Schizophrenia Clinical Presentation

Updated: Jan 26, 2017
  • Author: Frances R Frankenburg, MD; Chief Editor: Glen L Xiong, MD  more...
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History

Information about the medical and psychiatric history of the family, details about pregnancy and early childhood, history of travel, and history of medications and substance abuse are all important. This information is helpful in ruling out other causes of psychotic symptoms.

The patient usually had an unexceptional childhood. In retrospect, family members may describe the person with schizophrenia as a physically clumsy and emotionally aloof child. The child may have been anxious and preferred to play by himself or herself. The child may have been late to learn to walk and may have been a bed wetter. [58, 59]

A noticeable change in personality and a decrease in academic, social, and interpersonal functioning often begin during middle-to-late adolescence. Usually, 1-2 years pass between the onset of these vague symptoms and the first visit to a psychiatrist. [60] The first psychotic episode usually occurs between the late teenage years and the mid 30s.

The symptoms of schizophrenia may be divided into the following 4 domains:

  • Positive symptoms - Psychotic symptoms, such as hallucinations, which are usually auditory; delusions; and disorganized speech and behavior
  • Negative symptoms - A decrease in emotional range, poverty of speech, and loss of interests and drive; the person with schizophrenia has tremendous inertia
  • Cognitive symptoms - Neurocognitive deficits (eg, deficits in working memory and attention and in executive functions, such as the ability to organize and abstract); patients also find it difficult to understand nuances and subtleties of interpersonal cues and relationships
  • Mood symptoms - Patients often seem cheerful or sad in a way that is difficult to understand; they often are depressed
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Physical Examination

The findings from a general physical examination are usually noncontributory. This examination is necessary to rule out other illnesses.

It is sometimes helpful to perform a neurologic examination as a baseline before initiating antipsychotic medications, because these drugs themselves can cause some neurological signs. Some patients with schizophrenia have motor disturbances before exposure to antipsychotic agents. Schizophrenia has been associated with left and mixed handedness, minor physical anomalies, and soft neurologic signs.

Mental status examination

On a detailed mental status examination (MSE), the following observations may be made in a severely ill patient with schizophrenia:

  • The patient may be unduly suspicious of the examiner or be socially awkward
  • The patient may express a variety of odd beliefs or delusions
  • The patient often has a flat affect (ie, little range of expressed emotion)
  • The patient may admit to hallucinations or respond to auditory or visual stimuli that are not apparent to the examiner
  • The patient may show thought blocking, in which long pauses occur before he or she answers a question
  • The patient’s speech may be difficult to follow because of the looseness of his or her associations; the sequence of thoughts follows a logic that is clear to the patient but not to the interviewer
  • The patient has difficulty with abstract thinking, demonstrated by inability to understand common proverbs or idiosyncratic interpretation of them
  • The speech may be circumstantial (ie, the patient takes a long time and uses many words in answering a question) or tangential (ie, the patient speaks at length but never actually answers the question)
  • The patient’s thoughts may be disorganized, stereotyped, or perseverative
  • The patient may make odd movements (which may elated to neuroleptic medication)
  • The patient may have little insight into his or her problems (ie, anosognosia)
  • Orientation is usually intact (ie, patients know who and where they are and what time it is)

Persons with schizophrenia may display strange and poorly understood behaviors. These include drinking water to the point of intoxication, staring at themselves in the mirror, performing stereotyped activities, hoarding useless objects, and mutilating themselves. Their wake-sleep cycle may be disturbed.

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Complications

Substance abuse

Alcohol and drug abuse (especially nicotine) are common in schizophrenia, for reasons that are not entirely clear. For some people, these drugs provide relief from symptoms of the illness or the adverse effects of antipsychotic drugs, and the drive for this relief is strong enough to allow even patients who are impoverished and disorganized to find substances to abuse. [61]

Comorbid substance abuse occurs in 20-70% of patients with schizophrenia, particularly younger male patients, and is associated with increased hostility, crime, violence, suicidality, noncompliance with medication, homelessness, poor nutrition, and poverty. Drug use and abuse can also increase symptoms. For example, cannabis use has been shown to be associated with an earlier onset of psychosis and to correlate, in a bidirectional way, with an adverse course of psychotic symptoms in persons with schizophrenia. That is, people with more severe psychotic symptoms are more likely to use cannabis, and cannabis, in turn, seems to worsen psychotic symptoms. [62] However, other research has shown that the use of cannabis is associated with better cognitive functioning. [63]

A register-based study of more than 3000 inpatients from Scotland who experienced substance-induced psychoses showed that episodes of psychosis induced from several types of illicit substances are significantly linked to a later clinical diagnosis of schizophrenia. [64]

Patients who abuse substances may fare better in dual-diagnosis treatment programs, in which principles from the mental health field can be integrated with principles from the chemical dependency field.

Depression

Many patients with schizophrenia report symptoms of depression. It is unclear whether such depression is an independent problem, part of the schizophrenia, a reaction to the schizophrenia, or a complication of treatment. Addressing this issue is important because of the high rate of suicide in patients with schizophrenia.

The research evidence for the use of antidepressant agents in schizophrenic patients is mixed. Further complicating the situation are the findings that antipsychotic agents may have antidepressant properties. [65] One meta-analysis suggested that the addition of antidepressants to antipsychotics might help treat the negative symptoms of chronic schizophrenia, which can be difficult to distinguish from depression. [66]

Suicide attempts are lower in people treated with clozapine than with other antipsychotic agents. [67]

Anxiety

Many patients with schizophrenia report symptoms of anxiety. It is unclear whether such anxiety is an independent problem, part of the schizophrenia, a reaction to the schizophrenia, or a complication of treatment. Some adverse effects of medications, such as akathisia, may be experienced as anxiety. Anxiety may precede the onset of schizophrenia by several years. [68]

Treatment is keyed to the source of the anxiety. Antipsychotics usually relieve anxiety that is part of an acute psychotic episode; only limited data are available on treatment of comorbid anxiety disorders. Following treatment recommendations for primary anxiety disorder would be reasonable in many cases; however, fluvoxamine and other selective serotonin reuptake inhibitors (SSRIs) should be used cautiously in patients receiving clozapine; they can raise clozapine blood levels. Benzodiazepines may be helpful but carry their own risks. [69, 70]

Obsessive-compulsive symptoms

A number of patients with schizophrenia display obsessive-compulsive symptoms, such as the need to check, count, or repeat certain activities. As is similar to anxiety or depression, the connection between these symptoms and schizophrenia is not understood. Obsessive-compulsive symptoms are a known adverse effect of some antipsychotic medications, particularly clozapine. Patients with schizophrenia and obsessive-compulsive symptoms tend to do more poorly. There is no clear consensus on how to treat the obsessive-compulsive symptoms.

Violence

Most people with schizophrenia are not violent. However, a few may act violently, sometimes as a result of command hallucinations or delusions. [66] Because the violent acts carried out by these few patients may be unpredictable and bizarre, they are often highly publicized, and the intense publicity has the unfortunate consequence of exacerbating the stigma of the disease.

Violence may be associated with substance abuse. However, the rate of violence in patients with schizophrenia who do not abuse substances is higher than that in people without schizophrenia. [71, 72] Clozapine is sometimes recommended for treatment of patients with schizophrenia who are violent.

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