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Schizophrenia: Clinical manifestations, course, assessment, and diagnosis

Bernard A Fischer, MD
Robert W Buchanan, MD
Section Editor
Stephen Marder, MD
Deputy Editor
Richard Hermann, MD


Schizophrenia is a psychiatric disorder involving chronic or recurrent psychosis. It is commonly associated with impairments in social and occupational functioning [1]. It is among the most disabling and economically catastrophic medical disorders, ranked by the World Health Organization as one of the top ten illnesses contributing to the global burden of disease [2].

Characteristics of schizophrenia typically include positive symptoms such as hallucinations or delusions, disorganized speech, negative symptoms such as a flat affect or poverty of speech, and impairments in cognition including attention, memory and executive functions. A diagnosis of schizophrenia is based on the presence of such symptoms, coupled with social or occupational dysfunction, for at least six months in the absence of another diagnosis that would better account for the presentation.

This topic discusses clinical manifestations, assessment, diagnosis, and course of schizophrenia. The epidemiology and pathogenesis of schizophrenia are discussed separately. Anxiety, depression, and substance abuse in schizophrenia are discussed separately. The treatments for schizophrenia are discussed separately, as are other psychotic disorders. (See "Schizophrenia: Epidemiology and pathogenesis" and "Depression in schizophrenia" and "Anxiety in schizophrenia" and "Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment" and "Pharmacotherapy for schizophrenia: Side effect management" and "Co-occurring schizophrenia and substance use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis" and "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic medications: Pharmacology, administration, and side effects" and "Psychosocial interventions for schizophrenia" and "Psychosocial interventions for severe mental illness" and "Clinical manifestations, differential diagnosis, and initial management of psychosis in adults".)


Schizophrenia is a syndrome. People with schizophrenia generally present with several symptom domains (ie, areas of distinct psychopathology):

Positive symptoms


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Literature review current through: Sep 2016. | This topic last updated: Mar 24, 2016.
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  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  2. Murray CJL, Lopez AD. The Global Burden of Disease, Harvard University Press, Cambridge, MA 1996. p.21.
  3. Carpenter WT Jr, Strauss JS, Bartko JJ. The diagnosis and understanding of schizophrenia. Part I. Use of signs and symptoms for the identification of schizophrenic patients. Schizophr Bull 1974; :37.
  4. Bartko JJ, Strauss JS, Carpenter WT Jr. The diagnosis and understanding of schizophrenia. Part II. Expanded perspectives for describing and comparing schizophrenic patients. Schizophr Bull 1974; :50.
  5. Strauss JS, Carpenter WT Jr, Bartko JJ. The diagnosis and understanding of schizophrenia. Part III. Speculations on the processes that underlie schizophrenic symptoms and signs. Schizophr Bull 1974; :61.
  6. Thomas P, Mathur P, Gottesman II, et al. Correlates of hallucinations in schizophrenia: A cross-cultural evaluation. Schizophr Res 2007; 92:41.
  7. Andreasen NC, Flaum M. Schizophrenia: the characteristic symptoms. Schizophr Bull 1991; 17:27.
  8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC 2000.
  9. Cermolacce M, Sass L, Parnas J. What is bizarre in bizarre delusions? A critical review. Schizophr Bull 2010; 36:667.
  10. Andreasen NC, Olsen S. Negative v positive schizophrenia. Definition and validation. Arch Gen Psychiatry 1982; 39:789.
  11. Strauss GP, Horan WP, Kirkpatrick B, et al. Deconstructing negative symptoms of schizophrenia: avolition-apathy and diminished expression clusters predict clinical presentation and functional outcome. J Psychiatr Res 2013; 47:783.
  12. Blanchard JJ, Cohen AS. The structure of negative symptoms within schizophrenia: implications for assessment. Schizophr Bull 2006; 32:238.
  13. Buchanan RW, Kreyenbuhl J, Kelly DL, et al. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36:71.
  14. Kirkpatrick B, Fenton WS, Carpenter WT Jr, Marder SR. The NIMH-MATRICS consensus statement on negative symptoms. Schizophr Bull 2006; 32:214.
  15. Kirkpatrick B, Kopelowicz A, Buchanan RW, Carpenter WT Jr. Assessing the efficacy of treatments for the deficit syndrome of schizophrenia. Neuropsychopharmacology 2000; 22:303.
  16. Strauss GP, Harrow M, Grossman LS, Rosen C. Periods of recovery in deficit syndrome schizophrenia: a 20-year multi-follow-up longitudinal study. Schizophr Bull 2010; 36:788.
  17. Fenton WS, McGlashan TH. Antecedents, symptom progression, and long-term outcome of the deficit syndrome in schizophrenia. Am J Psychiatry 1994; 151:351.
  18. Kirkpatrick B, Buchanan RW, Ross DE, Carpenter WT Jr. A separate disease within the syndrome of schizophrenia. Arch Gen Psychiatry 2001; 58:165.
  19. Kirkpatrick B, Amador XF, Flaum M, et al. The deficit syndrome in the DSM-IV Field Trial: I. Alcohol and other drug abuse. Schizophr Res 1996; 20:69.
  20. Kirkpatrick B, Buchanan RW, Breier A, Carpenter WT Jr. Depressive symptoms and the deficit syndrome of schizophrenia. J Nerv Ment Dis 1994; 182:452.
  21. Nuechterlein KH, Barch DM, Gold JM, et al. Identification of separable cognitive factors in schizophrenia. Schizophr Res 2004; 72:29.
  22. Gold JM, Hahn B, Strauss GP, Waltz JA. Turning it upside down: areas of preserved cognitive function in schizophrenia. Neuropsychol Rev 2009; 19:294.
  23. Dickinson D, Iannone VN, Wilk CM, Gold JM. General and specific cognitive deficits in schizophrenia. Biol Psychiatry 2004; 55:826.
  24. Kraus MS, Keefe RS. Cognition as an outcome measure in schizophrenia. Br J Psychiatry Suppl 2007; 50:s46.
  25. Wilk CM, Gold JM, McMahon RP, et al. No, it is not possible to be schizophrenic yet neuropsychologically normal. Neuropsychology 2005; 19:778.
  26. Palmer BW, Heaton RK, Paulsen JS, et al. Is it possible to be schizophrenic yet neuropsychologically normal? Neuropsychology 1997; 11:437.
  27. Bora E, Murray RM. Meta-analysis of cognitive deficits in ultra-high risk to psychosis and first-episode psychosis: do the cognitive deficits progress over, or after, the onset of psychosis? Schizophr Bull 2014; 40:744.
  28. Bilder RM, Goldman RS, Robinson D, et al. Neuropsychology of first-episode schizophrenia: initial characterization and clinical correlates. Am J Psychiatry 2000; 157:549.
  29. Snitz BE, Macdonald AW 3rd, Carter CS. Cognitive deficits in unaffected first-degree relatives of schizophrenia patients: a meta-analytic review of putative endophenotypes. Schizophr Bull 2006; 32:179.
  30. Goldberg TE, Ragland JD, Torrey EF, et al. Neuropsychological assessment of monozygotic twins discordant for schizophrenia. Arch Gen Psychiatry 1990; 47:1066.
  31. Saeedi H, Remington G, Christensen BK. Impact of haloperidol, a dopamine D2 antagonist, on cognition and mood. Schizophr Res 2006; 85:222.
  32. Moore AR, O'Keeffe ST. Drug-induced cognitive impairment in the elderly. Drugs Aging 1999; 15:15.
  33. Kraepelin E. Dementia Praecox and Paraphrenia, Krieger, New York 1971.
  34. Torrey EF. Studies of individuals with schizophrenia never treated with antipsychotic medications: a review. Schizophr Res 2002; 58:101.
  35. Dickerson FB, Sommerville J, Origoni AE, et al. Experiences of stigma among outpatients with schizophrenia. Schizophr Bull 2002; 28:143.
  36. Drapalski AL, Lucksted A, Perrin PB, et al. A model of internalized stigma and its effects on people with mental illness. Psychiatr Serv 2013; 64:264.
  37. Yanos PT, Lysaker PH, Roe D. Internalized stigma as a barrier to improvement in vocational functioning among people with schizophrenia-spectrum disorders. Psychiatry Res 2010; 178:211.
  38. Tsang HW, Fung KM, Chung RC. Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia. Psychiatry Res 2010; 180:10.
  39. Yanos PT, Lucksted A, Drapalski AL, et al. Interventions targeting mental health self-stigma: A review and comparison. Psychiatr Rehabil J 2015; 38:171.
  40. Heinrichs DW, Buchanan RW. Significance and meaning of neurological signs in schizophrenia. Am J Psychiatry 1988; 145:11.
  41. Bombin I, Arango C, Buchanan RW. Significance and meaning of neurological signs in schizophrenia: two decades later. Schizophr Bull 2005; 31:962.
  42. Arango C, Kirkpatrick B, Buchanan RW. Neurological signs and the heterogeneity of schizophrenia. Am J Psychiatry 2000; 157:560.
  43. Arango C, Bartko JJ, Gold JM, Buchanan RW. Prediction of neuropsychological performance by neurological signs in schizophrenia. Am J Psychiatry 1999; 156:1349.
  44. Kohen D. Diabetes mellitus and schizophrenia: historical perspective. Br J Psychiatry Suppl 2004; 47:S64.
  45. Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005; 150:1115.
  46. Blueler M. The Schizophrenic Disorders: Long-Term Patient and Family Studies, Yale University Press, London 1978.
  47. Modestin J, Huber A, Satirli E, et al. Long-term course of schizophrenic illness: Bleuler's study reconsidered. Am J Psychiatry 2003; 160:2202.
  48. Harding CM, Brooks GW, Ashikaga T, et al. The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later. Am J Psychiatry 1987; 144:718.
  49. Harding CM, Brooks GW, Ashikaga T, et al. The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. Am J Psychiatry 1987; 144:727.
  50. Recovery from Schizophrenia: An International Perspective; A Report from the WHO Collaborative Project, The International Study of Schizophrenia, Hopper K, Harrison G, Janca A, Sartorius N. (Eds), Oxford University Press, New York 2007.
  51. Harrison G, Hopper K, Craig T, et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. Br J Psychiatry 2001; 178:506.
  52. Robinson DG, Woerner MG, McMeniman M, et al. Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder. Am J Psychiatry 2004; 161:473.
  53. Fischer BA, Carpenter WT. Remission. In: Clinical Handbook of Schizophrenia, Mueser KT, Jeste DV. (Eds), Guilford Publications, New York 2008. p.559.
  54. Andreasen NC, Carpenter WT Jr, Kane JM, et al. Remission in schizophrenia: proposed criteria and rationale for consensus. Am J Psychiatry 2005; 162:441.
  55. Bellack AS. Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. Schizophr Bull 2006; 32:432.
  56. Schneider K. Clinical Psychopathology, Grune & Stratton, New York 1959.
  57. Rosen C, Grossman LS, Harrow M, et al. Diagnostic and prognostic significance of Schneiderian first-rank symptoms: a 20-year longitudinal study of schizophrenia and bipolar disorder. Compr Psychiatry 2011; 52:126.
  58. Thorup A, Petersen L, Jeppesen P, Nordentoft M. Frequency and predictive values of first rank symptoms at baseline among 362 young adult patients with first-episode schizophrenia Results from the Danish OPUS study. Schizophr Res 2007; 97:60.
  59. Kendler KS, Gruenberg AM, Tsuang MT. Subtype stability in schizophrenia. Am J Psychiatry 1985; 142:827.
  60. Kendler KS, Gruenberg AM, Tsuang MT. A family study of the subtypes of schizophrenia. Am J Psychiatry 1988; 145:57.
  61. Malaspina D, Owen MJ, Heckers S, et al. Schizoaffective Disorder in the DSM-5. Schizophr Res 2013; 150:21.
  62. Debbané M, Eliez S, Badoud D, et al. Developing psychosis and its risk states through the lens of schizotypy. Schizophr Bull 2015; 41 Suppl 2:S396.
  63. World Health Organization. Schizophrenia, schizotypal and delusional disorders. International Statistical Classification of Disease and Related Health Problems. Tenth Revision. Version:2015. http://apps.who.int/classifications/icd10/browse/2015/en#/F20-F29.