Psychology Case Study: Schizophrenia Diagnosis

Schizophrenia

• A chronic, debilitating mental disorder characterized by periods of loss of touch with reality (psychosis), persistent disturbances of thought, behavior, appearance, and speech, abnormal affect, and social withdrawal.
• Peak age of onset: 15-25 years for men and 25-35 years for women.
• Occurs equally in men and women, all cultures, and all ethnic groups studied.

Symptoms

• Classified as positive or negative.
• Positive symptoms: delusions, hallucinations, agitation, and talkativeness.
• Negative symptoms: lack of motivation, social withdrawal, flattened affect, cognitive disturbances, poor grooming, and poor speech content.
• Positive symptoms respond well to most traditional and atypical antipsychotic agents.
• Negative symptoms respond better to atypical than to traditional antipsychotics.

Course

• Three phases: prodromal, active (psychotic), and residual.
• Prodromal phase: avoidance of social activities, physical complaints, and new interest in religion, the occult, or philosophy.
• Active phase: disorders of perception, thought content, thought processes, and form of thought.
• Residual phase: characterized by negative symptoms, intact memory capacity, and typical level of consciousness.

Prognosis

• Involves repeated psychotic episodes and a chronic, downhill course over years.
• Suicide is common: more than 50% attempt suicide, and 10% of those die in the attempt.
• Better prognosis and lower suicide risk if the patient is older at onset, is married, has social relationships, is female, has a good employment history, has mood symptoms, and has few negative symptoms.

Etiology

• Genetic factors: schizophrenia occurs in about 1% of the population, and persons with a close genetic relationship to a patient with schizophrenia are more likely to develop the disorder.
• Other factors: season of birth (more people with schizophrenia are born during cold weather months), and possible viral infection of the mother during pregnancy.

Neural Pathology

• Abnormalities of the frontal lobes, lateral and third ventricle enlargement, abnormal cerebral symmetry, and changes in brain density.
• Decreased volume of limbic structures (e.g., amygdala, hippocampus).
• Neurotransmitter abnormalities:
  • Dopamine hypothesis: excessive dopaminergic activity in the limbic system causes positive symptoms.
  • Serotonin hyperactivity: implicated in schizophrenia.
  • Glutamate: implicated in schizophrenia, and NMDA antagonists are useful in treating neurodegenerative symptoms.

Severity

• Rated on a 5-point scale using the DSM-5.

Differential Diagnosis

• Medical illnesses that can cause psychotic symptoms (e.g., neurologic infection, neoplasm, trauma, disease).
• Medications that can cause psychotic symptoms (e.g., analgesics, antibiotics, anticholinergics, antihistamines, antineoplastics, cardiac glycosides).
• Psychiatric illnesses other than schizophrenia that may be associated with psychotic symptoms (e.g., bipolar I disorder, major depressive disorder, neurocognitive disorders, substance-related disorders).
• Personality disorders (e.g., schizotypal, paranoid, borderline) that are not characterized by frank psychotic symptoms.

Management

• Pharmacologic management: traditional antipsychotics and atypical antipsychotic agents.
• Psychological management: individual, family, and group psychotherapy to provide long-term support and help patients adhere to the drug regimen.

A 45-year-old man with a history of depressive and psychotic symptoms is treated for depression, but remains withdrawn and expresses a delusional belief. What is the most appropriate diagnosis?