Medical professionals distinguish between positive and negative symptoms in schizophrenia.
Positive symptoms include all symptoms related to perception and behavior that do not occur in healthy individuals:
- Hallucinations
- Delusions
- Thought disorders
- Disturbances in the sense of self
Negative symptoms (deficit symptoms) encompass psychological characteristics that are reduced in comparison to healthy individuals.
These include:
- Limited capacity for emotional experience
- Inability to experience pleasure (anhedonia)
- Reduced facial expressions and gestures
- Slowed thinking with fewer thoughts
- Decreased interest and reduced activity
The World Health Organization (WHO) is responsible for the globally recognized diagnostic classification system, the ICD (International Classification of Diseases). In the current version, ICD-10-GM-2019, schizophrenic disorders are classified under code F20.ff.
To keep this article within its scope, we will describe only the main forms here.
The code F20.0 refers to paranoid schizophrenia. The primary symptoms are delusions and (mostly auditory or visual) hallucinations. An example: The patient is firmly convinced that he is being watched by the police.
He cannot accept his friends’ objections that there is no plausible reason for this. Instead, he finds it easier to believe that his friends are also involved in the police operation (delusion). The patient hears voices whispering that he is being spied on (auditory hallucination). He may see spies sneaking around in the dimly lit bedroom (visual hallucination).
F20.1 codes for hebephrenic schizophrenia. Here, affective disturbances are the primary feature. Those affected lack drive, their mood is flat, and their behavior is often inappropriate. Delusions and hallucinations occur only fleetingly. Hebephrenic schizophrenia is primarily a disease of adolescence and young adulthood.
An example: A retail trainee feels increasingly unmotivated and drained. She has the impression that customers are watching her in an uncomfortable way.
Her concentration is impaired. After work, all she wants to do is go home. She is increasingly withdrawing from her circle of friends. She is also convinced that her coworkers are talking about her behind her back—and that her boss can read her mind.
Catatonic schizophrenia (F20.2) is primarily characterized by psychomotor disturbances. Those affected compulsively assume a certain posture or move in a monotonous manner.
Hallucinations may also occur. For example: A 50-year-old man sits with his back perfectly straight in the dining room of a supervised group home. His head is tilted back against his neck. He stares fixedly at the ceiling and talks to beings that only he can see. During the conversation, he sways his upper body from side to side. At times, he is unresponsive.
After a schizophrenic episode, many affected individuals experience post-schizophrenic depression (F20.4).
In this condition, residual schizophrenic symptoms are present, and the patient suffers from typical features of depression, such as:
- Lack of motivation
- Recurring negative thoughts, and
- Depression
- During this phase of the illness, the risk of suicide increases significantly.
- Self-Assessment Checklist
The Early Detection and Treatment Center for Psychotic Crises (FETZ) at the University of Munich Medical Center has developed a checklist that identifies important warning signs. However, this test is in no way a substitute for a medical examination.
Only a specialist, such as a neurologist or psychiatrist, can make a reliable diagnosis.
The physician takes a medical history and asks the patient in detail about their symptoms.
The key symptoms are:
- Thinking out loud
- Delusions of control or influence
- Voices that comment or engage in dialogue
- Persistent delusions that are culturally inappropriate and
- possibly negative symptoms
- Depending on the individual case, experts may also interview family members.
- To confirm the diagnosis, additional tests are used:
- physical and neurological examination
- Complete blood count (markers of inflammation, liver, kidney, and thyroid function)
- Psychological testing, such as memory and attention tests
- drug screening
- Imaging techniques such as MRI (magnetic resonance imaging)
Research has not yet been able to conclusively explain the underlying causes of this mental illness. However, it appears to be a multifactorial condition.
The biopsychosocial model is generally used as an explanatory framework. It posits that schizophrenia arises from various factors (genes, environmental influences, and personality structures) and their interactions.
A study from 2002 provides clear evidence of the role genes play in the development of the disease: The closer a person is related to someone with schizophrenia, the higher the likelihood of experiencing a schizophrenic episode at some point in their life.
For children with a parent who has the disorder, the risk of developing it is up to 10 percent. For fraternal twins, the risk is 20 percent, and for identical twins, it rises to as high as 45 percent.
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Researchers have also demonstrated a link between schizophrenia and brain damage occurring early in life. This brain damage can occur as early as birth.
Early childhood infections (herpes viruses, influenza virus, Borrelia, or the parasite Toxoplasma gondii) can also contribute to the onset of schizophrenic psychosis. (P. Falkai: Diagnosis, Etiology, and Neuropathophysiology of Schizophrenia. In: Neuropsychology of Schizophrenia. 1, 2008, pp. 36–43.).
Examinations of the brains of schizophrenic patients have also revealed anatomical abnormalities. For example, many affected individuals have significantly fewer nerve fibers in certain brain regions than healthy people.
These include the amygdala, the entorhinal cortex, and the hippocampus. These structures play an important role in memory and the processing of emotions.
Furthermore, researchers found changes in brain metabolism. In particular, the neurotransmitters dopamine and glutamate appear to be affected by the disorder.
In addition, mind-altering substances can contribute to the onset of the mental illness. In particular, the use of THC, an active ingredient in the cannabis plant, can trigger schizophrenia in people with a predisposition to the condition. The same applies to other psychoactive substances such as cocaine or alcohol.
In addition to neurobiology, genetics, and toxic factors, psychosocial factors also influence the development of the disease.
According to the diathesis-stress model, stressful situations and contributing factors can trigger schizophrenia in genetically susceptible individuals.
Experts believe that schizophrenia cannot be completely cured. However, treatment can alleviate the symptoms of the mental illness and improve the patient’s quality of life.
During the acute phase, medication is often essential. Primarily, drugs from the class of psychotropic medications—known as neuroleptics—are used. These primarily target the positive symptoms. There is no risk of dependency. For negative symptoms, patients are prescribed antidepressants or anti-anxiety medications as needed.
One non-pharmacological treatment method is electroconvulsive therapy (ECT). Under brief anesthesia, the patient receives electrical impulses lasting a few seconds that trigger an artificial seizure.
These seizures lead to an increased release of neurotransmitters and alleviate the symptoms. The method is widely considered outdated or even brutal.
The German Medical Association published a statement explaining the benefits of ECT and the value of the method for patients.
Other components of therapy include:
- occupational therapy
- regular exercise (sports groups)
- psychotherapy, and
- providing information about the illness (psychoeducation)
Treatment typically lasts several weeks and takes place in a psychiatric hospital. For some patients, attending a day clinic may also be beneficial.
Once the acute phase of the illness subsides, the question of vocational rehabilitation arises. Depending on the patient’s health status, supervised group living arrangements and (temporary) employment in a sheltered workshop may also be options.
Self-help as an important pillar of therapy
Schizophrenia-spectrum disorders place an enormous burden on those affected and their loved ones.
Regional self-help groups form a close-knit network where those affected can share experiences and support one another. Caritas and Diakonie are typically the points of contact for information on active regional groups.
Family members can find comprehensive information on the website of the Federal Association of Relatives of People with Mental Illness.
The course of treated schizophrenia can be assessed using the “rule of thirds”:
- In one-third of patients, treatment leads to a significant improvement
- The second third shows no or only slight relief of symptoms
- One-third of patients suffer from treatment-resistant schizophrenia
The following factors indicate a favorable prognosis:
- acute onset of the illness
- short duration of illness
- predominantly positive symptoms
- a stable social environment
- meaningful activities
However, a complete cure is not possible.
