Depending on the individual, a person diagnosed with schizophrenia may experience hallucinations (especially hearing voices), delusions (especially ones that seem "bizarre"), and disorganized thinking and speech. The latter may range from loss of train of thought, to sentences only loosely connected in meaning, to incoherence known as word salad in severe cases. There is often an observable pattern of emotional difficulty, for example lack of responsiveness or motivation. Impairment in social cognition is associated with schizophrenia, as are symptoms of paranoia, and social isolation commonly occurs. In one uncommon subtype, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are signs of catatonia.
Late adolescence and early adulthood are peak years for the onset of schizophrenia. In 40% of men and 23% of women diagnosed with schizophrenia, the condition arose before the age of 19.[10] These are critical periods in a young adult's social and vocational development. To minimize the developmental disruption associated with schizophrenia, much work has recently been done to identify and treat the prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer.[11] Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and dysphoria in the prodromal period,[12] and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.[13]
Schneiderian classification
The psychiatrist Kurt Schneider (1887–1967) listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. These are called first-rank symptoms or Schneider's first-rank symptoms, and they include delusions of being controlled by an external force; the belief that thoughts are being inserted into or withdrawn from one's conscious mind; the belief that one's thoughts are being broadcast to other people; and hearing hallucinatory voices that comment on one's thoughts or actions or that have a conversation with other hallucinated voices.[14] Although they have significantly contributed to the current diagnostic criteria, the specificity of first-rank symptoms has been questioned. A review of the diagnostic studies conducted between 1970 and 2005 found that these studies allow neither a reconfirmation nor a rejection of Schneider's claims, and suggested that first-rank symptoms be de-emphasized in future revisions of diagnostic systems.[15]
Positive and negative symptoms
Schizophrenia is often described in terms of positive and negative (or deficit) symptoms.[16] The term positive symptoms refers to symptoms that most individuals do not normally experience but are present in schizophrenia. They include delusions, auditory hallucinations, and thought disorder, and are typically regarded as manifestations of psychosis. Negative symptoms are things that are not present in schizophrenic persons but are normally found in healthy persons, that is, symptoms that reflect the loss or absence of normal traits or abilities. Common negative symptoms include flat or blunted affect and emotion, poverty of speech (alogia), inability to experience pleasure (anhedonia), lack of desire to form relationships (asociality), and lack of motivation (avolition). Research suggests that negative symptoms contribute more to poor quality of life, functional disability, and the burden on others than do positive symptoms.[17]
A third symptom grouping, the disorganization syndrome, is sometimes described, and includes chaotic speech, thought, and behavior. There is evidence for a number of other symptom classifications.[18]
Diagnosis
Schizophrenia is diagnosed on the basis of symptom profiles. Neural correlates do not provide sufficiently useful criteria.[19] Diagnosis is based on the self-reported experiences of the person, and abnormalities in behavior reported by family members, friends or co-workers, followed by a clinical assessment by a psychiatrist, social worker, clinical psychologist or other mental health professional. Psychiatric assessment includes a psychiatric history and some form of mental status examination.[citation needed]
Standardized criteria
The most widely used standardized criteria for diagnosing schizophrenia come from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, version DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, the ICD-10. The latter criteria are typically used in European countries, while the DSM criteria are used in the United States and the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian first-rank symptoms, although, in practice, agreement between the two systems is high.[20]
According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met:[4]
Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment).
Delusions
Hallucinations
Disorganized speech, which is a manifestation of formal thought disorder
Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior
Negative symptoms: Blunted affect (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation)
If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication.
Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.
Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment).
If signs of disturbance are present for more than a month but less than six months, the diagnosis of schizophreniform disorder is applied.[4] Psychotic symptoms lasting less than a month may be diagnosed as brief psychotic disorder, and various conditions may be classed as psychotic disorder not otherwise specified. Schizophrenia cannot be diagnosed if symptoms of mood disorder are substantially present (although schizoaffective disorder could be diagnosed), or if symptoms of pervasive developmental disorder are present unless prominent delusions or hallucinations are also present, or if the symptoms are the direct physiological result of a general medical condition or a substance, such as abuse of a drug or medication.
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