Why This Type of Schizophrenia Is Often Overlooked

Source: Cottonbro/Pexels

Schizophrenia—incoherent activity, paranoia, talking gibberish to people who aren’t there, perhaps some catatonia, right?

Partially.

Schizophrenia Review

As of 2013 and the DSM-5, schizophrenia is no longer subtyped, as sufferers often have cross-subtype symptomatology. Those familiar will know, for instance, it’s not unusual to encounter someone having marked hallucinations or delusions of what was termed the paranoid type, with a grossly disorganized speech of the historical hebephrenic type, for example.

While many exhibit such mixed profiles, patients can still trend heavily toward particular symptom clusters. Therefore, it’s not unusual to still see references to subtyping by researchers and practitioners (e.g., Trifu et al., 2017; Krzystanek et al., 2019; Jaine & Mitra, 2022). Some may, for example, be much more obviously disorganized than hallucinating or delusional, or vice versa. Nowadays, instead of subcategorizing based on the most prominent symptom type, schizophrenia is defined as at least six months of a combination of the following symptoms:

• Positive symptoms: Positive means additional experiences (i.e., delusions and hallucinations). Such individuals may act in accordance with false beliefs (delusions) and be responding to stimuli (hallucinations) that aren’t there.
• Negative symptoms: This is the lack of things that are normally present. Lack of expression, social withdrawal, paucity of speech, and cognitive slowing are common examples.
• Disorganized symptoms: An incoherent thought process and similar activity is a hallmark. Thoughts are often derailed, and there may be no cohesion between words (“word salad”), words may be created (neologisms), or speech may be in a rhyming fashion. Further, there can be repetitious, meaningless activity and bizarre or inappropriate actions.
• Catatonic symptoms: Sufferers often are stuck in a posture, have Gumby-like flexibility where they can be molded into position, and speak little, if at all (e.g., “Chief” in One Flew Over the Cuckoo’s Nest). Conversely, they can also be very agitated with jerky motions and echo others’ speech or actions.

Historically, the paranoid type meant the patient’s experiences were dominated by positive symptoms; hebephrenic, by disorganized behavior; and catatonic, by the presence of any catatonia. Such colorful symptom presentations are hard to miss. However, there is one other, more subdued presentation that may fly under the radar, especially for those unfamiliar with schizophrenia. It’s a deficit (or negative symptom)—a predominant presentation that the DSM would historically have subtyped as “undifferentiated” as it didn’t fit with the other three more classic presentations.

Schizophrenia researchers (e.g., Kirkpatrick & Galderisi, 2008; Voineskos et al., 2013; Cyran et al., 2023) have advocated this be acknowledged as the “deficit subtype.” Such patients, in my experience, showed a depressive-like physical and mental torpor. This tends to be accented with the following:

• Little-to-no affective range, including voice intonation or hand motions. Sometimes odd expressions occur.
• Communication may be limited to one-word answers or fragments (“poverty of speech”). If answers are more verbose, they can lack substance (“poverty of content”). For instance, an individual being asked what it was like re-entering jail might say, “It feels like I’m someplace else.” Pressing for more meaning only brings clarification of, “Well, it’s not at home.”
• Another typical symptom is “thought-blocking.” It’s as if the sufferer has something to say, but the thought can’t gather traction to form into speech. A blank stare, sometimes looking through you, often accompanies the phenomenon.
• Avolition, or the decrease in motivation and ability to carry out tasks, is a common negative symptom. For instance, the person might know they have to eat but can’t rally the executive functioning to cook something.
• Cognitive deficits are an under-recognized aspect of schizophrenia (e.g., McCutcheon et al., 2023) but are often present. This means not only disorientation or trouble retaining information but a decrease in IQ (e.g., Zanelli et al., 2019).

Differential Diagnosis

Patients presenting with a combination of the above, at first glance, could seem to suffer a neurodevelopmental complication. After all, lack of expression, trouble communicating, avolition, and cognitive deficits aren’t unusual symptoms. However, underneath these marked negative symptoms is commonly a series of fragmented hallucinatory and delusional material and maybe some disorganized activity. The case of Jake (name disguised) illustrates this presentation:

Jake entered jail unknown to the facility. A frail-looking man in his late 50s, Jake would mingle with others, but never had much to say. Staff needed to provide him reminders and encouragement to carry out simple tasks, like cleaning his cell and managing hygiene. Correctional officers explained that Jake seemed “lost” if you tried to talk with him, and when alone would be seen mumbling to himself.

Upon introducing myself to Jake, he flashed an odd grin and said, “Are you here to talk about business?”

“What business were you thinking we’d discuss?” I asked.

After staring at me for a moment, he flatly replied, “business.” Jake made no effort to leave the interview, and answered my questions as best he could. Sometimes, he seemed to come “unplugged” and then back to life with brief answers.

Being unfamiliar with Jake, and provided the unusual presentation, I conferred with colleagues who opined he perhaps had serious cognitive impairments. Interestingly, as I got to know Jake, he would incoherently tell me something about “the snakes” and mumble to himself, “Oh, they’re out there, boy. They’re out there.” Soon, we received correspondence from Jake’s guardian, who happened to be an old friend of his. He explained that Jake, in his 20s, during Vietnam, was discharged from the service because of the onset of this presentation, which never abated. A product of deinstitutionalization, Jake became a local wanderer, but tended to steer clear of others. Now he was incarcerated for public intoxication and drug possession. When he engaged in treatment, explained Jake’s guardian, he was able to interact more effectively. The jail psychiatrist prescribed a second-generation antipsychotic, and within a couple of weeks, Jake no longer mumbled to himself and was considerably articulate. Though some features remained unchanged, he was able to engage more meaningfully and look after himself.

Clinical Implications

Clearly, differential diagnosis is essential. From a psychiatry standpoint, antipsychotic medication would likely not help a congenital cognitive complication but could bring about a better quality of life for someone like Jake. Further, regarding psychotherapy, people like Jake seem to have “gone into hibernation,” perhaps as a defense against revealing vulnerabilities to the outside world after some instigating event. It’s as if they want to be a part of the bigger world but are not sure if they fit or that it’s safe.

Psychiatry Essential Reads

Is Psychiatry Waking Up to the Truth About Mental Illness?

When Substance Abuse and Psychiatric Issues Collide

Regardless of the triggering experience, a relational approach to work can help immensely in rousing them to encounter the “outside” world again more effectively. Once a relationship is established, exploring their inner experiences and any hallucinatory or delusional material to better understand their conflicts can also help. Like people with more positive symptoms or disorganized presentations, there will also likely be an encouragement for medication compliance and family work to be done for the best results.

Source: Tumisu/Pixabay

Tips for Recognizing Deficit-Type Schizophrenia

• Presentation is marked by chronic, aforementioned negative symptoms, especially lack of expression and speech and struggles in articulating.
• Hallucinations or delusions, disorganized thoughts and behaviors, and catatonia are fragmented or fleeting if present.
• There is no developmental history congruent with neurodevelopmental disorders. This includes congenital cognitive complications, delayed milestones, and inability to relate and play effectively.
• There is a family history of schizophrenia-spectrum illness.
• Male-assigned gender (e.g., Roy et al., 2001; Li et al., 2016).
• The profile isn’t post-acute hallucinatory, delusional, or disorganized episode. Such schizophrenia sufferers can go into remission but maintain some prominent negative features.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual’s provider or formal supervision if you’re a practitioner or student.

Facebook/LinkedIn image: Bricolage/Shutterstock