the requirement for impairment in functioning. As described above, a diagnosis of schizophrenia requires impairment in functioning and a six-month minimum duration of symptoms. In contrast, impairment in functioning is not required to diagnose schizophreniform disorder. While many individuals with schizophreniform disorder do display impaired functioning, it is not essential for diagnosis. Moreover, symptoms must last at least one month but less than six-months do diagnose schizophreniform disorder. In this way, the duration of schizophreniform disorder is considered an “intermediate” disorder between schizophrenia and brief psychotic disorder (which we will consider next).

Approximately two-thirds of individuals who are initially diagnosed with schizophreniform disorder will have symptoms that last longer than six months, at which time their diagnosis is changed to schizophrenia (APA, 2013). The other one-third will recover within the six month time period and schizophreniform disorder will be their final diagnosis.

Finally, as with schizophrenia, any major mood episodes that are present concurrently with the psychotic features must only be present for a small period of time, otherwise, a diagnosis of schizoaffective disorder may be more appropriate.

8.1.2.3. Brief Psychotic Disorder

A diagnosis of brief psychotic disorder requires one or more of the following symptoms: delusions, hallucinations, disorganized speech, disorganized behavior. Moreover at least one of these symptoms must be delusions, hallucinations, or disorganized speech. Notice that negative symptoms are not included in this list. Also notice that while schizophrenia and schizophreniform disorder require a minimum of two symptoms, only one is required for a diagnosis of brief psychotic disorder. To diagnose brief psychotic disorder symptom(s) must be present for at least one day but less than one month (recall: one month is the minimum duration of symptoms required to diagnose schizophreniform disorder). After one-month individuals return to their full premorbid level of functioning. Also, while there is typically very severe impairment in functioning associated with brief psychotic disorder it is not required for a diagnosis.

8.1.2.4. Schizoaffective Disorder

Schizoaffective disorder is characterized by two or more of the symptoms of schizophrenia (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms) and a concurrent uninterrupted period of a major mood episode—either a depressive or manic episode. Those who experience only depressive episodes are diagnosed with the depressive type of schizoaffective disorder while those who experience manic episodes (with or without depressive episodes) are diagnosed with the bipolar type of schizoaffective disorder. It should be noted that because a loss of interest in pleasurable activities is a common symptom of schizophrenia, to meet criteria for a depressive episode within schizoaffective disorder, the individual must present with a pervasive depressed mood (not just anhedonia). While schizophrenia and schizophreniform disorder do not have a significant mood component, schizoaffective disorder requires the presence of a depressive or manic episode for the majority, if not the total duration of the disorder. While psychotic symptoms are sometimes present in depressive episodes, they often remit once the depressive episode is resolved. For individuals with schizoaffective disorder, psychotic symptoms should continue for at least two weeks in the absence of a major mood disorder (APA, 2013). This is the key distinguishing feature between schizoaffective disorder and major depressive disorder with psychotic features.

8.1.2.5. Delusional Disorder

As suggestive of its title, delusional disorder requires the presence of at least one delusion that lasts for at least one month in duration. It is important to note that any other symptom of schizophrenia (i.e., hallucinations, disorganized behavior, disorganized speech, negative symptoms) rules out a diagnosis of delusional disorder. Therefore the only symptom that can be present is delusions. Unlike most other schizophrenia-related disorders, daily functioning is not overtly impacted in individuals with delusional disorder. Additionally, if symptoms of depressive or manic episodes present during delusions, they are typically brief in duration compared to the duration of the delusions.

The DSM 5 (APA, 2013) has identified several subtypes of delusional disorder in efforts to better categorize the symptoms of the individual’s disorder. When making a diagnosis of delusional disorder, one of the following specifiers is included.

  • Erotomanic delusion – the individual reports a delusion of another person being in love with them. Generally speaking, the individual whom the convictions are about are of higher status such as a celebrity.
  • Grandiose delusion – involves the conviction of having a great talent or insight. Occasionally, individuals will report they have made an important discovery that benefits the general public. Grandiose delusions may also take on a religious affiliation, as some people believe they are prophets or even God, himself.
  • Jealous delusion – revolves around the conviction that one’s spouse or partner is/has been unfaithful. While many individuals may have this suspicion at some point in their relationship, a jealous delusion is much more extensive and generally based on incorrect inferences that lack evidence.
  • Persecutory delusion – involves beliefs that they are being conspired against, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in pursuit of their long-term goals (APA, 2013). Of all subtypes of delusional disorder, those experiencing persecutory delusions are the most at risk of becoming aggressive or hostile, likely due to the persecutory nature of their distorted beliefs.
  • Somatic delusion – involves delusions regarding bodily functions or sensations. While these delusions can vary significantly, the most common beliefs are that the individual emits a foul odor despite attempts to rectify their smell; there is an infestation of insects on the skin; or that they have an internal parasite (APA, 2013).
  • Mixed delusions – there are several themes of delusions (e.g., jealous and persecutory)
  • Unspecified delusion – these are delusions that don’t fit into one of the categories above (e.g., referential delusions without a persecutory or grandiose nature to them).
  • Bizarre delusion – delusions that are clearly not plausible and do not stem from ordinary experience (e.g., the delusion that one is an alien/vampire hybrid).

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