Acute Schizophrenia: Symptoms, Types, & Treatment

What Is Acute Schizophrenia?

Schizophrenia can present in phases, with the acute phase serving as the period when psychotic symptoms are present. The onset of schizophrenia is often subtle rather than acute, with the illness typically developing for many months before the first psychotic symptoms (e.g., hallucinations or delusions) emerge. This initial prodromal phase, comprised of negative symptoms (e.g., lack of motivation) and cognitive symptoms (e.g., memory impairment), eventually gives way to an acute phase during which positive (psychotic) symptoms appear. Psychotic symptoms can wax and wane as a residual or recovery phase cycles with the acute phase in this chronic disorder.

Schizophrenia is a broad diagnosis with a great deal of symptom variation between individuals. However, it usually onsets acutely between late adolescence and early adulthood. The acute phase of schizophrenia may vary in severity, type, duration, and frequency of symptoms. Several factors impact symptoms, including treatment adherence, substance use, stress, sleep quality, other medical conditions, and access to support.

The three phases of schizophrenia include:

• Prodrome: The prodromal phase of schizophrenia is a period that can last up to 24 months before an individual meets the full criteria for the illness. During this phase, some early warning signs may include isolated symptoms of the illness and a significant decline in IQ, general cognitive functioning, academic achievement, communication skills, or verbal memory.
• Active: The acute or active phase is marked by the emergence of positive schizophrenia symptoms, which refer to the presence of thoughts, feelings, or behaviors generally not experienced by most people. These symptoms often indicate a break from reality and can be quite scary for the individual. They can be hallucinations (i.e., faulty perceptions), delusions (i.e., distorted beliefs), disorganized thinking, and abnormal movements.
• Residual: The residual (or recovery) phase is the period between active (acute) episodes. Positive symptoms may become less severe or disappear completely, but negative and cognitive symptoms often persist.

Acute Schizophrenia Symptoms

While the prodromal phase can be difficult to discern, the acute phase usually consists of more observable symptoms that indicate a break from reality, such as hallucinations, delusions, and disorganized speech and behavior. These acute symptoms may spur an individual to seek or receive help. Although they can be different for each individual, it is usually clear that the person’s behavior and thoughts are out of the ordinary for that person. There is often a “trigger” for the acute onset of positive symptoms, such as high stress or trauma.

Symptoms of acute schizophrenia may include:

Delusions

Delusions are distorted beliefs that, despite possibly having a kernel of truth, are not supported by the overwhelming evidence accessible to most typical observers. These beliefs may be persecutory, referential, grandiose, erotomanic, nihilistic, or somatic. As a hallmark positive symptom of schizophrenia, they can range from clearly bizarre and implausible, such as a tracking device implanted in one’s brain without any scar or sign of surgery, to non-bizarre but still highly unlikely as being surveilled by police without having done anything wrong.

Hallucinations

A hallucination is a false perception of something without an external cause. These illusory perceptions can form within any of the senses, including hearing (auditory hallucinations), vision, touch (tactile hallucinations), taste, and smell. Hallucinations are often vivid and real and can provoke unusual behaviors, like speaking to someone who is not there.

Negative Symptoms

The term “negative” refers to the absence of typical healthy features, like motivation, interest, and expression, reflecting impairments in one’s emotional and social abilities. Negative schizophrenia symptoms are the most common first sign of schizophrenia and usually emerge during the condition’s prodromal (i.e., initial) phase.  They can be just as debilitating as positive symptoms and are quite common: 90% of individuals experiencing their first psychotic episode report at least one negative symptom.¹

Unlike positive symptoms, which tend to wax and wane during the disease (i.e., prodromal, active, and residual phases), negative symptoms persist through all phases. They may worsen over time, even as positive symptoms improve.¹
The more severe the negative symptom, the greater its impact on job and school performance, household integration, social functioning, and overall daily functioning.

Examples of negative symptoms in acute schizophrenia include:

• Alogia: Alogia is the lack of making logical sense in one’s arguments.
• Anhedonia: Anhedonia is the inability to experience pleasure (a.k.a. “hedonism”) when engaging in activities that usually bring joy, like sex or playing video games.
• Avolition: Avolition is a lack of motivation to complete regular tasks voluntarily.
• Blunted Affect: Blunted affect is a reduced emotional expression in one’s face (e.g., smile/frown, furrowed brow), body (e.g., gestures), or voice (e.g., intonation). Flat affect is an extreme case of blunted affect, characterized by the complete absence of emotional expression.
• Diminished Activities of Daily Living (ADLs): avoidance of bathing, oral hygiene, changing clothes, shaving, doing laundry, paying bills, food shopping, taking out the garbage, collecting the mail, cleaning the house, etc.

Disorganized Behavior & Speech

While hallucinations and delusions concern the content of thought, disorganized thinking (also referred to as formal thought disorder or disorganized speech) refers to a problem with how thoughts are organized or communicated. Though disorganized thinking is most easily assessed in speech, it may also be apparent in writing.²

Disorganized behavior may manifest as motor disturbances that highlight a disconnect between the individual and societal norms of appropriateness. These positive symptoms may present as repetitive actions, such as pacing or rocking, or inappropriate emotional responses, such as shouting or grimacing.

They can range from atypical ways of doing routine activities (such as dressing in a heavy coat, gloves, and scarves on a hot day) to an incredibly bizarre mismatch of behavior and location (such as masturbating or defecating in public).

Examples of disorganized symptoms in acute schizophrenia include:

• Pressured speech: Pressured speech is a rapid and continuous flow of speech that is difficult to interrupt. The person may seem frenzied, and the contents may contain elements listed below, such as tangentiality or derailment.
• Derailment (or loose associations): Speech in which one jumps between seemingly unrelated topics or ideas. It has been described as “knight’s move thinking,” referencing the chess piece that moves in one direction and then abruptly shifts direction by 90 degrees.³
• Tangentiality: Thoughts or responses to questions that are only obliquely related to the question. A person may ramble about irrelevant topics without answering the main question.
• Circumstantiality: Similar to tangentiality, a person digresses from what is relevant and provides ample, nonessential information before eventually arriving at the main point.
• Clanging (or clang associations): Speech in which similar sounding words are strung together despite not making sense; for example: “Fun pun shun stun stunk, punk, junk….”
• Incoherence (also called “word salad”): disorganized speech to the point where it is incomprehensible.
• Thought Blocking: Thought Blocking is speech that starts and stops irregularly, without completing the sentence or idea.
• Dyskinesia: repetitive, involuntary movements of face or body muscles. When these involuntary movements result from antipsychotic drugs (e.g., Haloperidol/Haldol), it is called tardive dyskinesia (TD). Still, when they occur in a non-medicated individual, it is called spontaneous dyskinesia (SD). SDs may improve with medication, while TDs, by definition, are caused by medication.
• Akathisia: Akathisia is an intense desire to move, which appears as restlessness and agitation. Certain antipsychotic medications can induce this symptom, and care should be taken to consider suicide risk.⁴
• Neurological Soft Signs (NSS): a general term encompassing problems with coordination, sensory integration, and movement sequences (e.g., trouble putting toothpaste on a toothbrush or doing so after brushing one’s teeth).
• Parkinsonism: a cluster of features including muscle rigidity (e.g., muscles are in a state of constant tension or contraction) and bradykinesia (i.e., slowing of movement, sometimes with hesitations and halts).
• Dystonia: involuntary muscle contractions that can lead to abnormal movements or positions, like a tremor or uncontrollable blinking eyes.
• Catatonia: within the context of positive symptoms, catatonia can take the form of maintaining a rigid posture, grimacing, stereotyped movements or vocalizations, waxy flexibility (i.e., when another person moves one’s limb, it will stay in the new position for extended periods), and catalepsy (i.e., maintaining a rigid posture while in a sleep-like state).
• Echopraxia & Echolalia: imitating other people’s movements/gestures (echopraxia) or what they say (echolalia).

Cognitive Symptoms

Though not yet an official diagnostic criterion for a DSM-5 diagnosis of schizophrenia, the onset of schizophrenia is often preceded by or accompanied by a marked reduction in cognitive functioning.

Cognitive symptoms reduced in acute schizophrenia include:

• Executive Functioning: the ability to plan, organize, make decisions, adapt to changing conditions, see things from alternate perspectives, and engage in abstract reasoning.
• Verbal Fluency: the ability to generate words and expand vocabulary.
• Verbal Encoding: the ability to commit things to memory when heard via verbal communication.
• Verbal Memory: the ability to recall information from verbal communication.

How Is Acute Schizophrenia Diagnosed?

Finding help for schizophrenia starts with the courage to acknowledge that something is wrong. One can seek help through several channels, such as a mental health clinic, private psychiatrist or psychologist, primary care provider, or hospital. The diagnostic process usually involves a comprehensive evaluation of the person’s current symptoms, medical and mental health, and family history.

Depending on the severity of symptoms, the individual may be asked to engage in neuropsychological assessment involving activities like solving puzzles, remembering words, and answering questions. A physician may request other medical tests to rule out other possible causes of symptoms, such as substance misuse or other medical conditions. Upon diagnosis, a healthcare team can establish an effective treatment plan.

These symptoms are necessary for an acute schizophrenia diagnosis:

• The presence of at least two symptoms of schizophrenia, with at least one being a positive symptom – i.e., delusions, hallucinations, disorganized speech, disorganized behavior.
• Negative symptoms can be among the symptoms to meet the criteria as long as a positive symptom is present.
• Key symptoms must last for at least one month. The condition’s effects must also last for at least six months.
• Social or occupational dysfunction must also be present during the dysfunction period.

Outlook for Acute Schizophrenia

Untreated acute schizophrenia can lead to social, occupational, relationship, and even legal complications in a person’s life. Managing and preventing symptoms starts with an effective treatment plan, which commonly involves medication, therapy, and support.

Lifestyle adjustments may be imperative to improving one’s outlook long term. They may include abstaining from drugs like marijuana and alcohol, prioritizing stress management, maintaining a healthy sleep/wake routine, engaging in positive social activities or support groups, and involving family in treatment if possible.

Acute Schizophrenia Treatment

Once diagnosed, a combination of schizophrenia treatment methods is the best way to manage symptoms of schizophrenia. Medication is often the first line of treatment if positive symptoms are present. Therapy, social skills training, and support groups also play an important role in treating and managing the illness.

Medication

Pharmaceutical treatment is often the first and most effective means of alleviating schizophrenia’s most challenging symptoms. However, finding the right medication can be difficult. While medication can be useful for reducing symptoms, many have side effects that also interfere with mental health. For this reason, medication compliance is a big challenge and can interfere with stability.

A skilled psychiatrist can help determine the best pharmaceutical regimen for the individual. If you have trouble finding a psychiatrist near you, you may want to consider online psychiatry options.

Medications for acute schizophrenia include:

• Typical Antipsychotics: First-generation or typical antipsychotics work by reducing dopamine levels. Typical antipsychotic medications have numerous serious side effects, such as tardive dyskinesia.
• Atypical Antipsychotics: Second-generation or atypical antipsychotics modulate serotonin and dopamine. Though atypical medications have a reduced propensity to cause side effects like tardive dyskinesia, they come with their own adverse effects, including severe weight gain and other metabolic issues, and their efficacy above typical antipsychotics remains questionable.⁵
• Injectables: Since antipsychotic medication often comes with unpleasant side effects, compliance is often problematic. Individuals may stop their medication regimen intentionally to avoid side effects, unintentionally because of cognitive deficits (i.e., forgetting), or because of the presence of positive symptoms (i.e., delusions that the medication is poison). Recently, clinicians have been developing longer-acting doses that medical professionals can inject to avoid reliance on regular daily adherence by the individual with psychosis.⁶
• Cannabidiol (CBD): There has been considerable optimism recently for the use of CBD (without THC) as a relatively safe and tolerable therapeutic to treat schizophrenia symptoms. Several studies have shown CBD to be as effective as some antipsychotic drugs (e.g., amisulpride) and without as many adverse side effects.^{7, 8}
  CBD has even shown some potential for use as a preventative in individuals at risk for schizophrenia and an add-on to antipsychotic medicine since it may help with certain negative and cognitive symptoms that antipsychotics are not effective in treating. *Please note that most CBD on the market is not regulated, and many products have been found to have inaccurate dose information. Furthermore, CBD also has side effects and can interact with other medications. It is always recommended to consult with your doctor before using.

Psychosocial Interventions

Psychotherapy often supplements medication in the treatment of schizophrenia. In most cases, a combination of individual therapy — particularly from a behavior therapy (BT) or cognitive behavior therapy (CBT) approach — along with family and group therapy is most effective. An online therapist directory can be an excellent resource for finding the right care.

Therapy options for acute schizophrenia type may include:

• Cognitive behavioral therapy for psychosis (CBTp): The goal of CBTp is to reduce distress from difficult symptoms like hallucinations, delusions, and negative symptoms by working with the patient to challenge these thought disturbances, form new thought patterns and establish effective coping strategies. This is a highly structured, time-limited, goal-based treatment that has been shown to reduce distress from psychotic symptoms in patients when use in conjunction with medication.
• Behavior Therapy (BT): Particularly useful for individuals experiencing cognitive deficits, BT can offer patients concrete rewards for concrete behavior successes, like achieving hygiene goals.
• Family therapy: Family therapy can help family members create an environment of support and positivity that reduces anxiety, anger, and confusion, thus preventing the symptoms before they arise, and can give family members the know-how to navigate acute episodes when they do happen effectively.
• Group therapy: Regardless of whether you have schizophrenia or care for someone with schizophrenia, realizing that you are not alone can be invaluable to feeling supported. Isolation can exacerbate the illness, and regular group therapy meetings help stay connected with others in a safe space.
• Social skills training: SST can be beneficial, especially in conjunction with psychotherapy and medication, to help the individual develop skills often deficient in schizophrenia and may involve individual and group work.⁹

Final Thoughts

If you or someone you care about is experiencing symptoms of acute schizophrenia, it is essential to seek help. Psychotic symptoms can be frightening and disruptive to daily life, but you do not have to suffer alone. Working with a professional can provide you with the support and treatment you need. The first step  is reaching out to a trusted healthcare provider, family member, or friend who can start you on the path. If you have trouble finding professional help near you, consider checking out these online therapy resources.