Pregnancy and birth complications with hypoxia and greater paternal age are associated with a higher risk of schizophrenia for the developing fetus. In addition, other prenatal and perinatal adversities, including stress, infection, malnutrition, maternal diabetes, and other medical conditions, have been linked with schizophrenia. However, the vast major- ity of offspring with these risk factors do not develop schizophrenia.
Cultural and socioeconomic factors must be considered, particularly when the individual and the clinician do not share the same cultural and socioeconomic background. Ideas that appear to be delusional in one culture (e.g., witchcraft) may be commonly held in another.
In some cultures, visual or auditory hallucinations with a religious content (e.g., hearing
God’s voice) are a normal part of religious experience. In addition, the assessment of dis- cultures. The assessment of affect requires sensitivity to differences in styles of emotional expression, eye contact, and body language, which vary across cultures. If the assessment is conducted in a language that is different from the individual’s primary language, care must be taken to ensure that alogia is not related to linguistic barriers. In certain cultures, distress may take the form of hallucinations 0r pseudo-hallucinations and overvalued ideas that may present clinically similar to true psychosis but are normative to the pa- tient’s subgroup.
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, par- ticularly among treated cases. The age at onset is later in females, with a second mid-life peak as described earlier (see the section ”Development and Course” for this disorder).
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, how- ever, frequent exceptions to these general caveats.
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 lifespan 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.
Functional Consequences of Schizophrenia
Schizophrenia is associated with significant social and occupational dysfunction. Making educational progress and maintaining employment are frequently impaired by avolition or other disorder manifestations, even when the cognitive skills are sufficient for the tasks at hand. Most individuals are employed at a lower level than their parents, and most, par- ticularly men, do not marry or have limited social contacts outside of their family.
Major depressive or bipolar disorder with psychotic or catatonic features. The distinc- tion between schizophrenia and major depressive or bipolar disorder with psychotic features or with catatonia depends on the temporal relationship between the mood distur- bance and the psychosis, and on the severity of the depressive or manic symptoms. If de- lusions or hallucinations occur exclusively during a major depressive or manic episode, the diagnosis is depressive or bipolar disorder with psychotic features.
Schizoaffective disorder. A diagnosis of schizoaffective disorder requires that a major depressive or manic episode occur concurrently with the active-phase symptoms and that the mood symptoms be present for a majority of the total duration of the active periods.