Schizophrenia

A patient hears a voice commanding them to stop eating because the food is poisoned. That's not anxiety or delirium — it's a positive symptom of schizophrenia, and your assessment response matters.

Positive symptoms represent an excess or distortion of normal function — things added to the patient's experience that shouldn't be there. The four pillars are hallucinations, delusions, disorganized speech, and disorganized or catatonic behavior. Auditory hallucinations are by far the most common type in schizophrenia (heard in roughly 60–80% of cases); visual hallucinations should raise suspicion for an organic cause. Delusions are fixed, false beliefs — persecutory (someone is out to harm them), grandiose (they have special powers), and referential (the TV is sending them personal messages) are the most tested types. Disorganized speech includes loose associations (jumping between unrelated topics), tangentiality, neologisms (made-up words), and word salad. Disorganized behavior ranges from unpredictable agitation to catatonia. These symptoms typically respond to antipsychotic medication and are the primary targets during acute psychotic episodes. For assessment, you document the specific content of hallucinations — especially command hallucinations directing self-harm — because these dictate the safety plan.

Key Distinctions

Don't confuse positive symptoms (additions: hallucinations, delusions) with negative symptoms (subtractions: flat affect, avolition, alogia). Students often mistake illusions (misperceptions of real stimuli) for hallucinations (perceptions without any external stimulus). A patient who hears a voice with no source present has a hallucination; one who sees a coat rack and thinks it's a person has an illusion.

Clinical Pearl

Positive means 'plus' — something extra got added to reality. If the patient is experiencing things that aren't there or believing things that aren't true, you're looking at positive symptoms.

Negative Symptoms & Function

Negative symptoms represent what is taken away from the patient's baseline personality and functioning. They are deficits, not additions. The classic cluster is remembered by the 5 A's: Affective flattening (near-complete absence of emotional expression — flat face, monotone voice, poor eye contact), Alogia (poverty of speech — brief, empty replies, not pressured speech), Avolition (inability to initiate or sustain goal-directed activity — the patient sits in bed all day, not from sadness but from absent motivation), Anhedonia (loss of pleasure in previously enjoyed activities), and Asociality (withdrawal from social interaction). These symptoms often appear before the first psychotic break and persist after positive symptoms are controlled with medication. Negative symptoms are harder to treat than positive ones; typical (first-generation) antipsychotics primarily target positive symptoms. Atypical (second-generation) antipsychotics like clozapine have better — though still limited — efficacy against negative symptoms. Nursing assessment focuses on functional changes: ADL participation, social engagement, speech quantity, and emotional responsiveness. These symptoms are the primary driver of long-term disability.

Key Distinctions

Don't confuse negative symptoms with depression — both show withdrawal and anhedonia, but depression includes sadness, guilt, and suicidal ideation; negative symptoms present with emotional blankness, not emotional pain. Students mistake alogia (poverty of speech) for mutism or sedation from medication. Flat affect (near-complete absence of expression) is different from blunted affect (significantly reduced but present expression) — NCLEX uses these terms precisely.

Clinical Pearl

Think of negative symptoms as the 5 A's: Affect flat, Alogia, Avolition, Anhedonia, Asociality. They subtract from the person — that's why they're called negative.