Schizophrenia, Core Symptoms, Clinical Subtypes, and Active vs. Deficit Symptoms

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Schizophrenia, Core Symptoms, Clinical Subtypes, and Active vs. Deficit Symptoms

Abnormal Psychology · Chapter 19: Psychotic Disorders and Disruptions to RealitySection 19.1 · lesson 70 of 9718 min · free with a free account

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In this lesson

Positive, negative, and cognitive features - and what really drives outcome.

  • Define psychosis, its symptom domains, and the psychosis continuum
  • Distinguish positive from negative symptoms, and their prognostic weight
  • Describe how schizophrenia is classified, and why the subtypes were removed
  • State what is known about outcome, functioning, and the mortality gap

Transcript

Everything said in the video, section by section (2,276 words). Read along, or search it.

Psychotic Disorders and Disruptions to Reality

Schizophrenia: Core Symptoms

Chapter nineteen covers psychotic disorders. This first section is about schizophrenia, and its core symptoms. We define psychosis and its symptom domains, and separate positive from negative symptoms, which carry very different weight for how a person's life goes. We look at how the condition is classified, why the old subtypes were removed, and what is known about outcome, functioning, and physical health. And we finish with differential diagnosis, and two composite cases.

Before You Begin

3 Statements Against the Public Impression

This material is educational, and not a basis for diagnosing yourself or anyone else. If any part of it affects you, please speak with a qualified professional, a doctor, or another trusted source of support. Three statements belong at the outset, because the public impression runs against all three. First. People with schizophrenia are far more likely to be victims of violence than perpetrators of it. The association with dangerousness is exaggerated, largely inaccurate, and materially harmful. Second. Schizophrenia is not a split personality. That popular confusion is with dissociative identity disorder, and it is simply wrong. Third. Outcomes vary widely. A substantial proportion of people improve significantly, and the historically pessimistic prognosis has been revised.

Psychosis Defined

A Syndrome, Not a Diagnosis

Psychosis is a loss of contact with consensus reality, involving disturbance in perception, belief, or the organization of thought. The phrase consensus reality does deliberate work. A departure is judged against what the people around the person take to be the case, which makes culture a diagnostic question, not a courtesy. The most important structural point is that psychosis is a syndrome, not a diagnosis. It occurs in schizophrenia, in mood conditions with psychotic features, in substance-induced presentations, in delirium, and in medical and neurological conditions. Recording that someone is psychotic settles nothing about which condition is producing it. And psychotic-like experiences occur in the general population far more often than any psychotic disorder. Most people who report them are not impaired, and will never develop a condition. So the boundary is a threshold drawn across a dimension. An unusual experience is not diagnostic in itself, which is why every criterion set in this chapter requires impairment.

Delusions

Fixed Beliefs - Judged by Degree

Delusions are fixed beliefs that do not change in light of conflicting evidence. Two elements matter. The fixity, and the resistance to evidence that would ordinarily produce revision. Themes are named here only as categories. Persecutory, referential, grandiose, somatic, and control themes. The specific content of any person's belief is clinical information about them, and is not reproduced. Belief is not binary. A person may hold a belief with complete conviction, partial doubt, or conviction that shifts by day and context. So the clinical judgment is about degree, not presence. The cultural question is genuinely hard. A belief that is shared and sanctioned within a person's community is not idiosyncratic, and recording it as delusional is a recognized route to over-diagnosis. The test is not whether the clinician finds the belief plausible. It is whether others in the person's community hold it, whether it works as their beliefs work, and whether it causes impairment. A clinician who cannot answer the first of those questions has not yet done the assessment.

More Positive Domains

Hallucinations, Disorganization, Catatonia

Hallucinations are perception-like experiences without an external stimulus. They have the clarity and impact of ordinary perception, and are not under voluntary control, which distinguishes them from imagination. They can occur in any sense. Auditory hallucinations are the most common in this condition. And the sense involved carries information. Prominent visual, smell, taste, or touch experiences should raise the possibility of a medical, neurological, or substance-related cause. Disorganized thinking is inferred from speech. Its recognized forms are derailment, tangentiality, incoherence, and circumstantiality. Ordinary speech is looser than people suppose, and the threshold is substantial impairment of communication. Disorganized motor behavior includes difficulty carrying out goal-directed activity, and catatonia, a marked disturbance of movement and responsiveness. Catatonia occurs in several conditions, not only this one, so it is now used as a specifier.

Negative Symptoms

Reductions - Not Moral Characteristics

Negative symptoms are reductions in functions that are ordinarily present. Positive symptoms, by contrast, are additions to ordinary experience. Five are recognized. Diminished emotional expression means reduced facial expression, vocal inflection, and gesture. It concerns expression. People with marked reduction often report ordinary inner emotional experience. Avolition is reduced initiation of goal-directed activity. Alogia is reduced quantity of speech. Anhedonia is a reduced capacity for pleasure, or for anticipating it. And asociality is reduced social drive. These are clinical features, not moral characteristics. Avolition is not laziness. Alogia is not rudeness. Diminished expression is not coldness. Asociality is not rejection of the people around the person. This is not about sensitivity. The misreading has consequences. A person understood as not trying is met with pressure and criticism, the expressed emotion pattern linked with poorer outcome. So the misreading actively worsens the course.

In the Clinic

When Families Misread Negative Symptoms

The misreading in families is entirely understandable, and correcting it is one of the more useful things a clinician can do. Families see someone who does not get up, does not say much, and does not seem pleased by anything. They reasonably read that as not trying, or as a change in how the person feels about them. Positive symptoms look strange, and are readily accepted as illness. Negative symptoms look like character, which is why they attract moral interpretation. The response is encouragement that escalates into pressure and criticism. Explaining that these are features of the condition is a specific, deliverable intervention, and a large part of what family psychoeducation does. And say explicitly that reduced expression does not mean reduced feeling. Relatives often believe the person no longer cares about them, and that belief causes real pain.

Table 19.1.2

The Most Consequential Asymmetry

Here is the most consequential asymmetry in managing the condition. Positive symptoms are additions, readily seen as illness, typically episodic, and often what brings a person to services. And they respond substantially better to available medication. Negative symptoms are reductions, misread as character, more persistent, and often present before onset. They respond poorly to medication, which is one of the most significant unmet needs in the field. Now read the treatment row and the prognosis row together. Negative symptoms and cognitive difficulty predict long-term functioning more strongly than positive symptoms do. So the symptoms that respond best to treatment, are not the ones that most shape how a person's life goes. A person with well-controlled positive symptoms, but marked avolition and cognitive difficulty, is not recovered. Describing them as stable misdescribes their situation. Measure function, not just symptoms. What a service records is what it ends up optimizing.

Cognitive Difficulties

Core, Early, and Predictive

Cognitive difficulties, in attention, working memory, processing speed, and executive function, are a core feature of the condition, not an incidental one. Two findings give them their significance. They are often present before onset, in the premorbid period. So they are not simply a consequence of the acute illness, or of its treatment. And together with negative symptoms, they are the strongest predictors of functional outcome, of whether a person returns to work or education, and sustains it. That is why supported employment, cognitive remediation, and family work are core parts of treatment, not optional additions to medication.

Schizophrenia as Classified

4 Parts - and the Exclusions Do Real Work

The diagnosis is described here in the course's own language, with no counts or intervals. Functionally, it has four parts. First, a set of symptoms from the domains we have covered, present for a significant part of a defined period. At least one must be delusions, hallucinations, or disorganized speech. That mandatory core matters. A presentation made only of negative symptoms and disorganized behavior does not meet it. Second, functional decline, meaning a marked fall below the level previously achieved in work, relationships, or self-care. Third, duration. Continuous disturbance over an extended period, of which the active phase is only part. This separates schizophrenia from the shorter conditions in section four. And fourth, three exclusions. The presentation is not better explained by a mood condition with psychotic features, not attributable to a substance, and not attributable to another medical condition. The exclusions do as much diagnostic work as the symptoms.

Table 19.1.4

Why the Classical Subtypes Were Removed

Earlier classifications divided schizophrenia into classical subtypes. Paranoid, disorganized, catatonic, undifferentiated, and residual. All were removed. The paranoid subtype was the most stable, but membership still shifted over time, and it did not reliably predict course or treatment response. Clinicians did not agree on assigning the disorganized subtype. Catatonia occurs across many conditions, so it became a specifier instead. The undifferentiated subtype was a residual category, and its size showed the scheme was not carving presentations well. And the residual subtype described a phase, not a type. The same two reasons recur. Clinicians did not agree on assignment, and assignment did not stay stable in the same person. A subtype earns its place by being reliable, stable, and informative about something. These were none of the three. The current classification uses dimensional ratings of each symptom domain instead.

Figure 19.1.3

Outcome Trajectories Vary Widely

Outcomes are heterogeneous. This schematic shows the range of documented trajectories. At one end, a single episode followed by full recovery. In the middle, an episodic course, with substantial recovery between episodes. And at the other end, persistent difficulty. Look at the spread between the lines, rather than at any one of them. The condition is still often described as uniformly deteriorating. But trajectories that end well account for a substantial share of outcomes. A person newly diagnosed should not be told otherwise.

Course and Outcome

Why the Old Prognosis Was Too Pessimistic

The historical pessimism has a specific origin. Early descriptions were based on people in long-term institutional care. That selected for the worst outcomes, and added the effects of the institution to the picture attributed to the illness. Studies following people from their first episode, in a range of countries, have found substantially better outcomes than that literature implied. Several factors are associated with better outcome. Better functioning before onset, later onset, and an acute rather than gradual onset. Prominent mood features, fewer negative symptoms, a shorter duration of untreated psychosis, and good social support. These are associations, not guarantees. None of them predicts an individual's course.

Functioning and Physical Health

A Mortality Gap Is an Inequity

The condition affects education, work, housing, and relationships, through several routes at once. Some are features of the condition, like negative and cognitive symptoms, and disruption of the years when education and careers are usually built. But some are not features of the condition at all. Stigma restricts work and housing directly, and structural disadvantage compounds it. Employment rates are low everywhere they have been studied, and symptoms do not fully explain them. People with schizophrenia also die substantially earlier than the general population. Be precise about why. The gap is largely due to cardiovascular, respiratory, and metabolic conditions, and inadequate physical healthcare, not to the psychiatric condition itself. Contributors include medication effects, higher smoking rates, poverty, and a documented pattern in which physical symptoms are attributed to the psychiatric condition, and not investigated. So this is a health inequity, not an inevitable feature of the condition. And inequities are remediable.

Table 19.1.5

Differential Diagnosis Takes Time

Several conditions share features with schizophrenia. A mood condition with psychotic features can look identical on the day. What settles it is a longitudinal history. Has psychosis ever occurred without a mood episode? Substance-induced psychosis is settled by the onset timeline and a period of observed abstinence. Medical and neurological causes need medical assessment and investigation, including imaging. Warning signs include prominent visual, smell, or touch hallucinations, fluctuating consciousness, and an unusual age of onset. For a culturally normative experience, the question is whether it is shared in the person's community, and whether there is impairment. And delusional disorder is distinguished by preserved functioning outside the delusional theme. Notice how many of these need time, or information from outside the consulting room. That is why the diagnosis is often provisional at first contact, and recording it as settled too early is a recognized error.

Case Vignette 1 (Composite)

Dilan: Meeting the Description

Now two composite cases, constructed for instruction. Dilan is twenty-three. His family describe a change beginning about fourteen months ago, with marked worsening over the past two months. He left his course nine months ago, has not worked since, has stopped seeing friends, and his self-care has declined markedly. Work through the domains. Delusions with a persecutory theme, recorded by category only. Auditory hallucinations most days. Derailment during the interview. Marked avolition and diminished expression, present since before the recent deterioration. And difficulty sustaining attention. The mandatory core is met. Functional decline is unambiguous. And the duration, including a prodromal period and a recent active phase, is well beyond the requirement. Then the exclusions, which is where the work is. The family's account shows no mood episode explaining the psychotic features. A period of observed abstinence has been arranged. And medical assessment, including imaging, has been completed. The exclusions carry as much weight as the symptoms, and they are what a hurried assessment leaves out.

Case Vignette 2 (Composite)

Ruth: Psychosis Within Mood Episodes

Ruth is forty-one. Her psychotic features, examined on the day, cannot be distinguished from Dilan's. But she has had two previous episodes of severe low mood, at twenty-nine and thirty-five, each lasting several months and resolving fully. She has held the same job throughout. The decisive information is longitudinal. Her psychotic features have occurred only while she also met criteria for a major depressive episode. Between episodes, she has had none, and her functioning returned to baseline. That places this as a mood condition with psychotic features, not a primary psychotic condition. If psychotic features had persisted when no mood episode was present, the picture would shift toward schizoaffective disorder. That is the timing rule, worked in full later in the chapter. The treatment, the expected course, and what Ruth and her family are told all differ. So when psychotic features are present, establish their relationship to mood episodes across the whole history first. The presentation on the day does not distinguish these conditions.

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FAQ

Questions students ask us

About Schizophrenia, Core Symptoms, Clinical Subtypes, and Active vs. Deficit Symptoms

What is the difference between positive and negative symptoms of schizophrenia?
Positive symptoms are additions to ordinary experience, such as delusions, hallucinations, and disorganized thinking, while negative symptoms are reductions in usual functions: diminished emotional expression, avolition, alogia, anhedonia, and asociality. Positive symptoms are often episodic and respond better to medication. Negative symptoms are more persistent, respond poorly to medication, and, together with cognitive difficulties, predict long-term functioning more strongly than positive symptoms do.
Is schizophrenia the same as a split personality?
No, schizophrenia is not a split personality; that popular confusion is with dissociative identity disorder. Schizophrenia involves psychosis, a loss of contact with consensus reality affecting perception, belief, or the organization of thought, along with negative and cognitive symptoms. Another common myth is dangerousness: people with schizophrenia are far more likely to be victims of violence than perpetrators of it, and the exaggerated association causes real harm.
Why were the subtypes of schizophrenia removed from the DSM?
The classical subtypes, paranoid, disorganized, catatonic, undifferentiated, and residual, were removed in DSM-5 because they failed as categories. Clinicians often disagreed on which subtype applied, a person's subtype shifted over time, and the subtypes did not reliably predict course or treatment response. Catatonia occurs in many conditions, so it became a specifier. The current approach uses dimensional ratings of each symptom domain instead.
What is the long-term outlook for people with schizophrenia?
Outcomes in schizophrenia vary widely, from a single episode with full recovery, to an episodic course, to persistent difficulty, and a substantial proportion of people improve significantly. The old pessimistic prognosis came from studying people in long-term institutional care. Better premorbid functioning, later and acute onset, fewer negative symptoms, shorter untreated psychosis, and good social support are associated with better outcomes, though none predicts an individual's course.

About the Abnormal Psychology course

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