9.

2
SCHIZOPHRENIA
Schizophrenia is the most severe and debilitating of the Schizophrenia Spectrum and Other Psychotic
Disorders included in DSM-5. It is characterized by a range of cognitive, behavioral, and emotional
dysfunctions that include impairments in perception, inferential thinking, fluency and productivity of
thought and speech, behavioral monitoring, cognition, and the ability to express emotions and be
motivated. To meet criteria for a diagnosis of Schizophrenia, the syndrome must persist for at least 6
months, at least 1 month of which is characterized by particularly severe and impairing symptoms
known as the active-phase symptoms. Moreover, the symptoms must be severe enough to have had a
sig ifi a tl egati e i pa t o the pe so ’s ps hoso ial fu tio i g i te s of aintenance and
quality of employment, interpersonal relations, or academic achievement. No single symptom by itself is
indicative of Schizophrenia; the diagnosis involves the recognition of a constellation of signs and
symptoms associated with impaired psychosocial functioning.

The characteristic active-phase symptoms may be thought of as falling into two broad categories:
positive symptoms, which reflect an excess or distortion of normal mental functions; and negative
symptoms, which reflect a diminution or loss of normal mental function. The positive symptoms include
delusions (which can be understood as distortions or exaggerations of inferential thinking),
hallucinations (distortions in perception), disorganized speech (distortions in language, communication,
and thought processes), and grossly disorganized or catatonic behavior (distortions in behavioral
monitoring). Negative symptoms in Schizophrenia include avolition (restrictions in the initiation of goal-
directed behavior) and diminished emotional expression (restrictions in the range and intensity of
emotions). At least two such symptoms present for a significant amount of time during the same 1-

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Arlington, VA, American Psychiatric Association Publishing, 2017.
© American Psychiatric Association Publishing. Used with permission.
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month period are required for the diagnosis (as long as at least one of the symptoms is a delusion, a
hallucination, or disorganized speech; if the two symptoms are disorganized behavior and negative
symptoms, the criteria for Schizophrenia are not met). Given the large number of combinations of
symptoms that can justify a diagnosis of Schizophrenia, there is tremendous heterogeneity in the
diagnosis—patients with Schizophrenia can have widely different presentations with the only common
feature being the persistence of the symptoms and their negative impact on psychosocial functioning.

Many individuals go through an early phase (known as the prodromal phase) which is a forerunner to
the first active phase of the illness (sometimes referred to as the first psychotic break), and most
individuals with Schizophrenia go through residual phases in between active phases. These prodromal
and residual phases consist of milder versions of the positive symptoms as well as negative symptoms.
For example, some individuals during prodromal or residual phases may have unusual perceptual
experiences, such as sensing the presence of an unseen force. Others may express a variety of odd or
unusual beliefs that are not so firmly held by the person so as to be considered delusions, such as a
pe so ’s ha i g a st o g feeli g that othe people a e o spi i g to ha hi o he .

Although some mood symptoms such as depression, irritability, and expansive mood may occur at times
in patients with Schizophrenia, such symptoms are present for a minority of time during the whole
disturbance. Otherwise, the diagnosis would be Schizoaffective Disorder (see Section 2.3).

Drugs and medical conditions can cause hallucinations and delusions: a diagnosis of Schizophrenia
should not be made if the psychotic symptoms are in fact a manifestation of drug use or if they are due
to a general medical condition such as a brain tumor or hyperthyroidism. Given that individuals with
Schizophrenia Spectrum and Other Psychotic Disorders often abuse drugs (especially cannabis), it is
important to determine whether psychotic symptoms are the result of drug use (i.e., a Substance/
Medication-Induced Psychotic Disorder) and thus not indicative of a diagnosis of Schizophrenia (see
Section 2.7 for a discussion of how to make this determination). Similarly, if the psychotic symptoms are
a manifestation of an underlying medical condition, the diagnosis is Psychotic Disorder Due to Another
Medical Condition rather than Schizophrenia. Clues that the psychotic symptoms may be due to a
general medical condition include a close temporal relationship between the onset (and offset) of the
psychotic symptoms and the course of the general medical condition and atypical features such as a late
age at onset.

Even though cognitive impairment is not among the defining symptoms of Schizophrenia, it is common
in Schizophrenia and is strongly linked to academic (school) and occupational (work) impairment.
Individuals with Schizophrenia tend to have problems with attention and memory, especially with
regard to planning and organization to achieve a goal. They also often lack insight into the fact that they

Reprinted from First MB, Skodol AE, Williams JBW, Spitzer RL: Learning DSM-5 by Case Example.
Arlington, VA, American Psychiatric Association Publishing, 2017.
© American Psychiatric Association Publishing. Used with permission.
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have a mental illness. Issues with cognitive impairment, attention, memory, and lack of insight can make
the treatment of the person with Schizophrenia quite challenging because these features can lead to
nonadherence with a medication regimen, the mainstay of treatment.

Schizophrenia affects between 0.3% and 0.7% of the population and occurs slightly less often in females
than in males. Prodromal symptoms of Schizophrenia commonly occur in the teenage years, but the
psychotic features of Schizophrenia typically emerge between the late teens and early 30s and tend to
be earlier for males (peak onset in early 20s) than females (peak onset in late 20s.). Although onset
before adolescence is rare, cases do occur in young children.

UNDER SURVEILLANCE

Arthur Stanton is a 44-year-old single, unemployed white man brought into the emergency room by the
poli e fo st iki g a elde l o a i his apa t e t uildi g. He stated, That da it h—she and the rest
of them deserved more than that for what the put e th ough.

He has been continuously ill since age 22. During his first year of law school, he gradually became more and
more convinced that his classmates were making fun of him. He noticed that they would snort and sneeze
whenever he entered the classroom. When a girl he was dating broke off her relationship with him, he
elie ed that she had ee epla ed a look-alike. He called the police and asked for their help to solve
the kid appi g. His a ade i pe fo a e i s hool de li ed d a ati ally, and he was asked to leave and
seek psychiatric care.

Mr. Stanton got a job as an investment counselor at a bank, which he held for 7 months. While working in
that positio , he had ee getti g a i easi g u e of dist a ti g sig als f o coworkers, and he
became more and more suspicious and withdrawn. It was during this time that he first reported hearing
voices. He was eventually fired and soon thereafter was hospitalized for the first time, at age 24. He has not
worked since.

Mr. Stanton has been hospitalized 12 times, the longest stay being 8 months. However, in the last 5 years he
has been hospitalized only once, for 3 weeks. During the hospitalizations, he has received various
antipsychotic medications. Outpatient medication has been prescribed, but he usually stops taking it shortly
after leaving the hospital. Aside from twice-yearly lunch meetings with his uncle and his contacts with mental

Reprinted from First MB, Skodol AE, Williams JBW, Spitzer RL: Learning DSM-5 by Case Example.
Arlington, VA, American Psychiatric Association Publishing, 2017.
© American Psychiatric Association Publishing. Used with permission.
http://www.appi.org
Page 3 of 5
health workers, he is totally isolated socially. He lives on his own, cooking and cleaning for himself, and
manages his own financial affairs, including a modest inheritance. He reads the Wall Street Journal daily.

Mr. Stanton maintains that his apartment is the center of a large communication system that involves all of
the major TV networks, his eigh o s, a d appa e tl hu d eds of a to s i his eigh o hood. The e a e
secret cameras in his apartment that carefully monitor all of his activities. When he is watching TV, many of
his minor actions (e.g., going to the bathroom) are soon directly commented on by the announcer. Whenever
he goes outside, the a to s ha e all ee a ed to keep hi u de su eilla e. E e o e o the st eet
at hes hi . His eigh o s ope ate t o diffe e t a hi es ; o e is espo si le fo all of his oi es e ept
the joke . He is ot e tai ho o t ols this oi e, hi h isits hi o l o asio all a d is e fu .
The other voices, which he hears many times each day, are generated by this machine, which he sometimes
thinks is directly run by the neighbor whom he attacked. For example, when he is going over his investments,
these ha assi g oi es o sta tl tell hi hi h sto ks to u . The othe a hi e, hi h he alls the
d ea a hi e, puts e oti d ea s i to his head, usuall of la k o e .

Mr. Stanton describes other unusual experiences. For example, he recently went to a shoe store 30 miles
fo his house i the hope of getti g so e shoes that ould ot e alte ed. Ho e e , he soo fou d out
that like the rest of the shoes he buys, special nails had been put into the bottom of the shoes to annoy him.
He was amazed that his decision concerning which shoe store to go to must have been known to his
ha asse s efo e he hi self k e it, so that the had ti e to get the alte ed shoes ade up espe iall for
hi . He ealizes that g eat effo t a d illio s of dolla s a e i ol ed i keepi g hi u de su eilla e. He
so eti es thi ks this is all pa t of a la ge e pe i e t to dis o e the se et of his supe io i tellige e.

At the interview, Mr. Stanton is well-groomed and his speech is coherent and goal directed. His affect is only
mildly blunted. He was initially very angry at being brought in by the police. After several weeks of treatment
with an antipsychotic medication failed to control his psychotic symptoms, he was transferred to a long-stay
facility with the plan to arrange a structured living situation for him.

Discussion of Under Surveillance

M . Sta to ’s lo g ill ess, ha a te ized ultiple hospitalizatio s fo S hizoph e ia, appa e tly began
with delusions of reference (his classmates making fun of him by snorting and sneezing when he entered
the classroom). Over the years, his delusions have become increasingly complex and bizarre (his
neighbors are actually actors; his thoughts are monitored; a machine puts erotic dreams in his head). In
addition, he has prominent hallucinations of different voices that harass him. Given that all of the
required elements of Schizophrenia are present (i.e., delusions and hallucinations lasting for over 20

Reprinted from First MB, Skodol AE, Williams JBW, Spitzer RL: Learning DSM-5 by Case Example.
Arlington, VA, American Psychiatric Association Publishing, 2017.
© American Psychiatric Association Publishing. Used with permission.
http://www.appi.org
Page 4 of 5
 ea s, se e e i pai e t i M . Sta to ’s a ilit to o k o de elop i te pe so al elatio ships ith
others, and absence of a sustained mood disturbance or another medical condition or substance that
can account for the disturbance), the diagnosis of Schizophrenia is made (DSM-5, p. 99).

As oted i the egi i g of the ase, M . Sta to ’s S hizoph e ia esulted i iole e. As a

o se ue e of M . Sta to ’s delusio that his elde l eigh o as ope ati g the a hi e that aused
him to hear voices, he assaulted her to get her to turn off the machines. If the neighbor had decided to
press charges against Mr. Stanton, it is likely that he would end up being judged to have diminished
capacity to make rational decisions or to exert control over his behavior as a result of his delusions and,
depending on the legal standard in the state in which he is tried, may not have been held criminally
responsible for his behavior. Although individuals with Schizophrenia are significantly more likely to be
violent than other members of the general population, the proportion of societal violence attributable
to Schizophrenia is actually quite small (less than 5%).

Reprinted from First MB, Skodol AE, Williams JBW, Spitzer RL: Learning DSM-5 by Case Example.
Arlington, VA, American Psychiatric Association Publishing, 2017.
© American Psychiatric Association Publishing. Used with permission.
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Page 5 of 5