Former "A" Student Now Failing and Behaving Oddly

Anne McBride, MD; Glen Xiong, MD


July 25, 2023


The patient appears to have a psychotic disorder. On the basis of the diagnostic criteria described in detail below, he is diagnosed with schizophrenia, a psychiatric disorder that affects approximately 1% of the population worldwide.[1]

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), specifies that an individual must have two or more of the following symptoms for a significant portion of a 1-month period (or less if treated successfully), where at least one symptom must include (1), (2), or (3):

  1. Delusions (fixed, false beliefs)

  2. Hallucinations (experiencing sensory stimuli that are not present for others)

  3. Disorganized speech (eg, frequent derailment or incoherence)

  4. Grossly disorganized or catatonic behavior

  5. Negative symptoms (ie, diminished emotional expression or avolition)

The DSM-5 further specifies that the individual's level of functioning is markedly below the level previously achieved before onset of the disturbance, continuous signs of the disturbance must persist for at least 6 months, criteria for schizoaffective disorder or mood disorders with psychotic features have been ruled out, and the disturbance is not attributable to substance use effects or another medical condition. The DSM-5 clarifies how to diagnose schizophrenia additionally if autism spectrum disorder or a communication disorder of childhood onset is also present. For the patient in this case, drugs and alcohol abuse were not sufficiently in evidence.

Course specifiers can be used after a 1-year duration of illness and include the following[1]:

  • First episode, currently in acute episode

  • First episode, currently in partial remission

  • First episode, currently in full remission

  • Multiple episodes, currently in acute episode

  • Multiple episodes, currently in partial remission

  • Multiple episodes, currently in full remission

  • Continuous

  • Unspecified

"With catatonia" should be specified if three or more of the following symptoms are present[1]:

  • Stupor

  • Catalepsy

  • Waxy flexibility

  • Mutism

  • Negativism

  • Posturing

  • Mannerism

  • Stereotypy

  • Agitation not influenced by external stimuli

  • Grimacing

  • Echolalia

  • Echopraxia


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