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Updated: Oct 8 2022


  • 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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