The Signs and Symptoms of Schizophrenia

The symptoms of schizophrenia can seem peculiar to people who observe them. However, when people are experiencing symptoms, they may have little or no insight that their thoughts or behaviors are strange. The lack of insight can make schizophrenia very frustrating and frightening for loved ones.

Symptoms of Schizophrenia
Verywell / Cindy Chung

Clinical Symptoms

The Diagnostic and Statistical Manual, 5th Edition (DSM-5), is a clinical resource that practitioners use to diagnose mental health conditions. As with other conditions, there are specific clinical criteria that need to be met in order for someone to be diagnosed with schizophrenia.

Psychosis

Schizophrenia is classified as a psychotic disorder. People with schizophrenia have symptoms of psychosis, an abnormal state of consciousness in which the higher functions of the mind are disrupted. In psychosis, some combination of a person's perceptions, thought processes, beliefs, and emotions appear to become disconnected from reality. These symptoms may come and go.

Positive Symptoms

Symptoms of schizophrenia are referred to as positive or negative. That doesn't mean that some are good and some are bad. Positive symptoms are those that are present in someone with schizophrenia that someone without schizophrenia or another mental health condition would not experience. Examples of this can include things like:

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Disorganized behavior

Delusions

Delusions are false beliefs that don’t make sense in the context of a person’s culture. Although everyone has wrong beliefs from time to time, psychotic delusions also have an abnormal obsessive quality. People with psychotic delusions can’t be convinced that their beliefs aren’t real.

Hallucinations

Hallucinations are false sensory experiences that have no basis in the external world. Psychotic hallucinations occur when the person is fully awake and not under the influence of alcohol or illicit drugs. Auditory hallucinations (hearing voices) and visual hallucinations (seeing things) are the most common, but a person can hallucinate a touch (for example, bugs crawling on the skin), taste, or smell.

Disorganized Speech

Also known as loose association. In psychotically disorganized speech, words are not linked together based on the normal rules of language but are strung together based on sounds, rhyme, puns, or free associations. Although everyone makes speech errors, especially when they’re tired or stressed, psychotically disorganized speech is obviously abnormal and is difficult or impossible to understand.

Disorganized Behavior

Psychotically disorganized behaviors are not goal-directed and don’t make sense in context. For example, taking one’s clothes off to take a bath is sensible. Taking one’s clothes off on a public bus is an example of disorganized behavior. Laughing at inappropriate times or for no reason is a disorganized behavior. Adopting strange postures or freezing are catatonic behaviors.

Negative Symptoms

In addition to these symptoms that become present in someone with schizophrenia, there are others that are referred to as negative symptoms. This means that the person is experiencing an absence or reduction of certain traits that are often present in healthier individuals. The term negative suggests that something feels as if it is being taken away or disappearing from the person's daily experience. Examples of negative symptoms can include things like:

  • Flattened affect
  • Anhedonia
  • Reduced speech
  • Lack of initiative

Flattened Affect

People with flattened affect appear emotionless or have a very limited range of emotions. They show little response to emotional or disturbing situations or images. This limited expression of emotion can be alarming to others, as it can feel like the person with schizophrenia is disappearing from them.

Anhedonia

Someone with the condition of schizophrenia can demonstrate a lack of joy in things that used to bring them pleasure. This change tends to be quite noticeable by others around them and is not simply a change in interests.

Reduced Speech

A negative symptom of schizophrenia can involve someone speaking noticeably less than they used to. This particular symptom could also be observed as someone speaking less fluently than before.

Lack of Initiative

The loss of will to do things in a negative symptom of schizophrenia. Remember that a negative symptom refers to a characteristic that seems to be lessening or disappearing from the person. Loss of motivation and initiative, also known as avolition, is a common negative symptom.

Positive Symptoms

  • Delusions

  • Hallucinations

  • Disorganized Speech

  • Disorganized Behavior

Negative Symptoms

  • Flattened Affect

  • Anhedonia

  • Reduced Speech

  • Lack of Initiative

Cognitive Symptoms of Schizophrenia

Cognitive symptoms of schizophrenia have to do with the way a person thinks. Although cognitive symptoms are not used to diagnose schizophrenia, some are fairly common with the condition, such as:

  • Difficulty maintaining attention - The inability to maintain focused attention makes people with schizophrenia seem spacey or “out of it.”
  • Memory problems - Schizophrenia often affects working memory, which is the kind of memory you use to keep things in your head for active processing, like the digits of a phone number you’re about to dial.
  • Difficulty planning and structuring activities - Caused by reduced executive control. Executive control is the mental process that allows us to identify the steps needed to complete a task and then execute them in a proper order. Executive control also allows us to suppress our response to distractions in order to get something done.
  • Lack of insight - People with schizophrenia have a specific cognitive blind spot that prevents them from understanding that they are ill. This means that loved ones and caregivers should remain as vigilant as possible to help the patient maintain the routines of treatment in order to control symptoms.

Psychiatric Assessment

Because of the variety of symptoms that can be present, schizophrenia can be difficult to diagnose. In an effort to achieve greater precision in the process of diagnosing, the clinical criteria for schizophrenia within the DSM-5 have become more complicated over time. There are reasons why it is important to diagnose schizophrenia accurately:

  • It is a more common condition than people might think.
  • People who develop schizophrenia can experience symptoms for the rest of their lives.
  • Symptoms can greatly impact someone's social abilities and work functioning.
  • Often medication must be taken for the rest of their lives.

DSM Criteria

As outlined within the Diagnostic and Statistical Manual, fifth edition (DSM-5), the clinical features that must be present for the condition of schizophrenia to be diagnosed include the following:

1. Presence of at least two of the following symptom types (with at least one of the symptoms being in the top three listed here):

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Disorganized behavior
  • Negative symptoms

2. The symptoms are to be experienced for at least six months, with the psychotic features (the top three listed above) being present for at least one month.

3. The person experiences significant problems with work and social functioning as a result of their symptoms.

4. The diagnosing clinician can determine that the symptoms the person has been experiencing are not caused by another medical condition, mood disorder or substance use.

Other Symptoms

In addition to the formal diagnostic criteria, there are a variety of other symptoms that can often be found in people with schizophrenia. These symptoms include things like:

  • Distractibility
  • Anger
  • Anxiety
  • Depression
  • Lack of insight
  • Sleep disturbances
  • Substance use (especially tobacco use)

Other Diagnostic Considerations

In addition to exploring and identifying whether or not someone meets the formal clinical criteria as listed in the DSM-5, there are additional things that a clinician will consider in the diagnostic process. Things that a mental health provider will consider include:

  • Family history of schizophrenia. A close relative with schizophrenia can increase someone's chance of also being diagnosed with schizophrenia.
  • Response to medication. People may have taken medication as part of mental health treatment in the past. Depending on someone's responses to certain medications in the past, a clinician may better be able to rule out other conditions.
  • Age at onset. Typically symptoms become present around someone's early to mid-'20s. If someone's symptoms are presenting later in life it could suggest there is something else going on. It doesn't necessarily rule out schizophrenia, it is simply something to consider in the diagnostic process.
  • Situational factors. Experiences that can cause severe emotional distress can lead to brief periods of psychosis. As a clinician conducts their assessment, they will likely be considering any significant life changes or events to determine duration and severity of symptoms and whether or not there are other mental health conditions that should be considered.

Comprehensive exams are an important aspect of diagnosing schizophrenia. A clinician will not rely on limited pieces of information or only on self-report from the client.

They will be gathering information about the client's family history, substance use and medications, sleep disturbances, appetite changes and more.

In addition, it is important for a clinician to explore information related to the person's values system, their perspectives on the world, their interests and talents as well as their beliefs and relationship dynamics. Family and close friends may also be interviewed in the process to help provide helpful collateral information.

When to Consult a Doctor

Because of the complexity and variety of symptoms associated with schizophrenia, it can be difficult for people to know if what their loved one is experiencing is concern enough to see a doctor.

Schizophrenia Discussion Guide

Get our printable guide to help you ask the right questions at your next doctor's appointment.

Mind Doc Guide

Onset and Duration of Symptoms

The onset of symptoms tends to be gradual, building in severity over time. This sometimes slow progression of symptoms can also make it difficult to know if what you, or someone you love, is experiencing is to be of concern.

Functioning in Social and Professional Situations

When social and work (or school) functioning is impaired it may be helpful to consult with a doctor. Because the symptoms tend to develop over time you may not realize how long you have been experiencing trouble in these areas of your life. Noticing that a pattern has developed can be a signal to consult with a professional.

Challenges in Reaching Out

It can be challenging for people with schizophrenia to reach out to a doctor or other health professional about their concerns. This can be particularly tough for people who may be experiencing symptoms that leave them feeling suspicious of others.

Reassurance from people they trust can be helpful in encouraging and prompting someone to speak with a doctor or other mental health professional.

Closely-Related Conditions

Schizophrenia is a complex diagnosis with a lot of symptoms and variables to consider. What makes things more complicated is that there are also several closely-related conditions that involve psychosis. Some of the conditions that are to be ruled out can include:

  • Schizophreniform disorder
  • Schizoaffective disorder
  • Brief psychotic disorder
  • Delusional disorder
  • Dissociative disorder
  • Substance or medication-induced psychotic disorder
  • Mood disorder with psychosis
  • Cognitive disorders with psychosis
  • Personality disorders
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Article Sources

  1. Tandon R. Schizophrenia and Other Psychotic Disorders in Diagnostic and Statistical Manual of Mental Disorders (DSM)-5: Clinical Implications of Revisions from DSM-IV. Indian J Psychol Med. 2014;36(3):223-5. doi: 10.4103/0253-7176.135365

  2. Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment options. P T. 2014;39(9):638-45.

  3. Boutros NN, Mucci A, Diwadkar V, Tandon R. Negative symptoms in schizophrenia. Clin Schizophr Relat Psychoses. 2014;8(1):28-35B. doi: 10.3371/CSRP.BOMU.012513

  4. Targum SD, Keefe RS. Cognition and schizophrenia: is there a role for cognitive assessments in diagnosis and treatment?. Psychiatry (Edgmont). 2008;5(12):55-9.

  5. Picchioni MM, Murray RM. Schizophrenia. BMJ. 2007;335(7610):91-5. doi:  10.1136/bmj.39227.616447.BE

Additional Reading

  • Schizophrenia: a detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping. National Institutes of Mental Health. (2006) http://www.nimh.nih.gov/health/publications/schizophrenia/summary.shtml
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  • Morrison, J. DSM-IV Made Easy: the Clinician’s Guide to Diagnosis. New York: The Guilford Press, 2006.
  • Torrey, E.F. Surviving Schizophrenia: a Manual for Families, Patients and Providers, 5th Edition. New York: HarperCollins Publishers, 2006.