SCHIZOPHRENIA

PSYCHOTIC DISORDERS
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What is Schizophrenia?

• The essential features of Schizophrenia are a mixture of characteristic signs and

symptoms (both positive and negative) that have been present for a significant
portion of time during a 1-month period (or for a shorter time if successfully
treated), with some signs of the disorder persisting for at least 6 months. These
signs and symptoms are associated with marked social or occupational
dysfunction.
• It is thought of as a syndrome or as a disease process with many different
varieties and symptoms
Onset

• It is usually diagnosed in late adolescence or early childhood.

• Rarely manifested in childhood.
• Peak onset is 15-25 years in males and 25-35 years in women.
Symptoms

POSITIVE OR HARD NEGATIVE OR SOFT

SYMPTOMS SYMPTOMS

• Flat affect – absence or near absence of facial

• Delusions
expression
• Hallucinations • Lack of volition (avolition)
• Grossly disorganized thinking, speech • Social withdrawal or discomfort
and behavior • Thought blocking
• Poverty of content of speech
• Poverty of speech
• Anergia
• Anhedonia
Symptoms

COGNITIVE SYMPTOMS AFFECTIVE SYMPTOMS

• Inattention, easily distracted • Dysphoria- mood that involves
unhappiness, restlessness, and malaise
• Impaired memory
• Suicidality
• Poor problem-solving skills
• Hopelessness
• Poor decision-making skills
• Illogical thinking
• Impaired judgement
• Medication can control the positive symptoms but often negative symptoms
continue after the positive symptoms have resolved.
• The persistence of negative symptoms over time can cause a major barrier to the
client’s recovery and thereby their overall functioning in their daily lives.
Psychotic Disorders other than
Schizophrenia
• Other disorders are related to, but are distinguished from Schizophrenia in terms
of presenting symptoms and the duration or magnitude of the impairment. DSM
–IV categorizes them as follows:
• Schizophreniform Disorder: This diagnosis is used when the client exhibits
symptoms of Schizophrenia but less the than 6 months necessary to meet the
diagnostic criteria for Schizophrenia. Social or occupational functioning may or
may not be impaired. It may or may not develop into Schizophrenia.
Psychotic Disorders other than
Schizophrenia (Delusional Disorder)
• Delusional disorder: the client has one or more non-bizarre delusions, meaning
the focus of the delusions is believable e.g. situations that can occur in real life
such as being followed, being loved by someone, or having a disease.
• Apart from the delusion, functioning is not significantly impaired and there are
not other symptoms of psychosis
• A related disorder Capgras Syndrome: is a delusion about a significant other
(family member or pet) being replaced by an imposter; this disorder may be due
to psychotic or organic brain disease.
Brief Psychotic Disorder

• The client experiences the sudden onset of at lease one psychotic symptom, such
as delusions, hallucinations, or disorganized speech, grossly disorganized or
catatonic behavior in response to extreme stress which lasts from 1 day to 1
month.
• The episode may or may not have an identifiable stressor or may follow
childbirth
Schizotypal Personality Disorder

• The patient demonstrates a personality alteration characterized by altered

interpersonal boundaries, eccentric behavior, eccentric use of language,
restricted or socially inappropriate expression of emotion, increased mistrust and
sensitivity regarding the intent or responses of others, and difficulty setting foals,
determining their own beliefs, and other alterations in identity.
• Although such persons may appear eccentric, or odd, they do not exhibit the
from psychotic features seen in psychotic disorders such as hallucinations and
delusions.
Substance-Induced Psychotic Disorder

• Psychosis induced by drugs of abuse, alcohol medications, or toxins.

Psychosis or Catatonia Associated with
Another Medical Condition
• Psychosis or catatonia caused by a medical condition (delirium, neurological or
metabolic conditions, hepatic or renal diseases and others).
• Medical conditions and substance abuse must always be ruled out before a
diagnosis of schizophrenia or other psychotic disorder can be made.
Schizoaffective Disorder

• When an episode of major depression, mania, or mixed depression and mania

occurs in the presence of symptoms of schizophrenia
Psychotic or Catatonic Disorder NOT
otherwise Specified
• Disorders that involve psychotic features such as impaired reality testing or
bizarre behavior but do not meet the criteria for diagnosis as specific psychotic
disorders are diagnosed as Psychosis Not Otherwise Specified (NOS).
• Similarly, persons exhibiting gross changes in the rate of motor behavior but
who do not meet the criteria for Catatonic Disorder are categorized as Catatonic
Disorder.
TYPES OF SCHIZOPHRENIA
(Paranoid Type)
• The essential feature is the presence of prominent delusions or auditory
hallucinations.
• Delusions are typically persecutory or grandiose, or both, but delusions with
other themes (e.g. jealousy, religiosity, or somatization) may also occur.
• Delusions may be multiple, but are usually organized around a coherent theme
• Hallucinations are also typically related to the content of the delusional theme
Paranoid type cont’d

• Associated features include:

• Anxiety
• Anger
• Aloofness
• Argumentativeness

• The individual may have a superior and patronizing and either a stilted formal quality
or extreme intensity in interpersonal interactions
• The persecutory themes may predispose the individual to suicidal behavior, and the
combination of persecutory and grandiose delusions with anger may predispose the
individual to violence.
Paranoid type cont’d

• Onset tends to be later in life than other types of Schizophrenia. The

distinguishing characteristics may be more stable over time.
• These individuals usually show little or no impairment on neuropsychological or
other cognitive testing.
• None of the following is prominent:
• Disorganized speech
• Disorganized or catatonic behavior
• Flat or inappropriate affect
Disorganized type

• The essential feature is disorganized speech, disorganized behavior, and flat or

inappropriate affect.
• Disorganized speech may be accompanied by silliness and laughter that are not
closely related to the content of speech.
• Disorganized behavior (lack of goal orientation) may lead to severe disruption in the
ability to perform activities of daily living (showering, dressing, preparing meals)
• Criteria for Catatonic type Schizophrenia are not met, and delusions or
hallucinations if present, are fragmentary and not organized into a coherent theme
Disorganized type cont’d

• Associated features include grimacing, mannerisms, and other oddities of behavior.

• Impaired performance may be noted on a variety of neuropsychological and
cognitive tests
• Disorganized type of schizophrenia is also usually associated poor premorbid
personality, early and insidious onset, and a continuous course without significant
remission.
• Historically was classified as bebephrenic.
• The criteria are not met for Catatonic Type
Catatonic Type

• Essential feature is marked by psychomotor disturbance that may involve

motoric immobility, excessive activity, extreme negativism, mutism,
peculiarities of voluntary movement, echolalia, or echopraxia (At least 2 must be
present to meet this criteria)
• Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor
• The excessive motor activity is apparently purposeless and is not influenced by
external stimuli.
•
Catatonia type cont’d

• There may be extreme negativism that is manifested by the maintenance of rigid

posture against attempts to be moved or resistance to all instructions.
• Peculiarities of voluntary movement are manifested by the voluntary assumption
of inappropriate or bizarre postures or by prominent grimacing.
• Echolalia: the pathological, parrotlike, and apparently senseless repetition of a
word or phrase just spoken by another person.
Catatonic type cont’d

• Echopraxia: repetitive imitation of the movements of another person.

• Additional features includes stereotypes, mannerisms, and automatic obedience
or mimicry.
• During severe catatonic stupor or excitement, the person may need careful
supervision to avoid self-harm or harming others.
• There are potential risks from malnutrition, exhaustion, hyperpyrexia, or self-
inflicted injury.
Catatonic type

• To diagnose the subtype the individual’s presentation must fist meet the full
criteria must first meet the full criteria for Schizophrenia and not be better
accounted for by another etiology:
• Substance-induced, general medical condition
• Manic or Major Depressive Episode.
Undifferentiated type

• The essential feature is the presence of symptoms that meet criterion A of

schizophrenia but that do not meet the criteria for Paranoid, Disorganized, or
Catatonic types.
• NOTE about Criterion A:
• Requires that at least 2 of the 5 items be present concurrently for much of at least 1 month,
however, if delusions are bizarre or hallucinations involve “voices commenting” or “voices
conversing” then the presence of only 1 item is required.
• The presence of this relatively severe constellations of signs and symptoms is referred to as the
active phase.
• If the active-phase symptoms remit within 1 month in response to treatment, Criterion A can still
be considered to have been met.
Residual type

• Is used when there has been at lease 1 episode of Schizophrenia but the current clinical
picture is without prominent positive symptoms.
• There is continuing evidence of the disturbance as indicated by the presence of negative
symptoms or 2 or more attenuated positive symptoms.
• If delusions or hallucinations are present, they are prominent and are not accompanied by
strong affect.
• The course of the Residual Type may be time limited and represent a transition between a
full-blown episode and complete remission
• However, it can also be continuously present for many years with or without exacerbations
Symptoms with meaning

• Delusions: A false belief to be true even with evidence to the contrary ( a false
belief that one is being singled out)
• Hallucinations: A sense perceptions (visual, auditory, tactile, olfactory,
gustatory) for which no external stimulus exist (e.g. hearing voices when no one
is present)
• Disorganized Speech: Includes moving from one subject to another that is totally
unrelated.
• Avolition: An inability to initiate and complete goal-directed behavior. It can
sometimes be misinterpreted as laziness; a negative symptom of Schizophrenia
Symptoms with meaning

• Affective Flattening: distinguished by a restricted range of expressed emotions,

is fairly common negative symptom among some Schizophrenia. Patients with
affective flattening show relatively immobility and unresponsive facial
expressions, often accompanied by poor eye contact and little body language or
movement.
• Alogia: Difficulty with speaking. In some Schizophrenic patients, alogia
manifest as reduced total speech output, and reduced verbal fluency (the ease
with which words are chosen). Patients displaying alogia struggle to give brief
answers to questions.
Symptoms with meaning

• Catatonic behavior: Disorganized behavior may range from simple problems

sustaining goal-directed objectives such as personal hygiene to unpredictable
and bizarre socially inappropriate outburst.
• In catatonia, people’s reaction to their surroundings becomes remarkedly
decreased. They may assume a rigid, uncomfortable looking posture and then
not move for hours or days.
• This is not an act or show but a genuine and unpremeditated symptoms of the
illness they cannot help.
Symptoms with meaning

• Social/ Occupational Dysfunction: Inappropriate expression of emotions,

oddness. E.g. laughing at a funeral, laughing at death.
• Thought blocking: a sudden interruption in the thought process, usually due to
internal stimuli e.g. a client abruptly stops talking in the middle of the a sentence
and remains silent.
• Anhedonia: Inability to experience pleasure in activities that usually produced it.
• Poverty of content of speech: While adequate in amount, speech conveys little
information because of vagueness or superficiality.
• Poverty of speech: Reduced spontaneity and amount of speech; rarely initiates
speech and responds in brief or one-word answers.
• Concrete thinking: Refers to an impaired ability to think abstract. Concreteness
is often assessed through the patient’s interpretation.
• Ambivalence: Holding seemingly contradictory beliefs or feelings about the
same person, event or situation.
Types of Delusions

• Control: Believing that another person, group of people, or external force

controls thoughts, feelings, impulses, or behavior.
• E.g:
• Brian covered his apartment walls with aluminum foil to block government efforts to
control his thoughts.

• Ideas of reference: Giving personal significance to unrelated or trivial events,

perceiving events as relating to you when they are not.
• E.g:
• Barbara believes that she birds sing when she walks down the street just for her.
Types of Delusions

• Persecution: Believing that one is being singled out for harm by others; this
belief often takes the form of a plot by people in power.
• E.g
• Peter believed that the Secret Service was planning to kill him by poisoning his food
therefore he would only eat prepackaged food.

• Grandeur: Believing that one is very powerful or important person

• E.g:
• Sam believed he was a famous playwright and tennis pro
• Somatic: Believing that the body is changing in unusual ways (rotting from inside)
• Erotomanic: Believing that another person desires you romantically.
• E.g:
• Although he barely knew her, Patti insisted that Eric would marry her if ony his current wife
would stop interfering.

• Jealousy: Believing that one’s partner is unfaithful.

• E.g:
• Sally wrongly accused her spouse of going out with other women. Her proof was that he
came home late twice from work (even though his boss explained that everyone worked late)
Clinical Presentation

• Children who later go onto to be diagnosed with Schizophrenia often have

unusual characteristics years before psychotic symptoms become apparent.
• They tend to do less well in school than their siblings, are less socially engaged,
less positive, and exhibit unusual motor development.
• Actual childhood Schizophrenia is extremely rare, carries a worse prognosis than
the adult-onset version, and is diagnosed before 12 years.
• Adolescents who are later diagnosed with schizophrenia often experience
prodromal symptoms (i.e. early symptoms that indicate that a problem may b
developing) for a few months or years.
Clinical Presentation

• Adolescents may experience social withdrawal, irritability, and depression and

become antagonistic.
• Conduct problems and academic decline often bring them to the attention of
school and community clinicians.
• Suspiciousness and low-level distortions in thought seem to be especially linked
to subsequent Schizophrenia.
• All people diagnosed with Schizophrenia have at least one psychotic symptoms
such as hallucinations, delusions, and or disorganized speech.
• In children, the symptoms are severe enough to interrupt normal childhood
activities (schooling or normal childhood or age-appropriate milestones)
• Adults have extreme or are unable to function in their family, social, or
occupational lives.
• Basic needs such as hygiene and nutrition are often neglected.
• During a 6-month period, individuals may have times when they are not
experiencing psychotic symptoms, but in those times, they tend to be apathetic
or depressed.
Epidemiology

• Childhood-onset is about 1 in 10,000 children.

• Adults, the lifetime prevalence is 1% worldwide with no differences related to
race, social status or culture.
• It is diagnosed more frequently in males and among persons growing up in
urban areas.
• Schizophrenia usually presents during the late teens and early twenties.
• Childhood schizophrenia, although rare, does exist, occurring in 1 out of 40,000
in children.
Epidemiology

• Early-onset Schizophrenia (18-25 years) occurs more often in males and is

associated with poor functioning before onset, more structural brain abnormality
and increased levels of apathy.
• Individuals with a later onset (25-35 years) are more likely to be female, to have
less structural brain abnormalities, and tend to have better outcomes.
Comorbidity

• Substance abuse disorders: occur in nearly 50% of persons with Schizophrenia

and are associated with non-compliance to treatment, relapse, incarceration,
homelessness, violence, suicide, and a poorer prognosis. May represent a
maladaptive way of coping with Schizophrenia.
• Nicotine dependence: rates in schizophrenia range from 70% - 90% and
contribute to an increased incidence of cardiovascular and respiratory disorders
Comorbidity

• Anxiety, depression and suicide: co-occur frequently in Schizophrenia. Anxiety may be a

response to symptoms (hallucinations) or circumstances (isolation, overstimulation) and
may worsen schizophrenia symptoms and prognosis.
• Approximately 10% of persons with schizophrenia commit suicide, a rate of 8.5 times that
of the general population; both depression and suicide attempts can occur at any point in
the illness.
• Physical health illness: are more common among people with schizophrenia than in the
general population. Pre-mature death 1.6 – 2.8 greater in population. On average, patients
with Schizophrenia die around 28 years prematurely due hypertension (22%), obesity
(24%), cardiovascular disease (21%), diabetes (12%) CPOD (10%), and trauma (6%)
Comorbidity

• Persons with psychotic disorders may be at a greater risk due to apathy, poor
health habits, medications, poverty, limited access to healthcare, and failure to
recognize signs of illness.
• Polydipsia: Can lead to fatal water intoxication (indicated by hyponatremia,
confusion, worsening psychotic symptoms, and ultimately coma).
Etiology

• Schizophrenia is a complicated disorder.

• It may be actually a group of disorders with common but varying features and
multiple, overlapping causes.
• What is known is that brain chemistry, structure, and activity are different in a
person with Schizophrenia.
• This scientific consensus is that Schizophrenia occurs when multiple inherited gene
abnormalities combine with nongenetic factors (viral infections, birth injuries,
environmental stressors, prenatal malnutrition) altering the structures of the brain
affecting the brain’s neurotransmitter systems and or injuring the brain directly.
Etiology: Biological Theories

• The biologic theories of Schizophrenia focus on genetic factors, neuroanatomic

and neurochemical factors (structure & function of the brain), and
immunovirology ( the body’s response to exposure to a virus)
• Genetic factors:
• Focus on immediate families (i.e. parents, siblings and offspring), to examine
whether schizophrenia is genetically transmitted or inherited.
• Evidence suggest that multiple genes on different chromosomes interact with
each other in complex ways, creating vulnerability for Schizophrenia
Etiology: Biologic Theories

• Neurobiological:
• Dopamine Theory – fist antipsychotic drugs are known as conventional/first-
generation antipsychotics (Haloperidol and chlorpromazine) that block the
activity of dopamine and reduce some of the symptoms of Schizophrenia.
• Cocaine, methylphenidate (Ritalin), and Levodopa increase the activity of
dopamine in the brain and in persons biologically susceptible, may bring on
schizophrenia.
• Amphetamines can be used to induce a model of schizophrenia in persons
without the disorder and can precipitate schizophrenia.
Etiology: Biologic Theories

• Any drug of abuse, including marijuana, can lead to schizophrenia in biologically vulnerable
persons.
• Because the dopamine-blocking agents do not alleviate all the symptoms of schizophrenia it
seems likely that other neurotransmitters or other factors may be involved.
• Other Neurochemical Hypotheses: second-generations (unconventional) antipsychotics block
serotonin as well as dopamine, suggesting that serotonin may play a role in schizophrenia.
• Brain Structure Abnormalities: Disruptions in communication pathways in the brain are
thought to be severe in schizophrenia.
• Evidence from imaging (CT, MRI, PET) indicate structural changes in the brain in persons with
schizophrenia.
Etiology: Psychological &
Environmental Factors
• Some biological, chemical, and environmental stressors, particularly those
occurring prenatally and during other vulnerable periods of neurological
development, are believed to combine with genetic vulnerabilities causing
schizophrenia.
• Prenatal Stressors: A history of pregnancy or birth complications is associated
with an increased risk.
• Prenatal risk factors include poor nutrition and hypoxia.
• Infectious agents like human herpes 2 and human endogenous retrovirus 2 are
associated with schizophrenia
Etiology: Psychological &
Environmental
• Psychological trauma to mother during pregnancy (death of a loved one) can
contribute to the development of the disorder.
• Other risk factors include a father older than 35 at the time of the child’s
conception and being born during late winter or early spring.
• Psychological Stressors: stress increases cortisol levels, slowing hypothalamic
development and causing other changes that may lead to schizophrenia in
vulnerable individuals.
• Schizophrenia often manifests at times of developmental and family stress
(beginning of college, moving away from family)
Etiology: Psychological &
Environmental
• Social, psychological, and physical stressors may play a significant role in both
the severity and course of the disorder and the person’s quality of life.
• Other factors increasing the risk include childhood sexual abuse, exposure to
social adversity (living in chronic poverty, high-crime environments), migration
to or growing up in a foreign culture, and exposure to psychological trauma or
social defeat.
Etiology: Psychological &
Environment
• Environmental Stressors: toxins e.g. tetrachloroethylene (solvent used in dry
cleaning, water pipes and may end up in potable water) has contributed to the
development of schizophrenia in vulnerable persons.
Cultural Considerations

• Awareness of cultural differences is important when assessing schizophrenia.

• Ideas that are considered delusional in one culture, may be commonly accepted
by other cultures.
• Auditory or visual hallucinations like seeing the Virgin Mary or hearing God’s
voice may be a normal part of religious experiences in the same cultures.
• The assessment of affect required sensitivity to differences in eye contact, body
language, and acceptable emotional expressions vary among cultures.
Cultural Considerations

• Psychotic behavior observed in countries other than in the USA or among certain
ethnic groups has been identified as culture-bound syndrome.
• While episodes are present in certain countries, it can also be seen in other
places as persons visit or migrate to other countries.
Culture Considerations (Types of
Psychotic Behaviors)

Bouffee delirante: Ghost Sickness:

• A syndrome found in West Africa and • Is preoccupation with death and the
Haiti where there is a sudden outburst decreased frequently observed among
of agitated and aggressive behavior, members of some Native American tribes.
marked confusion, and psychomotor • Symptoms include bad dreams, weakness,
excitement. feelings of danger, loss of appetite,
fainting, dizziness, fear, anxiety,
hallucinations, loss of consciousness,
confusion, feelings of futility, and a sense
of suffocation
Types of Psychotic Behaviors

Locura: Qi-gong:
• Chronic psychosis experienced by • This psychotic reaction is an acute, time-
Latinos in the USA and Latin America. limited episode characterized by
dissociative, paranoid, or other psychotic
• Symptoms: incoherence, agitations, symptoms that occur after participating in
visual and auditory hallucinations, the Chinese folk health-enhancing
inability to follow social rules, practices of qi-gong.
unpredictability, possibly violent
• Especially vulnerable persons are those
behavior
who become overly involved in the
practice.
Types of Psychotic Behaviors

• Zar: an experience of spirits possessing a person, is seen in Ethiopia, Somalia,

Egypt, Sudan, Iran, and other North African and Middle Eastern societies.
• The person may laugh, shout, wail, bang their head on the wall, or be apathetic
and withdrawn, refusing to eat or carry out daily tasks .
• For locals, this is not considered pathological
Cultural consideration

• Ethnicity may also be a factor in the way a person responds to psychotic

medications.
• This is a result of the person’s genetic makeup. Where some persons metabolize
certain drugs slower, causing the drug levels to be elevated in their bloodstream.
• African Americans, Caucasian Americans, and Hispanic Americans appear to
require comparable therapeutic doses of antipsychotic medications, however,
Asian clients need lower doses of drugs (Haloperidol) to reach the same effects;
therefore they would be likely to experience more severe side effects if given the
traditional or usual doses.
This Photo by Unknown Author is licensed under CC BY-NC-ND
Course of Disorder

• The onset of symptoms or forewarning (prodromal) symptoms may appear a

month or more than a year before the first psychotic break or full-blown
manifestations of the illness.
• The symptoms are a clear deterioration from previous functioning
• After this first episode, the course typically includes recurrent exacerbations
separated by periods or reduced or dormant symptoms.
• Occasionally a person may have a single episode of schizophrenia without
recurrences or will have several episodes and nothing after.
Course of Disorder cont’d

• For most clients with schizophrenia, it is a chronic or recurring disorder (Diab, HTN)
that can be managed but rarely cured.
• Very often, prior to the illness, a person with schizophrenia was socially awkward,
lonely, perhaps depressed, and expressed themselves in vague, odd or eccentric ways.
• In this prodromal phase, anxiety, phobias, obsessions, dissociation and compulsions
may be noted.
• As anxiety increased, indications of a thought disorder become evident: Concentration,
memory, and completion of work/school related work deteriorates. Intrusive thoughts,
‘mind wandering’ and the need to devote more time to maintaining one’s thoughts are
reported.
Course of Disorder cont’d

• The person may feel that something ‘strange’ or ‘wrong’ is happening.

• Routine stimuli (noise in traffic, noise at a gas station) can be overwhelming.
• Events are misinterpreted, and mystical or symbolic meanings may be given to
ordinary events (may think birds flying are telling them something; the
formation of how the birds are flying is a message from God).
• The ability to discern others’ emotions from facial expression or tone of voice
becomes more difficult, and others actions or words may be mistaken for signs
of hostility or evidence of harmful intentions.
Prognosis

• For most clients, most symptoms can be somewhat controlled through

medications and psychosocial interventions.
• Support and effective treatments allow people with schizophrenia a good quality
of life, success within families, occupation and in other roles.
• In most cases, however, schizophrenia does not fully respond to available
treatments, leaving residual symptoms, causing varying degrees of dysfunction
or disability.
• Some clients have to be hospitalized for long periods.
Prognosis

• An abrupt onset onset of symptoms is usually a favorable prognostic sign, and

those with good premorbid social and occupational functioning have a greater
chance for a good remission or a complete recovery.
• Factors associated with a less positive prognosis include a slow, insidious onset
(over 2-3 yrs), younger age at onset, longer duration between first symptoms and
first treatment, longer periods of untreated illness, and more negative symptoms.
Phases of Schizophrenia

• Schizophrenia usually progresses through predictable phases, despite the

presenting symptoms during a given phase and length can vary greatly.
• Phase I – Acute: Onset or exacerbation of florid, disruptive symptoms (e.g.
hallucinations, delusions, apathy, withdrawal) with resultant loss of functional
abilities, increased care or hospitalization may be required.
Phases of Schizophrenia

• Phase II – Stabilization: Symptoms are diminishing, and there is movement

towards the client’s previous (baseline) level of functioning; partial (output/ day
patient) hospitalization or supervision in a group home may be needed.
• Phase III – Maintenance: The client is at or nearing baseline (or premorbid)
functioning; symptoms are absent or diminished; level of functioning allows the
client to live in the community. Ideally, recovery with reduced or no residual
symptoms have occurred.
• Some doctors identify an earlier prodromal (pre-psychotic) phase were subtle
symptoms or deficits with schizophrenia are present these symptoms may or may
not lead to a later onset of schizophrenia