I. Clinical presentation
Most patients with schizophrenia have their first onset between the ages of adolescence and 30 years. The onset of the disease is more insidious and the acute onset is less frequent. The clinical manifestations of schizophrenia are intricate and complex, and a variety of psychiatric disorders can occur, except for uncommon disorders of consciousness and intellectual impairment.
II. Prodromal symptoms
Before the appearance of typical schizophrenic symptoms, patients are often accompanied by unusual changes in behavioral patterns and attitudes. Because such changes are slow and may last for months or even years, or because they are less dramatic, they are generally not immediately seen as pathological changes and are sometimes detected only when the medical history is retraced. According to Yung and McGorry’s summary, the development of prodromal symptoms is summarized in two main forms.
Huber et al. added a third type of “prodromal syndrome” as follows
1. nonspecific changes in the bucket of specific prepsychotic symptoms and psychosis.
2. atopic changes and neurotic reactions (symptoms) to these changes.
3, anterior posterior syndrome these prodromal symptoms may resolve spontaneously and do not progress directly to psychosis. The main prodromal symptoms are decreasing in frequency: decreased attention, decreased motivation and drive, lack of energy, psychotic symptoms, sleep disturbance, anxiety, social withdrawal, suspicion, impaired role functioning, and irritability.
IV. Psychiatric symptoms
1. Thought disorders
Among the many symptoms of schizophrenia, thought disorder is the most important and essential symptom, which often leads to incoordination and detachment from reality of the patient’s cognitive, emotional, volitional and behavioral mental activities, which is called “schizophrenia”.
(1) Thought form disorder.
Also known as association disorder. This is mainly due to the lack of coherence and logic in the association process, which is the most characteristic symptom of schizophrenia. Conversations with schizophrenic patients are mostly difficult to understand and impossible to penetrate. Reading written materials written by the patient is also often confusing. In conversation, the patient talks in meaningless circles and often wanders off topic, especially when answering the doctor’s questions, but every sentence seems to be on point, making it difficult for the listener to grasp the main points (scattered thinking).
In severe cases, the speech is so fragmented that it is impossible to talk (broken thinking). Sometimes the patient may describe things unnecessarily, with excessive specificity, or use words inappropriately. Some patients use ordinary words, symbols, or even actions to express particular meanings that only the patient can understand (pathological symbolic thinking). Sometimes the patient creates new words or symbols to give special meaning (new work of words).
Sometimes the patient’s logical reasoning is absurd and bizarre (logical inversion thinking); or the central idea is elusive and lacks practicality (sophistry); or the patient spends his days indulging in fantasies, grand plans, or theoretical discussions that have no realistic meaning and is not in contact with the outside world (introverted thinking). Sometimes there are two opposite, contradictory ideas in the patient’s head, and it is impossible to judge right and wrong, which affects the choice of behavior (paradoxical thinking). Some patients may experience a sudden pause or blankness in their thinking without the influence of external factors (thought interruption), or they may feel that their thinking has been withdrawn at the same time (thought seizure).
Some patients may experience a large number of thoughts with a distinct sense of involuntary or compulsive thinking (thought clouding or compulsive thinking), and sometimes patients may feel that some thoughts that do not belong to them have been forcibly inserted by others or by the outside world (thought insertion). Chronic patients may show a paucity of language, lack of active speech, and only superficial reactions to problems, lacking further associations (thought paucity).
(2) Thought content disorder.
Primarily, this refers to delusions. Delusions in schizophrenia are often absurd and bizarre and easily generalized. In the early stages of the illness, patients may be skeptical of some of their apparently unconventional thoughts, but as the illness progresses, they gradually become integrated with the pathological beliefs. Delusions can occur suddenly, independent of the patient’s past experiences, the reality of the situation, and the mental activity at the time (primary delusions).
They can also develop gradually or be secondary to hallucinations, internal discomfort, and passive experiences. The most common delusions are delusions of victimization and delusions of relationship. Delusions sometimes manifest as passive experiences, which are often typical of schizophrenia. Patients lose their sense of dominance and feel that their somatic movements, thinking activities, emotional activities, and impulses are controlled by someone or by an outside party. Passive experiences are often associated with delusions of victimization or described as delusions of influence (sense of being controlled), or feelings of insight. Other common delusions are delusions of interpretation, jealousy or belligerence delusions, and non-pedigree delusions.
2. Perceptual disorders
The most prominent perceptual disorder in schizophrenia is hallucinations, with verbal hallucinations being the most common. The content of hallucinations in schizophrenia can be argumentative or critical, or commanding. Hallucinations are sometimes expressed as thought chirps. The patient’s behavior is often dictated by the hallucinations, such as having a long conversation with a voice, or becoming angry, laughing, or fearful because of the voice, or mumbling, or making a sideways listen, or dwelling on the hallucinations and laughing to oneself.
Other types of hallucinations, although rare, can be seen in patients with schizophrenia. For example, a patient refuses to eat because she sees a plate with broken glass (hallucinations); a patient feels that someone is cutting her body with a scalpel and has the sensation of an electric current burning the wound (phantom touch), etc.
3.Emotional disorder
The main manifestation is emotional retardation or flatness. Emotional dullness is not only manifested by dull expressions and lack of change, but also by reduced spontaneous movements and lack of body language. Patients rarely or hardly use any gestures and body postures to express their thoughts in conversation, and their speech is monotonous and lacks intonation.
Patients lose their sense of humor and their response to humor, and it is difficult for the examiner’s wit to elicit a heartfelt smile. Emotional indifference first involves more delicate emotions, such as consideration for relatives, concern for colleagues and sympathy. Later, patients become emotionally unresponsive to things around them and less interested in life, learning or work. As the disease further progresses, the patient becomes increasingly emotionally indifferent to everything and loses the emotional connection with the surroundings.
The patient’s emotional reactions may manifest as a dissonance with internal thinking or the external environment. Some patients lack the emotional experience they should have when talking about their misfortunes or the content of their delusions, or show disproportionate emotions. A few patients show emotional inversions, such as rejoicing at learning of a loved one’s death. Depression and anxiety are also not uncommon in patients with schizophrenia, sometimes leading to diagnostic difficulties.
4. Will and behavior disorders
Patients’ activities decrease, lack initiative, and their behavior becomes withdrawn, passive, and retreating (diminished will). Patients have great difficulty in holding down a job, completing school, and taking care of household chores. They often have no concern for their future, have no plans, or have plans but never carry them out. Patients may sit for hours on end without any spontaneous activity, or they may neglect their grooming and do not know how to take care of their personal hygiene. Some patients eat things they cannot eat, such as drinking urine, eating feces, insects, grasses, or hurting themselves (inversion of intent).
Sometimes patients may have silly, childish behavior, or sudden, purposeless impulsive behavior, or even feel that their behavior is not governed by their own will. Some patients exhibit a catatonic syndrome: named after the increase in generalized muscle tone, it includes two states of catatonic rigidity and catatonic excitement, which may alternate and are typical of the catatonic form of schizophrenia. In xylosis, it is characterized by muteness, reduced or absent random movements, and psychomotor unresponsiveness. Patients with wood stiffness can sometimes suddenly develop impulsive behavior, i.e., catatonic excitation.