Residual Schizophrenia – What is it?

In the previous Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), schizophrenia was categorized into five subtypes: disorganized, catatonic, paranoid, residual, and undifferentiated ^[1]. In the current diagnostic manual, the DSM-5 ^[2], these five subtypes are no longer listed, due to debate around the legitimacy and use of these diagnoses ^[3].

Residual schizophrenia is now no longer considered a specific diagnosis. However, the symptoms of these five subtypes of schizophrenia can still be utilized when forming a diagnosis, depending on the nature of the presenting symptoms.

What is residual schizophrenia?

Schizophrenia can present as several symptoms, such as:

• Positive symptoms: including hallucinations, delusions, and thought disorders.
• Negative symptoms: including lack of energy and motivation, social withdrawal and isolation, catatonia, and diminished emotional expression.
• Cognitive symptoms: including bizarre or disorganized behavior and speech, such as unusual or repeated movements and poses, jumbled sentences, and inability to follow a train of thought.

According to the DSM-IV, for a diagnosis of residual schizophrenia, there will have been at least one psychotic episode in the past, as well as a diagnosis of schizophrenia, with one or more positive symptoms present.

The person will no longer be experiencing these symptoms in as severe a manner but may continue to experience disturbances in the form of negative symptoms, such as lack of motivation or flat affect, or milder positive and cognitive symptoms, such as odd beliefs and unusual experiences ^[1].

Symptoms of residual schizophrenia

People with a diagnosis of residual schizophrenia will have experienced symptoms such as hallucinations, delusions, or thought disorders in the past, but these symptoms will have since reduced significantly or entirely ^[1].

Although psychosis will no longer be clearly present, there will still be persistent disturbances, usually in the form of negative symptoms, or milder positive symptoms ^[4]. Therefore, this type of schizophrenia is named ‘residual’ schizophrenia, as the most pervasive symptoms will have abated, but residual, or remaining symptoms, continue to persist.

While this may seem to be an improvement or remission of the initial schizophrenia diagnosis, residual schizophrenia can still have a detrimental impact on quality of life, particularly in relation to social abilities ^[5].

Symptoms of residual schizophrenia may include:

• Social withdrawal
• Lack of motivation
• Decrease in communication
• Blunted or lack of emotions
• Low levels of energy
• Strange beliefs
• Difficulties with memory or concentration
• Some thought disorganization

Causes of residual schizophrenia

Although the cause of schizophrenia is unclear, research indicates that the development of the condition is likely related to several factors, including:

Brain structure and function

Abnormal levels of neurotransmitters, dopamine and glutamate, are thought to contribute to the development of schizophrenia ^[6].

The brain structure of people with schizophrenia has been found to be altered, including a decreased volume of gray matter, indicating that the condition may be due to abnormal development of the brain ^[7].

Furthermore, there are cases in which schizophrenia and psychotic symptoms have been found to be caused by traumatic brain injury, which further suggests that brain structure is involved in the onset of schizophrenia ^[8].

Genetics

The likelihood of developing schizophrenia is significantly higher for someone who has a parent or close relative with the condition. Research suggests that the prevalence of schizophrenia in individuals with a family history is six times that of the general population ^[6]. However, it is important to note that there are many people with a family history of schizophrenia who do not develop the condition.

Social and environmental influences

Various social and environmental factors have been found to increase the risk of psychosis and schizophrenia, including childhood abuse and trauma, social isolation, low socioeconomic class, complications during pregnancy and childbirth, and stressful life events ^[9][10].

Alcohol and drugs

Studies indicate that several substances can increase the risk of developing psychotic symptoms. For instance, those who engage in cannabis use from a young age are thought to be at a significantly increased risk of developing schizophrenia, particularly when used in large and frequent doses ^[10][11].

Similarly, it is also thought that substances such as amphetamines, cocaine, and alcohol may also increase the risk of psychotic symptoms ^[10].

Treatment of residual schizophrenia

Medication

Upon receiving a diagnosis of schizophrenia, antipsychotic medication will be prescribed, which is typically effective at treating psychotic symptoms. Second-generation (or atypical) antipsychotics are often the first choice of medication, such as aripiprazole, risperidone, or olanzapine. Your dosage or medication may need to be changed during your treatment if your symptoms change.

It is common for people to have different responses to medications, so what might be useful for one person, could be ineffective for someone else. Often, people need to try different medications, or a combination of several medications, until they find a treatment that works.

Antidepressants, benzodiazepines, and mood stabilizers can also be prescribed to treat some symptoms of schizophrenia, particularly negative symptoms such as low mood and anxiety ^[5].

It is common for antipsychotic medications to cause side effects, resulting in people not wanting to take their medication. Furthermore, some people with schizophrenia lack insight; they do not know they are unwell and therefore think they don’t require medication. It can be common for relapse to occur when medications are not taken as prescribed ^[12].

Therapy

Several types of therapy can be provided in the treatment of schizophrenia, such as:

• Cognitive behavioral therapy (CBT), which can help to adapt harmful and negative thoughts and behaviors, provide insight into the condition, and help to prevent relapse ^[5][7].
• Family therapy, which may be useful in helping family members gain a better understanding of their loved one’s condition and how to assist them in managing their symptoms ^[13].
• Psychosocial treatments can be especially helpful for those with residual schizophrenia compared with other types. This is due to the lack of pervasive positive symptoms which allows for a greater level of engagement ^[5]. Psychosocial interventions can help improve social and professional skills, recognize medication’s importance, and find support systems ^[6].

Self-care

• Avoid drugs and alcohol: It is advised to avoid drugs and alcohol, as they often impact mental well-being and could lead to ineffective medication, interactions with medication that can cause adverse effects, and relapse ^[9].
• Attend appointments: To ensure that you are receiving the necessary care and treatment that is required for your recovery, it is important to attend all appointments with your doctor, therapist, and any other professionals involved in your care.
• Get enough sleep: It is essential for good physical and mental health to get plenty of sleep. A lack of sleep can worsen symptoms and potentially lead to relapse. Forming and maintaining a bedtime routine can help with this.
• Be active: Engaging in hobbies and social activities can help to improve mental health, such as meditation, yoga, walking, spending time with friends, listening to music, and reading.

Other types of schizophrenia

Along with residual schizophrenia, the other subtypes that were previously used in the diagnosis of schizophrenia include ^[1]:

Paranoid schizophrenia

The DSM-IV ^[1] stated that, for a diagnosis of paranoid schizophrenia, there must be a presence of delusions and/or hallucinations. Commonly, someone with paranoid schizophrenia would become very focused on a specific delusion, often persecutory in nature, which would cause them to believe that someone or something intends to harm them.

This could present as a voice, or voices, which tells the individual that they are being watched, followed, or poisoned, or it may be that they may hear or see troubling messages. Because of these symptoms, it is common for people with a diagnosis of paranoid schizophrenia to be very suspicious and untrusting of others, sometimes resulting in expressions of fear, anger, or withdrawal.

For more information on persecutory delusions, click here.

Catatonic schizophrenia

Someone with catatonic schizophrenia will experience abnormal psychomotor function. This typically involves odd and unusual movements or poses, an inability to move, or hyperactive movements.

It may be common to see an individual with catatonic schizophrenia experience stupor, or immobility, causing a freezing in movement, that can last many hours or days, or the holding of odd positions for a long time ^[14].

Echolalia and echopraxia are also common symptoms of catatonic schizophrenia, which relate to copying other people’s words or actions, respectively.

Disorganized schizophrenia

For a diagnosis of disorganized schizophrenia, hallucinations and delusions may be present, but the primary symptoms would be disorganized speech and behavior. This could include saying bizarre things, abruptly changing topics during a conversation, repeating words and phrases, or often feeling confused about things.

Another common symptom of disorganized schizophrenia is flat affect, meaning that the person will be expressionless and show inappropriate or unusual responses.

Undifferentiated schizophrenia

Undifferentiated schizophrenia refers to the presence of schizophrenia symptoms that do not meet the criteria for one of the other subtypes.