Schizophrenia’s symptoms are sometimes informally divided into “positive” and “negative” categories. In this case, the term “positive” is used to mark the presence of abnormal features, like hallucinations, delusions, disorganized speech, and grossly unusual behavior.
What Is Schizophrenia?
Schizophrenia is a psychotic disorder, characterized by an individual’s marked break with reality, whereby delusions, hallucinations, and/or disorganized thinking may be present. Additionally, an individual may also exhibit unusual, repetitive or disorganized movements, as well as negative symptoms, like reduced emotional expression, decreased motivation, and diminished ability to feel pleasure.
Psychotic symptoms, such as hallucinations or delusions, can occur in other conditions besides schizophrenia, like bipolar disorder, depression, schizoaffective disorder, substance use, and schizophreniform disorder, to name a few. Thus, the mere presence of positive symptoms doesn’t automatically signal a diagnosis of schizophrenia. Often, a trained clinician is needed to distinguish schizophrenia from numerous other disorders with psychotic features.
Though schizophrenia has a relatively low prevalence (less than 1%), globally it is among the top 15 leading causes of disability. Recognizing the symptoms early can help individuals and families get treatment and support before the disorder advances.1, 2
Positive Symptoms of Schizophrenia
Positive symptoms refer to the presence of thoughts, feelings, or behaviors that are generally not experienced by most people. These symptoms, which often indicate a break with reality, can be quite scary for the individual. They can take the form of hallucinations, delusions, disorganized thinking, and abnormal movements.
Positive symptoms can result in behaviors that appear unusual to others, such as hiding from a threat that doesn’t really exist, or refusing to eat because of a delusion that one’s food is poisoned. Though positive symptoms might seem unusual and unnerving to others, most individuals living with schizophrenia are not violent or dangerous. However, when the disorder is left untreated, there is a higher likelihood for self-harm, with close to 5% of individuals with schizophrenia dying by suicide, often in the early stages of the disorder.4
The positive symptoms of schizophrenia include:
A hallucination is a false perception of something without an external cause. These illusory perceptions can form within any sensory modality, including hearing (which is the most common), vision, touch, taste, and smell. Hallucinations are often vivid and real, and they can provoke unusual behaviors, like speaking to someone who is not there.
The five types of hallucinations include:
- Auditory: hearing sounds or voices for which there is no real source. These are the most common form of hallucination in schizophrenia, and are often experienced in the form of voices.
- Visual: seeing objects, people, shadows or movement in an object that are not seen by others looking at the same space. As with other symptoms, it is important to weed out other sources of perceptual distortion, such as other physiological conditions of the sense organs.
- Tactile: feeling that one is being touched by something that is not present. Common tactile hallucinations include feeling insects crawling on or under one’s skin, or being tapped on the shoulder by someone who isn’t there.
- Olfactory: smelling a scent for which there is no real source, such as smoke, a perfume or a particular food.
- Gustatory: experiencing taste in one’s mouth in the absence of any real source. These can be connected to olfactory hallucinations, since the sense of taste and smell can influence each other.
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 in nature. They can range from clearly bizarre and implausible–such as a tracking device being implanted in one’s brain without any scar or sign of surgery, to non-bizarre. These are highly unlikely, but include examples such as being surveilled by police without having done anything wrong.
Four key features that can help identify a belief as delusional:5
- The overwhelming majority of one’s non-psychotic peers agree that it has no merit
- It’s idiosyncratic or unique to the individual
- It’s illogical
- It’s stubbornly maintained and unshakeable, despite evidence to the contrary
* Note About Paranoia: Previous versions of the Diagnostic & Statistical Manual of Mental Disorders (DSM) distinguished between various schizophrenia subtypes, with “paranoid schizophrenia” being one of them. However, DSM-5 no longer differentiates subtypes, and thus, the phenomena of paranoia is now subsumed under delusions, usually of the persecutory type.1
The six types of delusions include:
- Persecutory Delusions: a firm and often unshakeable belief that one is in danger of being harmed or ruined (perhaps in reputation) by another person, group, organization. Some of the most common delusional themes involve elaborate, conspiratorial plots.
- Referential Delusions: beliefs that one is the intended recipient of certain cues, signs, and gestures from external sources, especially in media. In some cases it may be a newspaper article containing secret coded instructions for them; or the president giving them instructions in a news conference, speaking in code, to carry out a certain act.
- Grandiose Delusions: also called delusions of grandeur, these are beliefs that one is significantly more important than they really are. These inaccurate self-assessments might concern ability, like being good enough at golf to play professionally despite never breaking 100. Sometimes, they might relate to being wealthy and famous, despite evidence to the contrary.
- Erotomanic Delusions: inaccurate beliefs that another person, often a highly respected person in one’s social circles, is in love with them.
- Nihilstic Delusions: fixed beliefs that a major catastrophe will occur, such as a nuclear bomb or asteroid hitting the earth, imminently, despite the lack of valid evidence.
- Somatic Delusions: unshakable beliefs about one’s health or body despite a lack of medical evidence. For example, a person might be convinced of having a tumor when tests show no sign of one. In other cases, people may see deformities on their body that no one else sees.
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.6 A person with this feature may struggle to maintain a coherent, relevant train of thought while communicating with others, which can be frustrating for both the individual with schizophrenia and the listener.
Linguistic abnormalities can be challenging to assess if a person is of a different linguistic or cultural background, or is deaf. Since instances of mild disorganized thinking may occur from time to time in many people, and may sometimes reflect an individual’s personality quirk, this feature must present frequently and severely to be a legitimate positive symptom of schizophrenia.
Examples of disorganized thinking include:
- 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.7
- 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: speech that starts and stops irregularly and without completing the sentence or idea.
Abnormal Motor Behaviors
As with other features of schizophrenia, motor disturbances tend to 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).
Unfortunately, the literature classifying motor disturbances in schizophrenia is fairly inconsistent, with the use of many different terms describing the same feature. There is significant disagreement over whether motor symptoms are part of schizophrenia psychopathology, a side effect of medication, or a separate underlying condition altogether. Thus, the list below might contain redundancy, but it reflects the current state of the scientific literature.
Examples of abnormal motor behaviors include:
- 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), but when they occur in a non-medicated individual, it is called spontaneous dyskinesia (SD).
- Akathisia: an intense desire to move, which appears as restlessness and agitation. This symptom can be induced by certain antipsychotic medications, and care should be taken to consider suicide risk.8
- 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 one’s limb is moved by another person, 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: imitation of other people’s movements/gestures (echopraxia) or what they say (echolalia).
Though in some cases motor abnormalities may be an inherent part of the disease of schizophrenia, they may also result as a side effect of medication.11 For example, tardive dyskinesia and akathisia are common side effects of antipsychotic drugs.10
What Causes the Positive Symptoms of Schizophrenia?
Schizophrenia is best explained by the diathesis-stress model of mental illness, whereby certain genetic factors play a role. However, stressors from the environment, including severe problems in one’s relationships, family, and academic life, trigger the onset of symptoms, often during adolescence or early adulthood. There is also evidence to suggest that certain viral infections during pregnancy can elicit neurological changes that eventually lead to schizophrenia.10
A unified theory on what precisely causes schizophrenia is still elusive, and it has even been suggested that schizophrenia is actually “multiple syndromes rather than a single disease entity.”11 Complicating research efforts in this area is the uncertainty about what symptoms and underlying neurobiological changes are inherent in the disease itself, and which are due to years of antipsychotic medication.
Possible causes of schizophrenia include:
- Genetic factors: Schizophrenia is believed to have a genetic component as having a first degree relative (parent or sibling) with the disorder increases the risk by seven to nine times.12 While genes do seem to play a role, a single gene has not been identified as the main cause; rather, many different genetic mutations have been implicated.
- Brain structure: The symptoms of schizophrenia are broad and likely stem from dysfunction in various parts of the brain and the connectivity between areas. The circuitry connecting the prefrontal cortex and limbic system with midbrain areas like the striatum are of particular interest to researchers trying to understand this disorder.13
- Neurotransmitters: The dopamine circuit encompassing the prefrontal cortex and limbic system seems to play a significant role in many of the psychotic symptoms. Other neurotransmitters such as GABA (gamma aminobutyric acid), glutamate and serotonin (5-HT) also seem to work in concert with dopamine, as neurotransmitters regulate one another in the complex brain system.
- Psychological & environmental factors: Numerous factors can impose immense stress on an individual, which can either lead to the gradual development of schizophrenia or trigger its sudden onset. Among the most common are sexual or physical abuse, trauma, social disadvantage, urbanicity, migration and separation from loved ones.
- Infection: Research suggests that prenatal exposure to certain viral or parasitic infections, including T. gondii, herpes simplex 1 and 2, cytomegalovirus, and influenza viruses, among others, increases the risk of developing schizophrenia later in life.11)
- Autoimmune & Inflammation: Individuals with certain autoimmune diseases are 2-5 times more likely to develop schizophrenia, possibly through a mechanism involving cytokines, which are small proteins involved in cell signaling. 11
- Drugs: Drug misuse is thought to increase vulnerability to schizophrenia, especially with substances affecting dopamine, like amphetamine, cocaine, and cannabis. With cannabis, specifically, it appears that heavy cannabis use among adolescents may disrupt the myelination of white matter pathways in the brain regions that are still developing, involving the same executive functions that are deficient with schizophrenia.14
How Is Schizophrenia Diagnosed?
There are often signs or mild symptoms that precede the full psychotic expression of the disorder, and this initial period is referred to as the prodromal phase of schizophrenia. Recognizing these early signs can improve the prognosis and secondary problems that schizophrenia can cause. Positive symptoms of schizophrenia tend to be more noticeable to others than negative symptoms and thus they often provide the impetus for family and friends seeking help or support for the individual.
The DSM-5 criteria for diagnosing schizophrenia include:
- The presence of at least two symptoms of schizophrenia must be present, with at least one being a positive symptom – i.e., delusions, hallucinations, disorganized speech, disorganized behavior.
- Negative symptoms, like flat affect, anhedonia, avolition, alogia and poor activities of daily living can be among the symptoms to meet criteria, as long as a positive symptom is present.
- Key symptoms must last for a period of 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 period of dysfunction.
How Are Positive Symptoms Treated?
Positive symptoms of schizophrenia are usually treated with antipsychotic medications, sometimes called neuroleptics. Antipsychotic medications are generally the most effective treatment for positive symptoms, like hallucinations and delusions. While medication can make a big difference for reducing the positive symptoms of schizophrenia, a combined treatment approach including medication, psychotherapy, and psychosocial interventions is most effective in treating schizophrenia for the long term.
Medications are generally considered to be the frontline treatment for the symptoms of schizophrenia. However, they carry with them negative side effects that a person should be aware of before starting a prescription regime.
Medications for the positive symptoms of schizophrenia include:
- Typical Antipsychotics: First-generation or typical antipsychotics work by blocking dopamine receptors. Typical antipsychotic medications have numerous serious side effects such as tardive dyskinesia.
- Atypical Antipsychotics: Second-generation or atypical antipsychotics work differently, modulating both serotonin and dopamine. Within this category, Clozapine (Clozaril) is the most effective at reducing positive symptoms, but it carries the most dangerous set of side effects in the form of serious blood disorders, like neutropenia and agranulocytosis.
- New Developments: Since antipsychotic medication often comes with unpleasant side effects, compliance is often a problem. Recently, clinicians have been developing longer acting doses that can be injected by medical professionals to avoid reliance on regular daily adherence by the individual with schizophrenia.11
- Antidepressants & Anti-anxiety Medications: Other medications commonly used for depression and anxiety may also be used to preempt positive symptoms that may be triggered by intense anxiety
While positive symptoms are most effectively treated with medication, psychotherapy can be very helpful in conjunction with medication, and during the prodromal phase or periods of remission. Stress is a major factor contributing to the expression of schizophrenia, and can trigger the expression of positive symptoms. Therapy can focus on ways to cope with stress, as well as work with the individual on strategies to challenge positive symptoms (like hallucinations and delusions) when they occur.
Even during times of remission, a therapist provides that safe place to check in and can monitor for signs of symptoms returning, so early intervention can prevent major consequences (i.e., losing one’s job) or hospitalization.
Therapy options for positive symptoms of schizophrenia include:
- Behavior therapy (BT): can offer patients concrete rewards for concrete behavior successes, like achieving hygiene goals.
- Cognitive behavioral therapy (CBT): can help individuals learn to perform reality testing on their hallucinations and delusions.
- Family therapy: helps family members create an environment of support and positivity that reduces anxiety, anger, and confusion, thus preventing schizophrenia symptoms before they arise.
- Psychodynamic therapy: while not typical for schizophrenia, can sometimes be helpful with patients who have good insight to recognize how their psychotic symptoms may be related to past traumas that haven’t been fully examined or acknowledged.
In extreme cases among those resistant to medication and psychotherapy, neuromodulation techniques, such as deep brain stimulation (DBS) or targeted neurosurgery may be performed. Immunomodulation and anti-inflammatory regimens are also promising areas of development for treatment of schizophrenia.
How to Cope With Positive Symptoms
Positive symptoms of schizophrenia can be quite intrusive and disruptive of daily functioning. Not only can they get in the way of performing tasks necessary for daily functioning, but they can affect relationships and interactions with others. At times, this can lead to the person feeling isolated and alienated from their normal social circles.
Here are some ways to cope with positive symptoms:
- Journaling: Journaling can be a great way for individuals experiencing positive symptoms to express in words or pictures what they are experiencing. In addition to serving as an outlet for the person, if shared with a therapist, it can be helpful in guiding and focusing psychotherapy.
- Stress management: Avoiding stressful situations is not always possible, and learning techniques to manage stress is important–such as recognizing stress before it becomes unmanageable, using relaxation techniques, reframing one’s thoughts, and (in a family or group setting) reducing stress of those who support the individual with schizophrenia.
- Stay as social as possible: Individuals with schizophrenia tend to isolate in response to their symptoms. This leads to a vicious cycle whereby loneliness develops, people feel others don’t care, anxiety and depression spike, unusual thoughts go unchallenged, and cognitive decline accelerates. The best antidote to break this cycle is maintaining many healthy relationships and increasing socialization as much as possible.
- Self-care: Maintaining good hygiene, such as brushing teeth, washing, and dressing properly are important to avoid other complicating health issues, and to encourage positive social interactions.
- Attention to nutrition and diet: Poor nutrition can be a stress factor rendering an individual who is already at risk for schizophrenia even more vulnerable. There is some evidence supporting the notion that foods with anti-inflammatory properties (such as omega 3 fatty acids, vitamins C and D) can be helpful in reducing symptoms and medication side effects.15
Schizophrenia, though not as common as depression or anxiety disorders, is still experienced by millions of people worldwide. What’s often referred to as the positive symptoms of schizophrenia are the hallmark features of the disease. These positive symptoms are very treatable with medication, but early diagnosis and intervention can be key to slowing the progression of the disease.