Psychotic Signs and Symptoms

  • Oliver Freudenreich
Part of the Current Clinical Psychiatry book series (CCPSY)


Descriptive psychopathology which includes phenomenology provides language to describe a patient’s behavior and inner experiences. This chapter reviews the main symptoms of psychosis (delusions, hallucinations, disorganized thinking), with emphasis on how to detect them. Recognizing Schneiderian first-rank symptoms which are evidence of psychosis remains an important clinical skill for psychiatrists even though these symptoms are de-emphasized in current classification systems. Overvalued ideas are introduced as not all extreme views are psychotic. Last, disorganized behaviors and unusual motor phenomena (catatonia) are described as those often occur in psychotic patients.


Psychosis Descriptive psychopathology Delusions Overvalued ideas Hallucinations Pseudohallucinations Eponyms Schneiderian first-rank symptoms Self-disturbances Formal thought disorder Disorganization Disorganized behavior Catatonia 


  1. 1.
    Goethe. Available from: Accessed Jan 7 2019.
  2. 2.
    Fusar-Poli P. One century of Allgemeine Psychopathologie (1913 to 2013) by Karl Jaspers. Schizophr Bull. 2013;39:268–9.CrossRefGoogle Scholar
  3. 3.
    Broome MR, Harland M, Owen GS, Stringaris A. Jaspers’ approach 1: static understanding – ‘phenomenology’. In: Broome MR, Harland M, Owen GS, Stringaris A, editors. The Maudsley reader in phenomenological psychiatry. New York: Cambridge University Press; 2012. p. 91–100.Google Scholar
  4. 4.
    Stanghellini G, Broome MR. Psychopathology as the basic science of psychiatry. Br J Psychiatry. 2014;205:169–70.CrossRefGoogle Scholar
  5. 5.
    Stanghellini G. Psychopathology: re-humanizing psychiatry. Acta Psychiatr Scand. 2013;127:436–7.CrossRefGoogle Scholar
  6. 6.
    Ban TA. Evolution of diagnostic criteria in psychoses. Dialogues Clin Neurosci. 2001;3:257–63.Google Scholar
  7. 7.
    Crocq MA. French perspectives on psychiatric classification. Dialogues Clin Neurosci. 2015;17:51–7.PubMedPubMedCentralGoogle Scholar
  8. 8.
    de Leon J. Is it time to awaken sleeping beauty? European psychiatry has been sleeping since 1980. Rev Psiquiatr Salud Ment. 2014;7:186–94.CrossRefGoogle Scholar
  9. 9.
    Gaebel W, Zielasek J. Focus on psychosis. Dialogues Clin Neurosci. 2015;17:9–18.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Jaspers K. General psychopathology. Baltimore: The Johns Hopkins University Press; 1997.Google Scholar
  11. 11.
    Lattman P. The origins of Justice Stewart’s “I know it when I see it”. The Wall Street Journal. 2007 September 27, 2007.Google Scholar
  12. 12.
    Glowinski R, Payman V, Frencham K. Confabulation: a spontaneous and fantastic review. Aust N Z J Psychiatry. 2008;42:932–40.CrossRefGoogle Scholar
  13. 13.
    Spitzer RL, First MB, Kendler KS, Stein DJ. The reliability of three definitions of bizarre delusions. Am J Psychiatry. 1993;150:880–4.CrossRefGoogle Scholar
  14. 14.
    Karmacharya R, England ML, Ongur D. Delirious mania: clinical features and treatment response. J Affect Disord. 2008;109:312–6.CrossRefGoogle Scholar
  15. 15.
    Mash DC. Excited delirium and sudden death: a syndromal disorder at the extreme end of the neuropsychiatric continuum. Front Physiol. 2016;7:435.CrossRefGoogle Scholar
  16. 16.
    Fink M. Delirious mania. Bipolar Disord. 1999;1:54–60.CrossRefGoogle Scholar
  17. 17.
    Barrelle A, Luaute JP. Capgras syndrome and other delusional misidentification syndromes. Front Neurol Neurosci. 2018;42:35–43.CrossRefGoogle Scholar
  18. 18.
    Pang L. Hallucinations experienced by visually impaired: Charles Bonnet syndrome. Optom Vis Sci. 2016;93:1466–78.CrossRefGoogle Scholar
  19. 19.
    Bar-el Y, Durst R, Katz G, Zislin J, Strauss Z, Knobler HY. Jerusalem syndrome. Br J Psychiatry. 2000;176:86–90.CrossRefGoogle Scholar
  20. 20.
    Pillmann F. Carl Wernicke (1848–1905). J Neurol. 2003;250:1390–1.CrossRefGoogle Scholar
  21. 21.
    Rahman T, Resnick PJ, Harry B. Anders Breivik: extreme beliefs mistaken for psychosis. J Am Acad Psychiatry Law. 2016;44:28–35.PubMedGoogle Scholar
  22. 22.
    Jenkins G, Rohricht F. From cenesthesias to cenesthopathic schizophrenia: a historical and phenomenological review. Psychopathology. 2007;40:361–8.CrossRefGoogle Scholar
  23. 23.
    Schildkrout B. Joan of Arc-hearing voices. Am J Psychiatry. 2017;174:1153–4.CrossRefGoogle Scholar
  24. 24.
    Hielscher E, Connell M, Lawrence D, Zubrick SR, Hafekost J, Scott JG. Prevalence and correlates of psychotic experiences in a nationally representative sample of Australian adolescents. Aust N Z J Psychiatry. 2018;52:768–81.CrossRefGoogle Scholar
  25. 25.
    Hearing Voices Network. Available from: Accessed Jan 7 2019.
  26. 26.
    Taylor FK. On pseudo-hallucinations. Psychol Med. 1981;11:265–71.CrossRefGoogle Scholar
  27. 27.
    Kamp KS, Due H. How many bereaved people hallucinate about their loved one? A systematic review and meta-analysis of bereavement hallucinations. J Affect Disord. 2019;243:463–76.CrossRefGoogle Scholar
  28. 28.
    Dening TR, Berrios GE. The enigma of pseudohallucinations: current meanings and usage. Psychopathology. 1996;29:27–34.CrossRefGoogle Scholar
  29. 29.
    Schneider K. Klinische Psychopathologie. 15. Auflage. Stuttgart: GeorgThieme Verlag; 2007.Google Scholar
  30. 30.
    Mishara AL, Lysaker PH, Schwartz MA. Self-disturbances in schizophrenia: history, phenomenology, and relevant findings from research on metacognition. Schizophr Bull. 2014;40:5–12.CrossRefGoogle Scholar
  31. 31.
    Tandon R, Gaebel W, Barch DM, Bustillo J, Gur RE, Heckers S, et al. Definition and description of schizophrenia in the DSM-5. Schizophr Res. 2013;150:3–10.CrossRefGoogle Scholar
  32. 32.
    Peralta V, Cuesta MJ. Diagnostic significance of Schneider’s first-rank symptoms in schizophrenia. Comparative study between schizophrenic and non-schizophrenic psychotic disorders. Br J Psychiatry. 1999;174:243–8.CrossRefGoogle Scholar
  33. 33.
    Soares-Weiser K, Maayan N, Bergman H, Davenport C, Kirkham AJ, Grabowski S, et al. First rank symptoms for schizophrenia. Cochrane Database Syst Rev. 2015;1:CD010653.PubMedGoogle Scholar
  34. 34.
    Heinz A, Voss M, Lawrie SM, Mishara A, Bauer M, Gallinat J, et al. Shall we really say goodbye to first rank symptoms? Eur Psychiatry. 2016;37:8–13.CrossRefGoogle Scholar
  35. 35.
    Mendez MF. Non-neurogenic language disorders: a preliminary classification. Psychosomatics. 2018;59:28–35.CrossRefGoogle Scholar
  36. 36.
    Howes OD, Weinstein S, Tabraham P, Valmaggia L, Broome M, McGuire P. Street slang and schizophrenia. BMJ. 2007;335:1294.CrossRefGoogle Scholar
  37. 37.
    Bedi G, Carrillo F, Cecchi GA, Slezak DF, Sigman M, Mota NB, et al. Automated analysis of free speech predicts psychosis onset in high-risk youths. NPJ Schizophr. 2015;1:15030.CrossRefGoogle Scholar
  38. 38.
    Denysenko L, Sica N, Penders TM, Philbrick KL, Walker A, Shaffer S, et al. Catatonia in the medically ill: etiology, diagnosis, and treatment. The academy of consultation-liaison psychiatry evidence-based medicine subcommittee monograph. Ann Clin Psychiatry. 2018;30:140–55.PubMedGoogle Scholar
  39. 39.
    Freudenreich O, Francis A, Fricchione GL. Psychosis, mania, and catatonia. In: Levenson JL, editor. The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. 3rd ed. Washington, D.C.: American Psychiatric Association Publishing; 2019. p. 249–79.Google Scholar
  40. 40.
    Chalasani P, Healy D, Morriss R. Presentation and frequency of catatonia in new admissions to two acute psychiatric admission units in India and Wales. Psychol Med. 2005;35:1667–75.CrossRefGoogle Scholar

Additional Resources


    1. Hearing Voices Network (HVN) is an alliance of support groups that operates worldwide and provides an alternative, non-medicalized view of hallucinations. It represents an effort by the peer movement to destigmatize hearing voices and avoid aggressive, unhelpful psychiatric treatment. I consider them an important, alternative voice, hopefully collaborative and not in opposition to mainstream care, even if I do not agree with all their assumptions.


    1. Oyebode F. Sims’ symptoms in the mind: textbook of descriptive psychopathology. 6th ed: Elsevier; 2018. The standard (English) text since its first edition in 1988 about everything you ever wanted to know about descriptive psychopathology, written in clear language.Google Scholar
    2. Enoch MD, Ball HN. Uncommon psychiatric syndromes. 4th ed. London: Arnold; 2001. Detailed account of 11 more unusual, mostly eponymous psychiatric syndromes like Capgras. A book that used to be in the psychiatric canon.Google Scholar
    3. Sacks O. Hallucinations. New York: Vintage Books; 2013. A brilliant book by the late neurologist and medical writer about the varied facets of hallucinations.Google Scholar


    1. Berrios GE, Dening TR. Pseudohallucinations: a conceptual history. Psychol Med. 1996;26:753–63. An excellent discussion about the conceptual history of pseudohallucinations and its problems.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Oliver Freudenreich
    • 1
  1. 1.Department of PsychiatryMassachusetts General HospitalBostonUSA

Personalised recommendations