Positive Symptoms in Schizophrenia

The typical positive symptoms of schizophrenia, such as hallucinatory experiences or fixed delusional beliefs, tend to be very upsetting and disruptive—not a positive experience at all for you or someone you care about who is experiencing them.

From the outside, a person with positive symptoms might seem distracted, as if they are listening to something. Psychiatrists call this “responding to internal stimuli”. They may have difficulty formulating their thoughts, and they speak in what is known as "word salad".

So why are these types of symptoms called "positive"?

The positive symptoms of schizophrenia according to the DSM-5-TR are hallucinations, delusions, disorganized thoughts, and abnormal motor behaviors. In contrast, the negative symptoms include a decrease in expressed emotions (previously known as flat affect), disinterest in usual activities and hobbies, and lack of motivation.

While these symptoms can be scary and extremely debilitating, taking the time to understand them (and the available treatments) can help you better cope or help a loved one do so.

Hallucinations

Hallucinations, which are not part of the normal, day-to-day experience for most people, are classified as a positive symptom for people with schizophrenia. In short, to hallucinate means to perceive things that others do not.

People with schizophrenia can experience a variety of hallucinations affecting all sensory modalities, including auditory, visual, touch, taste, and smell. The most commonly experienced by people with schizophrenia are auditory hallucinations (or hearing noises and voices). 

Each individual has a unique experience of hallucinations that can change over time with sounds and voices that can be quiet or loud, familiar or unfamiliar, frequent and infrequent. These can include:

• Clicks, knocks, telephone ringing, music, animal sounds
• Thought echos (where your thoughts are repeated back to you in a different voice)
• Full conversations between two or more people
• Tunning commentary about what you and others are doing
• Voices that talk to you directly

Hearing voices specifically is known as verbal auditory hallucinations. Some people experience helpful or useful auditory hallucinations that make them feel important and help them with daily tasks.

However, most of the time, the voices are described as mean, derogatory, threatening, and dismissive. At times, the voices can be in the form of commands and can tell you to do something that may cause harm to yourself or others.

In fact, a common reason for people with schizophrenia to come to the hospital is that the voices are telling them to harm or even kill themselves or others. If you feel like you are losing control and/or might act on the voice's orders, call your mental health provider or 911 immediately.

Delusions

Delusions are fixed beliefs that are not open to change despite the evidence to the contrary. For example, people with schizophrenia might think that the Secret Service is out to get them, that TV anchors are transmitting coded messages, or that their food is poisoned—and without any evidence.

Delusions can be experienced by people with schizophrenia, delusional disorder, mood disorders, dementia, delirium, brain injury, and other disorders. Delusions can be specified as bizarre, such as the belief that your organs have been removed by aliens, or non-bizarre, such as believing you are under surveillance by the police.

There are several types of delusions and, most often, they involve a specific theme. The DSM-5-TR recognizes the following subtypes:

Persecutory Delusions

Persecutory delusions are the most commonly experienced by someone with schizophrenia. A person with persecutory delusions believes others are out to harm them. This may include a belief that they are being followed or spied on, their house and phone are tapped, they are being drugged, slandered, or somehow conspired against.

Understandably, this can cause the person to become guarded, suspicious of anyone’s intention, and reluctant to answer questions or even associate with other people.

Reference Delusions

Delusions of reference are a belief that gestures, comments, or other cues in the environment have special meaning directed at oneself. That can mean you believe you are receiving secret messages from the newspaper or TV, or when people are laughing nearby, you might assume it is directed toward you.

Erotomanic Delusions

Erotomania occurs when a person believes that someone is in love with them, most frequently a famous or important person (like an actor or politician) but could be a co-worker or a stranger. This often results in them reaching out to that person who they believe is in love with them, and sometimes stalking behavior ensues.

Grandiose Delusions

Rooted in the French term "grande," grandiosity refers to an exaggerated sense of one's importance, power, talent, knowledge, or identity—without any corroborating evidence. They may believe they are a specific person who actually exists, and accuse the other of being an imposter. There are often religious themes of grandiosity, such as being "the chosen one" or Jesus himself.

Jealous Delusions

A person with jealous delusions goes beyond feelings of jealousy, and they are consumed by the thought that their spouse or partner is being unfaithful. They may install cameras, tracking devices, and other methods of keeping an eye on their lover. Despite lack of evidence, the jealous delusions persist, and can lead to interpersonal violence in relationships.

Nihilistic Delusions

Nihilistic thinking can reflect beliefs about the world or about one's own existence. They may believe the world is coming to a catastrophic end or has already ended, or that reality doesn't exist.

Somatic Delusions

A person with somatic delusions has central themes involving bodily functions or sensations. This may manifest as a feeling of bugs crawling on or inside your body. One might insist that they have a medical ailment or are pregnant even though medical tests assure them otherwise. There can be oral fixations, where you believe you have horrible bad breath, or you feel there are foreign bodies in your mouth.

• Walking corpse syndrome, or zombie syndrome (also known as Cotard syndrome) is when one believes they are dead, rotting away, or does not really exist. This can refer to one's entire body or person, or be specific to a certain limb, organ, blood, or soul.

Delusions of Control

Delusions of control refer to the belief that one does not have control over their own mind or body. There are several variations:

• Thought Broadcasting: The notion that your thoughts are perceivable by others.
• Thought Withdrawal: The belief that your thoughts have been withdrawn, against your will, by an outside entity.
• Thought Insertion: The belief that people (or aliens, entities, etc.) are inserting thoughts into your mind.
• Delusion of Outside Control: A belief that you are being controlled or manipulated by outside forces.

Delusions of Misidentification

There are several variations of delusions of misidentification that involve mixed themes of paranoia, conspiratorial thinking, magical thinking, and delusions of persecution:

• Delusion of Intermetamorphosis: A person with this delusion believes they can see other people change or morph into another person or being (intermetamorphosis). They typically perceive a change in both the external appearance and the core personality.
• Fregoli Syndrome: The belief that a familiar person is changing their appearance, usually due to an ulterior motive. You might believe someone is wearing a disguise with wigs or a mask or has undergone plastic surgery. This typically occurs in the context of paranoia, when you believe you are being followed, persecuted, or conspired against, and the familiar person takes on various identities to carry out their duties.
• Delusion of Doubles: Also known as Capgras syndrome, this is the belief that someone familiar has been replaced by an imposter, a clone, a look-alike, or has been taken over by an evil spirit. Some may believe their pet or even inanimate objects in their environment have been replaced.

Disorganized Thinking

Disorganized thinking can be extremely frustrating, making it nearly impossible for people with schizophrenia to keep their thoughts straight or express what's on their minds. This positive symptom causes a series of disjointed thoughts, making it hard to follow or make sense of what a loved one with schizophrenia is trying to say.

At times, the language structure is completely lost and the process of thinking may come to a complete, sudden stop (known as thought blocking).

Abnormal Motor Behavior

Another positive symptom of schizophrenia is disorganized or abnormal movements. This could look like agitation, pacing, silliness, and catatonia. Catatonia can have a range of motor behaviors including a severely diminished reaction to the environment, bizarre posturing, and resistance to instructions. There can be facial grimacing, repetitive movements, and echoing what others say.

Treatment

Treating the positive symptoms of schizophrenia ideally involves a multidisciplinary approach that includes psychiatric medication, psychological treatment, and social support.

Psychiatric Medication

Antipsychotic medications are the mainstay of treatment for positive symptoms. These include first generation or "typical" antipsychotics, including Haldol (haloperidol) and Thorazine (chlorpromazine), and second-generation antipsychotics or "atypical" antipsychotics, such as Abilify (aripiprazole), Clozaril (clozapine), Risperdal (risperidone), or INVEGA (paliperidone).

Psychological Treatment

When combined with the proper medication, therapy is a crucial part of treatment for people with schizophrenia as well as their family members. There are various types of therapies that can help you or someone you love better understand and cope with positive symptoms, including:

• Cognitive behavioral therapy (CBT): provides a sense of empowerment and strategies to help regulate your thoughts, emotions, and behaviors
• Family therapy: helps navigate challenges together and communicate each other's needs
• Group therapy: prevents isolation and provides a safe space to share challenges and fears
• Social skills training: helps navigate interpersonal dynamics in your family, social, and work lives

Social Support

With schizophrenia, you will need a good support system in place to be on the lookout for behavioral changes or signs of relapse; it's tough to notice these symptoms in yourself. This can include trusted friends and family members, peers, doctors or social workers, or coworkers or schoolmates who want to help you feel good and function at your best.

In addition to joining a local or online support group, people with schizophrenia may want to consider community housing and/or group homes, which can provide high-quality care in a safe environment. Of course, this is an individual decision best made with guidance from your family, mental health professional.

A Word From Verywell

Schizophrenia can be extremely isolating, especially when positive symptoms prevent you from organizing and communicating your thoughts or cause you to see, hear, and believe things no else does. Remember, you are not alone. Taking the time to find the right medication, therapy, and support can help you cope with your symptoms and gain better control of your life.