Case description: Mackson is a 13-year-old teenage boy reporting to Clinic Y. Before coming to Clinic Y, Mackson was diagnosed by a different doctor with schizophrenia. Due to no family history of schizophrenia and their own disagreement with the diagnostic approach, his parents have brought Mackson to Clinic Y to seek a second opinion on his diagnosis. Mackson is Black and lives in a lower income, predominantly Black neighborhood in Saint Paul. Mackson lives at home with his mother, who works as a CNA at a nearby nursing home, and father, who works as an EMT for Hennepin Healthcare. Mackson's family experienced economic hardship and stressors starting in his young childhood, leading to occasional stress about being able to cover bills for the month. Mackson attends a school where most students come from higher income families than his own. He was a strong student until about 6 months ago. He reports that his favorite subjects were history and math. He used to enjoy playing dungeons and dragons and going on hikes as hobbies. He reports that although he used to have several close friends in school, he began to experience bullying and exclusion around age 11. He states he now feels "no one wants to hang out with me because they can tell I am different." Mackson's parents report feeling concerned about his behavior and thinking patterns. They report he has seemed like a different boy in the last year or two, with symptoms escalating over the last two years. Roughly two years ago, Mackson began to become more withdrawn and stopped socializing outside of his family. He remains socially withdrawn. He has also lost interest in most hobbies, and has lost his ability to concentrate on work. He endorsed feeling persistently "low" and "down," and his parents state that he has "lost his smile." Low mood persisted for at least the last 1.5 years. At Clinic Y, Mackson is given a structured clinical interview, in which he does endorse symptoms of psychosis. Specifically, he endorses hearing voices whispering to him. Generally, these voices whisper hurtful comments such as "you are worthless," "you are evil," and "no one loves you." He notes that he first heard these voices about 6 months ago. Mackson also states "everyone is out to get me," and then references experiences of bullying as proof of this thought. Jackson has organized and largely logical patterns of speech, although he is soft spoken. In the interview itself, his psychologist notes markedly flat affect. Mackson also has experienced increased appetite, low levels of energy and slower motor responses, and thoughts that he would be better off dead. He denies any active suicide ideation or planning but states "no one would miss me if I disappeared tomorrow." Mackson's parents deny family history of schizophrenia or bipolar disorder. They endorse known family history of depression in Mackson's mother and maternal grandmother. Mackson's mother denies having been significantly ill during pregnancy. Mackson was born full-term and at an expected weight and height. He did not experience any birthing complications. He did not experience any milestone delays, and never needed extra support at school. Questions: 1. Do you agree with Mackson's diagnosis of schizophrenia? Is there sufficient evidence to conclude schizophrenia is the cause of his concerns? Are there any symptoms of schizophrenia that Mackson is missing? 2. What are the differential diagnoses that you would like to see considered in this case? Which diagnosis do you find most plausible? Explain your answer. 3. What is the yearly and lifetime prevalence for the schizophrenia? What is the prevalence information related to various demographic groups (e.g., are men more likely than women to have it? Is there a racial bias in diagnosis)? 4. What is the typical age of onset for schizophrenia? What about its course? 5. What about racial biases in the diagnosis of schizophrenia? How does this relate to Mackson's case? Explain your reasoning. 6. What neural differences would be expected for Jackson if he had schizophrenia? 7. What early life insults are identified for the development of schizophrenia (under the two-hit hypothesis)? Which (if any) of these insults is there evidence for in Mackson's case? 8. What is the significance of Mackson having no family history of schizophrenia or bipolar disorder? 9. Why is it important for Mackson to get an accurate diagnosis? 10. What are at least two challenges associated with diagnosing someone of Mackson's age using adult criteria? 11. In what ways might socioeconomic status impact Mackson's mental health and prognosis? 12. What does the state about the availability of mental health services in Mackson's neighborhood, given that he lives in a predominantly Black and lower income neighborhood? How might this impact ease of treatment options?