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ESSENTIALS OF DIAGNOSIS

  • Social withdrawal, usually slowly progressive, with decrease in emotional expression or motivation or both.

  • Deterioration in personal care with disorganized behaviors or decreased reactivity to the environment or both.

  • 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. The cause of schizophrenia is believed to be multifactorial, with genetic, environmental, and neurotransmitter pathophysiologic components. At present, there is no laboratory method for confirming the diagnosis of schizophrenia. 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. The patient usually attains higher levels of functioning. The acute psychotic episodes tend to be less disruptive of the person’s lifestyle, with a fairly quick return to previous levels of functioning.

CLASSIFICATION

A. Schizophrenia

Schizophrenia is the most common of the psychotic disorders that are all characterized by a loss of contact with reality. The term psychosis is broad and most often refers to having paranoia, auditory hallucinations, delusions, or all of these symptoms. One percent of the population suffers from schizophrenia. Schizophrenia is a chronic disorder that is characterized by increasing social and vocational disability that begins in late adolescence or early adulthood and tends to continue through life. The average age of onset for men is 18 years and for women is 25 years. Symptoms have been classified into positive and negative categories. Positive symptoms include hallucinations, delusions, and disorganized speech; these symptoms appear to be related to increased dopaminergic (D2) activity in the mesolimbic region, and all patients have at least one or two of these symptoms to meet criteria for diagnosis. There is often a component of paranoia involved. They may also have disorganized behavior, lack of emotional/cognitive responsiveness, or both. Negative symptoms include diminished sociability, restricted affect, and poverty of speech; these symptoms appear to be related to decreased D2 activity in the mesocortical system. Level of functioning is markedly below that before the onset of symptoms, which must last at least 6 months in some form.

B. Delusional Disorder

Delusional disorders are psychoses in which the predominant symptoms are persistent delusions (ie, beliefs that are false yet fixed despite being shown evidence that they are unfounded) with minimal impairment of daily functioning. Intellectual and occupational activities are little affected, whereas social and partner functioning tends to be markedly involved. Hallucinations are not ...

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