Snapshot A 47-year old man is brought to the ED by his older brother, who says that the patient has been "acting strangely and not himself" lately. Over the last 8 months, he has claimed to hear voices telling him that "he is the chosen savior of the world." He used to work as a janitor at a local elementary school but was fired recently due to his erratic behavior. On physical exam, he appears unkempt and irritated. He seems to respond to invisible stimuli, and he rambles continuously from topic to topic without a clear focus. Introduction Overview schizophrenia is a psychiatric disorder featuring periods of psychosis, commonly manifested as experiencing auditory hallucinations, 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 17-35 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 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 Diagnosis 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
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.PY.15.112604) A 20-year-old male is involuntarily admitted to the county psychiatric unit for psychotic behavior over the past three months. The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA. When he spoke, his sentences did not always seem to have any connection with each other. The mother finally decided to admit her son after he began stating that he "revealed too much information to her and was going to be eliminated by the CIA." Which of the following diagnoses best fits this patient's presentation? Tested Concept QID: 107068 Type & Select Correct Answer 1 Brief psychotic disorder 9% (2/23) 2 Schizophreniform disorder 65% (15/23) 3 Schizophrenia 9% (2/23) 4 Schizoid personality disorder 13% (3/23) 5 Schizotypal peronsality disorder 0% (0/23) M 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (M1.PY.15.14) A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis? Tested Concept QID: 100014 Type & Select Correct Answer 1 Schizophrenia 44% (7/16) 2 Schizotypal disorder 0% (0/16) 3 Schizoaffective disorder 38% (6/16) 4 Bipolar disorder 6% (1/16) 5 Unipolar mania 0% (0/16) M 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (M1.PY.13.40) A 20-year-old college student is brought to his primary care physician by his parents over the New Years holiday because they are concerned about his behavior since right after high school graduation in May the spring before. Prior to this year, he was generally an outgoing and social young man, who now reportedly has been spending the majority of his time alone in his dorm room and room at home, where his mother and father have overheard him talking to other people when he has no guests. When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove that will soon takeover the student union building by setting the trees on fire for all to see. On exam, his appears to be otherwise healthy and his urine toxicology screen is negative. What is the most likely diagnosis? Tested Concept QID: 106273 Type & Select Correct Answer 1 Schizoaffective disorder 8% (2/26) 2 Major depression 0% (0/26) 3 Schizophrenia 77% (20/26) 4 Schizophreniform disorder 12% (3/26) 5 Malingering 0% (0/26) M 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept
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