Patients being treated with clozapine (Clozaril) for treatment-resistant schizophrenia should be monitored with which one of the following?
Correct Answer A:
Clozapine is an antipsychotic agent which can be used to treat patients with schizophrenia resistant to standard phenothiazines. Drug levels are not usually monitoring for clozapine. Although seizures occur in 4% of cases, EEG monitoring is impractical and is not recommended. Extrapyramidal side effects and tardive dyskinesia do not occur with this drug.
Agranulocytosis, although rare, can be fatal. Therefore, it is recommended that patients on clozapine be monitored with weekly CBC counts.
A 24-year-old male, new to your practice, presents for a mental health evaluation. The patient has a past history of schizophrenia, diagnosed several years ago.
Which one of the following, if present, would lead to a re-evaluation of this diagnosis?
Correct Answer C:
Schizophrenia can be very difficult to definitively diagnose, and there are many subtypes. There are many sets of diagnostic criteria, but most, including DSM-V, include the presence of thought disorders such as hallucinations, delusions, and loose associations; disorganized speech, catatonic behavior; and apathy or flat affect (negative symptoms); two of these must be present to meet DSM-V criteria. Additionally, there must be social or occupational impairment and a minimum duration of symptoms (6 months for DSM-V). Mood disorders, including depression, mania, and schizoaffective disorder, must be excluded in order to diagnose schizophrenia. Obviously, treatment of these disorders is very different from that of schizophrenia.
The negative symptoms of schizophrenia include each of the following, except:
Correct Answer E:
Auditory hallucinations are considered positive symptoms of schizophrenia, along with ideas of reference, thought broadcasting, and delusional thinking. Although successful treatment of positive symptoms will keep patients out of the hospital, the negative symptoms can be a tremendous handicap to the patients, their families, and society. Converse to the hyperdopaminergic hypothesis of positive symptoms, negative symptoms may involve hypodopaminergic activity in the frontal lobes of the brain.
Identify the type of schizophrenia that is marked by psychomotor disturbances during which the patient may demonstrate rigidity, immobility or posturing. Patient may get excited and shout or be silent and withdrawn.
Correct Answer B:
Catatonic schizophrenia (choice B) is the type of schizophrenia that is marked by psychomotor disturbances during which the patient may demonstrate rigidity, immobility or posturing and may also be silent and withdrawn and may even get excited and shout. This is recognized as motor disturbances either psychological or physiological. Due to the rigidity the body fails to move for long periods. This also involves the slowdown of motor activity. Human thinking, feeling and behavior are affected by the catatonic schizophrenia. This affects the interpersonal relationship of the patient with others.
→ Disorganized schizophrenia (choice A) is marked by inappropriate responses or unresponsiveness. Even the hallucinations and delusions would be fragmented. Hypochondriacal behavior may be present.
→ Paranoid schizophrenia (choice C) is the schizophrenia during which the patient would be very anxious, excited, aggressive and argumentative.
→ Residual schizophrenia (choice D) is associated with vague associations, illogical thinking and withdrawal.
→ Undifferentiated schizophrenia (choice E) may be characterized by prominent hallucinations, delusions, incoherence and disorganized behavior.
A previously healthy 27-year-old female has had a progressive decline in social and occupational functioning over the past year, along with a withdrawal from activities. In addition, her family notes that over the past 6-7 months she has had paranoid delusions, exhibited disorganized speech, and heard voices. She has not had any major depressive or manic episodes. A physical examination reveals a disheveled female with a flat affect, poor eye contact, and loosely associated speech. A toxicology screen and basic laboratory analysis are unremarkable. She is not on any medications.
Which one of the following is the most likely diagnosis?
The diagnosis of schizophrenia requires two or more of the following characteristic symptoms (the syndrome must continue for at least 6 months, with at least 1 month of active symptoms present much of the time): delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (i.e., affective flattening, alogia, or avolition). In addition, one or more major areas of functioning, such as work, interpersonal relationships, or self-care, should be markedly below the level seen prior to the onset of symptoms. Schizoaffective and mood disorders, substance abuse, medical illness or medication-induced disorders, and pervasive developmental disorders should be ruled out.
→ Brief psychotic disorder is characterized by the presence of delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior lasting at least 1 day but less than 1 month.
→ Delirium may present with psychotic symptoms but is the direct physiologic consequence of a general medical condition and usually has a much shorter course.
→ Mood disorders with psychotic features can be ruled out if no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms, or if the duration of mood disturbance is brief compared to the overall duration of active and residual symptoms.
→ Delusional disorder does not cause bizarre delusions and also lacks other characteristic symptoms of schizophrenia such as hallucinations, disorganized speech or behavior, or prominent negative symptoms.
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