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Schizophrenia? Target 6 symptom clusters

During the interview include tests of verbal fluency and word list recall to detect problems in the cognitive symptom cluster

Vol. 8, No. 6 / June 2009

Diagnostic criteria for schizophrenia emphasize positive and negative symptoms at the expense of other domains, such as cognition or affective states. For a comprehensive, cross-sectional diagnostic assessment, I suggest looking for 6 symptom clusters—motor symptoms, disorganization, delusions and hallucinations, negative symptoms, cognitive symptoms, and affective symptoms—when treating patients with psychotic disorders.

Depicting these 6 symptom clusters graphically—in your mind or on paper—allows you to appreciate your patient’s problems and target interventions appropriately. View the diagram of a sample schizophrenia patient’s symptom clusters. A graph drawn on a blackboard or a piece of paper also is a good tool to educate patients and their friends, families, and caregivers about key aspects of schizophrenia beyond psychosis.

1 Motor symptoms

Note symptoms associated with antipsychotics (ie, iatrogenic morbidity), such as the restlessness with akathisia, tremor and bradykinesia with pseudoparkinsonism, and irregular abnormal movements with tardive dyskinesia. Consider catatonia if you see paucity of movement or peculiar motor behaviors.

2 Disorganization

Note speech, thinking, appearance, and behaviors that suggest disorganization. Symptoms in this cluster often make patients look “psychiatric.”

3 Delusions and hallucinations

For some patients with schizophrenia, symptoms in this cluster prevent treatment engagement (such as impairing paranoia) or pose a risk to the patient or the community (such as command hallucinations). Delusions and hallucinations often remit or are functionally irrelevant in patients who are treated successfully.

4 Negative symptoms

This symptom cluster, often associated with functional impairment, includes the 2 observable symptoms of blunted affect and alogia.

5 Cognitive symptoms

Executive dysfunction and verbal memory impairment also are associated with functional impairment but may not be apparent during the clinical encounter. To screen for typical problems in this cluster, I include tests of verbal fluency and word list recall during the interview.

6 Affective symptoms

Depression, anxiety, demoralization, and suicidality can affect your patient’s quality of life. Also look on the opposite pole for maniform or “mania-like” presentations, such as lack of inhibition, excitability, and irritability.

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