psychiatric disorders
Schizophrenia
Symptoms and Signs of Schizophrenia
Schizophrenia is a chronic illness that may progress through several phases, although duration and patterns of phases can vary. Patients with schizophrenia tend to have had psychotic symptoms an average of 8 to 15 months before presenting for medical care, but the disorder is now often recognized earlier in its course. Symptoms of schizophrenia typically impair the ability to perform complex and difficult cognitive and motor functions; thus, symptoms often markedly interfere with work, social relationships, and self-care. Unemployment, isolation, deteriorated relationships, and diminished quality of life are common outcomes. In theprodromal phase, individuals may show no symptoms or may have impaired social competence, mild cognitive disorganization or perceptual distortion, a diminished capacity to experience pleasure (anhedonia), and other general coping deficiencies. Such traits may be mild and recognized only in retrospect or may be more noticeable, with impairment of social, academic, and vocational functioning. , subclinical symptoms may emerge; they include withdrawal or isolation, irritability, suspiciousness, unusual thoughts, perceptual distortions, and disorganization ( Symptoms reference ). Onset of overt schizophrenia (delusions and hallucinations) may be sudden (over days or weeks) or slow and insidious (over years). But, even in an advanced prodromal phase, only a fraction ( In theearly psychosis phase, symptoms are active and often at their worst. In themiddle phase, symptomatic periods may be episodic (with identifiable exacerbations and remissions) or continuous; functional deficits tend to worsen. In thelate illness phase, the illness pattern may become established but there is considerable variability; disability may stabilize, worsen, or even diminish. Generally, symptoms are categorized as Positive: Hallucinations and delusions Negative: Diminution or loss of normal functions and affect Disorganized: Thought disorder and bizarre behavior Cognitive: Deficits in memory, information processing and problem solving Patients may have symptoms from one or all categories. Positive symptomscan be further categorized as Delusions Hallucinations Delusions are erroneous beliefs that are maintained despite clear contradictory evidence. There are several types of delusions: Persecutory delusions: Patients believe they are being tormented, followed, tricked, or spied on. Delusions of reference: Patients believe that passages from books, newspapers, song lyrics, or other environmental cues are directed at them. Delusions of thought withdrawal or thought insertion: Patients believe that others can read their mind, that their thoughts are being transmitted to others, or that thoughts and impulses are being imposed on them by outside forces Delusions in schizophrenia tend to be bizarre—ie, clearly implausible and not derived from ordinary life experiences (eg, believing that someone removed their internal organs without leaving a scar). Hallucinations are sensory perceptions that are not perceived by anyone else. They may be auditory, visual, olfactory, gustatory, or tactile, but auditory hallucinations are the most common. Patients may hear voices commenting on their behavior, conversing with one another, or making critical and abusive comments. Delusions and hallucinations may be extremely vexing to patients. Negative (deficit) symptomsinclude Blunted affect: The patient’s face appears immobile, with poor eye contact and lack of expressiveness. Poverty of speech: The patient speaks little and gives terse replies to questions, creating the impression of inner emptiness Anhedonia: There is a lack of interest in activities and increased purposeless activity. Asociality: There is a lack of interest in relationships. Negative symptoms often lead to poor motivation and a diminished sense of purpose and goals. Disorganized symptoms,which can be considered a type of positive symptom, involve Thought disorders Bizarre behaviors Thinking is disorganized, with rambling, non–goal-directed speech that shifts from one topic to another. Speech can range from mildly disorganized to incoherent and incomprehensible. Bizarre behavior may include childlike silliness, agitation, and inappropriate appearance, hygiene, or conduct. Catatonia is an extreme example of bizarre behavior, which can include maintaining a rigid posture and resisting efforts to be moved or engaging in purposeless and unstimulated motor activity. Cognitive deficitsinclude impairment in the following: Attention Processing speed Working and declarative memory Abstract thinking Problem solving Understanding of social interactions The patient’s thinking may be inflexible, and the ability to problem solve, understand the viewpoints of other people, and learn from experience may be diminished. Severity of cognitive impairment is a major determinant of overall disability. Some experts classify schizophrenia into deficit and nondeficit subtypes based on the presence and severity of negative symptoms, such as blunted affect, lack of motivation, and diminished sense of purpose. Patients with thedeficit subtypehave prominent negative symptoms unaccounted for by other factors (eg, depression, anxiety, an understimulating environment, drug adverse effects). Those with thenondeficit subtypemay have delusions, hallucinations, and thought disorders but are relatively free of negative symptoms. The previously recognized subtypes of schizophrenia (paranoid, disorganized, catatonic, residual, undifferentiated) have not proved valid or reliable and are no longer used. About 5 to 6% of patients with schizophrenia commit Suicidal Behavior , and about 20% attempt it; many more have significant suicidal ideation. Suicide is the major cause of premature death among people with schizophrenia and explains, in part, why on average the disorder reduces life span by 10 years. Risk may be especially high for young men with schizophrenia and a Substance Use Disorders . Risk is also increased in patients who have depressive symptoms or feelings of hopelessness, who are unemployed, or who have just had a psychotic episode or been discharged from the hospital. Patients who have late onset and good premorbid functioning—the very patients with the best prognosis for recovery—are also at the greatest risk of suicide. Because these patients retain the capacity for grief and anguish, they may be more prone to act in despair based on a realistic recognition of the effect of their disorder. Schizophrenia is a surprisingly modest risk factor for violent behavior. Threats of violence and aggressive outbursts are more common than seriously dangerous behavior. Indeed, people with schizophrenia are overall less violent than people without schizophrenia. Patients more likely to engage in significant violence include those with Substance Use Disorders , persecutory delusions, or command hallucinations and those who do not take their prescribed drugs. A very few severely depressed, isolated, paranoid patients attack or murder someone whom they perceive as the single source of their difficulties (eg, an authority, a celebrity, their spouse). 1.Tsuang MT, Van Os J, Tandon R, et al: Attenuated psychosis syndrome in DSM-5.Schizophr Res150(1):31–35, 2013. doi: 10.1016/j.schres.2013.05.004 