Review Question - QID 217737

This patient is presenting with 8 months of negative symptoms including anhedonia (loss of interest), social withdrawal, avolition (absence of spontaneous behaviors), as well as disorganized speech. According to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), possessing both negative symptoms and disorganized speech or behavior for at least 6 months meets the definition of schizophrenia.

Schizophrenia is a psychiatric disorder marked by disturbances in behavior and perception that cause social dysfunction. According to the DSM-5, schizophrenia can be diagnosed when patients exhibit 2 or more of the following symptoms for at least 6 months: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms; at least 1 symptom must be delusions, hallucinations, or disorganized speech. Negative symptoms include personality decline, anhedonia, social withdrawal, avolition, and flat affect. An imbalance in the dopaminergic pathways is thought to play an important role in the pathophysiology of the disease; excessive activity in the mesolimbic system and decreased activity in the mesocortical system are thought to lead to positive and negative symptoms, respectively. Treatment of schizophrenia includes a combination of cognitive-behavioral therapy and second-generation antipsychotics (e.g., olanzapine and risperidone).

Correll and Schooler review the impact of negative symptoms in schizophrenia. Despite the close association between positive symptoms and schizophrenia, negative symptoms are more linked to poor patient function and quality of life. The functional burden of negative symptoms is significant as they hinder social interactions and make societal integration difficult. While current antipsychotics can manage positive symptoms well, pharmacological treatment of negative symptoms is still relatively ineffective.

Incorrect Answers:
Answer 1: Major depressive disorder is marked by anhedonia and depressed mood. According to the DSM-5, diagnosis also requires at least 5 of the following symptoms for at least 2 weeks: sleep disturbance, anhedonia, guilt, loss of energy, loss of concentration, appetite changes, psychomotor retardation, depressed mood, or suicidal ideation; at least 1 of the symptoms needs to be anhedonia or depressed mood. While the patient’s anhedonia and appetite changes are similar to depression, there are not enough symptoms to qualify, and the disorganized speech suggests another diagnosis.

Answer 2: Schizoaffective disorder is a diagnosis that combines mood and psychotic symptoms. According to the DSM-5, there must be an uninterrupted period of both a major mood episode and schizophrenia. However, there also needs to be at least 2 weeks of psychotic symptoms (e.g., delusions, hallucinations, etc.) with the absence of a major mood episode. Treatments are personalized around antipsychotics, antidepressants, and/or mood stabilizers. The patient does not qualify for either a major depressive or manic episode.

Answer 3: Schizoid personality disorder is marked by chronic isolation, disinterest in close relationships, and restricted emotions. Like all personality disorders, it must be diagnosed in adulthood (but often develops during adolescence) and must not be attributed to another psychiatric or medical condition. However, disorganized speech would not be expected and personality disorders would not suddenly manifest at age 25.

Answer 5: Schizophreniform disorder is defined as schizophrenic symptoms that last between 1 and 6 months. Given that the patient has been exhibiting symptoms for 8 months, she would be diagnosed with schizophrenia.

Bullet Summary:
Schizophrenia is a psychiatric disorder characterized by disturbances of behavior and perception – it encompasses positive symptoms (delusions, hallucinations, and disorganized speech) and negative symptoms (anhedonia, avolition, social withdrawal, and flat affect).