Schizophrenia Symptoms & Signs

Symptoms of Schizophrenia

For a diagnosis of schizophrenia to be given, the DSM 5 requires a person to exhibit at least two symptoms for a month or more, with at least one of these being a positive symptom, such as hallucinations or delusions.¹ Generally, features of schizophrenia are divided into positive symptoms (i.e., the presence of something unusual), negative symptoms (i.e., the absence of something typical) and cognitive symptoms. Cognitive symptoms, like verbal fluency and memory impairment such as thought blocking, are not yet necessary for an official diagnosis of schizophrenia. However, expert clinicians use cognitive symptoms to distinguish schizophrenia from other disorders.

Positive Symptoms

Though not an official diagnostic term, what are often called the positive symptoms of schizophrenia refer to abnormal features that are present (as opposed to absent).

Common positive symptoms of schizophrenia include:²

• Hallucinations: These include sensory illusions, in any sensory modality, that can take the form of seeing, hearing, or tasting things that aren’t really there. Auditory hallucinations are more common than visual hallucinations.⁹
• Delusions: Delusions are distorted beliefs that, despite possibly having a kernel of truth, are not supported by the overwhelming evidence accessible to most other objective, non-psychotic observers.
• Thought disorder symptoms: Thought disorders are a general category of dysfunctional features that highlight a person’s break from reality, or indicate their illogical thinking patterns, including loose associations (i.e., bizarre links between two events that are related in a person’s mind).
• Disorganized speech: Speech that does not make logical sense or is incoherent is often referred to as disorganized speech. This can possibly include nonsense syllables or the repetition of the same word or phrase over and over.
• Disorganized behavior: Disorganized behaviors do not fit a given situation, like undressing on a busy street corner.
• Movement symptoms: Disturbances in typical movement may either take the form of simple repetitive movements—like tics—or the lack of movement altogether (also called catatonia).

Negative Symptoms

In contrast to the positive symptoms above, the negative symptoms of schizophrenia refer to the absence of typical, common, or normal features that most individuals regularly exhibit.

Negative symptoms of schizophrenia include the following:²

• Flat Affect: A person experiencing flat or blunted affect will show a minimal emotional response to positive or negative events.
• Anhedonia: Anhedonia is the inability to experience pleasure (i.e., hedonism) when engaging in activities that usually bring joy, like sex or playing video games.
• Alogia: Alogia is the lack of making logical sense in one’s arguments.
• Avolition: Someone experiencing avolition will have a lack of motivation to voluntarily complete their regular tasks.
• Diminished Activities of Daily Living (ADLs): These behaviors include avoidance of daily activities such as bathing, oral hygiene, changing clothes, shaving, doing laundry, paying bills, food shopping, taking out garbage, collecting the mail, and cleaning the house.

Cognitive Symptoms

Though not yet an official diagnostic criterion for a DSM V diagnosis of schizophrenia, the onset of schizophrenia is often preceded by or accompanied by a marked reduction in cognitive functioning. According to research, neurocognitive functioning for those with schizophrenia can be significantly below neurotypical individuals in certain aspects of mental functioning.^3,4

Cognitive symptoms of schizophrenia include impairment of the following:

• Executive functioning: The ability to plan, organize, make decisions, adapt to changing conditions, see things from alternate perspectives, and engage in abstract reasoning.
• Inattention.
• Verbal fluency: The ability to generate words and expand vocabulary.
• Verbal encoding: The ability to commit things to memory that were presented in verbal communication.
• Verbal memory: The ability to recall things that were presented in verbal communication.

Early Warning Signs of Schizophrenia

The prodromal phase of schizophrenia is a period that can last up to 24 months before an individual meets full criteria for the illness. During this phase, some early warning signs of mental illness may include isolated symptoms of the illness, along with a significant decline in IQ, general cognitive functioning, academic achievement, communication skills, or verbal memory. In contrast to schizophrenia, other disorders that may also have psychotic symptoms, like depression with psychotic features, don’t typically include such a drastic reduction in cognitive (and especially verbal) functioning.⁵

The onset of schizophrenia in children and adolescents is often insidious—rather than acute—with the illness typically developing for many months before the first psychotic symptoms manifest, usually in the form of auditory hallucinations and delusions. Further complicating the diagnosis of schizophrenia in children and adolescents is that other childhood disorders— such as autism spectrum disorder (ASD), pervasive developmental disorder, depression, conduct disorder can resemble the early signs of schizophrenia. Furthermore, treatment of attention deficit hyperactivity disorder (ADHD) with high doses of psychostimulants (like Vyvanse), as well as heavy use of cannabis, can trigger psychotic symptoms that mimic schizophrenia.⁵

Some warning signs of schizophrenia may include the following:^5,6,7,8

• Increased solitude
• Diminished desire to socialize
• Significant decline in motivation
• Bizarre speech, logic, or behavior
• Hallucinations
• Delusions
• Significant drop in cognitive abilities
• Marked reduction in school/work performance

How Schizophrenia is Treated

A combination of treatment methods is the best way to manage symptoms of schizophrenia.

Medications

Medication treatment is often the first and most effective means of alleviating schizophrenia’s most challenging symptoms, especially psychotic symptoms. However, finding the right medication can be difficult. The positive symptoms of schizophrenia and the aggressive behaviors they can sometimes trigger are often best treated with atypical antipsychotic medications. In rare cases, however, older, typical antipsychotics, like haloperidol, are used.

Unfortunately, the most effective medication for the positive symptoms of schizophrenia, clozapine (Clozaril), can lead to blood disorders, a rare but serious adverse effect. Thus, it is not as often used as it might otherwise be. Other atypical antipsychotics, such as risperidone (Risperdal), olanzapine (Zyprexa),  aripiprazole (Abilify),  and an injectible form of aripiprazole called Aristada, may be less effective. These medications can come with challenging adverse effects as well, like motor tics (e.g., tardive dyskinesia), weight gain, and additional metabolic problems. However, they still work well to treat both positive and negative symptoms.

Beyond antipsychotic medication, some psychiatrists have found that using antidepressants (e.g., Zoloft) to treat the affective symptoms of schizophrenia, along with anti anxiety medications (e.g., Xanax), to curb the panic symptoms, can work well, and without as many of the dangerous adverse effects that result from antipsychotic treatment.

Psychotherapy

Psychotherapy with individuals who have schizophrenia is generally less effective than it is for individuals with other mental illnesses. A combination of individual therapy—particularly from a behavior therapy (BT) or cognitive behavior therapy (CBT) approach—along with family therapy is most effective. Individual therapy from a BT or CBT perspective often focuses on setting concrete goals, like reality testing of one’s hallucinations and delusions, verbal skills enhancement, maintenance of ADLs, and medication adherence. Family therapy often focuses on the ways an individual’s family system can better prevent the afflicted individual from undue anxiety, frustration or confusion.

Therapeutic options for schizophrenia include:

• Behavior therapy can offer patients concrete rewards for concrete behavior successes, like achieving hygiene goals.
• Cognitive behavioral therapy 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, it 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.

Medical Procedures

Aside from medication and psychotherapy, medical procedures, such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), are sometimes used. When they are, it’s usually to treat the more affective components of the illness, such as depressed mood and negative symptoms.

Hospitalization

Often, the need for hospitalization is the first indication that one’s increasingly aberrant behavior and confusing internal experiences have crossed the line to a psychotic disorder, like schizophrenia. In fortunate situations, a doctor, friend or family member may point out privately that one’s logic or behavior is acutely concerning, thus prompting a trip to a psychiatric ER. In more extreme situations, individuals may behave bizarrely or violently in public, thus leading the police or an EMS team to have a patient involuntarily hospitalized.

In either case, hospitalizations can be brief (sometimes just a few days to re-stabilize an individual on the right medication), or they can lead to long term care, where patients may live in community treatment residences for years. Though psychotherapy is provided during hospitalizations for schizophrenia, treatment is very limited and is usually relegated to group therapy, covering only the most superficial aspects of the disorder. Hospitalization primarily aims to stabilize patients on the right medication in a supportive environment with maximum supervision.

How to Get Help for Schizophrenia

Finding help for schizophrenia starts with the courage to acknowledge that something is wrong. Many people are afraid for months, even years, to admit that something isn’t right, and valuable time is lost. Schizophrenia can be a progressively degenerative condition if left untreated. As with most medical and mental illnesses, the earlier schizophrenia is treated, the better.

Given the fear and uncertainty that schizophrenia can instill, an individual who thinks they could be affected should identify the person they most trust, and tell that person what they are experiencing. That person should, in turn, consider talking to a physician, mental health provider, or a family member to get recommendations regarding how to proceed. If one so chooses, they can take the initiative themselves and find a therapist to start the process of treatment.

Final Thoughts

Though many people experience individual symptoms associated with schizophrenia, it is important to remember that schizophrenia itself is actually a rare mental illness. Furthermore, even if someone is diagnosed with schizophrenia, they can still enjoy a long, productive, meaningful life if they seek treatment at an early stage and learn to adapt to their new realities. There are numerous accounts of individuals, like mathematician John Nash (after whom the film A Beautiful Mind was based) who have achieved great success despite early struggles with schizophrenia. On a personal level I draw inspiration from a colleague, Robert Francis, whose struggles with schizophrenia did not prevent him from being a successful social worker and author, who now treats others with myriad mental illnesses.