Signs and symptoms

"The consumer who lives with schizophrenia is more than a complex presentation of signs and symptoms. Not only does this person experience the internal effects of the illness, they also feel the interaction between their internal physical and psychological experience, and the external social world" (Paul, a Mental Health Professional).

There are a number of signs and symptoms that are characteristic of schizophrenia, however, the expression of these symptoms varies greatly from one individual to another. No one symptom is common to all people. As such, diagnosis and treatment must always be tailored to the individual's unique experience of schizophrenia.

The symptoms of schizophrenia are often divided into two groups:

• Positive symptoms, for example, hallucinations and delusions
• Negative symptoms, for example, flat affect, apathy and poverty of speech
  

It has also been proposed that disorganised symptoms (for example, disorganised speech and disorganised behaviour) constitute a third group, separate from the positive/negative groups.

Positive symptoms

The positive symptoms of schizophrenia (also referred to as 'psychotic' or 'active' symptoms) reflect an excess or distortion of normal functioning and include the following:

Delusions
Delusions are false personal beliefs held with extraordinary conviction in spite of what others believe and in spite of obvious proof or evidence to the contrary. They may revolve around persecutory, religious, grandiose, somatic or referential themes. For example, a person experiencing delusions may believe they are being spied on, tormented, followed or tricked (persecutory). Or they may believe gestures, comments, passages from books, television and other environmental cues are directed specifically at them (referential). Delusions may be bizarre (believing your thoughts have been removed by an outside force) or realistic (believing you are being followed by the police). Delusions will occur during some stage of the disorder in ninety percent of people who experience schizophrenia.

Hallucinations
Hallucinations can occur in any of the five senses but the most common are auditory. These are usually experienced as voices which are perceived as distinct from the person's own thoughts. For example, the person may hear voices repeating or mimicking their thoughts, arguing, commenting on their actions (often in a critical manner) or telling them what to do (command hallucinations). Hallucinations of any form occur in over 70 per cent of people who experience psychotic illnesses. Auditory hallucinations occur in approximately 50 per cent of people with schizophrenia, while visual hallucinations occur in 15 per cent.

Disorganised Thinking
This is usually expressed through abnormal spoken language. For example, the person's conversation jumps erratically from one topic to another, new words may be created, the grammatical structure of language breaks down and speech may greatly speed up or slow down.

Disorganised Behaviour
This can be manifested in a variety of ways and is the result of the underlying brain dysfunction. A person with schizophrenia may, for example, aimlessly wander, display child-like silliness or become unpredictable agitated. Or they may display behaviour that is considered inappropriate according to usual social norms, such as wearing many layers on a hot day, muttering aloud in public or inappropriately shouting or swearing. Disorganised behaviour can lead to problems in conducting the activities of daily living such as organising meals and maintaining hygiene. It may be difficult to link disorganised behaviour in adolescents as being a sign of early psychosis as teenagers are often intrinsically disorganised.

Catatonic Behaviour
This refers to states of muscular rigidity and immobility, stupor and negativism, or to states of wild excitement. The person may hold fixed or bizarre bodily postures for extended periods of time and resist any effort to be moved. The incidence of catatonic behaviour is very rare in developed countries (Cutting, 1996).

Negative symptoms

The negative symptoms of schizophrenia (also referred to as 'deficit' symptoms) reflect a loss of normal functioning and include the following:

Withdrawal, Loss of Motivation and Ambivalence (Avolition)
This may involve lack of energy, apathy or seeming absence of interest in what were usually routine activities. People experiencing avolition may be inattentive to grooming, personal hygiene, have difficulty making decisions and have difficulty persisting at work, school or household chores.

Loss of Feeling or an Inability to Experience Pleasure (Anhedonia)
This may manifest itself through having a lack of interest in social or recreational activities or through failure to develop close relationships. It may mean that the simple pleasures of life, like appreciating a beautiful sunset, being no longer enjoyed.

Poverty of Speech (Alogia)
The person's amount of speech is greatly reduced and tends to be vague or repetitious. People showing signs of alogia may be slow in responding to questions or not respond at all.

Flat Presentation (Affective Flattening)
This can be indicated by unchanging facial expressions, poor or no eye contact, reduced body language and decreased spontaneous movements. A person experiencing affective flattening may stare vacantly into space and speak in a flat, toneless voice. Flat affect refers to the outward expression of emotion and not the inner experience.

Some people with schizophrenia experience negative symptoms prior to and after and acute episode of the illness. However, the negative symptoms are difficult to assess because they may be caused by a variety of other factors such as medication side effects, mood disorders or the demoralisation often felt as a consequence of a mental illness.

It is also possible a person may have schizophrenia but be symptom-free. The symptoms may only emerge during an acute episode.

Cognitive impairments

Although not part of diagnostic criteria, cognitive dysfunction is often present in people with schizophrenia. A large body of research demonstrates schizophrenia is associated with cognitive impairments including problems with attention, concentration and memory.

Are there any early warning signs?

Yes. Usually before a person develops psychosis or schizophrenia, there is a period where 'something is not quite right'. During this time they may withdraw from their family and friends, have changes in their appetite and sleep patterns, find it difficult to concentrate and consequently have difficulties at school or work. The person may find this period very disturbing, even frightening, and may not want to talk about what is happening to them. This period is referred to in medical language as the ‘prodrome’.

The prodrome is the period of disturbance or mild symptoms that occurs before the onset of an illness. The prodrome for schizophrenia can be anything from a month to several years. New research is suggesting that if early interventions are begun during this period, the prospects for recovery or a milder course of illness are increased.

Some early warning signs and symptoms of psychosis are:

• Changes in thinking: Difficulty in concentrating, poor memory, preoccupation with odd ideas, increased suspiciousness.
• Changes in mood: Lack of emotional response, rapid mood changes, inappropriate moods.
• Changes in behaviour: Odd or unusual behaviour.
• Physical changes: Sleep disturbances or excessive sleep and loss of energy.
• Social changes: Withdrawal and isolation from family and friends.
• Changes in functioning: Decline in school or work performance.

Remember: none of these symptoms by themselves indicate the presence of schizophrenia or another mental illness. But if they are severe, persistent or recurrent, professional help should be sought as soon as possible.