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Key Features

Essentials of Diagnosis

  • Social withdrawal, usually slowly progressive, with decrease in emotional expression and/or motivation

  • Deterioration in personal care with disorganized behaviors and/or decreased reactivity to the environment

  • Disorganized thinking, often inferred from speech that switches topics oddly or is incoherent

  • Auditory hallucinations, often of a derogatory nature

  • Delusions, fixed false beliefs despite conflicting evidence, frequently of a persecutory nature

General Considerations

  • Schizophrenia is manifested by a massive disruption of thinking, mood, and overall behavior as well as poor filtering of stimuli

  • Cause is believed to be multifactorial, with genetic, environmental, and neurotransmitter pathophysiologic components

  • The characterization and nomenclature of the disorders are quite arbitrary and are influenced by sociocultural factors and schools of psychiatric thought

  • Recently, it was demonstrated that schizophrenia is at least eight distinct disorders

  • There may or may not be a history of a major disruption in the individual's life (failure, loss, physical illness) before gross psychotic deterioration is evident

  • Other psychotic disorders on this spectrum are conditions that are similar to schizophrenia in their acute symptoms but have a less pervasive influence over the long term

Clinical Findings

Symptoms and Signs

  • A history of a major disruption in the individual's life may precede gross psychotic deterioration

  • Gradual decompensation usually predates the acute episode

  • Positive symptoms

    • Delusions are often paranoid, involving perceived threat from others

    • Hallucinations are typically auditory

    • Hypersensitivity to environmental stimuli, with feelings of enhanced sensory awareness

  • Negative symptoms

    • Diminished sociability

    • Restricted affect

    • Impoverished speech

  • Appearance: may be bizarre, often with deterioration in personal care, though usually patients are just mildly unkempt

  • Motor activity: generally reduced, although a broad spectrum is seen

  • Social function: marked withdrawal, disturbed interpersonal relationships

  • Speech

    • Neologisms (made-up words or phrases)

    • Echolalia (repetition of others' words)

    • Verbigeration (repetition of senseless words or phrases)

  • Affect: flat, occasionally inappropriate

  • Mood: depression in most patients, less apparent during acute psychosis, may have rapidly alternating mood shifts irrespective of circumstances

  • Thought content

    • Varies from paucity of ideas to rich delusions

    • Concrete thinking with inability to abstract

    • Inappropriate symbolism

Differential Diagnosis

  • Schizophrenia should be distinguished from other psychoses

    • Delusional disorders are characterized by persistent delusions with minimal impairment on daily life

    • Schizoaffective disorders fail to fit within the definitions of either schizophrenia or affective disorders

    • Schizophreniform disorders have a duration of less than 6 months, but more than 1 month

    • Brief psychotic disorders result from psychological stress, last less than 1 month, and have a much better prognosis

    • "Other psychotic disorders"

      • Patient usually attains higher levels of functioning than in schizophrenia

      • Acute psychotic episodes tend to be less disruptive of the person's lifestyle, with a fairly quick return to previous levels of functioning

    • Clues are precipitous onset and a good premorbid history

  • Manic episodes

  • Obsessive-compulsive disorder

  • Psychotic depression

  • Drug intoxication and abuse

    ...

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