Previously, schizophrenia was categorized into five subtypes: paranoid, catatonic, disorganized, residual, and undifferentiated [1]. In the most recent publication of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [2], these five subtypes have been removed, due to concerns relating to the validity and stability of these diagnoses [3].

As such, these five subtypes are no longer used as specific diagnoses,. However, the varying symptoms of each subtype, and the severity of these symptoms, can still help professionals diagnose schizophrenia and recommend the appropriate treatment.

Characteristics and symptoms of schizophrenia

Schizophrenia can present as a variety of symptoms, including:

  • Positive symptoms: such as hallucinations, delusions, and thought disorders
  • Negative symptoms: such as social withdrawal, loss of motivation, and blunted emotions
  • Abnormal or disorganized speech and behavior: such as incoherent sentences, difficulty following a train of thought, catatonia, and odd or repeated movements.

Negative symptoms of schizophrenia may be more difficult to notice, as they typically result in fewer social interactions and fewer societal disturbances, and thus, may take longer to be diagnosed than positive symptoms or mistaken for signs of depression [4].

Although visual and auditory hallucinations are most common, hallucinations can involve any of the five senses [5]:

  • Visual hallucinations: seeing things that are not there, such as people, lights, and shapes
  • Auditory hallucinations: hearing things, such as voices talking to you or about you, or an ongoing commentary of your actions
  • Olfactory hallucinations: smelling things that are not there
  • Tactile hallucinations: feeling things that are not there, such as bugs on your skin or someone touching you
  • Gustatory hallucinations: tasting things that are not there

Delusions involve having a strong belief in something with no evidence, or that is clearly incorrect. Examples of delusions may include [5]:

  • Perception: a normal occurrence is given an abnormal meaning, for example, a bird flies overhead and this means that an alien spaceship is going to land, or that a song comes on the radio and that means the radio is communicating a special message to you.
  • Idea: a current belief, such as the idea that the CIA are listening to your phone calls, or that someone is trying to kill you.
  • Thoughts: thought insertion, broadcast, or withdrawal, which means that you feel you are not in control of your thoughts in some way. You may believe that other people can hear your thoughts, put thoughts into your head, or take them out.

Delusions may be based on certain themes, such as:

  • Love: believing that a certain person is in love with you, such as a boss, a celebrity, or a fictional character.
  • Persecution: believing that someone is trying to harm or kill you, or you are to blame for a terrible occurrence.
  • Illness: being convinced you have a certain disease or condition.
  • Jealousy: believing that your partner is cheating on you.
  • Grandiose: feeling especially important, such as believing you are a celebrity or superhero.

Types of schizophrenia

The following are the five types of schizophrenia that were previously outlined in the DSM-IV and have since been removed [1][2]. In the new diagnostic criteria, symptoms within these subtypes are still included. However, rather than specifying a subtype, they can be used to determine the severity of the condition for the individual, by rating the severity of each presenting symptom.

These changes were made due to the conclusion that diagnosing a specific subtype did not have an impact on the treatment of the condition, and the reliability and validity were often questionable [3].

The previous subtypes include:

Paranoid schizophrenia

According to the DSM-IV [1], for a diagnosis of paranoid schizophrenia, delusions and/or hallucinations must be present. The person will be very focused on at least one specific delusion, which will typically be persecutory in nature, causing a belief that someone or something will do them harm.

This could be a voice, or voices, telling them they are being followed, watched, or poisoned, or they may see or hear concerning messages. As such, people with a diagnosis of paranoid schizophrenia will typically be very suspicious and untrusting of others, which may result in expressions of anger, fear, or withdrawal [5].

Catatonic schizophrenia

Catatonic schizophrenia involves abnormal psychomotor function. This can be an inability to move, excessive or hyperactive moments, or odd and unusual movements or postures [6].

A common symptom of catatonic schizophrenia is immobility or stupor, which means that the person appears frozen in place, sometimes for hours or days, and can be in odd positions for long periods of time.

Other common symptoms are echolalia and echopraxia, which respectively mean mimicking other people’s words or mimicking other people’s actions.

Disorganized schizophrenia

For a diagnosis of disorganized schizophrenia, hallucinations and delusions may be present, but the primary symptoms would be disorganized speech and behavior [1]. This could include saying bizarre things, talking about something and then the topic going in a completely different direction, repetition of words and phrases, or experiencing frequent bouts of confusion.

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

Residual schizophrenia

People with a diagnosis of residual schizophrenia would have no prominent examples of positive symptoms, such as hallucinations, delusions, and disorganized speech, but there would be a clear disturbance in their cognition. They may experience negative symptoms and odd beliefs.

Undifferentiated schizophrenia

Undifferentiated schizophrenia was diagnosed when symptoms of schizophrenia were present, but the criteria for any of the other subtypes was not clearly met.

Diagnosing schizophrenia

For a diagnosis of schizophrenia, two of the following five symptoms must be present, with at least one of them being a positive symptom [2]:

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

There must also have been a significant decrease in functioning for several months, such as at work, in personal relationships, or in self-care. The disturbances, or changes in presentation, must have been present for at least six months, during which there must have been at least one month of symptoms, as listed above [2].

Psychotic symptoms can be present in several mental health conditions, such as bipolar disorder and schizoaffective disorder. As part of the diagnostic criteria, these conditions must be ruled out by determining whether a period of major depression or mania has been present alongside the active symptoms, and for how long [7][8]. This is to prevent a misdiagnosis, as some conditions can mask as others.

Psychosis can also be caused by several physical health conditions, such as brain injury, lupus, or encephalitis, or can be the result of substance use. As such, doctors will aim to rule out any of these other conditions or causes prior to a diagnosis of schizophrenia [9].

Long-term outlook for schizophrenia

The long-term outlook, or prognosis, for schizophrenia depends greatly on the severity of symptoms, age of onset, treatment, and several social and environmental factors [8].

If schizophrenia is treated after the occurrence of the first psychotic episode, this can reduce the risk of psychotic symptoms recurring. If left untreated, or treated later, psychotic symptoms may be chronic or recurring [10].

Sometimes, people with schizophrenia lack insight, meaning that they are not aware of their condition, which can complicate treatment and may require hospitalization to help manage and reduce symptoms.

People with schizophrenia typically have a shorter life expectancy. This may be due to side effects of medications such as cardiac conditions, poor exercise and diet, a higher prevalence of smoking, or suicide [7].

Schizophrenia often requires lifelong treatment, as there is no specific cure. However, there are several ways in which the condition can be effectively managed, enabling a good quality of life. Many people with schizophrenia can function well professionally and personally, utilizing medication and therapy to manage their symptoms [11].

Treatment options for schizophrenia

Medication

To treat schizophrenia, your doctor will likely prescribe you with an antipsychotic medication, such as aripiprazole, risperidone, or olanzapine. These are known as second generation antipsychotics. First generation antipsychotics are typically not used as a first treatment, as they have a higher risk of side effects, but may be used if other medications are unsuccessful [7].

If you have tried several medications with limited success, you may be prescribed clozapine. This has been shown to be very successful at treating psychotic symptoms, but is associated with serious side effects, so is not a first-choice medication. If you are prescribed clozapine, your doctor will closely monitor your physical health, including regular blood tests to ensure your safety [8].

It is important that you take your medication exactly as prescribed, as taking too much, missing doses, or suddenly stopping your medication can cause serious adverse effects. If you have concerns or questions about your medication, side effects, or symptoms, consult with your doctor. Ensure you always attend appointments, so your doctor can monitor your physical and mental wellbeing.

Therapy

Psychotherapy, in particular cognitive behavioral therapy (CBT), can be helpful in managing the symptoms of schizophrenia and learning positive coping strategies for the distressing symptoms [7].

You may wish to attend family therapy, so that your loved ones can be part of your treatment, better understand your condition, and learn how they can best support you [4].

Many find group therapy useful, as this can help to develop confidence in social situations, alongside people who have experienced similar symptoms and challenges. Group therapy can also help people with schizophrenia to develop skills that can be used in professional and personal relationships, in addition to reducing feelings of social isolation [10].

Inpatient care

If symptoms are considered dangerous or unmanageable, especially if you encounter thoughts of harming yourself or others, you may be treated in hospital. This will allow doctors, nurses, and other healthcare professionals to help you to manage your condition, so that you can integrate back into the community safely [7][10].

Ideally, inpatient care is for the shortest time possible and is aimed at reducing the most severe symptoms, so that you can manage your condition outside of hospital. You may start a new medication or therapy while in hospital, which can help you manage your symptoms.

Resources:

  1. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Washington, DC: American Psychiatric Association.
  2. American Psychiatric Association. (2013, text revision 2022). Schizophrenia Spectrum and Other Psychotic Disorders. In The Diagnostic and Statistical Manual of Mental Disorders(5th ed., text rev.). APA. Retrieved from https://doi.org/10.1176/appi.books.9780890425787.x02_Schizophrenia_Spectrum
  3. American Psychiatric Association. (2013). Highlights of Changes from DSM-IV-TR to DSM-5.Psychiatry. Retrieved from https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf
  4. National Institute of Mental Health. (n.d). Schizophrenia. NIH. Retrieved from https://www.nimh.nih.gov/health/topics/schizophrenia
  5. Kiran, C., & Chaudhury, S. (2009). Understanding Delusions. Industrial Psychiatry Journal, 18(1), 3-18. Retrieved from https://doi.org/10.4103/0972-6748.57851
  6. Jain, A., & Mitra, P. (2022). Catatonic Schizophrenia. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK563222/
  7. Patel, K.R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: Overview and Treatment Options. P & T: A Peer-Reviewed Journal for Formulary Management, 39(9), 638–645. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159061/
  8. Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2022). Schizophrenia. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK539864/
  9. Keshavan, M.S., & Kaneko, Y. (2013). Secondary Psychoses: An Update. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 12(1), 4–15. Retrieved from https://doi.org/10.1002/wps.20001
  10. Picchioni, M.M., & Murray, R.M. (2007). Schizophrenia. BMJ (Clinical research ed.), 335(7610), 91–95. Retrieved from https://doi.org/10.1136/bmj.39227.616447.BE
  11. National Alliance on Mental Health (NAMI). Schizophrenia. NAMI. Retrieved from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizophrenia/Overview