Is ambivalence a symptom of schizophrenia?

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Ambivalence is a state of mind involving mixed feelings or thoughts about a person, thing, or situation. These mixed feelings or thoughts can seem to pull in different directions.

Swiss psychiatrist Paul Eugen Bleuler, who first coined the psychiatric term “schizophrenia” in 1908, defined ambivalence as simultaneously having two separate ideas or personas in one’s mind or having conflicting attitudes or emotions.

Ambivalence is not an intrinsically negative state of mind. However, some evidence suggests that ambivalence might be more likely to arise in people with certain mental health conditions.

Schizophrenia is a psychotic disorder involving hallucinations, delusions, or disturbances in thoughts. Worldwide, schizophrenia affects about 1% of adults. In the United States, that figure lies between 0.6% and 1.9%.

Bleuler considered ambivalence as one of the four main symptoms of schizophrenia. The medical community no longer considers ambivalence an essential characteristic of this condition, but some evidence suggests that ambivalence is more prevalent among people with schizophrenia.

Doctors and scientists can measure ambivalence using a variety of methods. In older studies, experts sometimes used the Schizotypal Ambivalence Scale (SAS) to assess the degree to which a person was experiencing certain forms of ambivalence. The SAS uses a questionnaire to evaluate ambivalence as a schizotypal symptom or trait.

For instance, a 2008 study found that people with higher SAS scores were more likely to have schizophrenia-like symptoms than the control group members.

However, using different measurement techniques may yield different results. For example, the Revised Schizotypal Ambivalence Scale (rSAmb) is a different questionnaire for ambivalence. According to a 2014 study, there does not appear to be a strong correlation between a higher rSAmb score and schizophrenia symptoms.

A more recent 2020 study evaluated the level of ambivalence that people with schizophrenia showed toward their self-image. The study examined patterns in the participants’ brain activity using functional MRI (fMRI) and measured ambivalence using the SAS questionnaire. The people with schizophrenia showed a significantly higher level of ambivalence toward actual and ideal self-image in the behavioral task than the control group.

The relationship between ambivalence and schizophrenia is, therefore, unclear. Although people with this condition might experience mood changes that could lead to ambivalence, the research overall suggests that ambivalence is not the strongest indicator of schizophrenia.

Nowadays, healthcare professionals do not consider ambivalence to be definitive of schizophrenia. Doctors and psychiatrists will only diagnose someone with schizophrenia if that individual meets certain conditions. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) lists these as follows:

• Symptoms: For at least 1 month, the individual must have experienced at least two typical symptoms of schizophrenia. These symptoms include delusions, hallucinations, disorganized speech, highly disorganized behavior, or negative mood. At least one of those symptoms must be delusions, hallucinations, or disorganized speech.
• Dysfunction: During this period, the individual must have experienced significant problems in at least one major area of life, such as work, relationships, or self-care.
• Long lasting disturbance: The individual must have experienced at least 6 months of low mood or manifestations of the typical symptoms of schizophrenia.
• Ruling out other disorders: Doctors must be confident that the individual does not have other conditions, such as schizoaffective disorder, a depressive disorder with psychosis, or bipolar depressive disorder with psychosis. Healthcare professionals can rule these conditions out if the individual has not experienced any major depressive or manic episodes alongside their other symptoms for a significant length of time.
• No obvious cause: The individual must not have a condition or have taken any psychoactive substance that might explain their symptoms.

The DSM-5 also notes that healthcare professionals must take extra care in diagnosing schizophrenia when the individual has a history of autism spectrum disorder or a communication disorder that began in childhood. In this case, an individual should only receive a schizophrenia diagnosis if they have experienced prominent delusions or hallucinations for at least 1 month.

The DSM-5 notes that several conditions have some symptoms in common with schizophrenia, which can make the diagnosis challenging. Those conditions include:

• major depressive disorder with psychosis
• schizophreniform disorder and brief psychotic disorder
• delusional disorder
• bipolar disorder with psychosis
• schizoaffective disorder

Research suggests a strong association between some mood disorders and higher ambivalence levels. These disorders include depression and bipolar disorder but also schizoaffective disorder. Indeed, people with a higher rSAmb score are more likely to receive a diagnosis of schizoaffective disorder than one of schizophrenia.

Anyone who is experiencing symptoms of schizophrenia should contact a healthcare professional. The prospect of receiving a diagnosis of schizophrenia or another mental health condition may seem daunting, but healthcare professionals can offer care, support, and treatment options.

People who routinely experience ambivalence should also seek a doctor’s advice, even if it does not accompany other symptoms. Ambivalence may be related to a mood disorder such as depression. Early diagnosis and treatment typically lead to better outlooks for individuals with schizophrenia or a mood disorder.

It is normal to feel ambivalent about certain things from time to time. However, there is reason to believe that ambivalence might be more common among people with certain mental health conditions.

Although people with schizophrenia may be more likely than other people to experience regular ambivalence, healthcare professionals do not consider ambivalence a key symptom of this condition.