DSM 5 Clinical Cases - Schizophrenia and Other Psychotic Disorders

Schizophrenia Spectrum and
Other Psychotic Disorders

DSM-5® Clinical Cases
Introduction
John W. Barnhill, M.D.
Schizophrenia is the prototypical psychotic disorder. Not only is it the most com-
mon psychosis, but schizophrenia tends to involve abnormalities in all five of the empha-
sized symptom domains: hallucinations, delusions, disorganized thinking (speech),
grossly disorganized or abnormal motor behavior (including catatonia), and negative
symptoms. Like the DSM-5 neurodevelopmental disorders, schizophrenia is viewed as
a neuropsychiatric disorder with complex genetics and a clinical course that tends to
begin during a predictable stage of development. Whereas the neurodevelopmental
disorders tend to begin during childhood, symptoms of schizophrenia tend to reliably
develop during late adolescence and early adulthood.
The schizophrenia diagnosis has undergone some minor revisions for DSM-5.
First, because of their limited diagnostic stability, low reliability, and poor validity, schizo-
phrenia subtypes have been eliminated. They had included such categories as disor-
ganized, paranoid, and residual types of schizophrenia.
Long associated with schizophrenia, catatonia remains one of the potential diag-
nostic criteria for most of the psychotic diagnoses, including schizophrenia, but it can
now be designated as a specifier for other psychiatric and nonpsychiatric medical con-
Copyright © 2015. American Psychiatric Publishing. All rights reserved.
ditions, including depressive and bipolar disorders. “Other specified catatonia” can also
be diagnosed when criteria are either uncertain or incomplete for either the catatonia
or the comorbid psychiatric or nonpsychiatric medical condition.
The DSM-5 schizophrenia diagnosis requires persistence of two of five symptom-
atic criteria (delusions, hallucinations, disorganized speech, disorganized behavior or
catatonia, and negative symptoms). One pertinent change is the elimination of a spe-
cial status for particular types of delusions and hallucinations, any one of which
would previously have been adequate to fulfill symptomatic criteria for schizophre-
nia. A second change is the requirement for one of the two symptomatic criteria to be
a positive symptom, such as delusions, hallucinations, or disorganized thinking.
Criteria for schizoaffective disorder have been significantly tightened. As was the
case in DSM-IV, a diagnosis of schizoaffective disorder requires that the patient meet
criteria for schizophrenia and have symptoms of either major depressive or bipolar dis-
71
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72 Schizophrenia Spectrum and Other Psychotic Disorders: DSM-5® Selections
order concurrent with having active symptoms of schizophrenia. Also, as was the case
previously, there must have been a 2-week period of delusions or hallucinations with-
out prominent mood symptoms. The significant change is that in DSM-5 symptoms
that meet criteria for a major mood disorder must be present for the majority of the total
duration of the active and residual phases of the overall illness. Therefore, the DSM-5
schizoaffective diagnosis requires more attention to the longitudinal course than was
previously the case. Furthermore, the diagnostic requirement that major mood symp-
toms be present during most of the course of the psychotic disorder (including both
the acute and the residual phases) will likely lead to a significant reduction in the num-
ber of people who meet criteria for schizoaffective disorder.
Delusional disorder remains focused on the presence of delusions in the absence of
other active symptoms of schizophrenia, depressive or bipolar disorders, and perti-
nent substance use. Bizarre delusions are now included as symptomatic criteria for
delusional disorder, whereas delusions that are considered to be part of body dysmor-
phic disorder and obsessive-compulsive disorder should not lead to a delusional dis-
order diagnosis but rather to a primary diagnosis of either body dysmorphic disorder
or obsessive-compulsive disorder, along with the “absent insight/delusional beliefs”
specifier.
Brief psychotic disorder and schizophreniform disorder remain essentially un-
changed in DSM-5. They remain distinguished from schizophrenia primarily on the
basis of the duration of symptoms.
Not specifically discussed in this text are diagnoses that involve atypical or incom-
plete presentations or involve situations such as the emergency room setting where
information is often incomplete. These include “other specified schizophrenia spec-
trum and other psychotic disorder,” “unspecified catatonia,” and “unspecified schizo-
phrenia spectrum and other psychotic disorder.”
These “other” diagnoses reflect the reality that humans’ thoughts, feelings, and be-
haviors lie on a continuum, as do their disorders, and the “other” option is a diagnos-
tic option through much of DSM-5. This diagnostic gray zone is particularly poignant
in regard to schizophrenia spectrum illness. For many people who end up with a
chronic illness such as schizophrenia or schizoaffective disorder, there exists a period
of time in which they begin to show symptoms but are not yet diagnosed. It had been
proposed that this issue be addressed in DSM-5 by creating a new diagnosis, attenuated
psychosis syndrome. Psychiatrists are not yet able to robustly predict which patients are
most likely to go on to develop full-blown psychotic symptoms, but accurate predic-
tion is important enough that the syndrome is mentioned in two places in DSM-5.
First, attenuated psychosis syndrome can be used as a specifier within this chapter of
DSM-5, where it would be listed as “other specified schizophrenia spectrum and other
disorders (attenuated psychosis syndrome).” The condition is also discussed in more
detail among the “Conditions for Further Study.”
Suggested Readings
Bromet EJ, Kotov R, Fochtmann LJ, et al: Diagnostic shifts during the decade following first ad-
mission for psychosis. Am J Psychiatry 168(11):1186–1194, 2011
Lieberman JA, Murray RM: Comprehensive Care of Schizophrenia: A Textbook of Clinical
Management, 2nd Edition. New York, Oxford University Press, 2012
Schizophrenia Spectrum and Other Psychotic Disorders: DSM-5® Clinical Cases 73
Tamminga CA, Sirovatka PJ, Regier DA, et al (eds): Deconstructing Psychosis: Refining the Re-
search Agenda for DSM-V. Arlington, VA, American Psychiatric Association, 2010
Case 1: Emotionally Disturbed

Carol A. Tamminga, M.D.
Felicia Allen was a 32-year-old woman brought to the emergency room (ER) by po-
lice after she apparently tried to steal a bus. Because she appeared to be an “emotion-
ally disturbed person,” a psychiatry consultation was requested.
According to the police report, Ms. Allen threatened the driver with a knife, took
control of the almost empty city bus, and crashed it. A more complete story was elic-
ited from a friend of Ms. Allen’s who had been on the bus but who had not been ar-
rested. According to her, they had boarded the bus on their way to a nearby shopping
mall. Ms. Allen became frustrated when the driver refused her dollar bills. She looked
in her purse, but instead of finding exact change, she pulled out a kitchen knife that
she carried for protection. The driver fled, so she got into the empty seat and drove the
bus across the street into a nearby parked car.
On examination, Ms. Allen was a handcuffed, heavyset young woman with a ban-
dage on her forehead. She fidgeted and rocked back and forth in her chair. She appeared
to be mumbling to herself. When asked what she was saying, the patient made momen-
tary eye contact and just repeated, “Sorry, sorry.” She did not respond to other questions.
More information was elicited from a psychiatrist who had come to the ER soon
after the accident. He said that Ms. Allen and her friend were longtime residents at
the state psychiatric hospital where he worked. They had just begun to take passes ev-
ery week as part of an effort toward social remediation; it had been Ms. Allen’s first
bus ride without a staff member.
According to the psychiatrist, Ms. Allen had received a diagnosis of “childhood-
onset, treatment-resistant paranoid schizophrenia.” She had started hearing voices by
age 5 years. Big, strong, intrusive, and psychotic, she had been hospitalized almost
constantly since age 11. Her auditory hallucinations generally consisted of a critical
voice commenting on her behavior. Her thinking was concrete, but when relaxed she
could be self-reflective. She was motivated to please and recurrently said her biggest
goal was to “have my own room in my own house with my own friends.” The psy-
chiatrist said that he was not sure what had caused her to pull out the knife. She had
not been hallucinating lately and had been feeling less paranoid, but he wondered if
she had been more psychotic than she had let on. It was possible that she was just im-
patient and irritated. The psychiatrist also believed that she had spent almost no pe-
riod of life developing normally and so had very little experience with the real world.
Ms. Allen had been taking clozapine for 1 year, with good resolution of her audi-
tory hallucinations. She had gained 35 pounds during that time, but she had less trou-
ble getting out of bed in the morning, was hoping that she could eventually get a job
and live more independently, and had insisted on continuing to take the clozapine.
The bus trip to the shopping mall was intended to be a step in that direction.
Diagnosis
• Schizophrenia, multiple episodes, currently in active phase
Discussion
Stealing a city bus is not reasonable, and it reflects Ms. Allen’s inability to deal effec-
tively with the world. Her thinking is concrete. She behaves bizarrely. She mumbles
and talks to herself, suggesting auditory hallucinations. She lives in a state mental
hospital, suggesting severe, persistent mental illness.
DSM-5 schizophrenia requires at least two of five symptoms: delusions, hallucina-
tions, disorganized speech, disorganized or abnormal behavior, and negative symptoms.
Functioning must be impaired, and continuous signs of the illness must persist for at
least 6 months. Even without any more information about Ms. Allen’s history, the diag-
nosis of schizophrenia is clear.
Ms. Allen’s psychosis began when she was a child. Early-onset symptoms are often
unrecognized because children tend to view their psychotic experience as “normal.”
Identifying the symptom (e.g., hearing voices that are not there) and associating this
with a milestone (e.g., going to a certain grade or school) can help the adult patient
retrospectively identify symptom onset. Although the symptoms and treatments are
similar for both, childhood-onset schizophrenia is often more severe than adult-onset
schizophrenia. Early psychotic symptoms are highly disruptive to normal childhood
development. Florid psychotic symptoms are impairing in and of themselves, but they
also deprive the young person of the social learning and cognitive development that
take place during critical childhood years.
Ms. Allen’s behavior on the bus likely reflects not only the psychosis and cognitive
dysfunction that are part of schizophrenia but also her diminished experience in real-life
social settings. In addition to treating her psychotic symptoms with clozapine, her psy-
chiatric team appears to be trying to remediate her losses by connecting her to a “friend”
and organizing the shopping trip. They are also quite active and involved, as reflected
by the psychiatrist’s almost immediate presence in the ER after the bus incident.
Schizophrenia is a heterogeneous disorder, affecting multiple domains. It is likely
that there are multiple schizophrenias, differentiated by as yet unknown markers. Be-
cause of insufficient evidence about validity, DSM-5 has done away with categories such
as schizophrenia, paranoid type. Instead, DSM-5 outlines several ways in which the
diagnosis can be subtyped. One way is by overall activity and chronicity of symptoms
(e.g., single vs. multiple episodes; in acute episode, in partial remission, in full remis-
sion). Another way to categorize is by assessing the severity of each of the five core
schizophrenia symptoms, using a 0–4 scale.
For example, Ms. Allen was able to try to travel with a “friend,” and her hospital-based
psychiatrist did arrive in the ER very quickly. These might reflect an engaged, active
treatment program, but when combined with her apologetic attitude and her stated
efforts toward independence, they likely indicate a relative lack of negative symptoms
such as anhedonia, reduced social networks, and alogia. Such activity-driven behavior
is unusual in patients with schizophrenia and suggests that she is not depressed. It is
hard to judge Ms. Allen’s cognitive capacity without testing. Her obvious concrete think-
ing is represented by a failure to understand the process of paying for her bus ride or
abstracting behavioral clues. Whether she has the additional characteristics of a schizo-
phrenia-like working memory disorder or attentional dysfunction is hard to tell from
this vignette, but she should be tested.
In addition to assessing the extent of positive symptoms, it is crucial for the field of
psychiatry to better understand and categorize the negative symptoms and cognitive
dysfunction of schizophrenia. Whereas the most effective interventions for schizophre-
nia have long revolved around the antipsychotic medications that ameliorate positive
symptoms, future treatments will likely focus increasingly on the specific behavioral,
cognitive, and emotional disturbances that are also an integral part of schizophrenia.
Suggested Readings
Ahmed AO, Green BA, Goodrum NM, et al: Does a latent class underlie schizotypal personal-
ity disorder? Implications for schizophrenia. J Abnorm Psychol 122(2):475–491, 2013
Heckers S, Barch DM, Bustillo J, et al: Structure of the psychotic disorders classification in DSM
5. Schizophr Res 150(1):11–14, 2013
Tandon R, Gaebel W, Barch DM, et al: Definition and description of schizophrenia in the DSM-
5. Schizophr Res 150(1):3–10, 2013
Case 2: Increasingly Odd

Ming T. Tsuang, M.D., Ph.D., D.Sc.
William S. Stone, Ph.D.
Gregory Baker was a 20-year-old African American man who was brought to
the emergency room (ER) by the campus police of the university from which he had
been suspended several months earlier. The police had been called by a professor
who reported that Mr. Baker had walked into his classroom shouting, “I am the Joker,
and I am looking for Batman.” When Mr. Baker refused to leave the class, the profes-
sor contacted security.
Although Mr. Baker had much academic success as a teenager, his behavior had
become increasingly odd during the past year. He quit seeing his friends and spent
most of his time lying in bed staring at the ceiling. He lived with several family mem-
bers but rarely spoke to any of them. He had been suspended from college because of
lack of attendance. His sister said that she had recurrently seen him mumbling quietly
to himself and noted that he would sometimes, at night, stand on the roof of their
home and wave his arms as if he were “conducting a symphony.” He denied having
any intention of jumping from the roof or having any thoughts of self-harm, but
claimed that he felt liberated and in tune with the music when he was on the roof. Al-
though his father and sister had tried to encourage him to see someone at the univer-
sity’s student health office, Mr. Baker had never seen a psychiatrist and had no prior
hospitalizations.
During the prior several months, Mr. Baker had become increasingly preoccupied
with a female friend, Anne, who lived down the street. While he insisted to his family
that they were engaged, Anne told Mr. Baker’s sister that they had hardly ever spoken
and certainly were not dating. Mr. Baker’s sister also reported that he had written many
letters to Anne but never mailed them; instead, they just accumulated on his desk.
His family said that they had never known him to use illicit substances or alcohol,
and his toxicology screen was negative. When asked about drug use, Mr. Baker appeared
angry and did not answer.
On examination in the ER, Mr. Baker was a well-groomed young man who was
generally uncooperative. He appeared constricted, guarded, inattentive, and preoccu-
pied. He became enraged when the ER staff brought him dinner. He loudly insisted
that all of the hospital’s food was poisoned and that he would only drink a specific
type of bottled water. He was noted to have paranoid, grandiose, and romantic de-
lusions. He appeared to be internally preoccupied, although he denied hallucinations.
Mr. Baker reported feeling “bad” but denied depression and had no disturbance in his
sleep or appetite. He was oriented and spoke articulately but refused formal cognitive
testing. His insight and judgment were deemed to be poor.
Mr. Baker’s grandmother had died in a state psychiatric hospital, where she had lived
for 30 years. Her diagnosis was unknown. Mr. Baker’s mother was reportedly “crazy.”
She had abandoned the family when Mr. Baker was young, and he was raised by his
father and paternal grandmother.
Ultimately, Mr. Baker agreed to sign himself into the psychiatric unit, stating, “I don’t
mind staying here. Anne will probably be there, so I can spend my time with her.”
Diagnosis
• Schizophrenia, first episode, currently in acute episode
Discussion
Mr. Baker’s case involves an all-too-familiar scenario in which a high-functioning
young man undergoes a significant decline. In addition to having paranoid, grandi-
ose, and romantic delusions, Mr. Baker appears to be responding to internal stimuli
(i.e., auditory hallucinations) and demonstrating negative symptoms (lying in bed all
day). These symptoms have persisted and intensified over the prior year. The history
does not indicate medications, substances of abuse, or other medical or psychiatric dis-
orders that could cause these symptoms. Therefore, he meets DSM-5 criteria for schizo-
phrenia. Although a family history of psychiatric illness is not a requisite for his DSM-5
diagnosis, Mr. Baker’s mother and grandmother appear to have also had major mental
disorders.
Schizophrenia is, however, a heterogeneous disorder. For example, Mr. Baker’s most
prominent symptoms are delusions. Another person with schizophrenia might pres-
ent most prominently with disorganization of speech and behavior and without any
delusions. DSM-5 tries to address this heterogeneity by encouraging a dimensional
viewpoint rather than a categorical one. In other words, instead of clarifying whether
a patient has “paranoid” or “disorganized” schizophrenia, DSM-5 encourages an as-
sessment of a variety of specifiers. One important specifier, the course specifier, re-
quires a longitudinal assessment to determine whether this is a first episode or one of
multiple episodes, and whether it is an acute episode, in partial remission, or in full

remission.
DSM-5 also encourages specific ratings of symptoms. For example, is this schizo-
phrenic episode accompanied by catatonia? On a 5-point scale (from 0 to 4), how se-
vere is each of the five cardinal schizophrenia symptoms? DSM-5 also encourages an
assessment of cognition, mania, and depression domains. For example, some of Mr.
Baker’s behaviors (e.g., interrupting a class to proclaim his identity as the Joker) may
seem to be symptomatic of mania, but they are unaccompanied by disturbances in
sleep, mood, or level of activity. Similarly, Mr. Baker said he felt “bad” but not de-
pressed. These clinical observations likely distinguish Mr. Baker from other subcate-
gories of people with schizophrenia.
The schizophrenia diagnosis can be made without assessing these severity specifi-
ers. Nevertheless, the use of dimensional ratings improves the ability to assess Mr.
Baker for the presence of core symptoms of schizophrenia in a more individualized
manner. The inclusion of dimensions that cut across diagnostic categories will facilitate
the development of a differential diagnosis that includes bipolar disorder and schizo-
affective disorder. These assessments may clarify Mr. Baker’s functional prognosis in
major life roles (e.g., living arrangement or occupational status). Finally, repeated di-
mensional assessments may facilitate a longitudinal understanding of Mr. Baker’s
symptomatology, development, and likely responses to treatment.
Suggested Readings
Barch DM, Bustillo J, Gaebel W, et al: Logic and justification for dimensional assessment of
symptoms and related clinical phenomena in psychosis: relevance to DSM-5. Schizophr
Res 150(1):15–20, 2013 PubMed ID: 23706415
Cuesta MJ, Basterra V, Sanchez-Torres A, et al: Controversies surrounding the diagnosis of
schizophrenia and other psychoses. Expert Rev Neurother 9(10):1475–1486, 2009
5. Schizophr Res 150(1):11–14, 2013
Tandon R, Gaebel W, Barch DM, et al: Definition and description of schizophrenia in the DSM-
5. Schizophr Res 150(1):3–10, 2013
Case 3: Hallucinations of a Spiritual Nature

Lianne K. Morris Smith, M.D.

Dolores Malaspina, M.D., M.P.H.
Hakim Coleman was a 25-year-old U.S. Army veteran turned community college
student who presented to the emergency room (ER) with his girlfriend and sister. On
examination, he was a tall, slim, and well-groomed young man with glasses. He
spoke softly, with an increased latency of speech. His affect was blunted except when
he became anxious while discussing his symptoms.
Mr. Coleman stated that he had come to the ER at his sister’s suggestion. He said
he could use a “general checkup” because of several days of “migraines” and “halluci-
nations of a spiritual nature” that had persisted for 3 months. His headache involved
“sharp, shooting” sensations in various bilateral locations in his head and a “ringing”
sensation along the midline of his brain that seemed to worsen when he thought about
his vices.
Mr. Coleman described his vices as being “alcohol, cigarettes, disrespecting my par-
ents, girls.” He denied guilt, anxiety, or preoccupation about any of his military duties
during his tour in Iraq, but he had joined an evangelical church 4 months earlier in
the context of being “riddled with guilt” about “all the things I’ve done.” Three months
earlier, he began “hearing voices trying to make me feel guilty” most days. The last
auditory hallucination had been the day before. During these past few months, he had
noticed that strangers were commenting on his past sins.
Mr. Coleman believed that his migraines and guilt might be due to alcohol with-
drawal. He had been drinking three or four cans of beer most days of the week for sev-
eral years until he “quit” 4 months earlier after joining the church. He still drank “a beer
or two” every other week but felt guilty afterward. He denied alcohol withdrawal
symptoms such as tremor and sweats. He had smoked cannabis up to twice monthly
for years but completely quit when he joined the church. He denied using other illicit
drugs except for one uneventful use of cocaine 3 years earlier. He slept well except oc-
casional nights when he would sleep only a few hours in order to finish an academic
assignment.
Otherwise, Mr. Coleman denied depressive, manic, or psychotic symptoms and vi-
olent ideation. He denied posttraumatic stress disorder (PTSD) symptoms. Regarding
stressors, he felt overwhelmed by his current responsibilities, which included attend-
ing school and near-daily church activities. He had been a straight-A student at the
start of the school year but was now receiving Bs and Cs.
The patient’s girlfriend and sister were interviewed separately. They agreed that Mr.
Coleman had become socially isolative and quiet, after having previously been fun and
outgoing. He had also never been especially religious prior to this episode. His sister
believed that Mr. Coleman had been “brainwashed” by the church. His girlfriend, how-
ever, had attended services with Mr. Coleman. She reported that several members of
the congregation had told her they had occasionally talked to new members who felt
guilt over their prior behaviors, but none who had ever hallucinated, and they were
worried about him.
A physical examination of the patient, including a neurological screen, was unre-

markable, as were routine laboratory testing, a blood alcohol level, and urine toxicol-
ogy. A noncontrast head computed tomography (CT) scan was normal.
Diagnosis
• Schizophreniform disorder, provisional
Discussion
The differential diagnosis for a young military veteran with new-onset psychosis and a
history of substance abuse is broad. The primary possibilities include a primary psychotic
disorder, a psychotic mood disorder, substance-induced psychosis, a psychotic disorder
secondary to a general medical condition, a shared cultural syndrome, and PTSD.
Mr. Coleman seems most likely to fit a DSM-5 schizophreniform disorder, a diag-
nosis that differs from schizophrenia in two substantive ways: the total duration of
schizophreniform illness—including prodrome, active, and residual phases—is greater
than 1 month but less than 6 months. In addition, there is no criterion that mandates
social or occupational impairment. For both schizophreniform disorder and schizo-
phrenia, the patient must meet at least two of five symptomatic criteria. Mr. Coleman
describes hallucinations (“hearing voices trying to make me feel guilty”) and negative
symptoms (blunted affect, avolition, social isolation). The case report does not mention
delusions or disorganization of either speech or behavior.
Not relevant to DSM-5 criteria, but of interest, is that Mr. Coleman reports two
schneiderian symptoms besides auditory hallucinations: ideas of reference and pos-
sible cenesthetic hallucinations based on his description of his atypical headaches
(“ringing” in his brain).
DSM-5 indicates that depressive and manic symptoms should be explored as po-
tentially causing the psychosis, and Mr. Coleman denies pertinent mood symptoms.
The diagnosis of schizophreniform disorder also requires exclusion of a contributory
general medical condition or substance use disorder. Mr. Coleman appears to have no
medical complaints, and both his physical examination and laboratory testing are
noncontributory.
The patient himself is convinced that his symptoms are due to alcohol. At its worst,
however, his drinking appears to have been modest, and he has lately been drinking
“a beer or two” every other week. He denies ever having had symptoms of withdrawal
or other complications. His hallucinations began months after he cut back on his alco-
hol use, and they persisted for months. Additionally, his laboratory tests, including a
hepatic panel and complete blood count, were normal, which would be unusual in pa-
tients with the sort of chronic alcohol use that usually accompanies alcohol-induced
psychosis or significant withdrawal. Mr. Coleman’s chronic cannabis use could poten-
tially be implicated in the development of psychosis, but not only was his cannabis use
sporadic, he apparently had not used for several months prior to the onset of halluci-
nations, and results of a toxicology screen were negative. It would appear that Mr.
Coleman’s concerns about alcohol and cannabis are linked to hyperreligious guilt
rather than an actual substance use disorder. The possibility of a general medical con-
dition was considered, but his normal laboratory testing and physical examination re-
sults provided no such evidence.
Schizophreniform disorders last at least 1 month but less than 6 months. In regard to
Mr. Coleman, his initial 1–2 months of religious preoccupation and guilty ruminations
would be considered a prodrome phase. The 3 months preceding presentation to the ER
would represent the active phase of psychosis. Because Mr. Coleman’s psychotic symp-
toms have lasted 4–5 months but are ongoing, he would be said to have provisional
schizophreniform disorder. Obviously, everyone who goes on to develop schizophrenia
has a 6-month period in which they could be said to have schizophreniform disorder, but
about one-third of people with schizophreniform disorder do not go on to develop
schizophrenia or schizoaffective disorder.
Three other diagnostic possibilities that deserve mention include PTSD, a dissocia-
tive disorder, and a shared cultural syndrome. The case does not go into depth about
Mr. Coleman’s military experience, but simply the experience of being in an active
war zone can be a traumatic exposure. He did not report features of PTSD, but it is
not clear how extensively possible PTSD symptoms were discussed. Given that
avoidance is a cardinal feature of PTSD—making it less likely that he would spontane-
ously report the symptoms without being prompted—it would be useful to tactfully
explore the possibility.
Mr. Coleman’s family members indicate that his symptoms began around the time
of his initiation into an evangelical church and worry that he has been “brainwashed.”
DSM-5 includes a possibly pertinent category, listed under “other specified dissocia-
tive disorders,” within the chapter on dissociative disorders. This disorder is reserved
for individuals who experience an identity disturbance due to prolonged and coercive
persuasion in the context of such experiences as long-term political imprisonment or
recruitment by cults.
It is also possible that Mr. Coleman’s unusual beliefs are a nonpathological mani-
festation of religious beliefs that he shares with other members of his church.
It appears that his psychotic symptoms began prior to his entry into the church,
however, and may have been an underlying motivating factor for him to join a church
that had previously not been of interest to him. In addition, although he attended
church frequently, there is no evidence that he joined a cult or particularly manipula-
tive religious sect. Furthermore, other congregants viewed his hallucinations as aber-
rant, indicating that his views were not part of a shared cultural or religious mindset.
The initial diagnosis of provisional schizophreniform disorder is temporary. Lon-
gitudinal follow-up will clarify whether Mr. Coleman’s symptoms attenuate or prog-
ress to a chronic psychotic illness.
Suggested Readings
Bromet EJ, Kotov R, Fochtmann LJ, et al: Diagnostic shifts during the decade following first ad-
mission for psychosis. Am J Psychiatry 168(11):1186–1194, 2011
5. Schizophr Res 150(1):, 11–14, 2013
Tamminga CA, Sirovatka PJ, Regier DA, van Os J: Deconstructing Psychosis: Refining the Re-
search Agenda for DSM-V. Arlington, VA, American Psychiatric Association, 2010
Case 4: Mind Control

Rajiv Tandon, M.D.
Itsuki Daishi was a 23-year-old engineering student from Japan who was referred
to his university student mental health clinic by a professor who had become con-
cerned about his irregular school attendance. When they had met to discuss his declin-
ing performance, Mr. Daishi had volunteered to the professor that he was distracted
by the “listening devices” and “thought control machines” that had been placed in his
apartment.
While initially wary of talking to the psychiatrist, Mr. Daishi indicated that he was
relieved to finally get a chance to talk in a room that had not yet been bugged. He said
that his problems began 3 months earlier, after he returned from a visit to Japan. He said
his first indication of trouble was that his classmates sneezed and grinned in an odd way
when he entered the classroom. One day when returning from class, he noticed two
strangers outside his apartment and wondered why they were there.
Mr. Daishi said that he first noticed that his apartment had been bugged about a
week after the strangers had been standing outside his apartment. When he watched
television, he noticed that reporters commented indirectly and critically about him.
This experience was most pronounced when he watched Fox News, which he be-
lieved had targeted him because of his “superior intelligence” and his intention to
someday become the prime minister of Japan. He believed that Fox News was trying
to make him “go mad” by instilling conservative ideas into his brain, and that this
was possible through the use of tiny mind-control devices they had installed in his
apartment.
Mr. Daishi’s sleep became increasingly irregular as he became more vigilant, and
he feared that everyone at school and in his apartment complex was “in on the plot.”
He became withdrawn and stopped attending classes, but he continued to eat and main-
tain his personal hygiene.
He denied feeling elated or euphoric. He described his level of energy as “okay”
and his thinking as clear “except when they try to put ideas into my head.” He admit-
ted to feeling extremely fearful for several hours on one occasion during his recent
trip to Japan. At that time, he had smoked “a lot of pot” and began hearing strange
sounds and believing that his friends were laughing at him. He denied any cannabis
consumption since his return to the United States and denied ever having experi-
mented with any other substances of abuse, saying that he generally would not even
drink alcohol. He denied all other history of auditory or visual hallucinations.
When Mr. Daishi’s uncle, listed as his local guardian, was contacted, he described
his nephew as a healthy, intelligent, and somewhat shy boy without any prior history
of any major psychiatric illness. He described Mr. Daishi’s parents as very loving and
supportive, although his father “might be a little stern.” There was no family history
of any major mental illness.
On examination, Mr. Daishi was well groomed and cooperative, with normal psy-
chomotor activity. His speech was coherent and goal directed. He described his mood
as “afraid.” The range and mobility of his affective expression were normal. He denied
any ideas of guilt, suicide, or worthlessness. He was convinced that he was being con-
tinuously monitored and that there were “mind-control” devices in his apartment. He
denied hallucinations. His cognitive functions were grossly within normal limits. He
appeared to have no insight into his beliefs.
On investigation, Mr. Daishi’s laboratory test results were normal, his head com-
puted tomography scan was unremarkable, and his urine drug screen was negative
for any substances of abuse.
Diagnosis
• Delusional disorder, mixed type
Discussion
Mr. Daishi meets criteria for delusional disorder, which requires one or more delu-
sions that persist for greater than 1 month but no other psychotic symptoms. Most of
Mr. Daishi’s delusions are persecutory and related to monitoring devices. He has de-
lusions of reference (classmates sneezing and grinning at him), persecution (“trying
to make me go mad,” monitoring devices), and thought insertion (“machines trying
to put ideas into my head”). He warrants the “mixed” specifier because the apparent
motivation for his having been targeted appears to be grandiose (his “superior intel-
ligence” and plans to be the prime minister of Japan), but he has no other symptoms
of mania.
Other psychotic disorders should also be considered. The 3-month duration of
symptoms is too long for brief psychotic disorder (no longer than 1 month) and too brief
for schizophrenia (no briefer than 6 months) but is an appropriate duration for schizo-
phreniform disorder (between 1 and 6 months’ duration). Mr. Daishi does not appear,
however, to have a second symptom (e.g., hallucinations, negative symptoms, or disor-
ganization) as required for a schizophreniform diagnosis. In DSM-IV, a single bizarre
delusion—the delusion of thought insertion—would have been adequate to reach
symptomatic criteria for schizophreniform disorder (or schizophrenia), but bizarre de-
lusions no longer receive special treatment among the DSM-5 schizophrenia spectrum
disorders.
The absence of manic or major depressive mood symptoms excludes a diagnosis
of bipolar disorder (with psychotic symptoms), major depressive disorder (with psy-
chotic symptoms), or schizoaffective disorder.
Substance-induced psychotic disorder should be considered in view of Mr. Daishi’s
recent, significant cannabis consumption. His symptoms do seem to have developed
soon after consumption of a substance known to cause psychosis (cannabis, with or
without adulteration with another substance such as phencyclidine), and cannabis
might be considered a trigger that Mr. Daishi should avoid in the future. DSM-5 spe-
cifically excludes the diagnosis of substance-induced psychotic disorder, however,

when symptoms persist for a substantial period of time (e.g., 1 month) following the
discontinuation of the substance.
Suggested Readings
Cermolacce M, Sass L, Parnas J: What is bizarre about bizarre delusions? A critical review.
Schizophr Bull 36(4):667–679, 2010
Nordgaard J, Arnfred SM, Handest P, et al: The diagnostic status of first-rank symptoms.
Schizophr Bull 34(1):137–154, 2008
Tandon R: The nosology of schizophrenia: toward DSM-5 and ICD-11. Psychiatr Clin North
Am 35(3):557–569, 2012
Tandon R, Carpenter WT: DSM-5 status of psychotic disorders: 1 year prepublication.
Schizophr Bull 38(3):369–370, 2012
Case 5: Sad and Psychotic

Stephan Heckers, M.D., M.Sc.
John Evans was a 25-year-old single, unemployed white man who had been see-
ing a psychiatrist for several years for management of psychosis, depression, anxiety,
and abuse of marijuana and alcohol.
After an apparently normal childhood, Mr. Evans began to show dysphoric mood,
anhedonia, low energy, and social isolation by age 15. At about the same time, Mr. Ev-
ans began to drink alcohol and smoke marijuana every day. In addition, he developed
recurrent panic attacks, marked by a sudden onset of palpitations, diaphoresis, and
thoughts that he was going to die. When he was at his most depressed and panicky,
he twice received a combination of sertraline 100 mg/day and psychotherapy. In both
cases, his most intense depressive symptoms lifted within a few weeks, and he dis-
continued the sertraline after a few months. Between episodes of severe depression,
he was generally seen as sad, irritable, and amotivated. His school performance de-
clined around tenth grade and remained marginal through the rest of high school. He
did not attend college as his parents had expected him to, but instead lived at home and
did odd jobs in the neighborhood.
Around age 20, Mr. Evans developed a psychotic episode in which he had the con-
viction that he had murdered people when he was 6 years old. Although he could not
remember who these people were or the circumstances, he was absolutely convinced
that this had happened, something that was confirmed by continuous voices accusing
him of being a murderer. He also became convinced that other people would punish
him for what had happened, and thus he feared for his life. Over the ensuing few
weeks, he became guilt-ridden and preoccupied with the idea that he should kill him-
self by slashing his wrists, which culminated in his being psychiatrically hospitalized.
Although his affect on admission was anxious, within a couple of days he also became
very depressed, with prominent anhedonia, poor sleep, and decreased appetite and
concentration. With the combined use of antipsychotic and antidepressant medica-
tions, both the depression and the psychotic symptoms remitted after 4 weeks. Thus,
the total duration of the psychotic episode was approximately 7 weeks, 4 of which
were also characterized by major depression. He was hospitalized with the same pat-
tern of symptoms two additional times before age 22, each of which started with several
weeks of delusions and hallucinations related to his conviction that he had murdered
someone when he was a child, followed by severe depression lasting an additional
month. Both relapses occurred while he was apparently adherent to reasonable dos-
ages of antipsychotic and antidepressant medications. During the 3 years prior to this
evaluation, Mr. Evans had been adherent to clozapine and had been without halluci-
nations and delusions. He had also been adherent to his antidepressant medication and
supportive psychotherapy, although his dysphoria, irritability, and amotivation never
completely resolved.
Mr. Evans’s history was significant for marijuana and alcohol abuse that began at
age 15. Before the onset of psychosis at age 20, he smoked several joints of marijuana
almost daily and binge drank on weekends, with occasional blackouts. After the on-
set of the psychosis, he decreased his marijuana and alcohol use significantly, with
two several-month-long periods of abstinence, yet he continued to have psychotic ep-
isodes up through age 22. He started attending Alcoholics Anonymous and Narcotics
Anonymous groups, achieved sobriety from marijuana and alcohol at age 23, and had
remained sober for 2 years.
Diagnoses
• Schizoaffective disorder, depressive type
• Alcohol use disorder, in remission
• Marijuana use disorder, in remission
Discussion
Mr. Evans has struggled with depression and anxiety since adolescence, worsened by
frequent use of marijuana and alcohol. At first, his treaters diagnosed him with
depression and panic disorder and treated him accordingly. He did not enter college,
as his family had expected, and he has not been employed since graduation from high
school. At age 20, psychosis emerged and he required psychiatric hospitalization.
His major psychotic symptom is paranoia, with persecutory delusions and param-
nesias of homicide. The delusions are worsened by auditory hallucinations, which he
experiences as confirmation of his delusions. The delusions and hallucinations oc-
curred almost daily between ages 20 and 22, until they resolved with clozapine treat-
ment. Although he reports difficulties with his memory, he has not displayed marked
cognitive impairment or disorganization of thought. He is socially isolated and min-
imally 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. Evans’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 irrita-
bility. He can become suicidal when psychosis and depression reach peak intensity.
Mr. Evans 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 re-
sidual portions of his schizophrenia, the major depressive symptoms have been pres-
ent most of the time.
Mr. Evans 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 consid-
ered at various times in Mr. Evans’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.
His response to treatment with antipsychotic, antidepressant, and mood-stabilizing

medication is typical: several failed attempts with antipsychotic drugs, the need for
combined treatment during periods of exacerbations, and failed attempts to taper ei-
ther the antidepressant or the antipsychotic medication.
One complicating factor in regard to diagnosing a DSM-5 schizoaffective disorder
is the reality that although DSM-5 requires that the mood disorder be present for the
majority of the active and residual portions of the schizophrenia, mood and psychotic
disorders tend to vary significantly in regard to treatment response and clinical course.
For example, whereas depressive and bipolar disorders tend to run in cycles, schizo-
phrenia—once it unfolds—tends to persist. Furthermore, depressive and bipolar dis-
orders tend to be more amenable to treatment than schizophrenia, especially because
the diagnostic time frame for the latter includes the residual phase of schizophrenia,
which can be largely resistant to psychiatric interventions. It remains to be seen how
this tightening of the criteria for schizoaffective disorder will affect the identification
and treatment of this cluster of patients.
Suggested Reading
Heckers S: Diagnostic criteria for schizoaffective disorder. Expert Rev Neurother 12(1):1–3,
2012
Case 6: Psychosis and Cannabis

Melissa Nau, M.D.
Heather Warm, M.D.
Kevin Foster, a 32-year-old white man with a history of bipolar disorder, was brought
to the emergency room (ER) by police after his wife called 911 to report that he was
threatening to jump out of their hotel window.
At the time of the episode, Mr. Foster and his wife were on vacation, celebrating
their fifth anniversary. To commemorate the event, they decided to get tattoos. After-
ward, they went to a nearby park, where Mr. Foster bought and smoked a marijuana
cigarette. During the ensuing hour, Mr. Foster began to believe that the symbols in his
tattoo had mysterious meaning and power. He became convinced that the tattoo artist
was conspiring with others against him and that his wife was cheating on him. After
returning to the hotel, the patient searched his wife’s phone for evidence of her infi-
delity and threatened to jump out the window. The patient’s wife, an ER physician,
successfully convinced the patient to go to sleep, thinking that the episode would re-
solve.
The following day, the patient remained paranoid and delusional. He again threat-
ened to jump out the window, and indicated that he would have no choice but to kill
his wife the next time she slept. She called 911, and her husband was brought to the
ER of a large nearby hospital. Later that day, he was admitted to an acute inpatient
psychiatric unit with a diagnosis of unspecified psychotic disorder.
The patient had smoked cannabis sporadically from age 18 but began to smoke
daily 5 years prior to this admission. He and his wife denied that he had ever used
other illicit substances, and the patient indicated that he rarely drank alcohol. Until
1 year earlier, he had never seen a psychiatrist or been viewed by his friends and fam-
ily as having significant psychiatric issues.
In the past year, however, Mr. Foster had been hospitalized four times for psychi-
atric problems. He had been hospitalized twice with classic manic symptoms and
once for a suicidal depression. In addition, 7 months prior to this presentation, the pa-
tient had been hospitalized for a 6-week episode of cannabis-induced psychosis,
which responded well to risperidone. At that time, his main symptom was paranoia.
Two months prior to this admission, he entered a 1-month inpatient substance abuse
treatment program for cannabis use disorder. Until the weekend of this admission, he
had not used marijuana, alcohol, or any other substances since discharge from the re-
habilitation facility. He had also been functioning well while taking lithium mono-
therapy for 3 months.
Mr. Foster had been steadily employed as a film editor since graduating from col-
lege. His father had a bipolar disorder, and his paternal grandfather committed sui-
cide via gunshot but with an unknown diagnosis.
On the second day of hospitalization, the patient began to realize that his wife was
not cheating on him and that the symbols in his tattoo were not meaningful. By the
third day, he spontaneously said the paranoia was the result of cannabis intoxication.
He declined further risperidone but continued lithium monotherapy. He was dis-
charged with an appointment to follow up with his outpatient psychiatrist.
Diagnoses
• Cannabis-induced psychotic disorder
• Bipolar disorder, in remission
Discussion
Soon after smoking a marijuana cigarette, Mr. Foster began to believe that the sym-
bols of his new tattoo had mysterious meaning and power. Within hours, he became
paranoid about the tattoo artist and delusionally jealous. He threatened to kill himself
and his wife. He was admitted to a psychiatric unit. The psychotic symptoms cleared
within a few days, and the patient regained appropriate insight. This symptom tra-
jectory fits DSM-5 substance/medication-induced psychotic disorder, which requires
delusions or hallucinations that develop during, or soon after, a substance intoxica-
tion (or withdrawal or medication exposure).
An additional DSM-5 diagnostic criterion for cannabis-induced psychotic disorder re-
volves around whether Mr. Foster’s delusions might not be better explained by a primary
psychotic disorder such as schizophrenia or psychotic symptoms within depression or
mania. His symptoms resolved within 3 days, which is typical for a cannabis-induced
psychosis but not for an independent psychotic disorder. The rapid resolution of symp-
toms would support the likelihood that the cannabis caused his symptoms.
Mr. Foster’s psychiatric history complicates the diagnosis in two different ways. First,
of the four psychiatric hospitalizations Mr. Foster has had in the past year, one was for
paranoid delusions in the context of cannabis use, leading to a 6-week hospitalization.
The duration of the actual paranoid delusions is not entirely clear, but they appear to have
lasted far longer than would be typical for a cannabis-induced psychosis. DSM-5 specifi-
cally cautions that persistence of a psychosis beyond 1 month after the exposure implies
that the psychosis may be independent rather than substance induced.
Second, of Mr. Foster’s three other psychiatric hospitalizations, two were for “classic”
mania and one was for “suicidal depression.” It is not clear whether paranoia or psy-
chosis was part of these episodes. DSM-5 points out that a history of recurrent non-
substance-related psychotic episodes would make a substance-induced psychosis
less likely.
It is not clear whether these psychiatric episodes can be brought together under a
single diagnostic umbrella. For example, Mr. Foster could have bipolar disorder with
recurrent episodes of depression and mania. The cannabis might help him sleep—
which might reduce the mania—but could possibly trigger episodes. If manic and
depressive episodes (with or without psychosis) are triggered by a substance but
symptoms persist for an extended period of time, then the most accurate diagnosis
would be the bipolar disorder. This would be especially true if similar symptoms de-
velop in the absence of substance use. Mr. Foster has a family history significant for
bipolar disorder, which could further support such a diagnosis. On the other hand,
Mr. Foster did not endorse any mood symptoms during this most recent psychotic
episode, and psychotic symptoms resolved within 2–3 days. This history would
seem to indicate that although Mr. Foster has historically met criteria for bipolar dis-
order, it seems to be currently in remission.
Multiple schizophrenia spectrum disorders might be considered. Given a 3-day
duration of symptoms, however, most diagnoses are quickly eliminated as possibili-
ties. In addition, Mr. Foster appears to have only one affected domain (delusions). De-
lusional disorder involves only delusions, but the minimum duration is 1 month.
Brief psychotic disorder also requires only one of the four primary schizophrenia spec-
trum symptoms, but it does require an evaluation as to whether the precipitant might
be a substance or medication.
At the moment, then, a cannabis-induced psychotic disorder appears to be the most

likely diagnosis for Mr. Foster’s particular episode. Clarification might be possible
through more thorough investigation of prior medical records, but even more helpful
will be ongoing, longitudinal follow-up.
Suggested Readings
Caton CL, Hasin DS, Shrout PE, et al: Stability of early-phase primary psychotic disorders with
concurrent substance use and substance-induced psychosis. Br J Psychiatry 190:105–111, 2007
Ekleberry S: Treating Co-Occurring Disorders: A Handbook for Mental Health and Substance
Abuse Professionals. Binghamton, NY, Haworth, 2004
Grant BF, Stinson FS, Dawson DA, et al: Prevalence and co-occurrence of substance use disor-
ders and independent mood and anxiety disorders: results from the National Epidemio-
logic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 61(8):807–816, 2004
Pettinati HM, O'Brien CP, Dundon WD: Current status of co-occurring mood and substance
use disorders: a new therapeutic target. Am J Psychiatry 170(1):23–30, 2013
Case 7: Flea Infestation

Julie B. Penzner, M.D.
Lara Gonzalez, a 51-year-old divorced freelance journalist, brought herself to the

emergency room requesting dermatological evaluation for flea infestation. When no
corroborating evidence was found on skin examination and the patient insisted that
she was unsafe at home, she was admitted to an inpatient psychiatric service with
“unspecified psychotic disorder.”
Her concerns began around 1 week prior to presentation. To contend with financial
stress, she had taken in temporary renters for a spare room in her home and had begun
pet sitting for some neighbors. Under these conditions, she perceived brown insects bur-
rowing into her skin and walls and covering her rugs and mattress. She threw away a
bag of clothing, believing she heard fleas “rustling and scratching inside.” She was not
sleeping well, and she had spent the 36 hours prior to presentation frantically cleaning
her home, fearing that her tenants would not pay if they saw the fleas. She showered
multiple times using shampoos meant to treat animal infestations. She called an exter-
minator who found no evidence of fleas, but she did not believe him. She was upset
about the infestation but was otherwise not troubled by depressive or manic symptoms,
or by paranoia. She did not use drugs or alcohol. No one in the family had a history of
psychiatric illness. Ms. Gonzalez had had depression once in the past and was briefly
treated with an antidepressant. She had no relevant medical problems.
Her worries about infestation began in the setting of her sister’s diagnosis with in-
vasive cancer, the onset of her own menopause, financial strain that was likely forcing
her to move from the United States back to Argentina (her country of origin), and a re-
cent breakup with her boyfriend. At baseline, she described herself as an obsessive per-
son who had always had contamination phobias, which historically worsened during
times of anxiety.
On mental status examination, Ms. Gonzalez was calm and easily engaged, with
normal relatedness and eye contact. She offered up a small plastic bag containing
“fleas and larvae” that she had collected in the hospital while awaiting evaluation. In-
spection of the bag revealed lint and plaster. Her speech had an urgent quality to it,
and she described her mood as “sad right now.” She was tearful intermittently but other-
wise smiling reactively. Her thoughts were overly inclusive and intensely focused on
fleas. She expressed belief that each time a hair fell out of her head, it would morph
into larvae. When crying, she believed an egg came out of her tear duct. She was not
suicidal or homicidal. She expressed an unshakable belief that lint was larvae, and that
she was infested. She denied hallucinations. Cognition was intact. Her insight was im-
paired, but her judgment was deemed reasonably appropriate.
Dermatological examination revealed no insects or larvae embedded in Ms. Gon-
zalez’s skin. Results of neurological examination, head computed tomography scan,
laboratory tests, and toxicology data were normal. She was discharged on a low-dose
antipsychotic medication and seen weekly for supportive psychotherapy. Her preoc-
cupation improved within days and resolved entirely within 2 weeks. She developed
enough insight to refer to her belief that fleas were in her skin as a “crazy thought.” She
attributed her “break from reality” to multiple stressors, and was able to articulate that
she relied on her delusion as a way to distract herself from real problems. Her family
corroborated her quick return to baseline.
Diagnosis
• Brief psychotic disorder with marked stressors
Discussion
Ms. Gonzalez’s delusions with quick return to full premorbid functioning suggest a
diagnosis of brief psychotic disorder with marked stressors. Formerly called “brief
reactive psychosis,” a brief psychotic disorder (with or without marked stressors) may
not be diagnosed until return to baseline has occurred. The differential diagnosis of
this condition is important.
At the time of admission, the patient was diagnosed with “unspecified psychotic
disorder,” a term often used when psychosis is present but information is incomplete.
Only after her symptoms rapidly resolved could she be diagnosed with a brief psy-
chotic disorder. Ms. Gonzalez’s insight returned quite quickly, and she was able to link
her symptoms to antecedent stressors. Although treatment is likely to shorten the du-
ration of an acute psychotic episode, DSM-5 specifically does not factor treatment into
the requirement that the episode last less than 1 month.
It is worth noting that stressors can be positive (e.g., marriage, new job, new baby)
or negative, as in Ms. Gonzalez’s case. A favorable prognosis is often associated with
a history of good premorbid functioning, significant acute stressors, and a lack of
family or personal history of psychiatric illness.
Ms. Gonzalez’s sleeplessness, behavioral agitation, and premorbid depressive history
might also suggest bipolar episode, but there are no other symptoms to support this di-
agnosis. Similarly, her delusional obsession with flea infestation suggests a possible de-
lusional disorder, but Ms. Gonzalez’s symptoms resolved far too quickly for this to be
likely. Patients with personality disorders can have “micropsychoses,” but Ms. Gonza-
lez does not appear to have a personality disorder or particular personality vulnera-
bility. Malingering and factitious disorder appear unlikely, as do delirium and other
medically mediated illnesses.
Brief psychotic episodes have a low prevalence in the population, which could indi-
cate that brief psychoses are unusual. It could also indicate that people with a very short
duration of psychotic symptoms may not seek psychiatric help. The brevity and unpre-
dictability of symptoms also makes it difficult to do research and for any particular cli-
nician or institution to develop an expertise. Brief psychotic episodes are also noted to
have a relatively low stability over time, which makes sense given that—unlike schizo-
phrenia—brief psychotic episodes are, by definition, of short duration and cannot even
be diagnosed without both remission of symptoms and careful follow-up.
Suggested Readings
Jørgensen P, Bennedsen B, Christensen J, et al: Acute and transient psychotic disorder: comor-
bidity with personality disorder. Acta Psychiatr Scand 94(6):460–464, 1996
Salvatore P, Baldessarini RJ, Tohen M, et al: McLean-Harvard International First-Episode Proj-
ect: two-year stability of DSM-IV diagnoses in 500 first-episode psychotic disorder pa-
tients. J Clin Psychiatry 70(4):458–466, 2009

DSM 5 Clinical Cases - Schizophrenia and Other Psychotic Disorders

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Schizophrenia Spectrum and

Other Psychotic Disorders

Case 1: Emotionally Disturbed

Case 2: Increasingly Odd

multiple episodes, and whether it is an acute episode, in partial remission, or in full

Case 3: Hallucinations of a Spiritual Nature

Lianne K. Morris Smith, M.D.

A physical examination of the patient, including a neurological screen, was unre-

Case 4: Mind Control

cifically excludes the diagnosis of substance-induced psychotic disorder, however,

Case 5: Sad and Psychotic

an uninterrupted period in which his major depressive symptoms were concurrent

His response to treatment with antipsychotic, antidepressant, and mood-stabilizing

Case 6: Psychosis and Cannabis

At the moment, then, a cannabis-induced psychotic disorder appears to be the most

Case 7: Flea Infestation

Lara Gonzalez, a 51-year-old divorced freelance journalist, brought herself to the

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