Positive symptoms

What are positive symptoms? 

Positive symptoms are a well-documented feature of schizophrenia and are arguably the most recognisable and conspicuous symptoms. Positive symptoms include hallucinations and delusions. Hallucinations are defined as a perceptual experience that occurs in the absence of any external sensory input, and are most commonly auditory, but can occur in any modality. Delusions are distortions or exaggerations of inferential thinking, which lack any logical consistency, are not explained by cultural beliefs, and persist regardless of contradictory evidence. Persecutory delusions involve the belief that people are “out to get” the individual, resulting in a lack of trust in others. Delusion of reference refers to the belief that neutral events are directed specifically towards the individual. Somatic delusions involve the belief that the individual has a physical ailment contrary to medical advice. Delusions of grandeur are characterised by an exaggerated belief that the individual has power, ability, or fame. Positive symptoms can cause extreme distress for the person. The severity of positive symptoms can significantly affect a person’s day-to-day function, quality of life, and may also be associated with impaired cognitive ability. Positive symptoms have been shown to be more responsive to antipsychotic treatment than other symptom dimensions.

What is the evidence regarding positive symptoms?

Moderate quality evidence finds features of hallucinations are similar across psychiatric conditions, apart from age of onset of hallucinations, which is earlier in non-clinical and dissociative disorder groups (<12 years) than in schizophrenia (late teens to early 20s), and is later in affective disorders, neurological disorders, and alcohol-related conditions (middle or older age). Moderate to low quality evidence finds appraisal of hallucinatory voices as malevolent or intrusive and unable to be controlled is associated with increased levels of distress, depression, and anxiety. Voices appraised as high in power or supremacy are also associated with increased distress and depression. Negative affect is greatest when voices are personally meaningful or emotional.

Moderate to high quality evidence finds small relationships between increased paranoia and low self-esteem or increased externalising attributional bias (incorrectly holding others responsible for negative events). Compared to controls, people with psychosis and persecutory delusions show a medium-sized effect of more externalising attributional bias, a large effect of low explicit (conscious) self-esteem, and a small to medium-sized effect of low implicit (unconscious) self-esteem. Compared to people with depression, people with psychosis and persecutory delusions show a large effect of more externalising attributional bias, a large effect of more explicit self-esteem, with no differences in implicit self-esteem. Compared to people with psychosis without persecutory delusions, people with psychosis and persecutory delusions show a medium-sized effect of more externalising attributional bias, with no differences in explicit or implicit self-esteem.

High quality evidence finds a medium-sized association between more severe delusions and more belief inflexibility. Moderate to high quality evidence finds medium to large effects of more jumping to conclusions (JTC), bias against disconfirmatory or confirmatory evidence (BADE/BACE), and more liberal acceptance (LA) in people with schizophrenia with current delusions than in controls. In people with schizophrenia without delusions, there were small to medium-sized effects of more BADE and LA, with no differences in JTC or BACE. When directly comparing people with schizophrenia with or without delusions, high quality evidence finds small to medium-sized effects of more JTC, BADE, BACE, and LA in those with delusions. There were no differences in JTC, BADE, BACE, and LA between people with schizophrenia with delusions or people with other psychiatric disorders with delusions, however when compared to people with other psychiatric disorders without delusions, there were medium to large effects of more JTC, BADE, BACE and LA in people with schizophrenia with delusions.

August 2019

Last updated at: 4:11 am, 21st August 2019
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