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: 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