Schizophrenia Spectrum and Other Psychotic Disorders

Which of the following sets of specifiers is included in the DSM-5 diagnostic criteria for substance/medication-induced psychotic disorder? A. "With onset before intoxication" and "With onset before withdrawal." B. "With onset during intoxication" and "With onset during withdrawal." C. "With good prognostic features" and "Without good prognostic features." D. "With onset prior to substance use" and "With onset after substance use." E. "With catatonia" and 'Without catatonia."

"With onset during intoxication" and "With onset during withdrawal." Explanation: The specifier "with onset during intoxication" should be used if criteria for intoxication with the substance are met and the symptoms develop during intoxication. The specifier "with onset during withdrawal" should be used if criteria for withdrawal from the substance are met and the symptoms develop during, or shortly after, withdrawal.

Which of the following statements about catatonic motor behaviors is false? a. Catatonic motor behavior is a type of grossly disorganized behavior that has historically been associated with schizophrenia spectrum and other psychotic disorders. b. Catatonic motor behaviors may occur in many mental disorders (such as mood disorders) and in other medical conditions. c. A behavior is considered catatonic only if it involves motoric slowing or rigidity, such as mutism, posturing, or waxy flexibility. d. Catatonia can be diagnosed independently of another psychiatric disorder. e. Catatonic behaviors involve markedly reduced reactivity to the environment.

A behavior is considered catatonic only if it involves motoric slowing or rigidity, such as mutism, posturing, or waxy flexibility. Explanation: Catatonic behavior is a marked decrease in reactivity to the environment. This ranges from resistance to instructions (negativism); to maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and motor responses (mutism and stupor). It can also include purposeless and excessive motor activity without obvious cause (catatonic excitement). Other features are repeated stereotyped movements, staring, grimacing, mutism, and the echoing of speech. Although catatonia has historically been associated with schizophrenia, catatonic symptoms are nonspecific and may occur in other mental disorders (e.g., bipolar or depressive disorders with catatonia) and in medical conditions (catatonic disorder due to another medical condition).

Which of the following statements about gender differences in schizophrenia is true? a. Women with schizophrenia tend to have fewer psychotic symptoms than do men over the course of the illness. b. A first onset of schizophrenia after age 40 is more likely in women than in men. c. Psychotic symptoms in women tend to burn out with age to a greater extent than they do in men. d. Negative symptoms and affective flattening are more frequently observed in women with schizophrenia than in men with the disorder. e. The overall incidence of schizophrenia is higher in women than it is in men.

A first onset of schizophrenia after age 40 is more likely in women than in men. Explanation: The lifetime prevalence of schizophrenia appears to be approximately 0.3%-0.7%, although there is reported variation by race/ethnicity, across countries, and by geographic origin for immigrants and children of immigrants. The sex ratio differs across samples and populations: for example, an emphasis on negative symptoms and longer duration of disorder (associated with poorer outcome) shows higher incidence rates for males, whereas definitions allowing for the inclusion of more mood symptoms and brief presentations (associated with better outcome) show equivalent risks for both sexes. A number of features distinguish the clinical expression of schizophrenia in females and males. The general incidence of schizophrenia tends to be slightly lower in females, particularly among treated cases. The age at onset is later in females, with a second mid-life peak. Symptoms tend to be more affect-laden among females, and there are more psychotic symptoms, as well as a greater propensity for psychotic symptoms to worsen in later life. Other symptom differences include less frequent negative symptoms and disorganization. Finally, social functioning tends to remain better preserved in females. There are, however, frequent exceptions to these general caveats.

Criterion A for schizoaffective disorder requires an uninterrupted period of illness during which Criterion A for schizophrenia is met. Which of the following additional symptoms must be present to fulfill diagnostic criteria for schizoaffective disorder? A. An anxiety episode—either panic or general anxiety. B. Rapid eye movement (REM) sleep behavior disorder. C. A major depressive or manic episode. D. Hypomania. E. Cyclothymia.

A major depressive or manic episode. Explanation: The diagnosis of schizoaffective disorder is based on the presence of an uninterrupted period of illness during which Criterion A for schizophrenia is met. Criterion B (social dysfunction) and Criterion F (exclusion of autism spectrum disorder or other communication disorder of childhood onset) for schizophrenia do not have to be met. In addition to meeting Criterion A for schizophrenia, there must be a major mood episode (major depressive or manic) (Criterion A for schizoaffective disorder). Because loss of interest or pleasure is common in schizophrenia, to meet Criterion A for schizoaffective disorder, the major depressive episode must include pervasive depressed mood (i.e., the presence of markedly diminished interest or pleasure is not sufficient). The episodes of depression or mania must be present for the majority of the total duration of the illness (i.e., after Criterion A has been met) (Criterion C for schizoaffective disorder).

Which of the following patient presentations would not be classified as psychotic for the purpose of diagnosing schizophrenia? a. A patient is hearing a voice that tells him he is a special person. b. A patient believes he is being followed by a secret police organization that is focused exclusively on him. c. A patient has a flashback to a war experience that feels like it is happening again. d. A patient cannot organize his thoughts and stops responding in the middle of an interview. e. A patient presents wearing an automobile tire around his waist and gives no explanation.

A patient has a flashback to a war experience that feels like it is happening again. Explanation: Schizophrenia spectrum and other psychotic disorders are defined by abnormalities in one or more of the following five domains, the first four of which are considered to be psychotic symptoms: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms. A flashback to a traumatic experience is an intense, emotionally laden memory but does not reach the level of a psychotic symptom.

Label each of the following beliefs as a bizarre delusion, a nonbizarre delusion, or a nondelusion. a. A 25-year-old law student believes he has uncovered the truth about JFK's assassination and that CIA agents have been dispatched to follow him and monitor his Internet communications. b. A 45-year-old homeless man presents to the psychiatric emergency room complaining of a skin rash. Upon removal of his clothes, it is seen that most of his body is wrapped in aluminum foil. The man explains that he is protecting himself from the electromagnetic ray guns that are constantly targeting him. c. A 47-year-old unemployed plumber believes he has been elected to the House of Representatives. When the Capitol police evict him and bring him to the emergency department, he says that they are Tea Party activists who are merely impersonating police officers. d. A 35-year-old high school physics teacher presents to your office with insomnia and tells you that he has discovered and memorized the formula for cold fusion energy, only to have the formula removed from his memory by telepathic aliens. e. An 18-year-old recent immigrant from Eastern Europe believes that wearing certain colors will ward off the "evil eye" and prevent catastrophes that would otherwise occur.

A, nonbizarre delusion; B, bizarre delusion; C, nonbizarre delusion; D, bizarre delusion; E, nondelusion. Explanation: Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences. Thus, although it is probably untrue that the law student is being followed and that the plumber has been elected to Congress, these things could conceivably happen. By contrast, thought removal and external control by telepathically empowered aliens or electromagnetic ray guns is not in the realm of possibility by shared social consensus. The belief that use of colors or amulets will ward off bad events is an accepted part of many cultural belief systems and so is not classifiable as a delusion, even if it seems implausible to individuals from more secular backgrounds.

Which of the following is not a commonly recognized type of delusion? A. Persecutory. B. Erotomanic. C. Alien abduction. D. Somatic. E. Grandiose.

Alien abduction. Explanation: Commonly recognized delusion types include persecutory, refer- ential, somatic, nihilistic, grandiose and erotomanic, as well as combinations of these types. A delusional belief in alien abduction may be grandiose and may involve somatic and/or erotomanic aspects, but it is not itself a major category of delusional thought.

Schizophrenia spectrum and other psychotic disorders are defined by abnormalities in one or more of five domains, four of which are also considered psychotic symptoms. Which of the following is not considered a psychotic symptom? A. Delusions. B. Hallucinations. C. Disorganized thinking. D. Disorganized or abnormal motor behavior. E. Avolition.

Avolition. Explanation: Avolition is a negative symptom of schizophrenia, not a positive (psychotic) symptom. Avolition is an absence of motivation for goal-oriented behaviors. The term positive refers not to something of positive valuation but rather to something that is present and existing, as opposed to a deficit symptom such as the negative symptoms of schizophrenia. The other symptom types listed are considered psychotic.

In which of the following disorders can psychotic symptoms occur? A. Bipolar and depressive disorders. B. Substance use disorders. C. Posttraumatic stress disorder. D. Other medical conditions. E. All of the above.

Bipolar and depressive disorders, Substance use disorders, Post-traumatic stress disorder and Other medical conditions. Explanation: Mood disorders, substance use disorders, posttraumatic stress disorder, and other medical conditions all can include psychotic symptoms as part of their presentation. Thus, clinicians must consider these and other possibilities before concluding that a patient's psychosis to due to a primary psychotic disorder.

A 55-year-old man with a known history of alcohol dependence and schizophrenia is brought to the emergency department because of frank delusions and visual hallucinations. Which of the following would not be a diagnostic possibility for inclusion in the differential diagnosis? A. Schizophrenia. B. Substance/medication-induced psychotic disorder. C. Alcohol dependence. D. Psychotic disorder due to another medical condition. E. Borderline personality disorder with psychotic features.

Borderline personality disorder with psychotic features. Explanation: There is no evidence provided for a diagnosis of borderline personality disorder. A prior history of a primary psychotic disorder (schizophrenia) does not rule out the possibility of a substance/medication-induced psychotic disorder. The appearance of delusions de novo in a person older than 35 years without a known history of primary psychotic disorder should suggest the possibility of a substance/medication-induced psychotic disorder.

There is a requirement for a major depressive episode or a manic episode to be part of the symptom picture for a DSM-5 diagnosis of schizoaffective disorder. In order to separate schizoaffective disorder from depressive or bipolar disorder with psychotic features, which of the following symptoms must be present for at least 2 weeks in the absence of a major mood episode at some point during the lifetime duration of the illness? A. Delusions or hallucinations. B. Delusions or paranoia. C. Regressed behavior. D. Projective identification. E. Binge eating.

Delusions or hallucinations. Explanation: To separate schizoaffective disorder from a depressive or bipolar disorder with psychotic features, Criterion B for schizoaffective disorder specifies that delusions or hallucinations must be present for at least 2 weeks in the absence of a major mood episode (depressive or manic) at some point during the lifetime duration of the illness.

A 65-year-old man with systemic lupus erythematosus who is being treated with corticosteroids witnesses a serious motor vehicle accident. He begins to have disorganized speech, which lasts for several days before resolving. What diagnosis best fits this clinical picture? A. Schizophrenia. B. Psychotic disorder associated with systemic lupus erythematosus. C. Steroid-induced psychosis. D. Brief psychotic disorder, with marked stressor. E. Schizoaffectivedisorder.

Brief psychotic disorder, with marked stressor. Explanation: The essential features of psychotic disorder due to another medical condition are prominent delusions or hallucinations that are judged to be attributable to the physiological effects of another medical condition and are not better explained by another mental disorder (e.g., the symptoms are not a psychologically mediated response to a severe medical condition, in which case a diagnosis of brief psychotic disorder, with marked stressor, would be appropriate). In the vignette above, the symptoms are better understood as being a psychologically mediated response to the trauma of witnessing the accident.

A 19-year-old college student is brought by ambulance to the emergency department. His college dorm supervisor, who called the ambulance, reports that the student was isolating himself, was pacing in his room, and was not responding to questions. In the emergency department, the patient gets down in a crouching position and begins making barking noises at seemingly random times. His urine toxicology report is negative, and all labs are within normal limits. What is the best description of these symptoms? A. An animal delusion—the patient believes he is a dog. B. Intermittent explosive rage. C. A paranoid stance leading to self-protective aggression. D. Catatonic behavior. E. Formal thought disorder.

Catatonic behavior. Explanation: Delusions involve beliefs, but we cannot assess the patient's belief structure or his formal thought patterns since he is not answering questions. Similarly, rage is an emotion that may result in intense motor activity, but we have not been able to assess the patient's thought content or his emotions. The patient is likely exhibiting psychomotor agitation but it is of a specific type, namely catatonic excitement that does not relate to the environment or to any goal-directed motivation. Mutism followed by catatonic excitement, such as stereotypic vocalizations, can occur in catatonia.

Which of the following statements about childhood-onset schizophrenia is true? a. Childhood-onset schizophrenia tends to resemble poor-outcome adult schizophrenia, with gradual onset and prominent negative symptoms. b. Disorganized speech patterns in childhood are usually indicative of schizophrenia. c. Because of the childhood capacity for imagination, delusions and hallucinations in childhood-onset schizophrenia are more elaborate than those in adult-onset schizophrenia. d. In a child presenting with disorganized behavior, schizophrenia should be ruled out before other childhood diagnoses are considered. e. Visual hallucinations are extremely rare in childhood-onset schizophrenia.

Childhood-onset schizophrenia tends to resemble poor outcome adult schizophrenia, with gradual onset and prominent negative symptoms. Explanation: The essential features of schizophrenia are the same in childhood, but it is more difficult to make the diagnosis. In children, delusions and hallucinations may be less elaborate than in adults, and visual hallucinations are more common and should be distinguished from normal fantasy play. Disorganized speech occurs in many disorders with childhood onset (e.g., autism spectrum disorder), as does disorganized behavior (e.g., attention-deficit/hyperactivity disorder). These symptoms should not be attributed to schizophrenia without due consideration of the more common disorders of childhood. Childhood-onset cases tend to resemble poor outcome adult cases, with gradual onset and prominent negative symptoms. Children who later receive the diagnosis of schizophrenia are more likely to have experienced nonspecific emotional behavioral disturbances and psychopathology, intellectual and language alterations, and subtle motor delays.

Which of the following symptom combinations, if present for 1 month, would meet Criterion A for schizophrenia? A. Prominent auditory and visual hallucinations. B. Grossly disorganized behavior and avolition. C. Disorganized speech and diminished emotional expression. D. Paranoid and grandiose delusions. E. Avolition and diminished emotional expression.

Disorganized speech and diminished emotional expression. Explanation: To meet DSM-5 Criterion A, two (or more) of the following symptoms must be present for a significant portion of time during a 1-month period (or less if successfully treated): 1) delusions, 2) hallucinations, 3) disorganized speech (e.g., frequent derailment or incoherence), 4) grossly disorganized or catatonic behavior, 5) negative symptoms (i.e., diminished emotional expression or avolition). At least one of the two symptoms must be the clear presence of delusions (A1), hallucinations (A2), or disorganized speech (A3). Thus, two forms of hallucinations or two types of delusions alone in the absence of other symptoms would be insufficient to meet Criterion A. The combination of grossly disorganized behavior (although considered a psychotic symptom) with negative symptoms is also insufficient to meet Criterion A.

A 32-year-old man presents to the emergency department distressed and agitated. He reports that his sister has been killed in a car accident on a trip to South America. When asked how he found out, he says that he and his sister were very close and he "just knows it." After putting him on the phone with his sister, who was comfortably staying with friends while on her trip, the man expressed relief that she was alive. Which of the following descriptions best fits this presentation? a. He had a delusional belief, because he believed it was true without good warrant. b. He did not have a delusional belief, because it changed in light of new evidence. c. He had a grandiose delusion, because he believed he could know things happening far away. d. He had a nihilistic delusion, because it involved an untrue, imagined catastrophe. e. He did not have a delusion, because in some cultures people believe they can know things about family members outside of ordinary communications.

He did not have a delusional belief, because it changed in light of new evidence. Explanation: To be a delusion, a belief must be clearly false and must be fixed—that is, not amenable to change in light of additional information. This man's belief was false but held flexibly, and it was conditional on the evidence, such as talking to his living sister. Thus, it is not a delusion. Although cultural factors should be taken into account in determining whether a belief is delusional, that consideration is not relevant here, because the belief is not delusional independent of cultural background.

Which of the following statements correctly describes a way in which schizoaffective disorder may be differentiated from bipolar disorder? a. Schizoaffective disorder involves only depressive episodes, never manic or hypomanic episodes. b. In bipolar disorder, psychotic symptoms do not last longer than 1 month. c. In bipolar disorder, psychotic symptoms are always cotemporal with mood symptoms. d. Schizoaffective disorder never includes full-blown episodes of major depression. e. In bipolar disorder, psychotic symptoms are always mood congruent.

In bipolar disorder, psychotic symptoms are always co-temporal with mood symptoms. Explanation: Distinguishing schizoaffective disorder from depressive and bipolar disorders with psychotic features is often difficult. Schizoaffective disorder can be distinguished from a depressive or bipolar disorder with psychotic features by the presence of prominent delusions and/or hallucinations for at least 2 weeks in the absence of a major mood episode. In contrast, in depressive or bipolar disorders with psychotic features, the psychotic features primarily occur during the mood episode(s).

Which of the following statements about negative symptoms of schizophrenia is false? a. Negative symptoms are easily distinguished from medication side effects such as sedation. b. Negative symptoms include diminished emotional expression. c. Negative symptoms can be difficult to distinguish from medication side effects such as sedation. d. Negative symptoms include reduced peer or social interaction. e. Negative symptoms include decreased motivation for goal-directed activities.

Negative symptoms are easily distinguished from medication side effects such as sedation. Explanation: Negative symptoms of schizophrenia refer to the deficit aspects of the illness, in contrast to the "positive" symptoms (in the sense of being notable by their presence, not in the sense of being desirable). Positive symptoms include active hallucinations, delusions, disorganized behaviors, and disorganized thinking. Side effects of medication such as sedation and bradykinesia may mimic negative symptoms and be wrongly evaluated as primary negative symptomatology. The primary negative symptoms include diminished emotional expression, reduced interaction with others, and decreased motivation for goal-directed activities.

How common is schizoaffective disorder relative to schizophrenia? A. Much more common. B. Twice as common. C. Equally common. D. One-half as common. E. One-third as common.

One-third as common. Explanation: Schizoaffective disorder appears to be about one-third as common as schizophrenia, with a lifetime prevalence of 0.3%.

What is the most common type of delusion? A. Somatic delusion of distorted body appearance. B. Grandiose delusion. C. Thought insertion. D. Persecutory delusion. E. Former life regression.

Persecutory delusion. Explanation: Persecutory delusions are the most common form. This may be because such delusions are associated with a dysregulation of existing self-protective and/or social-psychological functionalities, but the reason that these are the most commonly encountered delusion is not yet well understood.

Which of the following statements about violent or suicidal behavior in schizophrenia is false? a. About 5%-6% of individuals with schizophrenia die by suicide. b. Persons with schizophrenia frequently assault strangers in a random fashion. c. Compared with the general population, persons with schizophrenia are more frequently victims of violence. d. Command hallucinations to harm oneself sometimes precede suicidal behaviors. e. Youth, male gender, and substance abuse are factors that increase the risk for suicide among persons with schizophrenia.

Persons with schizophrenia frequently assault strangers in a random fashion. Explanation: Hostility and aggression can be associated with schizophrenia, although spontaneous or random assault is uncommon. Aggression is more frequent for younger males and for individuals with a past history of violence, nonadherence to treatment, substance abuse, and impulsivity. It should be noted that the vast majority of persons with schizophrenia are not aggressive and are more frequently victimized than are individuals in the general population. Approximately 5%-6% of individuals with schizophrenia die by suicide, about 20% attempt suicide on one or more occasions, and many more have significant suicidal ideation. Suicidal behavior is sometimes in response to command hallucinations to harm oneself or others. Suicide risk remains high over the whole life span for males and females, although it may be especially high for younger males with comorbid substance use. Other risk factors include having depressive symptoms or feelings of hopelessness and being unemployed, and the risk is higher, also, in the period after a psychotic episode or hospital discharge.

Which of the following psychotic symptom presentations would not be appropriately diagnosed as "other specified schizophrenia spectrum and other psychotic disorder"? a. Psychotic symptoms that have lasted for less than 1 month but have not yet remitted, so that the criteria for brief psychotic disorder are not met. b. Persistent auditory hallucinations occurring in the absence of any other features. c. Postpartum psychosis that does not meet criteria for a depressive or bipolar disorder with psychotic features, brief psychotic disorder, psychotic disorder due to another medical condition, or substance/medication-induced psychotic disorder. d. Psychotic symptoms that are temporally related to use of a substance. e. Persistent delusions with periods of overlapping mood episodes that are present for a substantial portion of the delusional disturbance.

Psychotic symptoms that are temporally related to use of a substance. Explanation: Psychotic symptoms that are temporally related to use of a substance would likely meet criteria for a DSM-5 substance/medication-induced psychotic disorder. The category other specified schizophrenia spectrum and other psychotic disorder applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class. The other specified schizophrenia spectrum and other psychotic disorder category is used in situations in which the clinician chooses to com- municate the specific reason that the presentation does not meet the criteria for any specific schizophrenia spectrum and other psychotic disorder. This is done by recording "other specified schizophrenia spectrum and other psychotic disorder" followed by the specific reason (e.g., "persistent auditory hallucinations").

Substance/medication-induced psychotic disorder cannot be diagnosed if the disturbance is better explained by an independent psychotic disorder that is not induced by a substance/medication. Which of the following psychotic symptom presentations would not be evidence of an independent psychotic disorder? a. Psychotic symptoms that precede the onset of severe intoxication or acute withdrawal. b. Psychotic symptoms that meet full criteria for a psychotic disorder and that persist for a substantial period after cessation of severe intoxication or acute withdrawal. c. Psychotic symptoms that are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use. d. Psychotic symptoms that occur during a period of sustained substance abstinence. e. Psychotic symptoms that occur during a medical admission for substance withdrawal.

Psychotic symptoms that occur during a medical admis- sion for substance withdrawal. See explanation in book.

Which of the following presentations would not be classified as disorganized behavior for the purpose of diagnosing schizophrenia spectrum and other psychotic disorders? a. Masturbating in public. b. Wearing slacks on one's head. c. Responding verbally to auditory hallucinations in a conversational mode. d. Crouching on all fours and barking. e. Turning to face 180 degrees away from the interviewer when answering questions.

Responding verbally to auditory hallucinations in a conversational mode. Explanation: Disorganized behavior including catatonic motor behavior is one of four categories of psychotic symptoms used to diagnose schizophrenia spectrum and other psychotic disorders. To fulfill diagnostic criteria, the behavior must be grossly disorganized or inappropriate. Masturbating in public is behavior that shows obliviousness to the environment and unconcern for the usual social norms of modesty and privacy. Wearing clothing in odd ways without justification is a disorganized form of behavior. Both barking like a dog and turning away in a bizarre fashion while conducting a conversation (if not induced by an expression of anger or other reasonable explanation) are grossly inappropriate behaviors. However, responding verbally to auditory hallucination is not in itself a disorganized behavior. Given the belief in the actuality of communication in an auditory hallucination, talking back is contingently a logical and goal-oriented behavior. Thus, this would count as one psychotic symptom (hallucination) but not as two symptoms (hallucination and grossly disorganized behavior).

Which of the following does not represent a negative symptom of schizophrenia? A. Affective flattening. B. Decreased motivation. C. Impoverished thought processes. D. Sadness over loss of functionality. E. Social disinterest.

Sadness over loss of functionality. Explanation: Patients with schizophrenia may be aware of their functional losses and may feel sadness about this. That emotional response would be the opposite of negative symptoms, because it would involve an active and expressive-emotional response. The other symptoms mentioned—affective flattening, decreased motivation, impoverished thought process, and social disinterest—are all part of the negative or deficit symptoms of schizophrenia. It is thus important to distinguish the uses of the word "negative." In reference to sad emotions it has one meaning, but the "negative" symptoms of schizophrenia mean deficits of normal psychological functioning, including absence of sad feelings.

A 30-year-old single woman reports having experienced auditory and persecutory delusions for 2 months, followed by a full major depressive episode with sad mood, anhedonia, and suicidal ideation lasting 3 months. Although the depressive episode resolves with pharmacotherapy and psychotherapy, the psychotic symptoms persist for another month before resolving. What diagnosis best fits this clinical picture? A. Brief psychotic disorder. B. Schizoaffective disorder. C. Major depressive disorder. D. Major depressive disorder with psychotic features. E. Bipolar I disorder, current episode manic, with mixed features.

Schizoaffective disorder. Explanation: During this period of illness, the woman's symptoms concurrently met criteria for a major depressive episode and Criterion A for schizophrenia. Auditory hallucinations and delusions were present both before and after the depressive phase. The total period of illness lasted for about 6 months, with psychotic symptoms alone present during the initial 2 months, both depressive and psychotic symptoms present during the next 3 months, and psychotic symptoms alone present during the last month. The duration of the depressive episode was not brief relative to the total duration of the psychotic disturbance.

A 27-year-old unmarried truck driver has a 5-year history of active and residual symptoms of schizophrenia. He develops symptoms of depression, including depressed mood and anhedonia, that last 4 months and resolve with treatment but do not meet criteria for major depression. Which diagnosis best fits this clinical presentation? A. Schizoaffective disorder. B. Unspecified schizophrenia spectrum and other psychotic disorder. C. Unspecified depressive disorder. D. Schizophrenia and unspecified depressive disorder. E. Unspecified bipolar and related disorder.

Schizophrenia and unspecified depressive disorder. Explanation: The depressive and manic episodes, taken together, do not occupy more than 1 year during the 5-year history. Thus, the presentation does not meet Criterion C for schizoaffective disorder, and the diagnosis remains schizophrenia. The additional diagnosis of unspecified depressive disorder may be added to indicate the superimposed depressive episode.

A 19-year-old female college student is brought to the emergency department by her family over her objections. Three months ago, she suddenly started feeling "odd," and she came home from college because she could not concentrate. Two weeks after she came home, she began hearing voices telling her that she is "a sinner" and must repent. Although never a religious person, she now believes she must repent, but she does not know how, and feels confused. She is managing her activities of daily living despite the ongoing auditory hallucinations and delusions, and she is affectively reactive on examination. Which diagnosis best fits this presentation? A. Schizophreniform disorder, with good prognostic features, provisional. B. Schizophreniform disorder, without good prognostic features, provisional. C. Schizophreniform disorder, with good prognostic features. D. Schizophreniform disorder, without good prognostic features. E. Unspecified schizophrenia spectrum and other psychotic disorder.

Schizophreniform disorder, with good prognostic features, provisional. Explanation: Schizophreniform disorder is diagnosed under two conditions: 1) when an episode of illness lasts between 1 and 6 months and the individual has already recovered, and 2) when an individual is symptomatic for less than the 6 months' duration required for the diagnosis of schizophrenia but has not yet recovered (as in this vignette). One then adds the qualifier "provisional," because it is uncertain whether the individual will recover from the disturbance within the 6-month period. If the disturbance persists beyond 6 months, the diagnosis should be changed to schizophrenia. In either case, schizophreniform disorder takes the specifier "with good prognostic features" if at least two of the following features are present: 1) onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; 2) confusion or perplexity; 3) good premorbid social and occupational functioning; and 4) absence of blunted or flat affect. This vignette demonstrates all four of these features. Because we have enough information to make the diagnosis of schizophreniform disorder, unspecified schizophrenia spectrum and other psychotic disorder would be incorrectly applied.

A 64-year-old man who had been a widower for 3 months presents to the emergency department on the advice of his primary care physician after he reports to the doctor that he hears his deceased wife's voice calling his name when he looks through old photos, and sometimes as he is trying to fall asleep. His primary care physician tells him he is having a psychotic episode and needs to get a psychiatric evaluation. Which of the following statements correctly explains why these experiences are not considered to be psychotic? A. The voice he hears is from a family member. B. The experience occurs as he is falling asleep. C. He can invoke her voice with certain activities. D. The voice calls his name. E. Both B and C.

The experience occurs as he is falling asleep and He can invoke her voice with certain activities. Explanation: If an auditory experience occurs only secondary to a controllable action (such as looking through highly affectively charged photos) or in an altered sensorial state, such as just before falling asleep (hypnagogic) or just as one is waking up (hypnopompic), it is not classified as a hallucination. Frank auditory hallucinations can involve the voice of someone known to the patient and often includes hearing one's name called.

Which of the following statements about the incidence of schizoaffective disorder is true? A. The incidence is equal in women and men. B. The incidence is higher in men. C. The incidence is higher in women. D. The incidence rates are unknown. E. The incidence rates vary based on seasonality of birth.

The incidence is higher in women. Explanation: The incidence of schizoaffective disorder is higher in women than in men, mainly due to an increased incidence of the depressive type among women.

A 24-year-old male college student is brought to the emergency department by the college health service team. A few weeks ago he was involved in a car accident in which one of his friends was critically injured and died in his arms. The man has not come out of his room or showered for the last 2 weeks. He has eaten only minimally, claimed that aliens have targeted him for abduction, and asserted that he could hear their radio transmissions. Nothing seems to convince him that this abduction will not happen or that the transmissions are not real. Which of the following diagnoses (and justifications) is most appropriate for this man? a. Brief psychotic disorder with a marked stressor, because the symptoms began after the tragic car accident. b. Brief psychotic disorder without a marked stressor, because the content of the psychosis is unrelated to the accident. c. Unspecified schizophrenia spectrum and other psychotic disorder, because more information is needed. d. Schizophreniform disorder, because there are psychotic symptoms but not yet a full-blown schizophrenia picture. e. Delusional disorder, because the central symptom is a delusion of persecution.

Unspecified schizophrenia spectrum and other psychotic disorder, because more information is needed. Explanation: The diagnosis of brief psychotic disorder requires that there be psychotic symptoms lasting more than 1 day but less than 1 month and that the patient has shown a full recovery. In this vignette, we do not know how long the symptoms will last or whether the patient will fully recover. If the patient's symptoms remit in less than 1 month and he shows full recovery, one could diagnose brief psychotic disorder with a marked stressor. There is no requirement that the content of the psychotic symptoms match the events that constitute the stressor, as long as the temporal sequence holds. The diagnosis of delusional disorder requires 1 month of symptoms and does not usually involve bizarre de- lusions, nor does it involve the functional deficits seen here. Schizophreniform disorder requires 1 month of symptoms. If these symptoms continue for a month and functional deficits persist, the diagnosis could be schizophreniform disorder, and possibly progress to schizophrenia after 6 months. We do not yet know the future trajectory of these psychotic symptoms and therefore can justify only the diagnosis of unspecified schizophrenia spectrum and other psychotic disorder. The unspecified schizophrenia spectrum and other psychotic disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific schizophrenia spectrum and other psychotic disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).