31 Schizophrenia

Kenneth Lakritz

Clinical Vignette

This 22-year-old electrician was brought to the emergency room after frequently confronting his parents, friends, and supervisors about being pursued by extraterrestrial aliens. With increasing frequency, he became obsessed with the idea of developing a barrier to electronic emissions that were “emanating from outer space.” He was frightened that these signals were attempting to control his entire life by gaining control of his own body, and subsequently turn him into a baboon. When his parents attempted to be helpful, he found a lawyer and took them to court for persecuting him and invading his privacy.

Up until this time, he had been in perfect health with no outward signs of a thought disorder. He had never required any psychiatric treatment. He had done well in school, served in the armed forces for 4 years, where he learned to be an electrician and received an honorable discharge. Soon after arriving home and starting a civilian job, his parents recognized that a major personality change had occurred. This was characterized by both his paranoia and his withdrawal from most interpersonal relationships, spending almost all of his free time secluded in his room.

Psychiatric examination demonstrated him to be exceedingly tense and fearful. He stated that he was developing a computer system for his personal use that is to prevent alien communications from interfering with his daily activities. Further delusional thoughts were articulated, including his being concerned about a biologic invasion, voices telling him to do scary things, and feelings of being controlled by outside forces that are invading his own brain. Physical examination, cranial MRI, and routine laboratory testing, including drug screen, were unremarkable.

He was involuntarily hospitalized. An atypical antipsychotic drug helped to significantly improve his anxiety. Although this medication did not significantly impact on the presence and frequency of his delusional thinking, these thoughts seemed to be less bothersome to him. However, he was no longer capable of continuing in school and he withdrew from a formal educational environment to spend all of his time at home with his parents.

More than 120 years ago, Emil Kraepelin delineated schizophrenia as a global impairment of psychic functioning. It is distinguished from the affective psychoses by its unremitting course. Schizophrenia typically first occurs in late adolescence or early adulthood; this distinguishes it from the dementias. Sufferers, often initially odd or unsociable, eventually become progressively more isolated and eccentric, commonly failing to care for themselves and sometimes creating a public nuisance. It is quite uncommon for schizophrenia to first appear in midlife. However, when it does occur at this time in life, it overwhelmingly affects women, usually presenting with prominent paranoid symptoms.

During their initial evaluation, these patients overtly express their hallucinations—usually of commanding voices, disordered thinking, and delusional beliefs (Fig. 31-1

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