Updated: 10/20/2021

Schizophrenia

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Questions
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Evidence
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Videos / Pods
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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

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Questions (9)
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(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?

QID: 107068
1

Brief psychotic disorder

7%

(2/28)

2

Schizophreniform disorder

68%

(19/28)

3

Schizophrenia

7%

(2/28)

4

Schizoid personality disorder

14%

(4/28)

5

Schizotypal peronsality disorder

0%

(0/28)

M 2 D

Select Answer to see Preferred Response

(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?

QID: 100014
1

Schizophrenia

38%

(8/21)

2

Schizotypal disorder

0%

(0/21)

3

Schizoaffective disorder

38%

(8/21)

4

Bipolar disorder

10%

(2/21)

5

Unipolar mania

5%

(1/21)

M 2 D

Select Answer to see Preferred Response

(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?

QID: 106273
1

Schizoaffective disorder

6%

(2/33)

2

Major depression

0%

(0/33)

3

Schizophrenia

76%

(25/33)

4

Schizophreniform disorder

15%

(5/33)

5

Malingering

0%

(0/33)

M 2 E

Select Answer to see Preferred Response

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Evidence (6)
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