Children who later go on to be diagnosed with schizophrenia often have unusual characteristics years before psychotic symptoms become apparent (Minzenberger et al., 2011). 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 the age of 12.

Adolescents who are later diagnosed with schizophrenia often experience prodromal symptoms (i.e., early symptoms that indicate that a problem may be developing) for a few months or a few years (Minzenberger et al., 2011). 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 be especially linked to subsequent schizophrenia.

All people diagnosed with schizophrenia have at least one psychotic symptom, such as hallucinations, delusions, and/or disorganized speech. In children the symptoms are severe enough to interrupt normal childhood activities, such as schooling, or to disrupt important age-appropriate milestones. Adults have extreme difficulty or are unable to function in their family, social, or occupational lives. Basic needs such as hygiene and nutrition are often neglected. During a six-month period individuals may have times when they are not experiencing psychotic symptoms, but in those times they tend to be apathetic or depressed.

VIGNETTE

Sam, a 25-year-old man soon to be discharged from the hospital, constantly tells his family he wants his own apartment. When Sam is told that an apartment has been found for him, he asks, “But who will take care of me?” Sam is acting out his ambivalence between his desire to be independent and his desire to be taken care of.

Epidemiology

The prevalence of childhood-onset schizophrenia is about 1 in 10,000 children. In adults, the lifetime prevalence of schizophrenia is 1% worldwide with no differences related to race, social status, or culture. It is diagnosed more frequently in males (1.4:1) and among persons growing up in urban areas (Tandon et al., 2008). Schizophrenia usually presents during the late teens and early twenties. Childhood schizophrenia, although rare, does exist, occurring in 1 out of 40,000 children. Early-onset schizophrenia (18 to 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 to 35 years) are more likely to be female, to have less structural brain abnormality, and to have better outcomes.

Comorbidity

Substance abuse disorders occur in nearly 50% of persons with schizophrenia and are associated with treatment nonadherence, relapse, incarceration, homelessness, violence, suicide, and a poorer prognosis (Gottlieb et al., 2012). These disorders may represent a maladaptive way of coping with schizophrenia. Nicotine dependence rates in schizophrenia range from 70% to 90% and contribute to an increased incidence of cardiovascular and respiratory disorders (D’Souza & Markou, 2012).

Anxiety, depression, and suicide co-occur frequently in schizophrenia. Anxiety may be a response to symptoms (e.g., hallucinations) or circumstances (e.g., isolation, overstimulation) and may worsen schizophrenia symptoms and prognosis. Approximately 10% of persons with schizophrenia commit suicide, a rate 8.5 times that of the general population; both depression and suicide attempts can occur at any point in the illness (Kasckow, Felmet, & Zisook, 2011).

Physical health illnesses are more common among people with schizophrenia than in the general population. The risk of premature death is 1.6 to 2.8 times greater than that in the general population; on average, patients with schizophrenia die 28 years prematurely due to disorders such as hypertension (22%), obesity (24%), cardiovascular disease (21%), diabetes (12%), chronic obstructive pulmonary disease (COPD) (10%), and trauma (6%) (Miller et al., 2007).

Persons with psychotic disorders may be at greater risk due to apathy (a symptom of schizophrenia), poor health habits, medications (see the discussion of metabolic syndrome later in this chapter), poverty, limited access to health care, and failure to recognize signs of illness. Owing to poverty, stigma, or stereotyping (e.g., emergency department personnel assuming that because a patient has a psychotic disorder, his chest pain is imaginary), they may not receive adequate health care.

Polydipsia can lead to fatal water intoxication (indicated by hyponatremia, confusion, worsening psychotic symptoms, and ultimately coma). Polydipsia occurs in upwards of 20% of persons with schizophrenia and a seemingly insatiable thirst that results causes hyponatremia in 2-5%; contributing factors include antipsychotic medication (causes dry mouth), compulsive behavior, and neuroendocrine abnormalities (Goldman, 2009).

Etiology

Schizophrenia is a complicated disorder. In fact, what we call “schizophrenia” actually may be a group of disorders with common but varying features and multiple, overlapping etiologies. What is known is that brain chemistry, structure, and activity are different in a person with schizophrenia.

The scientific consensus is that schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors (e.g., 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 (Tandon et al., 2008). This is called the diathesis-stress model of schizophrenia (Walker & Tessner, 2008).

Biological factors

Genetic

Schizophrenia and schizophrenia-like symptoms, such as eccentric thinking, occur at an increased rate in relatives of individuals with schizophrenia. According to Giegling and colleagues (2010):

• Compared to the usual 1% risk in the population, having a first-degree relative with schizophrenia increases the risk to nearly 10%.

• Concordance rates in twins (how often one twin will have the disorder when the other one has it) is about 50% for identical twins and about 15% for fraternal twins.

• The degree to which genetics plays a role in causing schizophrenia is estimated at 65-80%

Evidence suggests that multiple genes on different chromosomes interact with each other in complex ways to create vulnerability for schizophrenia. Genes potentially linked to schizophrenia continue to be identified, suggesting a high degree of complexity (Tandon et al., 2008).

Neurobiological

PET scans also show a lowered rate of blood flow and glucose metabolism in the frontal lobes, which govern planning, abstract thinking, social adjustment, and decision making, all of which are affected in schizophrenia. Figure 3-5 in Chapter 3 shows a PET scan demonstrating reduced brain activity in the frontal lobe of a patient with schizophrenia. Such structural changes may worsen as the disorder continues. Postmortem studies on individuals with schizophrenia reveal a reduced volume of gray matter in the brain, especially in the temporal and frontal lobes; those with the most tissue loss had the worst symptoms (e.g., hallucinations, delusions, bizarre thoughts, and depression).

Psychological and environmental factors

A number of biological, chemical, and environmental stressors, particularly those occurring prenatally and during other vulnerable periods of neurological development, are believed to combine with genetic vulnerabilities to produce schizophrenia.

Prenatal stressors

A history of pregnancy or birth complications is associated with an increased risk for schizophrenia. Prenatal risk factors include poor nutrition (e.g., folate deficiency) and hypoxia. Infectious agents such as human herpes virus 2 and human endogenous retrovirus 2 are also implicated (Arias et al., 2011). Psychological trauma to the mother during pregnancy (e.g., the death of a relative) can also contribute to the development of schizophrenia (Khashan et al., 2008). Other risk factors include a father older than 35 at the child’s conception and being born during late winter or early spring (Tandon et al., 2008).

Psychological stressors

Stress increases cortisol levels, impeding hypothalamic development and causing other changes that may precipitate the illness in vulnerable individuals. Schizophrenia often manifests at times of developmental and family stress, such as beginning college or moving away from one’s family. 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 of schizophrenia include childhood sexual abuse, exposure to social adversity (e.g., living in chronic poverty or high-crime environments), migration to or growing up in a foreign culture, and exposure to psychological trauma or social defeat (Tandon et al., 2008).

Environmental stressors

Environmental factors such as toxins, including the solvent tetrachloroethylene (used in dry cleaning and to line water pipes and sometimes found in drinking water) are also believed to contribute to the development of schizophrenia in vulnerable persons (Aschengrau et al., 2012).

Course of the disorder

The onset of symptoms or forewarning (prodromal) symptoms may appear a month to more than a year before the first psychotic break or full-blown manifestations of the illness; such symptoms represent a clear deterioration from previous functioning. The course thereafter typically includes recurrent exacerbations separated by periods of reduced or dormant symptoms. Occasionally a person will have a single episode of schizophrenia without recurrences or will have several episodes and none thereafter. For most patients, however, schizophrenia is a chronic or recurring disorder that, like diabetes or heart disease, is managed but rarely cured.

Frequently, prior to the illness, a person with schizophrenia was socially awkward, lonely, perhaps depressed, and expressed himself or herself in vague, odd, or eccentric ways. In this prodromal phase, anxiety, phobias, obsessions, dissociation, and compulsions may be noted. As anxiety mounts, indications of a thought disorder become evident: Concentration, memory, and completion of school- or job-related work deteriorate. Intrusive thoughts, “mind wandering,” and the need to devote more time to maintaining one’s thoughts are reported.

The person may feel that something “strange” or “wrong” is happening. Routine stimuli such as traffic noise or voices in a café can become overwhelming. Events are misinterpreted, and mystical or symbolic meanings may be given to ordinary events. For example, the patient may think that certain colors have special powers or that a song on the radio is a message from God intended just for him. Discerning 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 intent (Gold et al., 2012).

Prognostic considerations

For the majority of patients, most symptoms can be at least somewhat controlled through medications and psychosocial interventions. With support and effective treatments, many people with schizophrenia experience a good quality of life and success within their families, occupations, and other roles. Associates may not even realize the person has schizophrenia.

In most cases, however, schizophrenia does not respond fully to available treatments, leaving residual symptoms and causing varying degrees of dysfunction or disability. Some persons require repeated or lengthy inpatient care or institutionalization. An abrupt 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 (e.g., over 2 to 3 years); 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, although the presenting symptoms during a given phase and the length of the phase can vary widely; these phases are (Chung et al., 2008):

• 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.

• Phase II—Stabilization: Symptoms are diminishing, and there is movement toward one’s previous level of functioning (baseline); partial hospitalization or care in a residential crisis center or a supervised group home may be needed.

• Phase III—Maintenance: The patient is at or nearing baseline (or premorbid) functioning; symptoms are absent or diminished; level of functioning allows the patient to live in the community. Ideally, recovery with reduced or no residual symptoms has occurred.

Some clinicians also designate an earlier Prodromal (or Prepsychotic) Phase in which subtle symptoms or deficits associated with schizophrenia are present; such symptoms may or may not herald the later onset of schizophrenia.

Application of the nursing process

Assessment

Nursing assessment of patients who may have a psychotic disorder focuses largely on symptoms, coping, functioning, and safety. Assessment involves interviewing the patient and observing behavior and other outward manifestations of the disorder; information from others who know the patient is also important as patients may conceal or minimize symptoms when under scrutiny. Assessment also should include a mental status examination, along with review of spiritual, cultural, biological, psychological, social, and environmental elements that might be affecting the presentation (or that could be potential resources for recovery). Sound therapeutic communication skills, an understanding of the disorder and the ways patients may be experiencing their world, and establishing trust in a therapeutic nurse-patient relationship all strengthen the assessment.

Prepsychotic phase

Early detection and treatment of symptoms is believed to lessen the risk of developing the disorder (or reduce the severity of the disorder if it does develop). A delay in diagnosis and treatment allows the psychotic process to become more entrenched; it can also result in maladaptive coping (e.g., drinking) and relational, work, housing, and school problems.

Therefore, early assessment plays a key role in improving the prognosis for persons with schizophrenia (Chung et al., 2008). This form of primary prevention involves monitoring those at high risk (e.g., children of parents with schizophrenia) for symptoms such as abnormal social development and cognitive dysfunction. Intervening to reduce stressors (i.e., reduce or avoid exposure to triggers), enhancing social and coping skills (i.e., build resiliency), and administering prophylactic antipsychotic medication may also be of benefit.

Research suggests that with each relapse of psychosis, there is an increase in residual dysfunction and deterioration (Crespo-Facorro et al., 2010). Recognition of the early warning signs of relapse—such as reduced sleep and concentration—followed by close monitoring and intensification of treatment is essential. For this reason, adherence to antipsychotics can be more important than the risk of side effects because most side effects are reversible whereas the consequences of relapse may not be.

General assessment

Not all people with schizophrenia (or even people with the same subtype of the disorder) have the same symptoms, and some of the symptoms of schizophrenia are also found in other disorders. Figure 12-1 describes the four main symptom groups of schizophrenia:

FIG 12-1 Four main symptom groups of schizophrenia.

1. Positive symptoms: The presence of something that is not normally present (e.g., hallucinations, delusions, bizarre behavior, paranoia, abnormal movements, gross errors in thinking)

2. Negative symptoms: The absence of something that should be present (e.g., interest in hygiene, motivation, ability to experience pleasure)

3. Cognitive symptoms: Often subtle changes in memory, attention, or thinking (e.g. impaired executive functioning [the ability to set priorities or make decisions])

4. Affective symptoms: Symptoms involving emotions and their expression

The positive symptoms usually appear early in the illness, and their dramatic nature captures our attention and often precipitates hospitalization. They are also the symptoms most laypersons connect with insanity, making schizophrenia the disorder most associated with being “crazy.” Positive psychotic symptoms, however, are perhaps less important prognostically and usually respond to antipsychotic medication. The negative symptoms tend to be more persistent and crippling because they reduce motivation and limit social and vocational success.

Positive symptoms

Positive symptoms are associated with an acute onset. These symptoms tend to respond well to medication, and individuals commonly function normally during remission. The positive symptoms presented here are categorized as alterations in thought, speech, perception, and behavior.

Alterations in thought.

We all experience thoughts that are irrational or exaggerated, yet we can usually catch and correct the error by using intact reality testing. This is an often automatic and unconscious process by which we sort out what is and is not real. People with impaired reality testing, however, make, maintain, and build upon errors in thinking, which contribute to delusions.

Delusions are false fixed beliefs that cannot be corrected by reasoning. About 75% of people with schizophrenia experience delusions at some time. Student nurses sometimes try unsuccessfully to reason a patient out of delusions by offering evidence of reality. This is counterproductive as an even stronger defense is developed for the position. Also, this may irritate the patient and slow the development of a therapeutic relationship.

The most common delusions are persecutory, grandiose, or those involving religious or hypochondriacal ideas. Table 12-1 provides definitions and examples of types of delusions. A delusion may be a response to anxiety or reflect areas of concern; for example, someone with poor self-esteem may believe he is Beethoven or an emissary of God, leading him to feel more powerful or important. Looking for and addressing such underlying themes or needs can be a key nursing intervention.

TABLE 12-1

Summary of Delusions *

DELUSION	DEFINITION	EXAMPLE
Control	Believing that another person, group of people, or external force controls thoughts, feelings, impulses, or behavior	Brian covered his apartment walls with aluminum foil to block governmental 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	Barbara believes that the birds sing when she walks down the street just for her.
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	Peter believed that the Secret Service was planning to kill him by poisoning his food; therefore, he would eat only prepackaged food.
Grandeur	Believing that one is a very powerful or important person	Sam believed he was a famous playwright and tennis pro.
Somatic Delusions	Believing that the body is changing in unusual ways (e.g., rotting inside)	David said his heart had stopped and was rotting away.
Erotomanic	Believing that another person desires you romantically	Although he barely knew her, Patti insisted that Eric would marry her if only his current wife would stop interfering.
Jealousy	Believing that one’s mate is unfaithful	Sally wrongly accused her spouse of going out with other women. Her proof was that he twice came home from work late (even though his boss explained that everyone had worked late).

^*A false belief held and maintained as true regardless of evidence to the contrary. This does not include sharing unusual beliefs maintained by one’s culture or subculture.

Just because someone has delusions does not mean that every story that sounds improbable is untrue. One patient repeatedly told the staff that the Mafia was out to kill him. The staff later learned that he had been selling drugs and had not paid his contacts and that gang members were trying to hurt or even kill him.

Concrete thinking refers to an impaired ability to think abstractly. For example, a nurse might ask what brought the patient to the hospital, and the patient might answer, concretely, “a cab” (rather than explaining that he had attempted suicide). Concreteness is often assessed through the patient’s interpretation of proverbs; a concrete interpretation of “The grass is always greener on the other side of the fence” would be “That side gets more sun, so it’s greener there.” Concreteness reduces one’s ability to understand and address abstract concepts such as love or the passage of time.

Alterations in speech.

Associations are the mental threads that tie one thought logically to another. In associative looseness, these threads are interrupted or disjointed; thinking becomes haphazard, illogical, and difficult to follow. Here”s an example: “I need to get a Band-Aid for my paper cut. My friend was talking about AIDs. Friends talk about French fries and how can you trust the French? They won’t let you take pictures of the menu at McDonald’s.”

Clang association is choosing words based on their sound rather than their meaning, often rhyming or having a similar beginning sound (“On the track …. have a Big Mac”; “Click, clack, clutch, close”). Clanging may also be seen in neurological disorders.

Word salad (schizophasia) is a jumble of words that is meaningless to the listener—and perhaps to the speaker as well—because of an extreme level of disorganization. (“Throat hoarse strength of policy dreadfully essential Brazilian highlighters on a boat reigning supreme!”)

Neologisms are made-up words (or idiosyncratic uses of existing words) that have meaning for the patient but a different or nonexistent meaning to others. (“I was going to tell him the mannerologies of his hospitality won’t do.”) This eccentric use of words represents disorganized thinking and interferes with communication.

Echolalia is the pathological repeating of another’s words and is often seen in catatonia.

Nurse: Mary, come get your medication.

Mary: Come get your medication.

Other disorders of thought or speech include:

• Religiosity: An excessive preoccupation with religious themes.

• Magical thinking: Believing that one’s thoughts or actions can affect others; this is common in children (e.g., wearing pajamas inside out to make it snow).

• Paranoia: An irrational fear of others, ranging from mild (wariness, guardedness) to profound (believing that another person intends to kill you). Note that persons who fear others may sometimes act defensively, harming the other person before that person harms the patient; this creates a risk to others.

• Circumstantiality: Including unnecessary and often tedious details in one’s conversation (e.g., describing your breakfast when asked how your day is going).

• Tangentiality: Leaving the main topic to talk about less important information; going off on tangents in a way that takes the conversation off-topic.

• Cognitive retardation: A generalized slowing in the pace of thinking, represented by delays in responding to questions or difficulty finishing one’s thoughts.

• Alogia, or poverty of speech: A reduction in spontaneity or volume of speech, represented by a lack of spontaneous comments and overly brief responses.

• Rapid or pressured speech

• Flight of ideas: Moving rapidly from one thought to the next, making it difficult for others to follow the conversation.

• Thought blocking: A reduction in the amount of thinking; an abrupt stoppage of thought that derails conversation.

• Thought insertion: Feeling that one’s thoughts are not one”s own or that they were inserted into one’s mind.

• Thought deletion: A belief that one’s thoughts have been taken or are missing.

• Illogical, disorganized or bizarre thinking

• Inability to maintain attention: Represented by easy distractibility, off-topic comments in group, or unfinished tasks.

Alterations in perception.

Alterations in perception involve errors in how one perceives reality. Hallucinations are the most common form of altered perception; other alterations in perception include the following:

• Depersonalization: A feeling that one is somehow different or unreal or has lost his identity. People may feel that body parts do not belong to them or may sense that their body has drastically changed (e.g., a patient may see her fingers as being smaller or more distant, or not her own).

• Derealization: A false perception that the environment has changed (e.g., everything seems bigger or smaller, or familiar surroundings seem somehow strange and unfamiliar).

Hallucinations involve perceiving a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking). Hallucinations differ from illusions in that illusions are misperceptions or misinterpretations of a real experience. For example, a man sees a coat on a shadowy coat rack and believes it is a bear; he sees something real, but misinterprets what it is.

Causes of hallucinations include psychiatric disorders, drug abuse, medications, organic disorders, hyperthermia, toxicity (e.g., digitalis), and other conditions. Types of hallucination include the following:

• Auditory: Hearing voices or sounds

• Visual: Seeing persons or things

• Olfactory: Smelling odors

• Gustatory: Experiencing tastes

• Tactile: Feeling bodily sensations

Auditory hallucinations are experienced by 60% of people with schizophrenia at some time during their lives (Riddle, Mason & Wykes, 2011). They may be vague sounds or indistinct or clear “voices.” Voices typically seem to come from outside the person’s head, and auditory processing areas of the brain are activated during auditory hallucinations just as they are when a genuine external sound is heard. This abnormal activation may cause hallucinations, but another leading theory is that “voices” are a misperception of one’s internally generated conversation.

John Nash, the world-renowned mathematician with schizophrenia portrayed in the film A Beautiful Mind (2001), describes the voices he heard:

I thought of the voices as …. something a little different from aliens. I thought of them more like angels …. It’s really my subconscious talking; it was really that …. I know that now.

Voices may be of person’s familiar or unknown, single or multiple. They may be perceived as supportive and pleasant or derogatory and frightening. Voices commenting on the person’s behavior or conversing with the person are most common. A person who hears voices struggles to understand the experience, sometimes developing related delusions to explain the voices (e.g., believing the voices are from God, the devil, or deceased relatives). Persons with chronic hallucinations may attempt to cope by drowning them out with loud music or by competing with them by talking loudly, and such auditory competition may in fact reduce hallucinations and serve as a recommended intervention (Na, 2009).

Command hallucinations direct the person to take an action. All hallucinations must be assessed and monitored carefully, because the voices may command the person to hurt self or others; for example, telling a patient to “jump out the window” or “hit that nurse.” Command hallucinations are often terrifying and may herald a psychiatric emergency. It is essential to assess what the patient hears, his ability to recognize the hallucination as “not real,” and his ability to resist any commands. Patients may falsely deny hallucinations, requiring observation for behavioral indications of hallucinations; these include tracking movements (e.g., turning or tilting the head as if to listen to someone), suddenly stopping current activity as if interrupted, talking to oneself, and moving the lips silently.

Visual hallucinations occur less frequently in schizophrenia and are more likely to occur in organic disorders such as acute alcohol withdrawal or dementia. Olfactory, tactile, or gustatory hallucinations are unusual; when present, other causes should be investigated.

Alterations in behavior.

Alterations in behavior include bizarre and agitated behaviors involving stilted, rigid demeanor or eccentric dress, grooming, and rituals. Other behavioral changes seen in schizophrenia include the following:

• Catatonia: A pronounced increase or decrease in the rate and amount of movement; the most common form is stuporous behavior in which the person moves little or not at all.

• Motor retardation: A pronounced slowing of movement.

• Motor agitation: Excited behavior such as running or pacing rapidly, often in response to internal or external stimuli; it can pose a risk to the patient (e.g., exhaustion, collapse, and even death) or others (being knocked down).

• Stereotyped behaviors: Repeated motor behaviors that do not serve a logical purpose.

• Waxy flexibility: The extended maintenance of posture, usually seen in catatonia. For example, the nurse raises the patient’s arm, and the patient continues to hold this position in a statue like manner.

• Echopraxia: The mimicking of movements of another. It is also seen in catatonia.

• Negativism: Akin to resistance but may not be intentional. The patient does the opposite of what he or she is told to do (active negativism) or fails to do what is requested (passive negativism).

• Impaired impulse control: A reduced ability to resist one’s impulses. Examples include interrupting in group or throwing unwanted food on the floor.

• Gesturing or posturing: Assuming unusual and illogical expressions (often grimaces) or positions.

• Boundary impairment: An impaired ability to sense where one’s body or influence ends and another’s begins. For example, a patient might stand too close to others or might drink another’s beverage, believing that, because it is near him, it is his.

Negative symptoms

Negative symptoms develop slowly and are those that most interfere with a person’s adjustment and ability to cope. Negative symptoms impede one’s ability to do the following:

• Initiate and maintain conversations and relationships

• Obtain and maintain employment

• Make decisions and follow through on plans

• Maintain adequate hygiene and grooming

Negative symptoms contribute to poor social functioning and social withdrawal. During the acute phase, they are difficult to assess because positive symptoms (such as delusions and hallucinations) dominate. See Table 12-2 for these and other negative symptoms.

TABLE 12-2

NEGATIVE SYMPTOMS OF SCHIZOPHRENIA

NEGATIVE SYMPTOM	DESCRIPTION
Affective blunting	A reduction in the expression, range, and intensity of affect (In flat affect, no facial expression is present.)
Anergia	Lack of energy; passivity, lack of persistence at work or school
Anhedonia	Inability to experience pleasure in activities that usually produce it
Avolition	Reduced motivation and spontaneous activity; inability to initiate tasks such as social contacts, grooming, and other activities of daily living (ADLs)
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
Thought blocking	A sudden interruption in the thought process, usually due to internal stimuli. Example: A patient abruptly stops talking in the middle of a sentence and remains silent. Nurse: What just happened now? Patient: I forgot what I was saying. Something took my thoughts away.