Learning Objectives
- List and describe distinguishing features that make up the clinical presentation of schizophrenia spectrum disorders.
- Describe how schizophrenia presents.
- Describe how schizophreniform disorder presents.
- Describe how schizoaffective disorder presents.
- Describe how delusional disorder presents.
The Clinical Presentation of Schizophrenia Spectrum Disorders
The schizophrenia spectrum and other psychotic disorders are defined by one of the following main symptoms: delusions, hallucinations, disorganized thinking (speech), disorganized or abnormal motor behavior, and negative symptoms. Individuals diagnosed with a schizophrenia spectrum disorder experience psychosis, which is defined as a loss of contact with reality. Psychosis episodes make it difficult for individuals to perceive and respond to environmental stimuli, causing a significant disturbance in everyday functioning. While there are a vast 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.
12.1.1.1. Delusions. Delusions are “fixed beliefs that are not amenable to change in light of conflicting evidence” (APA, 2022, pp. 101). This means that despite evidence contradicting one’s thoughts, the individual is unable to distinguish their thoughts from reality. The inability to identify thoughts as delusional is likely likely due to a lack of insight. There are a wide range of delusions that are seen in the schizophrenia related disorders to include:
- Delusions of grandeur– belief they have exceptional abilities, wealth, or fame; belief they are God or other religious saviors
- Delusions of control– belief that others control their thoughts/feelings/actions
- Delusions of thought broadcasting– belief that one’s thoughts are transparent and everyone knows what they are thinking
- Delusions of persecution– belief they are going to be harmed, harassed, plotted or discriminated against by either an individual or an institution; it is the most common delusion (Arango & Carpenter, 2010)
- Delusions of reference– belief that specific gestures, comments, or even larger environmental cues are directed directly to them
- Delusions of thought withdrawal– belief that one’s thoughts have been removed by another source
It is believed that the presentation of the delusion is primarily 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 (delusions of grandeur) than another type of delusion.
12.1.1.2. Hallucinations. Hallucinations are “perception-like experiences that occur without an external stimulus” (APA, 2022, pg. 102). They can occur in any of the five senses: hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), touching (tactile hallucinations), and tasting (gustatory hallucinations). Additionally, they can occur in a single modality or present across a combination of modalities (e.g., having 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 patients 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 patient or various voices talking to one another. Generally, these hallucinations are not attributable to any one person that the individual knows. They are usually clear, objective, and definite (Arango & Carpenter, 2010). Additionally, the auditory hallucinations can be pleasurable, providing comfort to the patient; however, in other individuals, the auditory hallucinations can be unsettling as they produce commands or malicious intent.
12.1.1.3. Disorganized thinking (Speech). Among the most common cognitive impairments displayed in patients with schizophrenia are disorganized thoughts, communication, and speech. More specifically, thoughts and speech patterns may appear to be circumstantial or tangential. For example, patients may give unnecessary details in response to a question before they finally produce the desired response. While the question is eventually answered in circumstantial speech patterns, in tangential speech patterns the patient never reaches the point. Another common cognitive symptom is speech incoherence or word salad, where speech is “nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization” (APA, 2022, pg. 102). Derailment, or the illogical connection in a chain of thoughts, is another common type of disorganized thinking. Although not always, derailment is often seen in illogicality, or the tendency to provide bizarre explanations for things.
These types 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.
12.1.1.4. Disorganized/abnormal motor behavior. These symptoms manifest as childlike “silliness” to unpredictable agitation. Catatonic behavior, the decreased or complete lack of reactivity to the environment, is among the most commonly seen grossly disorganized motor behavior in schizophrenia. There runs a range of catatonic behaviors from negativism (resistance to instruction); mutism or stupor (complete lack of verbal and motor responses); rigidity (maintaining a rigid or upright posture while resisting efforts to be moved); or posturing (holding odd, awkward postures for long periods). There is one type of catatonic behavior, catatonic excitement, where the individual experiences hyperactivity of motor behavior, in a seemingly excited or delirious way. Other features include repeated stereotyped movements, staring, grimacing, and the echoing of speech (APA, 2022, pg. 102).
12.1.1.5. Negative symptoms. Up until this point, all the symptoms can be categorized as positive symptoms, or symptoms that are an over-exaggeration of normal brain processes; these symptoms are also new to the individual. The final diagnostic criterion is negative symptoms, which are defined as the inability or decreased ability to initiate actions, speech, express emotion, or feel pleasure (Barch, 2013). Negative symptoms often present before positive symptoms and remain once positive symptoms remit. Because of their prevalence through the course of the disorder, they are also more indicative of prognosis, with more negative symptoms suggesting a poorer prognosis. The poorer prognosis may be explained by the lack of effectiveness antipsychotic medications have in addressing negative symptoms (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). There are six main types of negative symptoms seen in patients with schizophrenia. Such symptoms include:
- Diminished emotional expression – Reduction in emotional expression; reduced display of emotional expression
- Alogia – Poverty of speech or speech content
- Anhedonia – Inability to experience pleasure
- Asociality – Lack of interest in social relationships
- Avolition – Lack of motivation for goal-directed behavior
Schizophrenia
As stated above, the hallmark symptoms of schizophrenia include the presentation of at least two of the following during a one month period: delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, or negative symptoms. These symptoms create significant impairment in an individual’s ability to engage in normal daily functioning such as work, school, relationships with others, or self-care, and continuous signs of the disturbance persist for at least 6 months. It should be noted that the presentation of schizophrenia varies significantly among individuals, as it is a heterogeneous clinical syndrome (APA, 2022).
While the presence of symptoms must persist for a minimum of 6 months to meet the criteria for a schizophrenia diagnosis, it is not uncommon to have prodromal symptoms that precede the active phase of the disorder and residual symptoms that follow it. These prodromal and residual symptoms are “subthreshold” forms of psychotic 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, these mood symptoms are distinct from a mood disorder diagnosis in that psychotic features will exist beyond the remission of depressive symptoms.
Schizophreniform Disorder
Schizophreniform disorder is similar to schizophrenia, except for the length of presentation of symptoms. Schizophreniform disorder is considered an “intermediate” disorder between schizophrenia and brief psychotic disorder as the symptoms are present for at least one month but not longer than six months. Schizophrenia symptoms must be present for at least six months and a brief psychotic disorder is diagnosed when symptoms are present for less than one month. 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, 2022).
Another key distinguishing feature of schizophreniform disorder is the lack of criteria related to impaired functioning. While many individuals with schizophreniform disorder do display impaired functioning, it is not essential for diagnosis. Finally, any major mood episodes—either depressive or manic— that are present concurrently with the psychotic features must only be present for a short time, otherwise a diagnosis of schizoaffective disorder may be more appropriate (APA, 2022).
Making Sense of the Disorders
In relation to schizophrenia spectrum and other psychotic disorders, note the following:
- Diagnosis brief psychotic disorder …… if symptoms have been present for less than one month
- Diagnosis schizophreniform disorder …… if symptoms have been present for at least one month but not longer than six months
- Diagnosis schizophrenia … if the symptoms have been present for at least six months
Schizoaffective Disorder
Schizoaffective disorder is characterized by the psychotic symptoms included in schizophrenia and a concurrent uninterrupted period of a major mood episode—either a major depressive or manic episode. It should be noted that because the loss of interest in pleasurable activities is a common symptom of schizophrenia, to meet the criteria for a depressive episode within schizoaffective disorder, the individual must present with a pervasive depressed mood (APA, 2022). 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, 2022). This is the key distinguishing feature between schizoaffective disorder and major depressive disorder with psychotic features.
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 if an individual experiences hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms—in addition to delusions—they should not be diagnosed with delusional disorder as their symptoms are more aligned with a schizophrenia diagnosis. Unlike most other schizophrenia-related disorders, daily functioning is not overly impacted due to the delusions. Additionally, if symptoms of depressive or manic episodes present during delusions, they are typically brief compared to the duration of the delusions.
The DSM-V-TR (APA, 2022) has identified five main subtypes of delusional disorder to better categorize the symptoms of the individual’s disorder. When making a diagnosis of delusional disorder, one of the following modifiers (in addition to mixed presentation) is included. Erotomanic delusion occurs when an individual reports a delusion of another person being in love with them. Generally speaking, the individual whom the convictions are about is of higher status, such as a celebrity. Grandiose delusion involves the conviction of having great talent or insight. Occasionally, patients will report they have made an important discovery that benefits the general public. Grandiose delusions may also take on religious affiliation, as people believe they are prophets or even God. 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 the individual believing 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, 2022). 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. Finally, 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 the smell; there is an infestation of insects on the skin; or that they have an internal parasite (APA, 2022). If no one delusion predominates, the mixed type specifier is used and if the dominant delusional belief cannot be clearly determined, use the unspecified type specifier. A separate specifier is used when the content of the delusions are deemed bizarre or implausible, not understandable, and not derived from ordinary life experience.
Key Takeaways
You should have learned the following in this section:
- Schizophrenia spectrum disorders are characterized by delusions, hallucinations, disorganized thinking (speech), disorganized or abnormal motor behavior, and negative symptoms.
- Delusions are beliefs that do not change even when conflicting evidence is presented and can be of grandeur, control, thought broadcasting, persecution, reference, and thought withdrawal.
- Hallucinations occur in any sense modality and most individuals recognize that they are not real.
- Disorganized thinking, abnormal motor behavior, catatonic behavior, and negative symptoms such as affective flattening, alogia, anhedonia, asociality, and avolition are also common to schizophrenia spectrum disorders.
- Schizophrenia is characterized by delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, or negative symptoms lasting six months.
- Schizophreniform disorder is considered an “intermediate” disorder between schizophrenia and brief psychotic disorder as the symptoms are present for at least one month but not longer than six months.
- Schizoaffective disorder is characterized by the psychotic symptoms included in schizophrenia and a concurrent uninterrupted period of a major mood episode—either a depressive or manic episode.
- Delusional disorder requires the presence of at least one delusion that lasts for at least one month in duration to include erotomanic, grandiose, jealous, persecutory, and somatic.
Review Questions
- What are the four positive symptoms identified in a schizophrenia diagnosis? Define and identify their difference.
- What is meant by negative symptoms? What are the negative symptoms observed in schizophrenia related disorders?
- Identify diagnostic differences between schizophrenia, schizophreniform, schizoaffective, and delusional disorders.
