Cat #1 Josia Gonzalez: Schizophreniform Disorder
Josia Gonzalez is suffering from a number of symptom presentations that classify as
Schizophreniform Disorder. She meets more than two of the diagnostic criteria from criterion
(A), as well as criteria (B) through (D) of the Diagnostic and Statistical Manual of Mental
Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). As a 31-year old, she falls
close to the average age of onset for females developing a schizophrenia-spectrum disorder,
which is 28-years old (Gogtay et al., 2011).
In line with criterion (A) of the diagnosis of Schizophreniform Disorder, Josia is
experiencing hallucinations, classified as sensory events without any environmental input
(American Psychiatric Association, 2013). Explicitly, she is facing those classified as
somatosensory as well as auditory. Given the description of “brown insects burrowing into her
skin”, she is experiencing a tactile hallucination, otherwise known as formication, parasitosis or
infestation (Ansari et al., 2020). It is possible that her “perception” of bugs burrowing her walls
and covering her rugs and mattresses are a visual hallucination, but we cannot draw that
conclusion based on what is presented. Furthermore, she is experiencing auditory hallucinations
as she heard fleas “rustling and scratching inside”. This experience was so pervasive that she
“threw away a bag of clothing”. We can rule out that these experiences were reality, given a
dermatological evaluation found no corroborating evidence on her skin examination, and an
exterminator found no evidence of fleas.
As shown in a recent study, among people from the general population presenting with
auditory hallucinations, the vast majority of them (72%) also experienced hallucinations in at
least one additional modality (Laloyaux et al., 2019). The high prevalence rate of multimodal
hallucinations indicates that it is likely that hallucinations in the different modalities share
common neurological underpinnings (Laloyaux et al., 2019). Further, it was shown that
multimodal hallucinations are associated with poor mental health (Laloyaux et al., 2019). Josia’s
presentation of multiple types of hallucinations aligns with current research.
Second, in the DSM-5 diagnosis of Schizophreniform Disorder in criterion (A), Josia is
experiencing baseless thoughts in line with the topic of her hallucinations. The subject of bug
infestation is manifesting in the form of somatic delusions (American Psychiatric Association,
2013). Josia thought that insects were burrowing into her skin. She also offered a small plastic
bag containing “fleas and larvae” she gathered in the hospital as she was waiting for her
evaluation; the examination of the bag proved this untrue. She thought each time a hair fell out
of her head it would morph into a larvae. When crying, she believed an egg came out of her tear
duct. Both of these thoughts are clearly implausible and do not reflect a real health condition
that is based in science, and therefore represent bizarre delusions. When presented with the
dermatological results as well as the lack of findings from the exterminator, she did not believe
them. It is important to note that delusions of parasitosis are relatively uncommon as
psychiatrists and dermatologists rarely see the disorder; it is common that these patients do not
believe that their symptoms are delusions (Ansari et al., 2020).
Both the hallucinations and delusions are having a severe and implacable impact on her
and her functioning, given that she spent 36 hours prior to going to the hospital “frantically
cleaning her home”. She also “showered multiple times using shampoos meant to treat animal
infestations,” thereby suggesting evidence of disorganized behavior.
Even though Josia already meets three criteria in section (A), she also elicits a few
negative symptoms (American Psychiatric Association, 2013). She was not sleeping well and
presented lowered eye contact. Her speech was slow and linear. She described her mood as sad.
Josia does not meet the diagnosis for Schizophrenia or Brief Psychotic Disorder given the
duration requirements and her symptom presentation (American Psychiatric Association, 2013).
In line with the requirement of criterion (B), Josia’s episode is lasting for longer than a month,
given her concerns began five weeks prior to going to the emergency room (American
Psychiatric Association, 2013). Her diagnosis is likely schizophreniform disorder provisional,
because it is uncertain if she will recover from these disturbances within the 6-month period
(American Psychiatric Association, 2013). Only one-third of individuals with an initial diagnosis
of schizophreniform disorder recover within the six-month period, so her diagnosis would
change to schizophrenia after this time (American Psychiatric Association, 2013).
We can rule out schizoaffective disorder and depressive or bipolar disorder with
psychotic features, because we cannot definitively say there have been major depressive or
manic episodes occurring concurrently with the active-phase symptoms (American Psychiatric
Association, 2013). Further, we can rule out that these conditions are occurring due to substance
use or another medical condition (American Psychiatric Association, 2013).
Before making a definitive diagnosis, I would like to ask a few clarifying questions. First,
we should inquire about her Argentinian culture and religious beliefs; with that said, it does not
seem that those factors would impact her hallucinations and delusions of bug infestation.
Second, I would inquire about childhood background information. In a historical study, they
found that self-reported psychotic symptoms at the age of eleven predicted a very high risk of a
schizophreniform diagnosis at the age of 26 years old (Poulton et al., 2000). It would be
interesting to learn a bit more about Josia’s childhood in order to see if there were any
predictors of this diagnosis in her past. Finally, it seems pertinent to learn more about Josia’s
bout with depression, as she was treated with an antidepressant in the past. In a recent study it
was found that it is possible that depression not only explains some of the commonality in
biological findings in schizophrenia but also provides a potential aetiological pathway. The study
posits that depression might drive forward further symptom dimensions through a stressinflammation-structural brain change pathway (Upthegrove et al., 2016).
It is imperative that the treatment provider be careful with this diagnosis given a study
that showed that after six months of presentation of the first episode of schizophrenia and
schizophreniform disorder, along with acknowledgement by people that they had a mental
illness, the more depressed they were at four years and the greater the likelihood that they
would attempt suicide by four years (Crumlish et al,. 2005).
#2 Yolanda Rivera: Bipolar I disorder, current episode manic, severe, with psychotic features,
with peripartum onset.
Ms. Rivera presents with flight of ideas, pressured speech, distractibility, agitation, lability,
greatly diminished sleep, uncharacteristic hyperreligiosity, delusions about her friends and
family, and the fixed, false belief that she has already killed her child. She has a history of
multiple major depressive episodes and of one psychiatric hospitalization for mania. These
qualify her for a DSM-5 diagnosis of bipolar I disorder, severe, with psychotic features.
Ms. Rivera is also clearly experiencing an episode of what has traditionally been called
postpartum psychosis—the abrupt onset of an affective psychosis in the early postpartum
period.
Ellie #3 Leroy Lee: Major Depressive Disorder, moderate, recurrent
32-year old Leroy Lee presents with symptoms of depressed mood and a change from
previous functioning that are consistent with a diagnosis of Major Depressive Disorder (MDD),
moderate, recurrent. The Diagnostic and Statistical Manual of Mental Disorders (DSM;
American Psychiatric Association, 1980–2013) states that symptoms of either depressed mood or
loss of interest or pleasure must be met in a MDD diagnosis. Further, five or more symptoms
from Criteria A must be present in order to solidify the diagnosis. Leroy presents five out of nine
symptoms necessary for diagnosis and experiences depressed mood and loss of interest or
pleasure. He also meets Criteria B and C for MDD diagnosis in the DSM-5.
Leroy meets the following symptoms present in Criteria A of MDD: depressed mood,
diminished interest or pleasure, psychomotor agitation, fatigue, and diminished ability to think or
concentrate. Leroy clearly meets the standard of a depressed mood, with his reports of
unexpected flat affect and inability to imagine a future after his divorce. In a study conducted by
Janice Kiecolt-Glaser (2018), an effect of gender following a divorce was introduced. Research
found that men who had been divorced in the last three years had higher levels of depressive
symptoms, described themselves as lonelier, and experienced lower immunity function than
females. Thus, Leroy’s gender may be a contributor to his experience of both flat affect and
feelings of hopelessness following his recent divorce. Additionally, this gender prevalence
makes it more likely that Leroy is experiencing these symptoms following the divorce.
Leroy also experiences diminished pleasure in all or most activities throughout the day,
nearly every day. He specifically self-reports diminished apathy and states that Jazz music was a
passion of his but he no longer attends concerts. This indicates that he is experiencing loss of
interest in an activity that previously brought him pleasure. Further, his employer observed slow
movement, which indicates psychomotor agitation. Leroy also personally reports diminished
energy, which aligns with the symptom of fatigue or loss of energy nearly everyday in Criteria
A. Further, Leroy greatly exhibits difficulties concentrating at his job and reports that his
impaired concentration may have an impact on his loss of interest in Jazz. Grahek et al. (2019)
notes that impairments in cognitive control are often seen in individuals with depression, which
would explain Leroy’s difficulties maintaining focus and motivation with a goal-directed task in
his job. Leroy has a history of difficulty concentrating and has even had episodes of
indecisiveness that lasted for months. Research indicates that the types of cognitive impairments
that individuals with MDD suffer with include low motivation for tasks, depleted cognitive
resources, difficulty initiating efficient cognitive strategies, and slow processing speed, (Snyder,
2013). Leroy presents with all of these cognitive impairment symptoms, and thus meets the
criteria for diminished ability to think or concentrate, or indecisiveness, nearly every day in
Criteria A for MDD. Therefore, five out of nine symptoms in Criteria A of MDD are clearly
met.
In addition, Leroy meets the Criteria B of MDD that states that the present symptoms
cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning. It is evident that Leroy’s symptoms are causing functional impairment
because he is unable to succeed in work or activities of pleasure due to his impaired cognition.
Further, Leroy meets Criteria C of MDD regarding substance and/or medical interaction because
there is no substance use or medical conditions reported as a potential interference at this time.
Another important factor to take into account in the formulation of Leroy’s diagnosis is his
family history of depression. Leroy’s mother and brother had been diagnosed with MDD and
treated with medication. His maternal uncle had committed suicide, which indicates a possible
genetic component in Leroy’s diagnosis. Douglas F. Levinson (2006) notes that MDD is a
moderately heritable disorder, but research has not elucidated which genes are most clearly and
commonly found in families of individuals specifically diagnosed with MDD. Therefore, Leroy’s
genetic predisposition to MDD is something to consider in the diagnostic process but should not
be used as main indicator of MDD. Overall, Leroy meets Criterion A-C of MDD in the DSM-5
and relevant research further supports the likelihood of this diagnosis.
#4 Tomasso Tynan: Schizoaffective Disorder, depressive type
Mr. Tynan’s major psychotic symptom is paranoia, with persecutory delusions and paramnesias
of homicide. The delusions are worsened by auditory hallucinations, which he experiences as
confirmation of his delusions. Although he reports difficulties with his memory, he has not
displayed marked cognitive impairment or disorganization of thought. He is socially isolated
and minimally able to interact with others. The extent, severity, and duration of his psychotic
symptoms are consistent with the diagnosis of a schizophrenia spectrum disorder.
Mr. Tynan’s psychosis emerged after several years of depression, anxiety, and panic attacks.
Since the onset of his psychotic illness, he has experienced multiple episodes of depression,
which emerge after periods of delusion and hallucinations and feature overwhelming guilt,
prominent anhedonia, poor sleep, and occasional bursts of irritability. He can become suicidal
when psychosis and depression reach peak intensity.
Mr. Tynan meets criteria, therefore, for DSM-5 schizoaffective disorder. He has had an
uninterrupted period in which his major depressive symptoms were concurrent with his
schizophrenia symptoms. He has had several-week periods of hallucinations and delusions
without prominent mood symptoms. Since the onset of the active and residual portions of his
schizophrenia, the major depressive symptoms have been present most of the time.
Mr. Tynan also used marijuana and alcohol for 8 years. Although these might have contributed
to the emergence of his mood and psychotic symptoms, he continued to experience significant
delusions, hallucinations, and depression between ages 20 and 22, when he stopped using
marijuana and alcohol for several months. An alcohol- or marijuana-induced depressive,
anxiety, or psychotic disorder might have been considered at various times in Mr. Tynan’s life,
but the persistence of his mood and psychotic symptoms for months after the discontinuation of
marijuana and alcohol indicates that he does not have a substance-induced psychiatric disorder.