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Article Index
Overview of Schizophrenia
Social/occupational dysfunction
Cognitive Dysfunction
Cultural Variation
Course and Recovery
Onset
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Our understanding of schizophrenia has evolved since its symptoms were first catalogued by German psychiatrist Emil Kraepelin in the late 19th century (Andreasen, 1997a). Even though the cause of this disorder remains elusive, its frightening symptoms and biological correlates have come to be quite well defined. Yet misconceptions abound about symptoms: schizophrenia is neither "split personality" nor "multiple personality." Furthermore, people with schizophrenia are not perpetually incoherent or psychotic (DSM-IV; Mason et al., 1997) (Table 4-6).

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Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect, and sense of self. The array of symptoms, while wide ranging, frequently includes psychotic manifestations, such as hearing internal voices or experiencing other sensations not connected to an obvious source (hallucinations) and assigning unusual significance or meaning to normal events or holding fixed false personal beliefs (delusions). No single symptom is definitive for diagnosis; rather, the diagnosis encompasses a pattern of signs and symptoms, in conjunction with impaired occupational or social functioning (DSM-IV).

Symptoms are typically divided into positive and negative symptoms (see Table 4-7) because of their impact on diagnosis and treatment (Crow, 1985; Andreasen, 1995; Eaton et al., 1995; Klosterkotter et al., 1995; Maziade et al., 1996). Positive symptoms are those that appear to reflect an excess or distortion of normal functions (Peralta & Cuesta, 1998). The diagnosis of schizophrenia, according to DSM-IV, requires at least 1-month duration of two or more positive symptoms, unless hallucinations or delusions are especially bizarre, in which case one alone suffices for diagnosis. Negative symptoms are those that appear to reflect a diminution or loss of normal functions (Roy & DeVriendt, 1994; Crow, 1995; Blanchard et al., 1998). These often persist in the lives of people with schizophrenia during periods of low (or absent) positive symptoms. Negative symptoms are difficult to evaluate because they are not as grossly abnormal as positives ones and may be caused by a variety of other factors as well (e.g., as an adaptation to a persecutory delusion). However, advancements in diagnostic assessment tools are being made.

Diagnosis is complicated by early treatment of schizophrenia's positive symptoms. Antipsychotic medications, particularly the traditional ones, often produce side effects that closely resemble the negative symptoms of affective flattening and avolition. In addition, other negative symptoms are sometimes present in schizophrenia but not often enough to satisfy diagnostic criteria (DSM-IV): loss of usual interests or pleasures (anhedonia); disturbances of sleep and eating; dysphoric mood (depressed, anxious, irritable, or angry mood); and difficulty concentrating or focusing attention.

Currently, discussion is ongoing within the field regarding the need for a third category of symptoms for diagnosis: disorganized symptoms (Brekke et al., 1995; Cuesta & Peralta, 1995). Disorganized symptoms include thought disorder, confusion, disorientation, and memory problems. While they are listed by DSM-IV as common in schizophrenia—especially during exacerbations of positive or negative symptoms (DSM-IV)—they do not yet constitute a formal new category of symptoms. Some researchers think that a new category is not warranted because disorganized symptoms may instead reflect an underlying dysfunction common to several psychotic disorders, rather than being unique to schizophrenia (Toomey et al., 1998).

Table 4-6. DSM-IV diagnostic criteria for schizophrenia
Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

• delusions
• hallucinations
• disorganized speech (e.g., frequent derailment or incoherence)
• grossly disorganized or catatonic behavior
• negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

Disorders - Schizophrenia