Second Opinion Paper: Schizophrenia Diagnosis
The following paper discusses the diagnosis of schizophrenia (disorganized type) given to a seventeen-year-old male by a colleague of mine. Below I will discuss the disorder known as schizophrenia, the client to whom it was given, and the evidenced provided by my colleague to support the diagnosis. Lastly, I will provide an alternative diagnosis which I believe may more accurately describe the client’s condition.
Schizophrenia is, indeed, one of the most insidious mental disorders. It disrupts all aspects of life for those unfortunate enough to be inflicted by it. Those who suffer from it are classically--albeit derogatorily--referred to as “crazy.”
People with schizophrenia may present with many of the following symptoms:
A history of acute psychosis with delusions, hallucinations, disorganized speech, catatonia, grossly disorganized behavior, or flat effect; chronic deterioration of functioning; duration that exceeds six months; the absence of a concurrent mood disorder, substance abuse, or a general medical condition (Maxmen & Ward, 1995).
Hallucinations and delusions are the hallmark symptoms of schizophrenia. However, other symptoms, such “as disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (i.e. affective flattening, alogia, or avolition)” may qualify one for schizophrenia (Maxmen & Ward, 1995). Two of these aforementioned symptoms (known as active-phase symptoms) must be present for at least a month. What is more, they must be present for most of the time during this month. However, if delusions are present that are very strange or if hallucinations include voices that constantly comment on the person’s behavior or if the voices talk with one another, then only one symptom (i.e., a hallucination or delusion) must be present for most of the time over a one-month period (American Psychiatric Association, 2000).
Other criteria/symptoms necessary to make a diagnosis of schizophrenia include social and/or occupational difficulties. A decline in social and/or occupational functioning usually coincides with the onset of schizophrenia (e.g., problems at work, interpersonal difficulties, a decline in self-care, or academic underachievement). It is important to note that such social and/or occupational dysfunction may not have been present in the individual before the onset of schizophrenia (American Psychiatric Association, 2000).
In order to give a diagnosis of schizophrenia, other disorders must first be ruled out. For example, schizoaffective disorder, as well as a mood disorder with psychotic features must be ruled out. In addition, a diagnosis of schizophrenia cannot be given when symptoms were induced by drugs or a medical condition. Lastly, a diagnosis of schizophrenia must be cautiously given if the client is known to have a developmental disorder. A schizophrenia diagnosis would only be given to individuals with developmental disorders when delusion or hallucinations are prominent (American Psychiatric Association, 2000).
An important aspect of the criteria for a diagnosis of schizophrenia is the length of time requirement. “Schizophrenic symptoms” must be present for at least six months. In addition, active-phase symptoms (described above) must be continuously present for at least a month within the six-month period (American Psychiatric Association, 2000).
The DSM-IV-TR describes, in addition to schizophrenia, schizophrenia subtypes. For example, paranoid, disorganized, catatonic, undifferentiated, and residual are all subtypes of schizophrenia. These subtypes are used as a means of describing the dominant symptoms at the time of evaluation. In other words, some schizophrenics may display a unique set of symptoms that somewhat differentiates them from other schizophrenics. As different types of symptoms become more dominant, a different subtype may be diagnosed (American Psychiatric Association, 2000). Although a full description of each subtype is beyond the scope of this paper, the disorganized type warrants some attention (as my colleague diagnosed the aforementioned client with this subtype).
“The essential features of the Disorganized Type of Schizophrenia are disorganized speech, disorganized behavior, and flat or inappropriate affect” (American Psychiatric Association, 2000). Disorganized types usually do not express goal-directed behavior, which may lead to problems in basic, daily living tasks (i.e., bathing, cooking, and dressing). Delusions and hallucinations may or may not be present. When present, delusions and hallucinations are fragmented and disorganized. In other words, they do not follow along a specific theme (a specific theme may be something like one thinking the government is reading one’s thought via the television) (American Psychiatric Association, 2000).
“Disorganized speech may manifest [itself] as incoherence, derailment, loose associations, tangentiality, circumstantiality, and/or illogical thinking” (Maxmen & Ward, 1995). Schizophrenics may present with poverty of speech, though they are more likely to seem as if they are flooded with ideas and unable to filter out the pertinent information required for a coherent conversation (Maxmen & Ward, 1995).
Disorganized behavior often appears incongruent. For example, schizophrenics may cry when hearing a weather report, or laugh when hearing about a plane crash. One theory is that they are responding more to internal stimuli than to external stimuli (Maxmen & Ward, 1995).
During the earlier phases of the disease, disorganized types may simply appear lazy or aloof. They often have no motivation to participate in activities, as well as little desire to interact with others. To the general public they may often seem like “oddballs,” “eccentrics,” and “weirdos” (Maxmen & Ward, 1995). However, as the disorder progresses and the schizophrenic’s condition worsens, such labels would hardly seem derogatory.
The following is a description of the client in question. The description is based on information my colleague provided. To reiterate, my colleague diagnosed the client with schizophrenia (disorganized type). The client will be referred to as Franz.
Franz is a seventeen-year-old male. He has experienced many medical difficulties throughout his short life, such as corneal ulcers, severe conjunctive in both eyes, and nearly debilitating bouts of migraine attacks. Franz’s migraines are reportedly so severe, they sometimes cause him to experience auditory hallucinations. According to Peres, Gonclaves, and Krymchantowski, auditory hallucinations may accompany severe migraines (2007). However, Franz reported that he sometimes experiences auditory hallucinations without accompanying migraines.
Franz’s mother experienced some medical problems while pregnant with Franz, such as anemia and influenza. In addition, Franz’s father was an alcoholic and was reportedly abusive during the pregnancy. In short, the mother’s pregnancy was difficult and stressful to be sure.
During the diagnostic interview, my colleague reports that Franz was dull and rather unresponsive. His speech was monotonous, fragmented, and lacked spontaneity. All in all, he was emotionally cold and distant.
Franz’s mother stated that he is sociable and plays with other children. However, she went on to say that he spends a lot of time sitting around the house, not engaged in any activity. Franz’s mother stated that he has few desires, and enjoys few activities outside of reading. These statements appear to be in strong contrast to her first statement that he is sociable.
Franz is no longer attending school. He never had behavioral problems in school, but quit as a result of too many absences. This may be the result of his medical problems mentioned above.
Franz recently committed physical and sexual assaults on two boys on two different occasions. He claimed that he was told to commit these assaults by voices in his head. Mother revealed that Franz does, in fact, have a temper.
As I mentioned above, my colleague diagnosed Franz with schizophrenia (disorganized type). Franz does exhibit some tell-tale signs of schizophrenia. For example, Franz experiences auditory hallucinations; his speech is disjointed and unimaginative; he lacks motivation and appears somewhat socially isolated; he is emotionally unexpressive with a flat affect (American Psychiatric Association, 2000).
In addition, Franz’s mother experienced a difficult pregnancy. She reportedly was anemic and came down with influenza while pregnant with Franz. Cannon, Jones, and Murray found that prenatal exposure to the flu may predispose one to develop schizophrenia later in life (2002).
Franz’s mother was abused by his alcoholic father during the pregnancy. This leads me to believe that Franz may have experienced a traumatic or difficult childhood. Traumatic events during childhood may predispose one to develop schizophrenia later in life, as well. Lastly, Franz (17) is at an age when there is an increased likelihood for the development of schizophrenia (Maxmen & Ward, 1995).
That being said, however, my colleague fails to address the timeline of Franz’s symptoms. This is a critical oversight, as schizophrenia may not be diagnosed if the symptoms have been present for less than six month. Furthermore, my colleague does not address the length of time that Franz experienced his active-phase symptoms (auditory hallucinations, disorganized speech, affective flattening, alogia, and avolition). These symptoms must be present for most of the time during a one-month period within the six-month time frame that other additional symptoms are experienced (such as social or occupational dysfunction) (American Psychiatric Association, 2000). Without such vital information, I cannot concur with my colleague’s diagnosis.
Failing to address the timeline, opens up the possibility of other diagnoses, such as schizophreniform disorder and brief psychotic disorder. For example, a diagnosis of schizophreniform disorder requires that “schizophrenic-like” symptoms be present for at least one month, but less than six months. Brief psychotic disorder requires that such symptoms are present for at least one day, but less than a month (American Psychiatric Association, 2000). A full description of these disorders in beyond the scope of this paper. However, a timeline would be needed to diagnose these disorders, as well.
Conclusion and Recommendations
I do not doubt that Franz is experiencing some sort of schizotypic disorder (Millon, Blaney, & Davis, 1999). In addition to establishing a timeline, other things should be taken into consideration, as well. For example, the presences of a developmental disorder should be investigated and ruled out before diagnosing a schizotypic disorder. Franz’s mother experienced a difficult pregnancy. There was an illness and abuse. The father was an alcoholic, which may also mean that the mother drank during pregnancy (this is only speculation, but should be ruled out). To be sure, these prenatal factors taken together could easily result in a developmental disorder.
In my opinion, a diagnosis of schizoid personality disorder may be more appropriate. Franz exhibits many features of this disorder. For example, Franz is solitary, takes little pleasure in activities, is emotionally cold and aloof, and has few close relationships. Given that Franz’s psychotic symptoms appear to be transient, I believe that a diagnosis of schizoid personality disorder is more appropriate. I would encourage my colleague to take this diagnosis into consideration.
Schizophrenia and other schizotypic disorders are tragic to say the least. They often attack adolescents--those who are just beginning to live their lives. It is, therefore, extremely important to ensure a correct diagnosis in order to provide proper treatment to those who have their entire lives ahead of them. Only then may they get on with their lives.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (4th ed. tr.). Arlington: Amer. Psychiatric Assn.
Cannon, M., Jones, P.B., & Murray, R.M. (2002). Obstetric complications and schizophrenia: Historical and meta-analytic review. American Journal of Psychiatry, 159, 1080-1092.
Maxmen, J. S., & Ward, N. G. (1995). Essential Psychopathology and Its Treatment. (2nd.). New York: W.W. Norton and Company.
Million, T., Blaney, P.H, & Davis, R.D. (Eds.). (1999). Oxford Textbook of Psychopathology. New York: Oxford University Press.
Peres, M.F., Goncalves, A.L., & Krymchantowski, A. (2007). Auditory hallucinations associated with migraine. Headache, 42, 646-648.