Updated: 3/10/2018

Schizophrenia

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Snapshot
  • A 21-year-old male college student has become increasingly bizarre over the course of the last semester and is referred by his academic advisor to the student health clinic. He will not leave his room for weeks at a time because he believes that voices in his head are telling him to continue searching the internet for hidden alien messages. He believes he is the only one on earth with this special ability. He is paranoid that the FBI knows this secret and is trying to prevent him from receiving these messages. A consulting psychiatrist admits the patient to the psychiatry ward.  The patient is started on low doses of risperidone.
Introduction
  • Epidemiology
    • genetic factors outweigh environmental factors in etiology
    • 1.4 times more diagnoses in men than women
    • presents earlier in men 
      • late teens to early 20s in men
      • late 20s to early 30s in women
    • higher risk for suicide than general population
  • Potential causes
    • overactive dopaminergic activity (association for board exams)
      • in reality, this hypothesis is weak based on fact that the weakest D2 antagonist used for treatment (clozapine) is most effective agent for schizophrenia
        • NMDA, GABA, acetylcholine are all implicated
  • NOTE: subtypes (paranoid, disorganized, catatonic, undifferentiated, residual) have been eliminated from DSM-V due to poor validity and low reliability
  • Associated conditions
    • brief psychotic disorder
      • schizophrenic symptoms lasting < 1 month
      • usually stress related
    • schizophreniform disorder
      • schizophrenic symptoms lasting between 1 and 6 months
    • schizoaffective disorder
      • schizophrenic symptoms with manic or depressed episode
        • mood disturbance must be present for majority of total duration of disorder
Presentation
  • Positive symptoms  
    • delusions
      • fixed, false beliefs
    • hallucinations
      • sensory perceptions without physical stimuli
      • auditory is most common
    • disorganized speech
      • loose associations, word salad, tangential speech
    • grossly disorganized behavior
  • Negative symptoms 
    • flat affect
    • social withdrawal
    • lack of motivations
    • lack of speech or thought
    • grossly catatonic behavior
      • symptoms improve with lorazepam
Evaluation
  • Diagnostic criteria
    • at least 2 of symptoms listed above (so-called Criterion A symptoms)
      • at least 1 must be a delusion, hallucination, or disorganized speech
      • these have to manifest for a 1 month period
    • persistent symptomatic dysfunction lasting > 6 months
    • rule out schizoaffective disorder
      • mood disturbances only present during minority of symptomatic period
    • rule out depressive/bipolar disorder with psychotic features
      • schizophrenic symptoms manifest only during mood disturbances
    • rule out substance use and other medical conditions
  • Imaging (boards knowledge, not part of diagnostic criteria)
    • may demonstrate increased ventricular size, decreased cerebral mass, decreased hippocampal mass, decreased temporal mass
Management
  • Hospitalization for acute psychotic episode
    • baseline physical and neurological exam
      • important to establish existing musculoskeletal symptoms 
    • investigations: 
      • best initial test: urine toxicology to rule out an easy and reversible cause 
      • CBC, Chem-7, LFTs, TSH, fasting glucose, EKG
        • important to assess presence or absence of metabolic syndrome
        • important to know baseline QTc interval before starting antipsychotic
    • atypical (2nd generation) antipsychotic medications  
      • first-line drug due to less extrapyramidal side effects compared to 1st generation (typical) antipsychotics
      • typical first agents: olanzapine, ziprazidone, quetiapine 
      • if not compliant, long-acting risperidone or depot haloperidol may be used
      • clozapine used as a last-line drug for refractory schizophrenia  
        • refractoriness established if first-line drug fails to improve symptoms after 2-6 weeks
        • adding a second first-line drug is not effective
 

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Questions (9)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PY.79) A 17-year-old patient with a past medical history of recent marijuana use presents to her primary care physician for a routine check-up. Although the patient has been well-groomed on past visits, the patient is noticeably disheveled, with a strong odor and dirty clothes. When asked why she has come to the office, she responds, "I just returned from the moon." During follow-up questions, she seems distracted, often stopping in the middle of a sentence. Which of the following is most likely to denote a poor prognosis in this patient? Review Topic

QID: 106915
1

Female gender

20%

(1/5)

2

Mostly positive symptoms

0%

(0/5)

3

Early age of onset

80%

(4/5)

4

An absence of a family history

0%

(0/5)

5

Recent use of marijuana

0%

(0/5)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M2.PY.81) A 63-year-old man with a past medical history of schizophrenia is brought to the emergency room by his daughter after he wandered off from her home for several days. He appears disheveled, has a strong body odor, and has lost 10 pounds since his previous visit 1 month ago. He is prescribed quetiapine, but his daughter reports that she has difficulty making sure that he takes his medications every day. Which of the following medications may be most appropriate for this patient? Review Topic

QID: 106934
1

Risperidone

50%

(2/4)

2

Quetiapine

0%

(0/4)

3

Chlorpromazine

25%

(1/4)

4

Sertraline

0%

(0/4)

5

Clozapine

25%

(1/4)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M2.PY.54) A 29-year-old man with a chronic mental disorder marked by disorganized speech, catatonic behavior, a flat affect, and social withdrawal, presents with his family after his third psychiatric hospitalization in the last four months. The patient's family is concerned because his disease has been extremely resistant to first line treatments. You start him on a medication which is used primarily for treatment-resistant schizophrenia. The feared side effect of this drug is also a potential side effect of which of the following? Review Topic

QID: 105724
1

Carbamazepine

59%

(27/46)

2

Phenytoin

9%

(4/46)

3

Methotrexate

20%

(9/46)

4

Lithium

7%

(3/46)

5

Halothane

2%

(1/46)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M2.PY.61) A 26-year-old male presents with 'voices in my head." The patient was well until 8 months ago when he began to hear voices of two men plotting to kill him. His fear of being killed has resulted in his missing multiple days of work, and he was recently fired. On physical exam he is disheveled and has incoherent, disorganized speech. Which of the following findings would you NOT expect to see on head CT? Review Topic

QID: 105731
1

Decreased cerebellar mass

100%

(6/6)

2

Increased ventricular size

0%

(0/6)

3

Decreased cerebral mass

0%

(0/6)

4

Decreased hippocampal mass

0%

(0/6)

5

Decreased temporal mass

0%

(0/6)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M3.PY.15) A 24-year-old male presents with 6 months of auditory hallucinations, paranoid delusions, and gross disorganization. The patient's head CT is shown in Figure A. Which of the following would favor a good prognosis for this man's condition? Review Topic

QID: 103750
1

Insidious onset

0%

(0/3)

2

Prior psychiatric history

0%

(0/3)

3

Negative symptom predominance

0%

(0/3)

4

History of a precipitating event

100%

(3/3)

5

Family history of mental illness

0%

(0/3)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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