Updated: 11/7/2018

Schizophrenia

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Snapshot
  • A 47-year-year old man is brought to the ED by his older brother for "acting strangely." 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 jumps from topic to topic without clear focus. 
Overview
  • Diagnostic criterion
    • chronic disorder marked by periods of psychosis and disturbed behavior with a decline in social functioning 
    • patient must meet at least 2 of the following 5 symptoms*:
      • delusions
        • fixed, false beliefs
      • hallucinations
        • sensory perceptions without physical stimuli
      • disorganized speech
        • loose associations
      • disorganized or catatonic behavior
      • negative symptoms 
        • flat affect
        • social withdrawal
        • lack of motivations
        • lack of speech or thought
      • *at least 1 of these symptoms must be delusions, hallucination, or disorganized speech
    • the diagnostic criteria must be experienced for a period of at least 1 month, with social and/or occupational impairments lasting at least 6 months 
    • previously described "sub-types" of schizophrenia are no longer recognized in the DSM-V
  • Good prognosis predictors
    • late and fast onset
    • no family history of schizophrenia
  • Epidemiology
    • genetic factors outweigh environmental factors in etiology
    • lifetime prevalence 1.5%
      • same in males, females, blacks, whites
    • presents earlier in men
      • late teens to early 20s in men
      • late 20s to early 30s in women
    • marijuana use is a risk factor in teens
    • patients are at increased risk for suicide (50% attempt)
  • Potential causes
    • ↑ dopaminergic activity in mesolimbic circuit
    • ↓ dendritic branching
    • structural abnormalities in the limbic system
Differential Diagnosis
  • Organic causes of psychosis
    • delirium
    • dementia
    • Cushing syndrome
    • substance abuse (i.e., hallucinogens)
    • thyroid disorder (i.e., thyrotoxicosis)
    • vitamin B12 deficiency
    • systemic lupus erythematosus
    • neoplasm (i.e., brain tumor)
    • epilepsy (i.e. temporal lobe)
    • Wilson's disease
    • porphyria
  • Psychiatric causes of psychosis
    • brief psychotic disorder 
      • delusions, hallucinations, and disorganized speech or behavior
      • duration < 1 month
      • usually related to acute stressors
    • schizophreniform disorder
      •  delusions, hallucinations, and disorganized speech or behavior 
      • duration > 1 month, < 6 months
    • schizoaffective disorder
      • schizophrenic psychotic symptoms plus manic, depressive, or mixed mood 
      • must have 2 weeks of schizophrenic symptoms without mood disorder
        • if mood disorder is invariably present, diagnosis is bipolar with psychotic features 
    • major depressive disorder with psychotic symptoms
      • psychotic symptoms occur exclusively during periods of mood disturbance
    • schizoid personality disorder (see Personality Disorders topic )
      • voluntary social withdrawal
      • limited emotional expression
      • content with social isolation
    • schizotypal personality disorder
      • schizoid plus odd thinking
    • posttraumatic stress disorder
      • traumatic inciting event
      • symptoms relate to reliving or reacting to the event
Treatment
  • Urgent psychiatric evaluation is required to assess the severity of illness
  • Inpatient treatment may be required to bring symptoms under control
  • Medical treatment:
    • start with a single antipsychotic
      • selection based on side effect profile (see Antipsychotic Pharmacology topic )
    • response to treatment during the first 2-4 weeks is highly predictive of long-term response
      • several months often needed to achieve maximal effect
    • first generation antipsychotics:
      • chlorpromazine
      • haloperidol
      • perphenazine
      • thiothixine
    • second generation antipsychotics:
      • aripiprazole
      • lurasidone 
      • clozapine
      • olanzapine
      • quetiapine 
      • risperidone
      • ziprasidone
  • Psychosocial (adjunctive) treatment:
    • cognitive behavioral therapy (CBT)
    • social skills training
 

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Questions (7)
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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(M1.PY.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? Review Topic

QID: 107068
1

Brief psychotic disorder

7%

(1/15)

2

Schizophreniform disorder

80%

(12/15)

3

Schizophrenia

7%

(1/15)

4

Schizoid personality disorder

7%

(1/15)

5

Schizotypal peronsality disorder

0%

(0/15)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M1.PY.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? Review Topic

QID: 106273
1

Schizoaffective disorder

13%

(2/15)

2

Major depression

0%

(0/15)

3

Schizophrenia

87%

(13/15)

4

Schizophreniform disorder

0%

(0/15)

5

Malingering

0%

(0/15)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M1.PY.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? Review Topic

QID: 100014
1

Schizophrenia

40%

(4/10)

2

Schizotypal disorder

0%

(0/10)

3

Schizoaffective disorder

50%

(5/10)

4

Bipolar disorder

0%

(0/10)

5

Unipolar mania

0%

(0/10)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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