Hypothet

ical
CaseofanAdultMal
ewhohasSchi
zopheni
awi
th
nohistor
yofsubst
anceabuse

Basedontheonthegiveninf
ormat
ion,Thepati
ent’
smedi cal
pr oblemsweret
heref
ore
i
denti
fi
edasschizophr
enia295.
90(F20.9)—afi
rstepi
sodepsy chosiswi
thi
nwhichhe
exhi
bit
edsignsandsymptomsofparanoia,i
nsomnia,andanorexia.

Cur
rentsev
eri
ty:
SEVERE

PRESENTI
NGPROBLEM:

Xav ier ,anmal eper sonaged21y earsol dcompl ainedofhear ingv oicesf ort hepast
8mont hsandl ossofappet it
e.Heal socompl ainedt hather oamedar oundt own
unconsci ousl ywhi l
ler eturni
nghome.Thepat ientf urtheraddedt hathef el tunsaf eand
thoughtt hati ndi vi
dual swant edt ohar m hi m.Hesai dhehadal sor eceiveddeat ht hreat s,
oneamongstwhi chwasacal lfrom anunf ami li
arnumber .Nowor dswer espoken,but
heper cei vedt hati thadbeenani ndi cationt hatmeantt hathisl ifewast obet aken.Hi s
soci alhi stor yr evealedt hathel i
v edwi thint heci t yal ongwi t
hhi smot herandsi ster .He
hadagi rl
friendwhom hecl aimedt obe i nnumer ouscount rybuti snonexi stent
accor dingt ohi spar entandsi ster .Ther ewasnocasehi storyofment alorphy sical
i
llness.Hehadaper sonalit
yofbei ngi ntrov ert .Whent hepat ientwasf irstseenatt he
psy chi at ricuni t,relev antsi gnsi ncl udedcompl aintsofdi ff
icultyi nsl eepi ng,l ossof
appet i
t e,and r oami ng ar ound t own.The pat i
entappear ed i nformal lydr essed.He
exhi bitedappr ehensi vebehav i
our ,f atuousl aught er,andhesi tancy .Heal sopacedt o
andf roont hewar d.Thepat i
entexper iencedaudi t
or yhal l
ucinat ions.Hecompl ainedof
hear ingv oicesandengagedi nt hirdper sonconv ersat i
onsi nvolvingdi ff erentpeopl e
ev ent houghhei sal one. Thepat iental socompl ainedt hathehear dpeopl et alking
abouthi m andi nsultinghi m,anumberofwhom heknew.Hewast herefor esuspi cious
andf el tuneasywi t
hot hers.Asar esult,thepat ientsai dthathehadbeenspendi ngt he
nightal oneandr efusedt oretur nt ohi spar ent s’ housebecausehewasn' tsaf et her e.He
bel i
ev edt hathehadbeent ar get ed.Thepat ient ’ssi st ersaidheof tencompl ainedt hat
peopl e want ed t o har m hi m and he f eltunsaf e.She al so added t hathe of ten
compl ai nedofr eceivingdeat ht hr eat sthroughphonecal lsfrom anunf ami li
arnumber .)
Upont hehospi t
aladmi ssi
ont her epor tindi cat edt hathebel iev edhewaspr eoccupi ed
wit hspi ritualityandbel ievedhi ssy mpt omswer espi ri
tual.Hesai dthatt her easonwhy
hev isitedt hehospi talwasbet weenhi m andhi sgi rl
friendwhosenthi mf oradmi ssi on.
Thepat iental sohadpoori nsight .Thepat i
entdemonst r
atedsuspect edadher ence
concer nssi ncehehadpoori nsi ghtandal sot hepat i
entr epeat edsev eralt imest hathe
bel i
ev edt her ewasnot hingwr ongwi thhim anddesi redt obedi schar ged.

Thepat i
enthadnott akenpr escript
ionmedi cati
onswi thi
nt hepastsi xmont hs
beforebeingseenatt hehospi t
alsincehehadnotbeendi agnosedwi thanyment al
statepreviously.Hehadnoknownal lergi
es,andhi sli
festyleinfor
mat i
onr evealedt hat
doesnotsmokeoruser ecreationaldrugs.Thepat i
ent’
sbl oodsampl esshowedt hathis
renalfunct i
on t est,lipid profil
et est,liverf uncti
on test ,and descentcountt est
conductedont het hir
ddayofhospi taladmi ssi
onwer ewithinnormal l
imits
Thepat ient’smedi calpr oblemswer et hereforei denti
fi
ed asschi zophrenia—a f i
rst
episodepsy chosiswi thinwhi chheexhi bit
edsignsandsy mpt omsofpar anoia,insomni a,
andanor exia.

DYNAMI
CS:
Hypothet
ical
CaseofanAdultMal
ewhohasSchi
zopheni
awi
th
nohistor
yofsubst
anceabuse
Xavierpr esent s.inappr opriateaf fect( e.g., l
aughi ngi ntheabsenceofan
appr opri
at est i
mul us) ,di st
ur bedsl eeppat ter nandal ackofi nter estineat ingorf ood
refusal.Deper sonal i
zat ion,der ealizat ion,andsomat icconcer nsoccurandsomet imes
reachdel usi onal propor ti
ons.Abnor mal it
iesi nsensor ypr ocessi ngandi nhibit
ory
capaci t
y, aswel lasr educt ionsi nat tent i
on, ar eal sof ound.Xav iershowsoci alcogniti
on
def i
cit
s,incl udingdef i
ci tsi
nt heabi li
tyt oinf ert hei ntentionsofot herpeopl eandmay
attendt oandt heni nteφr etirrelev antev entsorst imul iasdanger ousper hapsl eadingt o
thegener ationofexpl anat or ydel usi ons.Hei sal sol ackingi ni nsightorawar enessof
theirdisor der( i
.e.,anosognosi a).Thi slackof" '
insight "includesunawar enessof
sy mptomsofschi zophr eniaandi apr esenti nt heent i
recour seofi l
lness.Unawar eness
ofill
nessi st y
pi cal
lyasy mpt om ofschi zophr eni aitselfr athert hanacopi ngst r
ategy.It
i
scompar abl et othel ackofawar enessofneur ol ogical def i
citsf oll
owi ngbr aindamage,
termedanosognosi a.Thi ssy mpt om i st hemostcommonpr edict orofnon- adherencet o
treatment , andi tpredi ctshi gherr el apser at es, increasednumberofi nv ol
unt ar
y
treatment s, poor erpsy chosoci alf unct ioning, aggr ession, andapoor ercour seofi l
lness.

SYMPTOMS:

SCHI
ZOPHRENIA295.
90(
F20.
9)
DSM 5CRI
TERI
A PRESENTI
NGSYMPTOMS
A.Two( ormor e)oft hef ol
lowing,each Xavierexhibits sy mpt oms ofDel usions
presentf orasi gnifi
cantpor ti
onoft ime andHal l
uci
nati
onsbecausehecl aimedt o
during a 1 - mont h period (orl ess i
f havehear dv oi
cesofpeopl einsult
inghim
successfullyt r
eated) .Atl eastone of ev en ifi tdoes notexi stwhi ch i s an
thesemustbe( 1), (
2),or(3): i
ndicationofhallucination.Healsocl ai
med
torecievedeat ht hreatsfrom phonecal l
s
1.Delusions. evenifi tappear edt hatitdoesnothav e
any messages and added t hathe f el
t
2.Hallucinati
ons. unsafebecausepeopl ewant ed to harm
equent hi
m ev enwithoutbasi s.Hebel i
evedhi s
3.Di sorganized speech ( e.g.
,f r
derail
mentori ncoher ence). symp t
o ms appe ar b ecause he w as
preoccupied byspi ri
tuali
tyand had al so
4. Gr ossly disorganized or cat atoni
c cl
a i
me dt oh aveag irl
fr
iend( whoi sn on
behav i
or. exist
en t) wh i
ch i
s an indicat
ion of
Delusi
on.
5.Negat ivesy mpt oms( i
.e.
,di mini
shed
emot i
onal expressionorav ol
iti
on).
B.Forasi gnif
icantporti
onoft het ime Xav ier's int
erper
sonal funct
ioni
ng was
sincet heonsetoft hedisturbance,l evel aff
ect ed because ofhis delusi
ons.He
off unct i
oning in one ormor e maj or suspect edpeoplewhom heknew so,he
areas, such as wor k, interpersonal av oi
dedhi m andhealsosepar at
edf r
om
relat
ions,orsel f-
car
e,ismar kedlybel ow hisf ami l
ybecause he beli
eved he was
thelev elachievedpr i
ortot heonset( or al
way sindanger.
when t he onset i s in chi ldhood or
adolescence,t hereisf ai
luret oachi ev e
expected l evel of i nterpersonal,
Hypothet
ical
CaseofanAdultMal
ewhohasSchi
zopheni
awi
th
nohistor
yofsubst
anceabuse
academi
c,oroccupat
ional
funct
ioni
ng)

C.Cont i
nuoussi gnsoft hedi st
ur bance Hi s sy mptoms hav e persi
sted f or 8
persistf oratl east6 mont hs.Thi s 6- mont hs. He has been sufferi
ng f r
om
mont h per i
od musti nclude atl east1 hal l
ucinati
onsanddelusi
onsfor8mont hs.
mont h of sy mpt oms ( or l ess i f Hehadoddbel ief
sandunusualperceptual
successf ul
lytreated)t hatmeetCr i
terion experiencescausedbyhi
shall
ucinati
ons.
A( i
.e.,acti
ve-phasesy mpt oms)andmay
i
ncludeper i
odsofpr odromalorr esi dual
sympt oms.Dur ing t hese pr odromalor
resi
dual per i
ods, t he si gns of t he
dist
ur bancemaybemani festedbyonl y
negat i
vesy mpt omsorbyt woormor e
sympt omsl istedi nCr i
teri
onApr esenti n
an at tenuated for m ( e.
g.,odd bel iefs,
unusual perceptual experiences) .
D. Schi zoaffect
ive di sorder and Ther ewasnoi ndicati
onofmanicepi
sodes
depressive or bi polar disorder wi th ormajordepressiv
esy mptomsandthere
psychoticf eatureshav ebeenr uledout isabsenceformoodepi sodes.
becauseei ther1)nomaj ordepressiveor
manic epi sodes hav e occur red
concurrently wi t
h t he act ive-phase
symptoms,or2)i fmoodepi sodeshav e
occurreddur i
ngact i
ve-phasesy mpt oms,
theyhav ebeenpr esentf orami nor i
tyof
the totaldur ati
on of t he act i
ve and
resi
dual periodsofthei l
lness.
E.Thedi sturbanceisnotatt
ri
butableto The pat i
enthad nott aken prescri
pti
on
thephy si
ologicaleff
ectsofasubstance medi cati
onswi thi
nt he pastsi xmont hs
(e.
g.,adr ugofabuse,amedi cat
ion)or beforebei ngseenatt hehospitalsincehe
anothermedi calcondi
ti
on. hadnotbeendi agnosedwi thanyment al
state pr evi
ously. He had no known
all
ergies,and hi s lifesty
le infor
mat i
on
revealed thatdoes notsmoke oruse
recreati
onaldrugs.
F.Ift
hereisahistoryofaut ism spect r
um Xav i
erdosnotpassthecr
it
eri
aforAuti
sm
disor
deroracommuni cati
ondi sor derof Spect
rum Disorder and any r el
ated
chil
dhoodonset,theaddi t
ionaldi agnosis i
ll
nesses.
of schizophreni
a i s made onl y if
prominentdel
usionsorhal l
ucinations,in
addit
iontotheot herrequiredsy mpt oms
ofschizophr
enia,areal sopr esentf orat
l
east1 mont h( orl ess ifsuccessf ull
y
tr
eated).

ASSESSMENTSTRATEGY:
Hypothet
ical
CaseofanAdultMal
ewhohasSchi
zopheni
awi
th
nohistor
yofsubst
anceabuse
Di
agnosisofschi
zophreni
ainvol
vesrul
ingoutothermentalheal
thdi
sor
der
sand
deter
mi ni
ngthatsympt
omsar enotduetosubstanceabuse,medicat
ionoramedi
cal
condit
ion.Det
ermini
ngadiagnosisofschi
zophreni
amayi ncl
ude:

Physi
calexam.Thi
smaybedonetohelprul
eoutotherprobl
emst
hatcoul
dbe
causingsymptomsandtocheckf
oranyr
elatedcompl
icati
ons.

Test
sandscreeni
ngs.Thesemayi
ncludetest
sthathel
pruleoutcondit
ionswith
si
mil
arsymptoms,andscr
eeningf
oral
coholanddrugs.Thedoctormayalsorequest
i
magingstudi
es,
suchasanMRIorCTscan.

Psychi
atriceval
uati
on.Adoctorormentalhealt
hprofessi
onalchecksmental
statusbyobser v
ingappearanceanddemeanorandaskingaboutthoughts,moods,
delusions,hall
ucinat
ions,
substanceuse,andpotenti
alf
orviol
enceorsuici
de.Thi
salso
i
ncludesadi scussi
onoffami l
yandpersonalhi
story
.

Diagnosti
ccri
ter
iaforschi
zophreni
a.Adoctororment
alheal
thprofessi
onalmay
usethecri
ter
iaint
heDi agnost
icandStat
ist
ical
ManualofMental
Disorders(DSM-5)
,
publ
i
shedbyt heAmericanPsychiat
ri
cAssociat
ion.

DI
SCUSI
ON:

DI
AGNOSTI
CFEATURES

SCHI
ZOPHRENI
A295.
90(
F20.
9)

The char act eri

stic sympt oms ofschi zophreniai nvolvear ange ofcogni ti
v e,
behav ioral,andemot ionaldysfunct ions,butnosi nglesy mpt om i spat hognomoni cof
thedi sor der.Thedi agnosisi nvolvest her ecognitionofaconst ell
ati
onofsi gnsand
sympt omsassoci atedwi thimpai redoccupat ionalorsoci alf unctioning.I ndi
v i
dualswi th
the di sor der wi l
lv ary subst antially on most f eat ures,as schi zophr eni
ai sa
heterogeneous cl i
nicalsy ndrome.Mood sy mptoms and f ullmood epi sodes ar e
commoni nschi zophr eni
aandmaybeconcur rentwi thact ive-phasesy mpt omat ology .
Howev er,as di st i
nctf rom a psy chot ic mood di sor der,a schi zophrenia diagnosi s
requirest hepr esenceofdel usionsorhal l
ucinationsi nt heabsenceofmoodepi sodes.
Inaddi ti
on,moodepi sodes,takeni nt otal
,shoul dbepr esentf oronl yami norit
yoft he
totaldur at i
onoft heact iveandr esi dualper i
odsoft hei llness. I
naddi tiont othef iv e
sympt om domai nareasi denti
fiedi nt hediagnost i
ccr i
t eria,theassessmentofcogni ti
on,
depressi on,and mani a sympt om domai ns isv i
talf ormaki ng cr i
ticall
yi mpor tant
disti
nct i
onsbet weent hevari
ousschi zophr eniaspect rum andot herpsy chot icdisorder s.