Acute schizophrenia

The first presentation of schizophrenia is usually with an acute episode, consisting of positive symptoms. In some cases, the patient has been well prior to the onset of these symptoms. In many, however, there will have been a prodromal phase lasting months or years, in which non-specific changes of behaviour such as social withdrawal and reduced level of function occur.

The acute episode often starts with delusional mood, in which the patient believes that something strange is going on but doesn’t know what it is. The patient then begins to experience other positive symptoms. The most common are delusions, especially of reference and persecution, and auditory hallucinations, which may be in the 2nd or 3rd person. However, any combination of positive symptoms can occur.

Patients’ behaviour can be affected by their positive symptoms in a number of different ways. If the patient is thought-disordered, their behaviour may become disorganised as a result. Unusual behaviour in acute schizophrenia may also be an understandable response to delusions and hallucinations. For instance, a patient may be suspicious or aggressive because of persecutory delusions, or may refuse medication they think is poisoned. They may smash a television because of frightening delusions of reference. They may refuse to remove a cycle helmet, feeling a need to protect themselves because of delusions of control. They may talk or laugh to themselves or appear preoccupied as a result of auditory hallucinations.

An example of a mental state examination of a patient with acute schizophrenia is shown in Figure 1. While most patients present with some of these abnormalities, it would be unusual for them to have quite so many. In fact, some patients may appear completely normal until they begin to discuss their delusions or hallucinations.

Fig. 1 Mental state examination of patient with acute onset schizophrenia.

Chronic (residual) schizophrenia

Some patients make a good recovery from episodes of acute schizophrenia. Others are less fortunate, going on to develop a chronic unremitting illness in which function is markedly reduced. As discussed below, positive symptoms often continue in such patients but the clinical picture is usually dominated by the gradual emergence of negative symptoms and it is these which are usually the greatest cause of disability. Illnesses which run this chronic course are known as chronic or residual schizophrenia.