For years, schizophrenia was a “wastebasket category” for diagnosticians, particularly for those in the United States, where the label was at times assigned to anyone who acted unpredictably or strangely. The disorder is defined more precisely today, but still its symptoms vary greatly, and so do its triggers, course, and responsiveness to treatment (APA, 2013). In fact, a number of clinicians believe that schizophrenia is actually a group of distinct disorders that happen to have some features in common (Boutros et al., 2014; Arango & Carpenter, 2011).

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Regardless of whether schizophrenia is a single disorder or several disorders, the lives of people who struggle with its symptoms are filled with pain and turmoil. One particularly coherent and articulate patient described what it is like to live with this disorder:

Think back to Laura and Richard, the two people described at the beginning of the chapter. Both of them deteriorated from a normal level of functioning to become ineffective in dealing with the world (Laloyaux et al., 2014). Each had some of the symptoms found in schizophrenia. The symptoms can be grouped into three categories: positive symptoms (excesses of thought, emotion, and behavior), negative symptoms (deficits of thought, emotion, and behavior), and psychomotor symptoms (unusual movements or gestures). Some people with schizophrenia are more dominated by positive symptoms and others by negative symptoms, although most tend to have both kinds of symptoms to some degree. In addition, around half of those with schizophrenia have significant difficulties with memory and other kinds of cognitive functioning (Eich et al., 2014; Ordemann et al., 2014).

Positive SymptomsPositive symptoms are “pathological excesses,” or bizarre additions, to a person’s behavior. Delusions, disorganized thinking and speech, heightened perceptions and hallucinations, and inappropriate affect are the ones most often found in schizophrenia.

DELUSIONSMany people with schizophrenia develop delusions, ideas that they believe wholeheartedly but that have no basis in fact. The deluded person may consider the ideas enlightening or may feel confused by them. Some people hold a single delusion that dominates their lives and behavior; others have many delusions. Delusions of persecution are the most common in schizophrenia (APA, 2013). People with such delusions believe they are being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized. Laura believed that her neighbors were trying to irritate her and that other people were trying to harm her and her husband.

People with schizophrenia may also have delusions of reference: they attach special and personal meaning to the actions of others or to various objects or events. Richard, for example, interpreted arrows on street signs as indicators of the direction he should take. People with delusions of grandeur believe themselves to be great inventors, religious saviors, or other specially empowered persons (see MediaSpeak below). And those with delusions of control believe their feelings, thoughts, and actions are being controlled by other people.

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DISORGANIZED THINKING AND SPEECHPeople with schizophrenia may not be able to think logically (Briki et al., 2014) and may speak in peculiar ways (Millier et al., 2014). These formal thought disorders can cause the sufferer great confusion and make communication extremely difficult. Often such thought disorders take the form of positive symptoms (pathological excesses), as in loose associations, neologisms, perseveration, and clang.

People who have loose associations, or derailment, the most common formal thought disorder, rapidly shift from one topic to another, believing that their incoherent statements make sense. A single, perhaps unimportant word in one sentence becomes the focus of the next. One man with schizophrenia, asked about his itchy arms, responded:

Some people with schizophrenia use neologisms, made-up words that typically have meaning only to the person using them. One person said, for example, “I am here from a foreign university … and you have to have a ‘plausity’ of all acts of amendment to go through for the children’s code … it is an ‘amorition’ law … the children have to have this ‘accentuative’ law so they don’t go into the ‘mortite’ law of the church” (Vetter, 1969, p. 189). Others may have the formal thought disorder of perseveration, in which they repeat their words and statements again and again. Finally, some use clang, or rhyme, to think or express themselves. When asked how he was feeling, one man replied, “Well, hell, it’s well to tell.” Another described the weather as “So hot, you know it runs on a cot.” Research suggests that some people may have disorganized speech or thinking long before their full pattern of schizophrenia unfolds (Remington et al., 2014; Covington et al., 2005).

HEIGHTENED PERCEPTIONS AND HALLUCINATIONSA deranged character in Edgar Allan Poe’s “The Tell-Tale Heart” asks, “Have I not told you that what you mistake for madness is but the overacuteness of the senses?” Similarly, the perceptions and attention of some people with schizophrenia seem to intensify (Rossi-Arnaud et al., 2014). The persons may feel that their senses are being flooded by all the sights and sounds that surround them (Galderisi et al., 2014). This makes it almost impossible for them to attend to anything important:

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Laboratory studies repeatedly have found problems of perception and attention among people with schizophrenia (Bozikas et al., 2014; Park et al., 2011). In one study, participants were instructed to listen for a particular syllable recorded against an ongoing background of speech (Harris et al., 1985). As long as the background speech was kept simple, participants with and without schizophrenia were equally successful at picking out the syllable in question; but when the background speech was made more distracting, those with schizophrenia became less able to identify the syllable. In many studies, people with schizophrenia have also demonstrated deficiencies in smooth pursuit eye movement, weaknesses that may be related again to attention problems. When asked to keep their head still and track a moving object back and forth with their eyes, research participants with schizophrenia tend to perform more poorly than those without schizophrenia (Franco et al., 2014; Egan & Cannon, 2011).

The various perception and attention problems that people with schizophrenia have may develop years before the onset of the actual disorder (Remington et al., 2014; Goldberg et al., 2011; Cornblatt & Keilp, 1994). It is also possible that such problems further contribute to the memory impairments that are common to many people with schizophrenia (Ordemann et al., 2014).

Another kind of perceptual problem in schizophrenia consists of hallucinations, perceptions that a person has in the absence of external stimuli (see InfoCentral below). People who have auditory hallucinations, by far the most common kind in schizophrenia, hear sounds and voices that seem to come from outside their heads. The voices may talk directly to the hallucinator, perhaps giving commands or warning of dangers, or they may be experienced as overheard:

Research suggests that people with auditory hallucinations actually produce the nerve signals of sound in their brains, “hear” them, and then believe that external sources are responsible (Chun et al., 2014; Sarin & Wallin, 2014). One line of research measured blood flow in Broca’s area, the region of the brain that helps people produce speech (Homan et al., 2014; McGuire et al., 1996). The investigators found more blood flow in Broca’s area while patients were having auditory hallucinations. A related study instructed six men with schizophrenia to press a button whenever they had an auditory hallucination (Silbersweig et al., 1995). PET scans revealed increased activity near the surfaces of their brains, in the tissues of the auditory cortex, the brain’s hearing center, when they pressed the button.

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Hallucinations can also involve any of the other senses (Stevenson, Langdon, & McGuire, 2011). Tactile hallucinations may take the form of tingling, burning, or electric-shock sensations. Somatic hallucinations feel as if something is happening inside the body, such as a snake crawling inside one’s stomach. Visual hallucinations may produce vague perceptions of colors or clouds or distinct visions of people or objects. People with gustatory hallucinations regularly find that their food or drink tastes strange, and people with olfactory hallucinations smell odors that no one else does, such as the smell of poison or smoke.

Hallucinations and delusional ideas often occur together (Shiraishi et al., 2014). A woman who hears voices issuing commands, for example, may have the delusion that the commands are being placed in her head by someone else. A man with delusions of persecution may hallucinate the smell of poison in his bedroom or the taste of poison in his coffee. Might one symptom cause the other? Whatever the cause and whichever comes first, the hallucination and delusion eventually feed into each other.

INAPPROPRIATE AFFECTMany people with schizophrenia display inappropriate affect, emotions that are unsuited to the situation (Gard et al., 2011). They may smile when making a somber statement or upon being told terrible news, or they may become upset in situations that should make them happy. They may also undergo inappropriate shifts in mood. During a tender conversation with his wife, for example, a man with schizophrenia suddenly started yelling obscenities at her and complaining about her inadequacies.

In at least some cases, these emotions may be merely a response to other features of the disorder. Consider a woman with schizophrenia who smiles when told of her husband’s serious illness. She may not actually be happy about the news; in fact, she may not be understanding or even hearing it. She could, for example, be responding instead to another of the many stimuli flooding her senses, perhaps a joke coming from an auditory hallucination.

Negative SymptomsNegative symptoms are those that seem to be “pathological deficits,” characteristics that are lacking in a person. Poverty of speech, blunted and flat affect, loss of volition, and social withdrawal are commonly found in schizophrenia (Azorin et al., 2014; Rocca et al., 2014). Such deficits greatly affect one’s life and activities (Ferhava et al., 2014).

POVERTY OF SPEECHPeople with schizophrenia often have alogia, or poverty of speech, a reduction in speech or speech content. Some people with this negative kind of formal thought disorder think and say very little. Others say quite a bit but still manage to convey little meaning (Haas et al., 2014; Birkett et al., 2011). These problems are revealed in the following diary entry written in 1919 by Vaslav Nijinsky, one of the twentieth century’s great ballet dancers, as his pattern of schizophrenia was unfolding:

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RESTRICTED AFFECTMany people with schizophrenia have a blunted affect—they show less anger, sadness, joy, and other feelings than most people (Rocca et al., 2014). And some show almost no emotions at all, a condition known as flat affect. Their faces are still, their eye contact is poor, and their voices are monotonous. In some cases, people with these problems may have anhedonia, a general lack of pleasure or enjoyment. In other cases, however, the restricted affect may reflect an inability to express emotions as others do. One study had participants view very emotional film clips. The participants with schizophrenia showed less facial expression than the others; however, they reported feeling just as much positive and negative emotion and in fact displayed more skin arousal (Kring & Neale, 1996).

LOSS OF VOLITIONMany people with schizophrenia experience avolition, or apathy, feeling drained of energy and of interest in normal goals and unable to start or follow through on a course of action (Gard et al., 2014; Gold et al., 2014). This problem is particularly common in people who have had schizophrenia for many years, as if they have been worn down by it. Similarly, people with schizophrenia may feel ambivalence, or conflicting feelings, about most things. The avolition and ambivalence of Richard, the young man you read about earlier, made eating, dressing, and undressing impossible ordeals for him.

SOCIAL WITHDRAWALPeople with schizophrenia may withdraw from their social environment and attend only to their own ideas and fantasies (Gard et al., 2014; Pinkham, 2014). Because their ideas are illogical and confused, the withdrawal has the effect of distancing them still further from reality. The social withdrawal seems also to lead to a breakdown of social skills, including the ability to recognize other people’s needs and emotions accurately (Fogley, Warman, & Lysaker, 2014; Lysaker et al., 2014).

Psychomotor SymptomsPeople with schizophrenia sometimes experience psychomotor symptoms. Many move relatively slowly (Bervoets et al., 2014), and a number make awkward movements or repeated grimaces and odd gestures that seem to have a private purpose—perhaps ritualistic or magical (Stegmayer et al., 2014).

The psychomotor symptoms of schizophrenia may take certain extreme forms, collectively called catatonia. People in a catatonic stupor stop responding to their environment, remaining motionless and silent for long stretches of time. Recall how Richard would lie motionless and mute in bed for days. People with catatonic rigidity maintain a rigid, upright posture for hours and resist efforts to be moved. Still others exhibit catatonic posturing, assuming awkward, bizarre positions for long periods of time. They may, for example, spend hours holding their arms out at a 90-degree angle or balancing in a squatting position. Finally, people with catatonic excitement, a different form of catatonia, move excitedly, sometimes wildly waving their arms and legs.

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Schizophrenia usually first appears between the person’s late teens and mid-thirties (Lindenmayer & Khan, 2012). Although its course varies widely from case to case, many sufferers seem to go through three phases—prodromal, active, and residual (Perkins & Lieberman, 2012). During the prodromal phase, symptoms are not yet obvious, but the person is beginning to deteriorate (Le Galudec et al., 2014; French, 2010). He or she may withdraw socially, speak in vague or odd ways, develop strange ideas, or express little emotion. During the active phase, symptoms become apparent. Sometimes this phase is triggered by stress or trauma in the person’s life (Bebbington & Kuipers, 2011; Callcott et al., 2011). For Laura, the middle-aged woman described earlier, the immediate trigger was the loss of her cherished dog.

Many people with schizophrenia eventually enter a residual phase in which they return to a prodromal-like level of functioning (Fukumoto et al., 2014). They may retain some negative symptoms, such as blunted emotion, but have a lessening of the striking symptoms of the active phase (Fervaha et al., 2014; Harvey, 2014). Although 25 percent or more of patients recover completely from schizophrenia, the majority continue to have at least some residual problems for the rest of their lives (an der Heiden & Häfner, 2011; Fischer & Carpenter, 2008).

Each of these phases may last for days or for years. A fuller recovery from schizophrenia is more likely in people who functioned quite well before the disorder (had good premorbid functioning); whose initial disorder is triggered by stress, comes on abruptly, or develops during middle age; and who receive early treatment, preferably during the prodromal phase (Remberk et al., 2014; Conus et al., 2007). Relapses are apparently more likely during times of life stress (Bebbington & Kuipers, 2011, 2008).

DSM-5 calls for a diagnosis of schizophrenia only after symptoms of the disorder continue for six months or more (APA, 2013). In at least one of those months, the person must be in an active phase, marked by significant delusions, hallucinations, or disorganized speech. In addition, there must be a deterioration in the person’s work, social relations, and ability to care for him or herself (see again Table 14-1).

Many researchers believe that in order to help predict the course of schizophrenia, there should be a distinction between so-called Type I and Type II schizophrenia. People with Type I schizophrenia are thought to be dominated by positive symptoms, such as delusions, hallucinations, and certain formal thought disorders (Crow, 2008, 1995, 1985, 1980). Those with Type II schizophrenia have more negative symptoms, such as restricted affect, poverty of speech, and loss of volition. Type I patients generally seem to have been better adjusted prior to the disorder, to have later onset of symptoms, and to be more likely to show improvement, especially when treated with medications (Marchesi et al., 2014; Corves et al., 2014; Blanchard et al., 2011). In addition, as you will soon see, the positive symptoms of Type I schizophrenia may be linked more closely to biochemical abnormalities in the brain, while the negative symptoms of Type II schizophrenia may be tied largely to structural abnormalities in the brain.

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