Schizophrenia vs Delusional Disorder | UWorld Psychiatry, USMLE Step 1, NCLEX

Schizophrenia is a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior. 

Schizophrenia symptoms are described in terms of positive, negative, and cognitive symptoms.

Positive ("pathologic excesses")
Positive symptoms are those symptoms that are not normally experienced, but are present in people during a psychotic episode in schizophrenia, including
• Hallucinations: false sensory perception in the absence of stimuli (eg, hearing voices)
• Delusions: false belief despite evidence to the contrary (eg, "the neighbors are aliens")
• Disorganized/incoherent speech
• Disorganized/agitated behavior

Negative ("pathologic deficits")
Negative symptoms are deficits of normal emotional responses, or of other thought processes. The five recognized domains of negative symptoms are: 
• Apathy: lack of motivation
• Social withdrawal
• Flat affect emotional flattening/monotone speech
• Poverty (lack) of speech
• Anhedonia: inability to experience pleasure

Cognitive symptoms
An estimated 70% of those with schizophrenia have cognitive deficits, and these are most pronounced in early-onset and late-onset illness. These are often evident long before the onset of illness in the prodromal stage, and may be present in childhood or early adolescence.

Schizophrenia presents with a variety of cognitive, behavioral, and emotional disturbances and typically has an onset in early adulthood (peak age: men, early 20s; women, late 20s).
Schizophrenia has a gradual onset but occasionally a precipitating stressor unmasks the disorder, such as in a patient with symptoms after the death of his father.
The diagnosis is made with continuous signs of disturbance for at least 6 months, including at least 1 month of 2 of the following active symptoms (with at least 1 from the first 3):
Delusions (eg, fixation on a date and time, thinking that it has special meaning)
Hallucinations
Disorganized speech (eg, frequent change of topics, random remarks)
Disorganized/catatonic behavior (eg, bizarre drawings)
Negative symptoms (eg, apathy, flat affect, social withdrawal, lack of speech, anhedonia)
Although positive symptoms (eg, delusions, hallucinations) are characteristic in schizophrenia, some patients, demonstrate largely negative symptoms with increasing social withdrawal (eg, not responding to friends), apathy (eg, not completing homework assignments), and affective blunting.
The primary treatment of schizophrenia is the use of antipsychotic medications (eg, risperidone, olanzapine). However, these drugs are more effective at managing positive symptoms; negative symptoms are typically refractory to intervention.
Fixation on date and time as having special meaning is a referential delusion (ie, a belief that cues from the environment are individualized messages). Patients with delusional disorders typically do not have referential delusions, negative symptoms, or disorganized speech.
Response to a significant loss may include withdrawal, apathy, flat affect or preoccupation with memories of the deceased. However, normal bereavement does not cause disorganized speech, disorganized behavior, or delusions.
Behaviors related to obsessive-compulsive disorder (OCD), such as ritualistic washing or chewing food a certain number of times, can appear bizarre. However, bizarre, indecipherable speech; negative symptoms; and referential delusions are not associated with OCD.
Post-traumatic stress disorder (PTSD) involves psychological distress following a traumatic event. It can present with distress-related disturbances resembling hallucinations and/or mood alterations with anhedonia and negative emotionality. However, disorganized, incoherent speech and thought are not seen in PTSD.
Schizophrenia is diagnosed in patients with signs of disturbance for 6 months, including at least 1 month of 2 of the following active symptoms (with at least 1 from the first 3): delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, and negative symptoms.

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