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Updated: Dec 26 2021


  • 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
        • a psychotic episode must have been present for at least 2 weeks without mood symptoms for the diagnosis to be made
      • steroid-induced psychosis
        • occurs after starting a steroid medication and presents with symptoms of psychosis
        • improves when the medication is discontinued.
  • 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
        • olanzapine
        • quetiapine
        • risperidone
        • ziprasidone
      • long-acting injectables
        • intramuscular injections of antipsychotics administered every 2 weeks up to 6 months
        • useful for patients with poor medication compliance
  • 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
        • command hallucinations in the setting of suicidal ideation requires inpatient psychiatric hospitalization
        • addition of antidepressants to antipsychotics has mixed evidence, but may help treat the negative symptoms of chronic schizophrenia
  • Prognosis
    • Full recovery is rare
    • Factors associated with poor prognosis:
      • early onset
      • family history of schizophrenia
      • structural brain abnormalities
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