4 Categories of Psychotic Symptoms

To further understand the spectrum of psychosis, it's important to become familiar with the broad range of symptoms. These are more expansive than the “hearing voices” and paranoia most often associated with the experience.

Readers may be surprised to discover four categories of psychotic symptoms. These include the positive, negative, disorganized and catatonic categories. While four categories and dozens of symptoms may at first seem overwhelming, I‘ve found my students quickly memorize and recognize them so long as they kept well-organized, as follows:

Positive symptoms

This category is not called positive because the symptoms are somehow beneficial or preferable. Rather, positive indicates additional experiences, and the two items under this umbrella are hallucinations and delusions.

Hallucinations are internally generated sensory experiences. There is nothing in the person’s environment generating the (to them) very real, voices, noises, visions, smells, tastes or tactile experiences they are experiencing. The latter three hallucinatory experiences are very rare outside of psychosis generated by underlying medical conditions or effects of a substance, and should always lead to referral for medical evaluation. (Readers can learn more about this here.)

Delusions are fixed, false beliefs that are held with conviction. In essence, the individual is convinced there are things happening for which there is no clear evidence. Sometimes these are plausible or believable in nature, known as non-bizarre delusions. Examples include being cheated on, someone plotting against them, or of a somatic nature, such as being pregnant or having a disease.

Bizarre delusions, on the other hand, are implausible, or highly unlikely in nature. These can range from the belief that others can hear their thoughts or put thoughts into their head, to being experimented on by aliens. One of the more bizarre delusions is nihilistic in nature, like someone believing they don’t actually exist.

Many people experience both hallucinations and delusions, and the delusional material informs the hallucinations. I once worked with someone who believed they were the second coming of Christ. Not surprisingly, he reported hearing God’s voice telling him this. Additionally, he became unable to grasp items, and often looked at his palms and then to the floor. When asked if he was OK, he said, “You can’t see it?” and explained the holes from crucifixion hurt, and he was bleeding on the floor.

Negative symptoms

In contrast to the positive, negative symptoms indicate an absence of things that should be present. This category includes:

• Avolition: The inability to do the things someone wishes to.
• Cognitive impairments: These include the inability to focus and slow cognition.
• Flat or inappropriate affect/facial expression: A lack of expression or expression that’s incongruent to the content, like smiling brightly while talking about being scared.
• Poverty of speech/mutism: This often manifests in one-word or otherwise simple verbalizations, or complete lack of speech.
• Poverty of speech content: What the person is saying lacks any substance. It’s best illustrated in this video at the 1:25-1:40 mark when the interviewer asks why the person is hospitalized.
• Social withdrawal: Disengagement from others that’s often driven by feelings of not fitting in due to the illness or paranoia.
• Thought blocking: The person clearly has something to say, or is in the process of saying it, and falls silent, appearing as if they still have something on their mind to complete, but can’t get it out. To use a railroad metaphor, it is as if the gates are down, the lights are flashing, but the train isn’t coming.

Disorganized symptoms

Disorganization in psychosis does not simply mean someone lives in clutter. Rather, they suffer from severe thought disorganization with the following characteristics:

• Circumstantial thought process: The person does not get to the point linearly. There are many unnecessary/unrelated details leading listeners to lose sight of the topic at hand, but the person eventually ties it together.
• Clanging: A rhyming or sing-song speech pattern. The person is more interested in how what they’re saying sounds, than in its meaning, perhaps almost Dr. Seuss-like. For example, “I like that boat. Boat or goat? Goats on boats, boats in motes.”
• Flights of ideas/thought derailment: This includes jumping between topics without fully completing thoughts. Derailment is severe, where someone will be talking about, say, the clothes they’re wearing and halfway through, start on an unrelated topic without warning or transition.
• Loose associations: Drawing parallels between two unrelated items. For instance, a patient once said to me, while holding a carton of Hood brand milk, “Look! I told you it’s OK. There’s no trouble here. This milk is Hood. I’m from the ‘hood. It’s all good.”
• Neologisms: Literally translated, this means “new words.” In terms of psychosis, the words don’t make much sense except to the patient, and are used to try and describe some experience they have for which there is no known word. I recall one person saying their day was “purpling” them, which had something to do with trying to describe their moody vibe, given they vacillated between irritation (red) and sadness (blue).
• Word salad: A gross inability for verbal cohesion. Words pour out in a jumbled mass, such as, “Can we see that door off my shopping cart and monkeys?”

Catatonic presentations

It seems most people think of catatonia in terms of the Chief in One Flew Over the Cuckoo’s Nest; a withdrawn, unmovable, silent state. However, catatonic states can be withdrawn or excited, and we thus break catatonic symptoms in two categories.

People in withdrawn catatonic states tend to exhibit strange postures held for hours, and can also be placed in a posture by others. Conversely, they may also remain rigid, resisting others’ attempts to move them. They tend to not speak or have facial expression, though sometimes exhibit grimacing, and have no response to external stimuli.

Those in an excited catatonic state can appear agitated, act impulsively, perform meaningless, repetitious movements called stereotypes, echo others’ verbalizations or noises, and mirror others’ motions

In my last post, we reviewed how psychosis is more expansive than the schizophrenia diagnosis. For the next post, we'll examine how to accurately differentiate the various psychotic conditions.