THE CLASSIFICATION OF SCHIZOPHRENIA
Suspicious and frightened, the victim fears he can trust neither his senses nor the motives of other people…his skin prickles, his head seems to hum, and 'voices' annoy him. Unpleasant odours choke him, and bright and colourful visions pass before his eyes. When someone talks to him, he hears only disconnected words. When he tries to speak, his own words sound foreign to him..
SCHIZOPHRENIA SPECIFICATION
Classification of schizophrenia. Positive symptoms of schizophrenia include hallucinations and delusions. Negative symptoms of schizophrenia include speech poverty and avolition.
DEAR STUDENTS
AQA requires you to formally know very little about the classification of schizophrenia, e.g., what schizophrenia actually is.
The specification says you must know:
Positive symptoms of schizophrenia, including hallucinations and delusions.
Negative symptoms of schizophrenia, including speech poverty and avolition.
And that’s it, which is surprising given the complexity of schizophrenia. It is one of the more difficult illnesses to understand. The truth is, AQA are never really going to ask you what schizophrenia is in the examination.
At most, they occasionally ask a five-mark question, such as
“Outline the classification of schizophrenia”
And when they do, the answer below is what the examiner is looking for :
ANSWER:
“Schizophrenia (SZ) is a complicated disorder to classify, as each individual can have different characteristics of the illness. It is a condition characterised by disordered, disorganised thought processes, manifesting in the patient’s language and behaviour. There is also a loss of contact with reality and a disturbance of form and thought content. Schizophrenia affects the mood of the person and their sense of self about the external world. The behaviour of schizophrenics may be purposeless, and they can distort reality and withdraw from society. Some types of schizophrenia develop slowly and insidiously, and the absence of emotion, language and self-initiation may dominate the early clinical picture. Yet other kinds of schizophrenia are dominated by auditory hallucinations, paranoid delusions, and excessive behaviours. As a result, schizophrenia is now classified as a spectrum disorder. “
You may also see multiple-choice or short-answer questions on the difference between positive and negative symptoms. But that is it. HONESTLY!
Yet students are often tempted to tell the examiner what schizophrenia is when asked, for example,
“Outline and evaluate biological explanations for schizophrenia”.
They produce a half-paragraph (or more) describing the disorder before finally getting to the biological explanation. In those cases, everything they wrote that “describes” what schizophrenia is earns no credit at all. This is because the question did not ask you what schizophrenia is. It asked you to “describe” two biological explanations (theories ) of schizophrenia. Therefore, the essay should have started like this:
“One biological explanation/theory of schizophrenia is the dopamine hypothesis/genetic theory …”
This naturally raises the question of why we bother studying the disorder in such depth. The short answer is that without a proper grasp of schizophrenia, the explanations make no sense. You cannot meaningfully understand the dopamine hypothesis if you have no firm idea of the symptoms dopamine is supposed to be influencing. The same applies to validity and reliability. How can anyone evaluate whether schizophrenia is a “valid” or “reliable” construct — whether it is, in effect, a social construction — if they are unclear on what the symptoms look like, how they present, or how effectively they respond to treatment?
That is why this section is so substantial, despite the specification itself appearing to ask for very little. If you do not understand the disorder, you cannot understand the explanations. If you do not understand the explanations, you cannot evaluate them. And if you cannot assess them, you cannot secure high marks. In other words, the foundation is non-negotiable.
DEMOGRAPHICS OF SCHIZOPHRENIA
DEMOGRAPHICS OF SCHIZOPHRENIA
Schizophrenia ranks among the top ten causes of disability in developed countries [GBD 2019]. Of all disorders recognised within modern diagnostic systems, it remains one of the most severe and enduring [WHO 2022]. At any given time, approximately 24 million people worldwide are living with schizophrenia [GBD 2019; WHO 2022].
The disorder is diagnosed slightly more often in urban than rural areas [McGrath et al., 2008] and overlaps with other psychiatric conditions, particularly bipolar disorder of the manic type [DSM-5; Kessler et al., 2005].
The prevalence of developing schizophrenia in individuals without a biological relative with the condition is around 1.1% of the population over the age of fifteen. Onset before age 15 is sporadic and poses significant challenges for researchers studying early development [Sullivan et al., 2003; Remschmidt and Theisen, 2005].
There are modest gender differences. Slightly more males develop schizophrenia and tend to present earlier, whereas females often develop the disorder in middle age and typically show less severe symptoms [Aleman et al., 2003]. Schizophrenia occurs between the ages of fifteen and sixty, with peak incidence in the early twenties for males and the mid-forties for females [Kirkbride et al., 2012].
The disorder occurs in all societies regardless of class, ethnicity, religion, or cultural background, although incidence and outcomes differ between groups. For example, in individualistic cultures, black individuals are diagnosed more frequently than in collectivist cultures [Fearon and Morgan, 2006].
Schizophrenia appears more common in working-class populations, although this pattern may reflect the “social drift hypothesis” rather than a genuine class-based difference [Dohrenwend et al., 1992].
Suicide rates are high: up to 50% will attempt suicide and around 10% will die by suicide [Hawton et al., 2005].
Lifetime unemployment ranges from 50–75% [Marwaha and Johnson, 2004]. Life expectancy is approximately ten years shorter than that of the general population, partly due to increased rates of cardiovascular disease, cancer, and metabolic disorders [Saha et al., 2007].
Substance-related problems are common: over 50% of people with schizophrenia smoke cigarettes regularly, and many experience weight gain, metabolic syndrome, diabetes, cardiovascular disease, and pulmonary disease. These combined factors help to explain the increased mortality rate [De Hert et al., 2011].
Schizophrenia treatment is still regarded as largely palliative in many cases [Leucht et al., 2012].
COMORBIDITY
Comorbidity refers to the presence of one or more additional disorders or health problems occurring alongside a primary diagnosis. In schizophrenia, this means the individual is experiencing another clinically significant condition at the same time as schizophrenia.
Schizophrenia is comorbid with depression, suicide, anxiety, and high levels of drug, tobacco, and alcohol use. These comorbidities contribute to impaired functioning, reduced quality of life, and increased mortality
LONG-TERM OUTCOME (10 YEARS AFTER DIAGNOSIS)
Approximately:
• 25% completely recover
• 25% are much improved and relatively independent
• 25% improve but require an extensive support network
• 15% remain hospitalised and unimproved
• 10% have died, predominantly by suicide
WHERE PEOPLE WITH SCHIZOPHRENIA LIVE
Approximate distribution:
• 6% are homeless or living in shelters
• 6% are in prison
• 5–6% live in hospitals
• 10% live in nursing homes
• 25% live with a family member
• 28% live independently
• 20% live in supervised group housing or supported accommodation
A BRIEF HISTORY OF SCHIZOPHRENIA
At the end of the nineteenth century, the German psychiatrist Emil Kraepelin gave the illness its first proper name: dementia praecox (literally “premature dementia”). He was convinced it only struck the young and always ended in irreversible mental wreckage – a slow slide into emptiness that nothing could stop. That bleak picture did not survive for long.
By 1911, the Swiss psychiatrist Eugen Bleuler had seen enough patients to realise that the illness often started later in life and did not always lead to total collapse. He therefore scrapped Kraepelin’s label and introduced a new one: schizophrenia. The word comes from Greek roots – schizein (to split) and phren (mind). Bleuler meant a splitting apart of mental functions: thought, emotion, and behaviour no longer working together. The popular idea that it means “split personality” or “multiple personalities” (Jekyll and Hyde, the Green Goblin in Spider-Man, etc.) is completely wrong. That is a different disorder entirely.
This is far from the truth. Schizophrenia refers to a splitting in the functions of the mind and a disorder where the personality loses its unity.“Psychiatrists often refer to Schizophrenia as a royal disease because of the wealth of symptoms that accompany it. The syndromes are so diverse and complex that there has been disagreement over how they should be classified (Hunca-Bednarska, 1997).
Since then, schizophrenia as a construct has been through many metamorphoses – from the crude categories of DSM-I in 1952 right through to the spectrum approach of DSM-5 (2013) and now ICD-11.
Schizophrenia is a Greek word and means split mind (Schizein = to split and phren = mind). The media have popularly mistaken this term for many identities, such as in multiple personality disorder, where the patient presents with dual characters like Jekyll and Hyde or The Green Goblin in Spiderman.
WHAT IS SCHIZOPHRENIA?
The detailed descriptions that follow relate specifically to positive symptoms, particularly the disturbances of thought and language that appear in the early and more acute phases of schizophrenia. These symptoms are the most visible and clinically striking, and they have historically shaped the terminology used to describe the disorder. The speech patterns that follow – derailment, word salad, clang associations, neologisms and so on – all belong to this positive symptom cluster. They do not represent the whole disorder and they do not account for negative symptoms, which form a separate and often more enduring part of schizophrenia.
Schizophrenia is a breakdown of perpetual filtering.
Schizophrenia can be described as a collapse in the usual filtering and organising of experience. In everyday life, people are constantly exposed to a vast amount of sensory information, yet they can effortlessly screen out what is irrelevant. This selective focus is what allows perception, thought, and behaviour to remain coherent. You read a sentence and ignore the sound of traffic; you follow a conversation and disregard the colour of the wallpaper. The mind sorts, prioritises, and dismisses without conscious effort.
Individuals with schizophrenia cannot rely on that filtering system. Incoming sensations, stray thoughts, memories, associations, and background noise all compete on an equal level. Nothing is ranked, nothing is discarded, and nothing is automatically recognised as unimportant. The result is an overload of impressions that cannot be integrated into a clear, stable whole. Their attention jumps not because they choose to but because everything presses in at once.
This failure of filtering is expressed directly in language. A simple sentence such as “I went outside to get some bread” may not form a single meaningful unit. Instead, individual words branch into uncontrollable chains of associations: bread leads to breakfast, breakfast leads to star, a film star brings up an unrelated memory. They cannot trace why their thoughts have gone where they have, which in turn leads to confusion and often paranoia: if a thought appears suddenly and inexplicably, it is easy to feel as though someone else has put it there.
Most people recognise their inner voice as belonging to them; in schizophrenia, this boundary becomes unreliable. Internal speech can feel alien, intrusive, or broadcast outward. This is why some individuals believe their thoughts are being controlled, stolen, or heard by others. The usual connection between thought, emotion, and behaviour becomes fragmented. What they think, what they feel, and what they do are no longer aligned. The self loses its role as the integrating centre of experience, and the person may feel detached from their own mind or body.
Individuals with schizophrenia cannot filter incoming stimuli and attend selectively when racing thoughts plague them or when they become ‘locked in’ on a theme, and when their thoughts fail to line up with their feelings. Not only does the disorganisation of thought and emotion involve the external environment, but it also involves the self-structure itself. The self, which ordinarily functions as the integrating core of personality, becomes diffused, fragmented, and chaotic. Individuals may experience varying degrees of confusion about who and what they are, accompanied by depersonalisation. The loss of control over thoughts and feelings, combined with self-fragmentation and a sense of detachment, can lead to episodes of acute panic.
THE ONSET OF SCHIZOPHRENIA:
WIDE VARIATION OCCURS IN THE ONSET OF SYMPTOMS IN SCHIZOPHRENIC PATIENTS
EPISODIC SCHIZOPHRENIA
Some patients can have sudden symptoms, often after a stressful event. But every type of schizophrenia is variable, for example, at one end of the spectrum, a person can have a single psychotic episode of schizophrenia followed by complete recovery or a person can have many episodes of schizophrenia for an unspecified amount of time, e.g., periods where the illness might last weeks or months. This type of schizophrenia is known as “episodic schizophrenia.”
With episodic schizophrenia, there is often a complete remission in symptoms between each episode of schizophrenia, e.g., periods of relative normality, which can last from weeks to several months. Other persons, however, can have a fluctuating course in which symptoms are continuous but rise and fall in intensity.
CHRONIC ONSET SCHIZOPHRENIA
Conversely, some patients may have a gradual onset over years or months, with symptoms usually continuous and unrelenting; there is no remission and evidence of a steady decline over time.
Other schizophrenics have relatively slight variations in the symptoms of their illness over time.
Recent research increasingly shows that the disease process of schizophrenia gradually and significantly damages the brain of the person.
POSITIVE & NEGATIVE SYMPTOMS
Schizophrenia can be broadly divided into positive and negative symptoms, though many patients experience a mix of both.
Positive symptoms (such as hallucinations, delusions, and disorganised thinking) are more prominent in the early stages of the illness. They are present in around 60-70% of patients with schizophrenia at some point during their illness.
Negative symptoms (such as avolition, anhedonia, and social withdrawal) affect approximately 20-40% of patients. These symptoms can be more persistent and are associated with poorer functional outcomes.
Many patients experience both types of symptoms, but the proportions can vary depending on the individual case and the illness stage.
Clinicians distinguish two kinds of schizophrenia, one with Positive symptoms + and the other with Negative symptoms -
WHY NEGATIVE SYMPTOMS WERE OVERLOOKED FOR MOST OF THE TWENTIETH CENTURY
For most of the history of psychiatry, the formal concept of schizophrenia centred almost entirely on positive symptoms. Hallucinations, delusions, and disorganised speech were dramatic, disruptive, and impossible to miss. By contrast, negative symptoms such as avolition, emotional flattening, and poverty of speech were either ignored, misinterpreted as depression, or treated as a simple reaction to chronic psychosis.
Early diagnostic systems reflected this bias. In both DSM-I (1952) and DSM-II (1968), schizophrenia was defined almost exclusively in terms of bizarre behaviour, hallucinations, and delusional thinking. Negative symptoms were present in the clinical descriptions but not recognised as a central diagnostic feature. Even DSM-III (1980), which introduced more standardised criteria, emphasised positive symptoms as the disorder's distinguishing features.
As a result, the dominant theories developed before the 1980s—including early dopamine theories, family-based explanations, and cognitive accounts—were built almost entirely around the positive symptom profile. They were not designed with negative symptoms in mind because the diagnostic manuals of the time did not formally acknowledge these symptoms as core.
Negative symptoms were only formally recognised and routinely measured when researchers began developing structured clinical scales in the late 1970s and early 1980s (e.g., the SANS [Scale for the Assessment of Negative Symptoms]) and when DSM-III-R (1987) and DSM-IV (1994) began systematically integrating them into the diagnostic criteria.
This historical context explains why many “classic” explanations of schizophrenia appear incomplete. They were never intended to account for negative symptoms because negative symptoms had not yet been formally defined, categorised, or reliably measured.
TYPE 1 & TYPE 2 SCHIZOPHRENIA
Some clinicians distinguish between the following two subtypes of schizophrenia.
TYPE 1 SCHIZOPHRENIA
ACUTE Sudden onset often after a stressful event.
EPISODIC. It usually occurs in episodes, and there can be periods of remission in between—e.g., periods of relative normality between episodes for several months.
CHARACTERISED BY: Hallucinations, delusions, and thought control;
TYPE 2 SCHIZOPHRENIA
GRADUAL ONSET: Over years or months, there is evidence of a steady decline.
CHRONIC: Symptoms are usually continuous and unrelenting; there is no remission.
CHARACTERISED BY: Negative symptoms: alogia, avolition, and flattened affect;
Some patients experience both type-one and type-two symptoms; this is when the categorisation system seems flawed.
POSITIVE SYMPTOMS IN DEPTH
POSITIVE SYMPTOMS ARE THOSE THAT ARE PRESENT IN SCHIZOPHRENIA BUT ARE ABSENT IN NEUROTYPICAL PEOPLE
Positive symptoms are features that reflect an excess or distortion of ordinary psychological function or additions to normal experience — excesses, distortions or intrusions. They reflect abnormal PRESENCE of experiences or processes.
In schizophrenia, these additions include hallucinations, delusions and the various disturbances of thought and language described below. They arise from disorganised thinking and impaired filtering, so that irrelevant associations intrude into consciousness and derail the typical structure of speech.
EXAMPLES:
hallucinations
delusions
disorganised speech
disorganised behaviour
thought disorder
derailment, loose associations, clang, neologisms
bizarre behaviour or agitation
thought insertion, withdrawal, broadcasting
ideas of reference
These are always positive symptoms.
HALLUCINATIONS
Hallucinations are bizarre unreal sensory perceptions of the environment that can be from any sense modality but, in schizophrenics, are usually auditory (hearing voices in the third person, usually in the form of a running commentary on the patient’s behaviour that is derogatory) but maybe visual (seeing lights, objects or faces), olfactory (smelling things) or tactile (feeling bugs are crawling in or on the skin, feeling numb or disconnected from one’s body). Typically, voices are heard from outside the individual’s head and offer a running commentary on behaviour in the third person (such as ‘he is washing his hands, he is an idiot’. The voices often comment on the individual’s character, usually in an insulting way or give demands. Thus, they may hear voices telling them what to do, commenting on or criticising their actions. In some instances, the voices are ascribed to relatives or friends; in others, to 'enemies'; and in still other cases, the messages received "from God" or from some organisation tell them of great powers conferred on them or of their mission to save humanity.
Somatosensory hallucinations involve changes in how the body feels. They may be described as burning or numb. They may also evoke a feeling of depersonalisation, e.g., a sense of being disconnected from one's body.
Anwesenheit Hallucination: Anwesenheit refers to the feeling of the presence of something or some person. It can be seen in normal grief reactions, schizophrenia and some emotionally arousing situations.
WHAT DOES IT FEEL LIKE TO HALLUCINATE?
The frequency of auditory hallucinations can range from low (once a month or less) to continuous all day long. Loudness also varies, from whispers to shouts. The intensity and frequency of symptoms fluctuate during the illness, but the factor that determines whether auditory hallucinations are a central feature of the clinical picture is the degree of interference with activities and mental functions.
The most common type of auditory hallucinations in psychiatric illness consists of voices. Voices may be male or female, with intonations and accents that typically differ from the patient's. Persons with auditory hallucinations usually hear more than one voice, and these are sometimes recognised as belonging to someone familiar (such as a neighbour, family member, or TV personality) or to an imaginary character (God, the devil, an angel). Verbal hallucinations may comprise complete sentences, but single words are more often reported.
Voices that comment on or discuss the individual’s behaviour and that refer to the patient in the third person were thought by Schneider13 to be positive symptoms and of diagnostic significance for schizophrenia. Studies show that approximately half of patients with schizophrenia experience these symptoms.
A significant proportion of patients also experience nonverbal hallucinations, such as music, tapping, or animal sounds. Another type of hallucination is functional hallucinations, in which the person experiences auditory hallucinations simultaneously through another real noise (e.g., a person may perceive auditory hallucinations only when he hears a car engine).
The content of voices varies between individuals. Often, the voices contain damaging, malicious content. They might speak to the patient in a derogatory or insulting manner or give commands to perform unacceptable behaviour. The experience of negative voices causes considerable distress.12 However, a significant proportion of voices are pleasant and positive, and some individuals feel loss when the treatment causes the voices to disappear.
Studies in cross-cultural psychiatry show that auditory hallucinations occur in similar forms in all societies around the world, but that there are cultural differences in the content and interpretation of voices. In cultures where they are understood in the context of local beliefs and practices, auditory hallucinations are valued. This arises because the interpretation is embedded in a strong cultural framework, with less emphasis on the distinction between imaginary and authentic experiences.
DELUSIONS
Delusions: False beliefs that persist despite contradictory evidence. They are maintained despite their logical absurdity or objective evidence showing they lack any foundation. They are often overrepresented in abstract and metaphysical ideas and verbal abuse of themes like death, power and hostility that have to do with the schizophrenic vision of the world.
TYPES OF DELUSIONS
PARANOID DELUSIONS: Persecutory delusions are the most common type of delusions experienced by schizophrenic people, per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). These delusions are based on suspicions of being targeted by someone or something. Schizophrenic people with these types of delusions mistakenly believe that they are being followed, harmed, poisoned, or tormented. Delusions of persecution are suggestive of the paranoid type of schizophrenia.
DELUSIONS OF CONTROL/ THOUGHT CONTROL: This delusion involves people believing that outside forces control their actions or thoughts. They may think that certain people or groups put thoughts into their heads or "steal" their thoughts. They may also believe that a person or object compels them to perform specific actions, and that they are powerless to control their behaviour. Sometimes, the person may think their thoughts are being broadcast so others can hear them. Experiences of control – also include the belief that one is under the control of an alien force that has invaded one's mind and body.
DELUSIONS OF THOUGHT BROADCAST: Patients may believe their thoughts are being broadcast to the outside world.
DELUSIONS OF REFERENCE: Schizophrenics who believe ordinary events occur especially for them are suffering from delusions of reference, basically, ideas wherein seemingly random stimuli are thought to be referring to the individual. Schizophrenics with referential delusions believe that the gestures and words of others are specifically directed at them. They become convinced that they are the focus of song lyrics, books or comments made by someone on television. This delusion can manifest itself in a variety of ways. Some schizophrenics may believe that current events are happening "for" them or because of something they did. Others may think that what strangers or celebrities do or say is meant mainly for them, even when they have never met or spoken to them. Another example is that if a car beeps outside, the individual feels it was directed toward them.
DELUSIONS OF NIHILISM: The delusion that things (or everything, including the self) do not exist; a sense that everything is unreal.
RELIGIOUS DELUSIONS: Religious delusions centre on misguided ideas about one's relationship with God. Schizophrenic people with this type of delusion may believe they have a special relationship with God or that God has given them special powers. They may profess an ability to speak directly to God or a responsibility to carry out God's plans. In some cases, these individuals may believe that they are God.
AUTOCHTHONOUS DELUSION: Jasper defined this as a delusion arising without apparent cause; for example, suddenly, without obvious cause, having the delusional belief that you are an alien.
GRANDIOSE DELUSIONS/DELUSIONS OF GRANDEUR: Those who believe they are famous, influential or have extraordinary abilities when this is not accurate may suffer from delusions of grandeur. For example, some schizophrenics may feel they’re influential people from the past, such as Jesus Christ or Cleopatra, while others may think they can fly or become invisible. Even when presented with evidence that disproves their beliefs, these people will refuse to accept that they are not as powerful, magical, or famous as they think.
SOMATIC DELUSIONS are beliefs about the body that are untrue. For example, some schizophrenics may believe they have a deadly disease even when it has been proven that they do not or may think that there are foreign objects inside their bodies when there aren't.
DISORGANISED SPEECH
Schizophrenic speech disturbances reflect a failure to maintain coherent lines of thought. Individuals struggle to keep track of what they are saying, to sort relevant from irrelevant ideas, or to ignore distracting associations. They may respond to the sound of words rather than their meaning, or follow accidental links between ideas instead of the intended sentence. Everyday conversation requires continuous selection and suppression; in schizophrenia, that mechanism breaks down, and the result is evident in language.
WORD SALAD
Word salad (Wortsalat, schizophasia) consists of real words strung together in a way that fails to form coherent meaning. The grammar, structure and content have broken down so thoroughly that the utterance becomes incomprehensible. The words themselves are recognisable, but their arrangement is chaotic.
EXAMPLES:
Why do people comb their hair? Elicits a response like, Because it makes a twirl in life.
“I went to the post office because the morning was grey, and the manager said the forms were upstairs, but the upstairs was closed since Monday, so the buses have been running late again. People don’t understand that the electricity keeps changing the rules. I tried to tell them, but the white doors won’t listen properly.”
LOOSE ASSOCIATIONS AND KNIGHT’S MOVE THINKING
Loose associations occur when the speaker drifts from one idea to another via weak, accidental or only marginally related links. The shift can be followed, but the line of thought is meandering and unfocused.
Knight’s move thinking is more abrupt. The jump between ideas is sharper, less predictable and more bizarre, resembling the chess piece’s sudden sideways–vertical movement. Loose associations drift; knight’s move thinking leaps.
EXAMPLES:
A patient identifying his family as mother, father, son and Holy Ghost.
If you think you are being wise to send me a bill for money I have already paid, I am in no wise going to do so unless I get the whys and wherefores from you to me. But where there have been twos, then fives will be, and other numbers and calculations and accounts to your no account…
“I am writing on paper. The pen which I am using is from a factory called Perry and Co. This factory is in England. I assume this. Behind the name of Perry Co. the City of London is inscribed, but not the city. The City of London is in England. I know this from my schooldays. Then, I always liked geography. My last teacher in that subject was Professor August A. He was a man with black eyes. I also like black eyes. There are blue and grey eyes and other sorts too. I have heard it said that snakes have green eyes. All people have eyes. There are some too who are blind. These blind people are led about by a boy. It must be very terrible not to be able to see. There are people who cannot see so much. In addition, cannot hear. I know some who hear too much. One can hear too much. There are many sick people in Burghölzli; they are called patients. One of them I like a great deal. His name is S H. He taught me that in Burghölzli there are many markets, inmates and attendants. Then there are some who are not here at all. They are all peculiar people…”
CLANG ASSOCIATIONS
Clang associations occur when speech is governed by sound rather than meaning. Words are linked through rhyme, alliteration or phonetic similarity, rather than any logical or semantic connection. The utterance follows auditory patterns rather than coherent thought.
EXAMPLES:
I am a nun. If that’s not enough, you are still his. That is a brave cavalier, take him as your boomswagger, Caroline, you know well you are my lord, because I am bored, and you like a sword in the Fjord. If you are the haboicnnth, Mrs K is still best by fear. Handle the gravy carefully. Where is my paintbrush? Where are you, Monet?
The train rain brained me.
He ate the skate, inflated yesterday’s gate toward the cheese grater.
Many mouldy mushrooms merge out of the mildewy mud on Mondays.
Heard the bell. Well, hell, then I fell.
The King of Spain feels no pain in the drain of the crane.
I am lame, you are tame with fame, I will be the same.
NEOLOGISMS
Neologisms are invented words or private combinations of words used in a way that carries no shared meaning. They do not arise from creativity but from a breakdown in the organisation of thought and language.
EXAMPLES:
Belly bad luck.
Brutal and outrageous to describe lunch.
I got so angry, I picked up a dish and threw it at the geshinker.
OTHER SCHIZOPHRENIA RELATED SPEECH PATTERNS
EVASIVE INTERACTION: Attempts to express ideas or feelings become vague or diluted. I er, ah, you are, uh, I think you have acceptable, erm, hair.
FLIGHT OF IDEAS: Rapid shifts between loosely connected ideas, often with pressured speech. I own five cigars. I have been to Havana. She rose out of the water in a bikini.
ILLOGICALITY: Responses that do not logically answer the question. Do you think this will fit in the box? Well, duh, it is brown, isn’t it?
LOSS OF GOAL: The train of thought is abandoned before concluding. Why does my computer keep crashing? Well, you live in a stucco house, so the pair of scissors needs to be in another drawer.
PERSEVERATION: Inappropriate, persistent repetition of words or ideas. It is great to be here in Nevada, Nevada, Nevada. Are you a table? Yes.
PHONEMIC PARAPHASIA: Mispronounced or reordered syllables. I slipped on the lice and broke my arm.
PRESSURE OF SPEECH: Increased rate, quantity or difficulty pausing speech.
SELF REFERENCE: Repeated, inappropriate references back to the self. What is the time? It is seven o’clock. That is my problem.
SEMANTIC PARAPHASIA: Substitution of an inappropriate word. I slipped on the coat, on the ice, I mean, and broke my book.
STILTED SPEECH: Excessively formal or pompous expression. The attorney comported himself indecorously.
TANGENTIALITY: Replies that wander away from the point. What city are you from? That is a tricky question. I am from Iowa.
WORD APPROXIMATIONS: Conventional words used in unconventional ways. His boss was a seeover.
DISORGANISED BEHAVIOUR
Disorganised behaviour is a positive symptom because it reflects a breakdown in the ability to plan, sequence, and regulate behaviour, leading to additional, chaotic, or socially inappropriate actions.
Patients may appear unable to manage the ordinary demands of daily life or to follow expected social norms.
Examples include:
Dressing in unusual or inappropriate clothing
Fatuous, child-like behaviour
Sudden or inexplicable episodes of aggression
Suspicious
Hostile
Hoarding food
Collecting rubbish
Sexually inappropriate behaviour (for example, masturbating in public)
Hyperactive
NEGATIVE SYMPTOMS IN DEPTH
NEGATIVE SYMPTOMS ARE THOSE THAT ARE NOT PRESENT IN SCHIZOPHRENIA BUT ARE PRESENT IN NEUROTYPICAL PEOPLE
In contrast to positive symptoms, the negative symptoms of schizophrenia represent a relative absence of feelings, cognition and goal-directed behaviour, which has a detrimental effect on psychosocial functioning and quality of life in short. Negative symptoms appear to reflect a lessening (reduction) or loss of standard functions. Negative symptoms reflect an abnormal absence of experience or behaviour.
NEGATIVE SYMPTOMS: THE TWO DOMAINS
In contemporary clinical psychology and psychiatry, negative symptoms are grouped into two formal domains. This structure is used in research, diagnosis and treatment.
1. DIMINISHED EXPRESSION DEFICITS
This domain concerns reductions in outward emotional and communicative expression. It reflects impaired output rather than impaired experience.
EMOTIONAL AFFECTS
Blunted affect – noticeably reduced range and intensity of emotional expression.
Flat affect – minimal or absent expression of emotion, even in situations that typically elicit feeling.
Incongruent affect – emotional expression that does not match the context, reflecting output failure rather than excess emotion.
• Reduced facial expression – minimal movement of facial muscles during communication.
• Diminished eye contact – markedly reduced or absent gaze engagement.
• Reduced prosody – monotone speech lacking normal variation in pitch, rhythm or emphasis.
• Reduced gesturing and body language – limited non-verbal expression accompanying speech.
• Alogia (speech poverty) – reduced quantity and spontaneity of speech.
• Poverty of thought – sparse, slow or empty cognitive output reflected in speech.
2. MOTIVATIONAL–VOLITIONAL DEFICITS
This domain concerns loss of drive, initiation and persistence in mentally effortful or goal-directed behaviour.
Avolition – difficulty initiating or sustaining purposeful activity; lack of motivation.
Apathy – global reduction in interest, curiosity and emotional engagement with life.
Anhedonia – reduced ability to anticipate pleasure or sustain enjoyment from activities.
Asociality – reduced interest in social interaction and withdrawal from relationships
Lack of volition – reduced capacity to make decisions, form plans or carry out intentional actions
Impaired persistence – inability to maintain effort or complete tasks requiring continuous engagement.
All of the above are always negative symptoms.
DIMINISHED EXPRESSION IN DEPTH
DISTURBANCES OF AFFECT (EMOTION)
Affect refers to a person’s observable emotional expression — the outward display of feeling through facial expression, tone of voice, posture and general emotional presence. It is one of the core clinical indicators used to assess how well a person’s internal emotional state aligns with what would typically be expected in a given context. In schizophrenia, disturbances of affect are common, and significantly, they fall under negative symptoms because they reflect a loss, reduction or failure of regular emotional expression rather than the addition of anything new.
Disturbed affect is one of the most characteristic features of the disorder. Emotional expression becomes reduced, muted, or incongruent, and the usual alignment between internal feelings, external context, and outward expression breaks down.
FATUOUS AFFECT
Fatuous affect describes an emotional presentation that resembles that of a child — playful, silly or inappropriately light-hearted in situations where such behaviour would not ordinarily occur. It is not an added emotional experience but a failure to regulate and match emotional output to context, and therefore remains a negative symptom.
BLUNTED AFFECT
Blunted affect refers to a marked reduction in the range and intensity of emotional expression. Facial movement, eye contact, vocal tone and body language all become noticeably diminished. The individual may describe emotions internally, yet their outward behaviour does not display them. A blank, vacant facial expression is typical, alongside difficulty smiling or showing warmth, even in situations that would normally evoke emotion.
FLATTENED AFFECT
Flattened affect represents a more severe form of blunting. Emotional expression is almost absent: even distressing or joyful events elicit little or no observable reaction. Facial expression remains fixed or empty; speech lacks inflexion; posture appears inert. All non-verbal channels — facial expression, gesture, gaze, prosody — show a near-complete loss of emotional signalling. This phenomenon is known clinically as affective flattening, and it is one of the most recognisable negative symptoms in schizophrenia.
INCONGRUENT AFFECT
Incongruent affect occurs when the observable emotional expression does not match the situation or the content of what the person is saying. For example, an individual may laugh while describing a distressing event, appear fearful when praised, or show irritation when something pleasant happens. Although the behaviour looks “excessive” on the surface, it is not a positive symptom. It reflects a failure to generate the appropriate emotional output, not an additional emotional experience.
Clinically, an incongruent affect signals a disruption in the system that usually aligns internal feelings, contextual meaning, and outward expression. The emotional response is mismatched, poorly regulated or incorrectly signalled. This makes incongruent affect part of negative symptomatology, as it indicates a loss of normal emotional integration rather than the creation of a new symptom.
LANGUAGE PROBLEMS (NEGATIVE)
Typical language change with negative symptoms
POVERTY OF SPEECH:
Speech where little is conveyed or communicated, although grammatically correct. Characterised by brief and empty replies to questions. It should not be confused with shyness or reluctance to talk. The patient exhibits many of the following.
Becomes monosyllabic,
Limits the use of their words
Speak hesitatingly,
Suddenly become mute,
They never relate anything to their initiative. For example, they never begin a conversation with anyone (they ask no questions, make no complaints, and never pass on the news - not even to close relatives.
Allows all their responses to be laboriously pushed out of them. For example: “Q. How do you like it in the hospital?
A. Well, er … not quite the same as, er … don’t know quite how to say it. It isn’t the same, being in hospital as, er … working. Er … the job isn’t quite the same, er … very much the same, but, of course, it isn’t the same.
ALOGIA
Means "not having words." It is characterised by reduced speech fluency and productivity, reflecting slowed or blocked thoughts. This may also be seen in advanced dementia.
THOUGHT AND SPEECH BLOCKING:
Stopping in the middle of a word or sentence. Interruption of a train of speech before completion. e.g. "Am I early?" "No, you're just about on..."(silence). To an extreme degree, the speaker does not recall the topic they were discussing after a block. True blocking is a common sign of schizophrenia. Lack of speech spontaneity, Incoherence and disfluency of utterances, showing fluency, among other things, rare conjunctivitis and anaphoric and idiosyncratic pauses.
NEOLOGISMS AND OTHER PECULIARITIES IN SPEECH
Neologism perseverance, rare use of retreat group pronouns and animate nouns, and poor use of adjectives, especially emotive ones, make the utterances sound “calm and colourless.
MOTIVATIONAL–VOLITIONAL DEFICITS IN DEPTH
ANHEDONIA
Anhedonia literally means “without pleasure”. Its linguistic opposite is hedonistic, referring to a person who actively seeks pleasure. This contrast is helpful because it captures exactly what is lost in anhedonia: not the ability to act, but the ability to feel reward.
In schizophrenia, anhedonia refers to a diminished capacity to experience pleasure, especially anticipatory pleasure. People with anhedonia do not look forward to enjoyable activities because the internal emotional “pull” that usually accompanies anticipation is absent. Even when they engage in an activity they once enjoyed, the emotional response may feel muted or strangely hollow. Importantly, anhedonia is not the same as avolition. Anhedonia is about the absence of pleasure, not the absence of initiative. A person may intellectually recognise that something should feel good, yet the emotional system fails to deliver the reward.
APATHY
Apathy comes from the Greek a-pathos, meaning “without feeling”. It refers to a generalised emotional quietness — a flattening of interest, concern and psychological engagement with the world.
In schizophrenia, apathy manifests as a pervasive sense of indifference. Events that would ordinarily provoke an emotional response — excitement, concern, curiosity, frustration — evoke very little. This is not withdrawal born of fear or low mood, nor a deliberate decision to disengage. Instead, the internal emotional system loses its usual reactivity. The world continues to unfold, but it no longer “stirs” the individual in the ways it once did.
Apathy sits alongside anhedonia but is not identical. Anhedonia concerns pleasure specifically. Apathy concerns feeling more broadly. Together, they create a psychological stillness that is profoundly disabling.
AVOLITION (LOSS OF VOLITION)
Avolition refers to the loss or weakening of volition — the internal psychological force that links thought to action. It is not that the individual refuses to act or is insufficiently motivated in the everyday sense of the word. The mechanism of initiative itself has deteriorated.
In schizophrenia, avolition leads to a striking reduction in self-initiated, goal-directed behaviour. Tasks that rely on internal drive — washing, dressing, organising daily activities, leaving the house, attending appointments, preparing food — become increasingly difficult to begin or sustain. The individual may sit for long periods doing very little, not out of choice but because the system that converts intention into action has effectively stalled.
Avolition often affects even basic self-care. Clothes may remain unchanged, hygiene may be neglected, and routines may be abandoned. In severe cases, movement slows markedly, leading to long periods of inactivity that can border on catatonia.
Avolition is distinct from both anhedonia and apathy. Anhedonia is a loss of pleasure. Apathy is a loss of emotional resonance. Avolition is a loss of drive and action, even when the person knows what needs to be done.
ASOCIALITY
Asociality refers to a diminished desire for social contact. It is not the same as antisocial behaviour, nor does it imply fear of others. Instead, it reflects a weakening of the motivational and emotional systems that typically make sociability rewarding.
Individuals with asociality may withdraw from friendships, avoid conversation, and show little interest in forming new relationships. This absence of social drive is closely tied to anhedonia and apathy: when pleasure and emotional resonance decline, social life loses its meaning and value.
SOCIAL WITHDRAWAL
Social withdrawal is the behavioural expression of the internal deficits described above. As pleasure, feeling and volition decline, people naturally retreat from social engagement and everyday activities. This withdrawal is often misinterpreted as rudeness, laziness or deliberate avoidance, but in schizophrenia, it is usually the downstream effect of anhedonia, apathy and avolition working in combination.
PHYSICAL SYMPTOMS (NEGATIVE)
These features reflect reductions, losses or impairments in normal motor and behavioural functioning. They do not represent added or exaggerated behaviours, so they fall under negative symptomatology.
• Staring with infrequent blinking – reduced spontaneous motor activity while absorbed in internal thought.
• Clumsy or inexact motor skills – impaired coordination and slowed motor planning.
• Sleep disturbances – insomnia or excessive sleep, reflecting disrupted circadian and motivational systems.
• Parkinsonian-type symptoms – rigidity, tremor, jerking limb movements, or other involuntary motor signs (these may arise from the illness itself or from antipsychotic medication).
• Awkward gait – unusual or slowed walking patterns.
• Abnormal eye movements – difficulty maintaining smooth pursuit when tracking slow-moving objects.
• Unusual gestures or postures – reduced fluidity of movement, odd positioning or limited expressive motor behaviour.
These physical changes arise from diminished neurological and behavioural output rather than from any form of psychotic excess, which is why they are placed within negative symptom clusters.
SCHIZOPHRENIC CASE STUDY
Carl was twenty-seven years old when he was first admitted to a psychiatric facility. Gangling and intensely shy, he was so incommunicative at the outset that his family had to supply initial information about him. They, it seemed, had been unhappy and uncomfortable with him for quite some time. His father dated the trouble to “sometime in high school.” He reported, “Carl turned inward, spent a lot of time alone, had no friends and did no schoolwork.” His mother was especially troubled about his untidiness. “He was really an embarrassment to us then, and things haven’t improved since. You could never take him anywhere without an argument about washing up. And once he was there, he wouldn’t say anything to anyone.” His twin sisters, six years younger than Carl, said very little during the family interview, instead passively agreeing with their parents.
One would hardly have guessed from their report that Carl graduated from high school in the upper quarter of his class and went on to college, where he studied engineering for 3 years. Though he had always been shy, he had had one close friend, John Winters, throughout high school and college. John had been killed in a car accident a year earlier. (Asked about Winters, his father said, “Oh, him. We don’t consider him much of anything at all. He didn’t go to church either. And he didn’t do any schoolwork.”) Carl and John were unusually close. They went through high school together, served in the army at the same time, and, upon discharge, began college together and roomed in the same house. Both left college before graduating, much to the chagrin of Carl’s parents, took jobs as machinists in the same firm, and moved into a nearby apartment. They lived together for three years until John was killed. Two months later, the company for which they worked went out of business. John’s death left Carl enormously distraught. When the company closed, he found himself without the energy and motivation to look for a job. He moved back home.
Disagreements between Carl and his family became more frequent and intense. He became more reclusive, sloppy, and bizarre; they became more irritable and isolating. Finally, they could bear his behaviour no longer and took him to the hospital. He went without any resistance. After ten days in the hospital, Carl told the psychologist who was working with him, “I am an unreal person. I am made of stone, or else I am made of glass. I am not wrong, precisely. But you will not find my key. I have tried to lose it. You can look at me closely if you wish, but you see more from far away.”
Shortly thereafter, the psychologist noted that Carl “…smiles when he is uncomfortable, and smiles more when in pain. He cries during television comedies. He seems angry when justice is done, frightened when someone compliments him, and roars with laughter on reading that a young child was burned in a tragic fire. He grimaces often. He eats very little but always carries food away.” After two weeks, the psychologist said to him, “You hide a lot. As you say, you are wired precisely wrong. But why won’t you let me see the diagram?” Carl answered: “Never, ever will you find the lever, the eternal lever that will sever me forever with my real, seal, deal, heel. It is not on my shoe, not even on my sole. It walks away
SUBTYPES OF SCHIZOPHRENIA
Some psychologists classify schizophrenia in terms of subtypes, although both ICD-11 and DSM-5 classification systems have now omitted these.
THE SUBTYPES ARE
DSM’s five subtypes were Paranoid, Disorganised, Catatonic, Undifferentiated or Residual schizophrenia.
ICD’s seven subtypes were Paranoid, Hebephrenic, Catatonic, Undifferentiated, Simple Schizophrenia Residual, Simple and Post-schizophrenic depression
Simple schizophrenia and post-schizophrenic depression were never in the DSM.
Disorganised and Hebephrenic are the same subtypes. They are just named differently in DSM and ICD.
THE ERADICATION OF THE SCHIZOPHRENIA SUBTYPES IN ICD AND DSM
Schizophrenia subtypes have been omitted from DSM-5 because of their “limited diagnostic stability, low reliability, and poor validity,” according to the American Psychological Association (APA). The APA also justified the removal of schizophrenia subtypes from the DSM-5 because they didn’t appear to help with providing better-targeted treatment or predicting treatment response.
Psychologists are now supposed to refer to the condition as schizophrenia without reference to subtypes.
DSM-IV contains no sub-classifications of schizophrenia: Schizophrenia is now known as a spectrum disorder with a variety of symptoms and causes. According to the DSM-5, a schizophrenia diagnosis requires the following: At least two of five main symptoms. The symptoms explained above are delusions, hallucinations, disorganised or incoherent speaking, disorganised or unusual movements and negative symptoms.
ICD-11 contains no sub-classifications of schizophrenia. For an ICD-11 diagnosis of schizophrenia, at least two symptoms must be present, including positive, negative, depressive, manic, psychomotor, and cognitive symptoms. Of the two symptoms, one core symptom needs to be present, such as delusions, thought insertion, thought withdrawal, hallucinations, or thought disorder.
DSM-5 SCHIZOPHRENIA
DSM states that “no single symptom is pathognomonic of [schizophrenia]”, and it is a “heterogeneous clinical syndrome”. Two people diagnosed with schizophrenia may look and behave nothing like each other.
DSM-5 acknowledges that any risk factor for developing schizophrenia will combine biology and the environment. Therefore, the aetiology is no longer a fight between nature and nurture. A mixed explanation like this is known as a diathesis-stress model (DS).
The addition of the term “spectrum” and the less stringent guidelines show that the DSM-5 is acknowledging that it sees schizophrenia as an umbrella term.
Many researchers still question why schizophrenia has been labelled a spectrum disorder, as most patients fall into either a negative symptomology with hypo dopamine function or a positive symptomology with hyper dopamine function.
DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA
Below is the official DSM-5 criteria, added cleanly and factually, with no interference in your prose:
A. Characteristic symptoms (two or more present for at least one month):
At least one must be (1), (2), or (3)
Delusions
Hallucinations
Disorganised speech
Grossly disorganised or catatonic behaviour
Negative symptoms (e.g., diminished emotional expression or avolition)
B. Level of functioning is markedly below the previous level
(e.g., work, interpersonal relations or self-care).
C. Duration:
Continuous signs of disturbance for at least six months, including one month of active symptoms.
D. Schizoaffective disorder and mood disorders ruled out.
E. Not attributable to substances or a medical condition.
F. If autism or a communication disorder is present:
A diagnosis of schizophrenia requires prominent delusions or hallucinations.
ICD-11 DEFINITION OF SCHIZOPHRENIA
ICD-11 defines schizophrenia as a primary psychotic disorder characterised by:
• Disturbances in perception, thought content, thought form, self-experience, affect, motivation and behaviour
• Persisting for most of one month, with continuous signs of disturbance for at least six months
• Marked impairment in personal, social, occupational or educational functioning
• Mood disorders, substance use, or neurological disease cannot better explain symptoms
ICD-11 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA
A. Characteristic symptoms
The person must show several of the following, but ICD-11 does not require a fixed number. Symptoms should be clearly present most of the time for at least one month.
Typical symptoms include:
Persistent delusions
Persistent hallucinations (all modalities)
Disorganised thinking (typically evident as disorganised speech)
Marked disorganisation in behaviour
Negative symptoms such as:
• affective flattening
• alogia
• avolition
• apathy
• anhedonia
• social withdrawal
ICD-11 emphasises that symptoms must show explicit psychotic content (e.g., loss of reality testing, impaired self–other boundaries).
B. Disturbances in self-experience
ICD-11 includes the possibility of:
• disturbances in the sense of self
• experiences of thought interference
• thought insertion, withdrawal, broadcasting
• experiences of external control over one’s thoughts or actions
These features strengthen diagnostic confidence but are not mandatory.
C. Functional impairment
Symptoms must cause significant impairment in personal, social, occupational, or educational functioning.
D. Duration
Symptoms must persist for at least one month, though ICD-11 allows the diagnosis earlier if symptoms are severe and characteristic.
E. Exclusion criteria
The disturbance must not be better explained by:
• a primary mood disorder with psychotic symptoms
• substance intoxication or withdrawal
• a medical or neurological condition
KEY DIFFERENCES BETWEEN DSM-5 AND ICD-11 (SUMMARY)
(If you want this expanded later, I can produce a full page for your website.)
• ICD-11 does not require two specific symptoms. DSM-5 requires two symptoms (one must be delusions, hallucinations, or disorganised speech).
• ICD-11 has no six-month duration requirement. DSM-5 requires six months of disturbance.
• ICD-11 removes all subtypes (paranoid, catatonic, etc). DSM removed them in 2013 as well.
• ICD-11 focuses more on disturbances of self-experience. DSM does not emphasise this.
• ICD-11 is more flexible and descriptive. DSM-5 is more structured and symptom-count driven
HOW DO YOU DEFINE SCHIZOPHRENIA CONCISELY FOR AN ESSAY QUESTION?
Below is a concise definition of schizophrenia—suitable for a quick essay outline. Remember, unless specifically asked, you do not need to describe schizophrenia.
In other words, if you are answering a question about what causes schizophrenia or the best way to treat it, you do not need to describe it. If you do, you will not receive marks for the description.
You may now be asking yourself why I have gone to such lengths to describe schizophrenia if learning this is not often required in exams. You need to know the symptoms well to evaluate theories on cause and treatment effectively. If you don’t know what schizophrenia is, then you certainly won’t be able to judge theories that explain or treat it.
ESSAY QUESTION: “OUTLINE THE CLASSIFICATION OF SCHIZOPHRENIA” (6 MARKS = A01)
Schizophrenia (SZ) is a complicated disorder to classify, as each individual can have different characteristics of the illness. It is a condition characterised by disordered, disorganised thought processes, manifesting in the patient’s language and behaviour. There is also a loss of contact with reality and a disturbance of form and thought content. Schizophrenia affects the mood of the person and their sense of self about the external world. The behaviour of schizophrenics may be purposeless, and they can distort reality and withdraw from society. Some types of schizophrenia develop slowly and insidiously, and the absence of emotion, language and self-initiation may dominate the early clinical picture. Yet other kinds of schizophrenia are dominated by auditory hallucinations, paranoid delusions, and excessive behaviours. As a result, schizophrenia is now classified as a spectrum disorder.
