A 65-Year-Old Man Brought to the ED by Military Police

Jeffrey S. Forrest, MD; Alexander B. Shortridge

Disclosures

August 06, 2019

Discussion

This patient appears to be experiencing an exacerbation of schizophrenia. This diagnosis is supported by his history of erratic and irrational behavior, delusional constructs, and florid impairment in reality testing. He also lacks any evidence of mental organic impairment, such as orientation and recollection problems. After further questioning, his son recalls his mother telling him that a previous physician had suggested a diagnosis of schizophrenia four decades earlier.

Schizophrenia is a lifelong psychotic disorder in which symptoms have been present for at least 6 months.[1] The term "psychosis" connotes a syndrome in which a patient's ability to discern reality from fiction is impaired. The core features of schizophrenia include the following:

  • Delusions (fixed, firm beliefs that are false)

  • Hallucinations (any false sensation—including visual, auditory, gustatory, olfactory, and touch—although auditory hallucinations are most common)

  • Disorganized speech (frequent derailment, loose associations, neologism, or incoherence)

All cases of schizophrenia feature at least one of these three core features. In addition, grossly disorganized or catatonic behavior and/or negative symptoms (absence of typically present behavior) may be present.

Distinguishing between positive symptoms and negative symptoms in schizophrenia is important. Positive symptoms include the presence of abnormal phenomena, such as delusions (eg, this patient's belief that he had orders from the military and was a prisoner of war), hallucinations, ideas of reference (beliefs that innocuous events have personal significance, such as this patient's concern about cell phone towers), or paranoia (eg, this patient's belief that government agents were attempting to harm his spouse). Other psychotic symptoms include a belief that one can broadcast his or her thoughts to others (thought broadcasting) or receive the thoughts of others (thought insertion).[2]

By contrast, negative symptoms of schizophrenia describe the absence of typical behaviors. Examples of this might include a flattened affect, avolition (such as poor grooming or eating behaviors), amotivational syndrome, poor eye contact, anhedonia, poverty of speech, and poor social attention. Generally, the presence of negative symptoms is a predictor of a relatively poorer prognosis in schizophrenia. Whereas positive symptoms of schizophrenia frequently respond to antipsychotic medication to at least some extent, negative symptoms do not necessarily respond as readily.[3] Although negative symptoms of schizophrenia are historically more difficult to treat with medication, psychosocial interventions that support individuals building and maintaining social networks have been correlated with reduction of negative symptoms in schizophrenia.[4]

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