Schizophrenia Clinical Symptoms and Diagnostic Characteristics

Schizophrenia Clinical Symptoms and Diagnostic Characteristics
Symptoms of schizophrenia may appear suddenly or develop gradually over time. Tension, the inability to concentrate, insomnia, withdrawal, or cognitive deficits may precede the first psychotic episode. In fact, cognitive deficits have been proven to occur 20 years before the onset of schizophrenia (Moon, 1999).
In 1896, Emil Kraepelin differentiated manic-depression psychosis from dementia praecox, a syndrome characterized by hallucinations and delusions. Eugene Bleuler (1857-1939) introduced the term schizophrenia and cited symptoms referred to as Bleuler's 4 A's: affective disturbance, autistic thinking, ambivalence, and looseness of association. Affective disturbance refers to the person's inability to show appropriate emotional responses. Autistic thinking is a thought process in which the individual is unable to relate to others or to the environment. Ambivalence refers to contradictory or opposing emotions, attitudes, ideas, or desires for the same person, thing, or situation. Looseness of association is the inability to think logically. Ideas expressed have little, if any, connection and shift from one subject to another.
Clinical symptoms fall into three broad categories: positive symptoms, negative symptoms, and disorganized symptoms. Positive symptoms reflect the presence of overt psychotic or distorted behavior, such as hallucinations, delusions, or suspiciousness, possibly due to an increased amount of dopamine affecting the cortical areas of the brain. Negative symptoms reflect a diminution or loss of normal functions, such as affect, motivation, or the ability to enjoy activities; these symptoms are thought to be due to cerebral atrophy, an inadequate amount of dopamine, or other organic functional changes in the brain. The category of disorganized symptoms was recently added. This category refers to the presence of confused thinking, incoherent or disorganized speech, and disorganized behavior such as the repetition of rhythmic gestures.

Two categories have been developed to describe the etiology and onset of schizophrenia:

Type I schizophrenia
type I schizophrenia, the onset of positive symptoms is generally acute. Type I symptoms generally respond to typical neuroleptic medication. Theorists believe that an increased number of dopamine receptors in the brain, normal brain structure, and the absence of intellectual deficits contribute to a better prognosis than for those identified with type II schizophrenia

Type II schizophrenia
Type II schizophrenia is characterized by a slow onset of negative symptoms caused by viral infections and abnormalities in cholecystokinin. Intellectual decay occurs. Enlarged ventricles are present. Response to typical neuroleptic medication is minimal. However, negative symptoms generally respond to atypical antipsychotic medication (Sherman, 1999c).

Additionally, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) identifies five subtypes of schizophrenia: paranoid, catatonic, disorganized, undifferentiated, and residual (American Psychiatric Association, 2000):

Paranoid Type
Clients exhibiting paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory hallucinations (Figure 18-2). They also may exhibit behavioral changes such as anger, hostility, or violent behavior. Clinical symptoms may pose a threat to the safety of self or others. (See Clinical Example 18-1: The Client With Schizophrenia, Paranoid Type.) Prognosis is more favorable for this subtype of schizophrenia than for the other subtypes of schizophrenia. Clients in whom schizophrenia occurs in their late twenties and thirties usually have established a social life that may help them through their illness. In addition, ego resources of paranoid clients are greater than those of clients with catatonic and disorganized schizophrenia (Sadock & Sadock, 2003).

Catatonic Type
Psychomotor disturbances, such as stupor, rigidity, excitement, or posturing, are the prominent feature of catatonic schizophrenia. Echolalia, the pathological parrot-like repetition of a word or phrase, and echopraxia, the repetitive imitation of movements of another person, are also features of catatonic schizophrenia. Clients are at risk medically because of extreme withdrawal, which can result in a vegetative condition or excessive motor activity that could produce exhaustion or self-inflicted injury.

Disorganized Type
The clinical symptoms of disorganized schizophrenia are considered the most severe of all subtypes. The client experiences a disintegration of personality and is withdrawn. Speech may be incoherent. Behavior is uninhibited, along with a lack of attention to personal hygiene and grooming.

Undifferentiated Type
Undifferentiated schizophrenia usually is characterized by atypical symptoms that do not meet the criteria for the subtypes of paranoid, catatonic, or disorganized schizophrenia. The client may exhibit both positive and negative symptoms. Odd behavior, delusions, hallucinations, and incoherence may occur. Prognosis is favorable if the onset of symptoms is acute or sudden

Residual Type
Residual schizophrenia is the subtype used to describe clients experiencing negative symptoms following at least one acute episode of schizophrenia. Clinical symptoms may persist over time, or the client may experience a complete remission.

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