Updated: 1/3/2021

Schizophrenia

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Questions
6
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Evidence
9
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Videos / Pods
1
Topic
Snapshot
  • A 21-year old senior college student is referred by his academic advisor to the student health clinic due to reports of increasingly bizarre behavior over the course of the last semester. His roommate reported that he often does not leave his room for weeks at a time because he is obsessed with the voices in his head that tell him to continue searching the internet for hidden alien messages. He adamantly believes that he is the only one on the planet with this special ability. He is paranoid that the FBI will discover his secret and is attempting to prevent him from receiving these messages. A consulting psychiatrist admits the patient to the psychiatry ward. The patient is started on a low dose of risperidone.
Introduction
  • Overview
    • schizophrenia is a psychiatric disorder featuring periods of psychosis, commonly manifested as experiencing auditory hallucinations and delusions, and disturbed behavior with a decline in social functioning
  • Epidemiology
    • prevalence
      • lifetime prevalence is approximately 1% worldwide
        • similar prevalence in men and women
    • demographics
      • onset usually between age 17 to 35
        • peak age of onset for males is early to mid 20's
        • peak age of onset for females is late 20's
    • risk factors
      • marijuana use in teenagers
  • Pathophysiology
    • abnormalities of the dopaminergic system
      • ↓ dopaminergic activity in the mesocortical system leads to negative symptoms
      • ↑ dopaminergic activity in the mesolimbic system leads to positive symptoms
  • Associated conditions
    • brief psychotic disorder 
      • schizophrenic symptoms lasting < 1 month
      • usually stress related
    • schizophreniform disorder
      • schizophrenic symptoms lasting between 1-6 months
    • schizoaffective disorder
      • schizophrenic symptoms with manic or depressed episode
      • mood disturbance must be present for majority of total duration of disorder
    • steroid-induced psychosis 
      • occurs after starting a steroid medication and presents with symptoms of psychosis
      • improves when the medication is discontinued.
  • Prognosis
    • full recovery is rare
    • factors associated with poor prognosis:
      • early onset
      • family history of schizophrenia
      • structural brain abnormalities
Presentation
  • Symptoms
    • positive symptoms
      • auditory hallucinations
      • delusions
        • fixed, false beliefs
      • disorganized speech and behavior
    • negative symptoms 
      • flat affect
      • social withdrawal
      • lack of motivations
      • lack of speech or thought
      • grossly catatonic behavior
  • Physical exam
    • diagnostic criteria for schizophrenia
      • presence of 2 or more of the following for at least 6 months
        • delusions*
        • hallucinations*
        • disorganized speech*
        • disorganized or catatonic behavior
        • negative symptoms
        • *at least 1 of the symptoms must be delusions, hallucination, or disorganized speech
Studies
  • Urine toxicology
    • rule out reversible causes for symptoms
  • Serum labs
    • EKG
      • check baseline QTc interval before starting antipsychotic
    • complete blood count, electrolytes, liver function tests, thyroid stimulating hormone, and fasting glucose 
      • assess presence or absence of metabolic syndrome
Differential
  • Delusional disorder
    • key distinguishing factors
      • paranoid beliefs are not bizarre
      • other symptoms of schizophrenia are not present
  • Schizotypal personality disorder
    • key distinguishing factor
      • presence of odd thoughts and behaviors, though not as extreme as seen in schizophrenia
  • Schizoid personality disorder
    • key distinguishing factor
      • reclusive; lack of interest in forming close relationships with others
      • other symptoms of schizophrenia are not present
  • Paranoid personality disorder
    • key distinguishing factor
      • distrustful and suspicious of others
      • no delusions or other symptoms of schizophrenia are present
Treatment
  • Lifestyle
    • cognitive-behavioral therapy (CBT)
    • social skills training
  • Medical
    • first-generation antipsychotics
      • chlorpromazine
      • haloperidol
      • perphenazine
      • thiothixine
    • second-generation antipsychotics
      • aripiprazole
      • lurasidone 
      • clozapine
      • olanzapine
      • quetiapine 
      • risperidone
      • ziprasidone
Complications
  • Substance use
    • incidence
      • 20-70% of patients with schizophrenia
    • risk factors
      • younger male patients
    • treatment
      • dual-diagnosis treatment programs addressing alcohol and drug abuse
  • Suicide
    • incidence
      • high rate in patients with schizophrenia
    • risk factors
      • comorbid symptoms of depression
    • treatment
      • addition of antidepressants to antipsychotics has mixed evidence, but may help treat the negative symptoms of chronic schizophrenia

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(M2.PY.17.4684) During an emergency room shift, you encounter a disheveled looking man claiming that he is President Kennedy’s love child and the FBI is out to get him. He also endorses that the aliens are responsible for his fathers death and that the aliens implanted a chip in his head to constantly speak to him. Upon review of his medical record, you notice that he made a previous visit to the ER for a similar episode about 8 months ago. Besides his eccentric demeanor and disorganized speech, his vitals and physical exam are all within in normal range. No illicit substances were identified following a urinary toxicology screening. What type of medication would be best long-term for our patient?

QID: 107317
1

Quetiapine

50%

(2/4)

2

Lithium

25%

(1/4)

3

Fluoxetine

0%

(0/4)

4

Chlorpromazine

25%

(1/4)

5

Escitalopram

0%

(0/4)

M 7 C

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(M2.PY.15.4679) A 19-year-old man is brought to the emergency department by his roommate for 'strange' behavior over the past 48 hours. The patient states that he is hearing voices speak to him, giving him secret messages and instructions to carry out. He believes that the FBI is following him and spying on his conversations. The patient is concerned that they are listening to these messages and will find out his secrets. The patient's roommate states that his symptoms started 8 months ago, and that they have been off and on. The patient came to the ED several weeks ago for similar symptoms but left against medical advice. The patient's roommate does not believe the patient ingested any substance or used any recreational drugs prior to this episode. A negative drug screen is obtained and confirms this. Physical examination does not reveal any abnormalities. Which of the following treatments might best target this patient's symptoms?

QID: 107286
1

Sertraline

0%

(0/22)

2

Risperidone

59%

(13/22)

3

Haloperidol

23%

(5/22)

4

Chlorpromazine

9%

(2/22)

5

Psychotherapy

5%

(1/22)

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Evidence (9)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (24)
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