Schizophrenia Symptoms and Diagnosis

There Are Many Roads That Lead to a Diagnosis of Schizophrenia

Mental Institution #26 Richard Avedon East Louisiana Mental Hospital Jackson, Louisiana, February 7, 1963. Public Domain

Schizophrenia is a puzzling disorder 

To make a diagnosis doctors look for a pattern of changes in a patient's well-being that is consistent over time. For example, cough, fever, chest pain that gets worse with deep breathing together with breathing difficulties is highly suggestive of pneumonia. Or a combination of sudden chest tightness and then pain that goes to the left arm is usually a red flag for a heart attack.

The point is that most physical and mental problems present in ways that are consistent over time. It is this consistency (doctors talk about a homogeneous clinical picture) that allows doctors to diagnose the vast majority of medical conditions.

Well, schizophrenia is NOT a homogeneous condition. A patient tormented by demonic voices and convinced there are hidden messages encoded in TV programs can be diagnosed with schizophrenia. A patient who has no interest in his surroundings, no motivation and no emotional response to anything might be equally diagnosed with schizophrenia. Two very different presentations, one diagnosis.

So then how do they put it all together?

To make a diagnosis of schizophrenia doctors look for a combination of problems or symptoms, typically a sum of the so-called positive and negative symptoms in addition to cognitive and emotional problems. Catatonia represents yet another category of symptoms seen in schizophrenia.

Is there a diagnostic test for schizophrenia?

Unfortunately, there is no test that would either diagnose schizophrenia beyond any doubt, nor safely eliminate schizophrenia as a possible diagnosis in cases of severe mental distress.

If there is no test why did the doctor send me to have a head CT/MRI?

As there are other conditions that can present with symptoms similar to schizophrenia.

Those might include brain masses/ tumors that by compressing on different parts of the brain can lead to changes in personality as well as unusual perceptions (illusions or hallucinations) or strange thought patterns (delusions). Head imaging (CT/MRI) is helpful in establishing that a tumor is NOT the cause of psychosis - in clinical terms rule out a tumor as a possible explanation for symptoms.

What are the positive symptoms?

Thoughts and feelings that are in excess of the day-to-day normal experience are classified as positive symptoms. Hallucinatory experiences such as hearing voices and seeing visions as well as fixed beliefs that are not based in reality (delusional ideas) such as feeling that people are following you or actively plotting to harm you in some way are typical examples of positive symptoms.

There is really not much "positive" about positive symptoms - this label only refers to the fact that these symptoms are added ("addition" = "plus" or a positive sign, remember Math 101) to what's considered to be the usual mental state.

Positive symptoms include hallucinations of all types and delusional thinking - usually grouped together as "psychotic symptoms" - as well as disorganized thinking.

The typical medications for schizophrenia - so-called antipsychotics, both first- and second-generation - work pretty well for treating positive/psychotic symptoms.

What are the negative symptoms?

Well, if positive symptoms are symptoms of "excess" then negative symptoms are symptoms of a lack of what's considered to be a normal mental state. Humans are social beings, thus a lack of interest in anything social, which will result in social isolation, is a negative symptom. Emotions play an essential part in our day-to-day mental functioning, thus a lack of emotions, which could go all the way to a "flat affect" - meaning there is no facial emotion (affect), is also a negative symptom.

Other negative symptoms include an overall decrease in interest, motivation or ability to enjoy things.

When the negative symptoms are severe it might find it difficult to even start simple, day-to-day activities, such as getting out of bed, taking a shower and getting dressed or starting and keeping up with a conversation ("paucity of speech").

The first generation anti-psychotics don't do much for the negative symptoms and at times even make these symptoms worse. The good news is that second generation anti-psychotics do not make the negative symptoms worse; however it is not clear if they make them better.

What are the cognitive symptoms?

Schizophrenia commonly impairs attention, concentration, as well remembering things that you just learned (working memory deficits). Not surprisingly these problems will make it hard to learn new information, solve problems or take decisions on the spot (executive function deficits).

To date, there is no good treatment for the cognitive deficits in schizophrenia.

What are the emotional problems?

Depression and anxiety are common.

Antipsychotics do not have great mood effects so if the depression and  anxiety are severe enough for treatment to be indicated your doctor might discuss starting an antidepressant or anti-anxiety (anxiolytic) medication.

How about catatonic symptoms?

Catatonia is a state of extreme motor immobility culminating with a state of appearing frozen. Patients with catatonia look like living statues. In cases of severe catatonia the patients are unresponsive and stuck in a body posture that is either frozen (with active resistance if anyone attempts to change it) or display a fluid plasticity, called "waxy flexibility", when the body can be "modeled" in any position. A state of extreme motor agitation with purposeless activity might be also classified as catatonic excitement.

Catatonia can be a part of the presentation in schizophrenia but can also be seen in patients with severe depression and mania.

Antipsychotics can help but are not the treatment of choice for catatonia. A different category of medications, called benzodiazepines (including lorazepam and diazepam among others) are the treatment of choice for catatonia.

There are so many symptoms. Do all of them count for a diagnosis of schizophrenia?

No. A diagnosis of schizophrenia requires that a patient must have at least two symptoms (positive or negative or a combination). The symptoms need to be severe enough to result in decreased ability to function in family and society at large. The symptoms also need to be present for a minimum of six months for schizophrenia to be diagnosed. Lastly, the symptoms need to be seen as "primary" meaning that there is no other explanation of why the patient would experience them (such as the use of alcohol, drugs or prescription medications, or other medical or mental health conditions).

Further reading:

1. NIMH: What is schizophrenia?

2. NHS: Schizophrenia

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