A 19-year-old female patient used to be an A student in high school. Now that she's in college (past 8 months) she has manifestations of irritability, paranoia, declining grades, and not desiring to go out with friends and preferring to stay home in her room. Her parents don't think that she's taking any drugs and her drug screen is negative. Her mother, however, tells you that, on multiple occasions, her daughter has answered her questions with "mom, I had to do it because the voices said so."
Which of the following is the most likely cause of her behaviour?
Correct Answer D:
Schizophrenia is characterized by psychosis, hallucinations, delusions (false beliefs), disorganized speech and behavior, flattened affect, cognitive deficits, and occupational and social dysfunction.
DSM-V: Diagnostic criteria for schizophrenia:
Criterion A:
Characteristic symptoms: two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated).
At least one of these should include 1-3:
Criterion B: Social/occupational dysfunction: for a significant portion of the time since the onset of the disturbance, one or more major areas of functioning, such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
Criterion C:
Duration: continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
Criterion D:
Schizoaffective and major mood disorder exclusion Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
Criterion E:
Substance/general mood condition exclusion Substance/general medical condition exclusion: The disturbance is not attributed to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Criterion F: Relationship to Global Developmental Delay or Autism Spectrum Disorder If there is a history of autism spectrum disorder or other communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 month (or less if successfully treated).
The average age at onset is 18 years in men and 25 years in women. Onset is rare in childhood, but early adolescent or late-life onset (when it is sometimes called paraphrenia) may occur.
A patient with schizophrenia is not responding to treatment with conventional antipsychotics.
What will you try now?
Correct Answer A:
Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect (restricted range of emotions), cognitive deficits (impaired reasoning and problem solving), and occupational and social dysfunction.
The cause is unknown, but evidence for a genetic component is strong. Symptoms usually begin in adolescence or early adulthood. One or more episodes of symptoms must last ≥ 6 months before the diagnosis is made.
Treatment consists of drug therapy with conventional antipsychotics such as haloperidol, thioridazine and chlorpromazine, psychotherapy, and rehabilitation.
About 30% of patients with schizophrenia do not respond to conventional antipsychotics. They may respond to a 2nd generation antipsychotic such as clozapine or risperidone.
A 19-year-old male college student is brought to your office in a state of agitation. He claims that people have been calling him a homosexual, even though his best friend, who brought him in, states he is not aware of that. Although he has been attending classes, his academic performance has been poor for the past several months. He admits he cannot focus and does not try hard since his new 'friends' told him his purpose in life was to keep close contact between aliens and humans. On examination, he is found to be well-oriented in all spheres. Memory and immediate recall are good.
This clinical picture is most compatible with which one of the following?
Correct Answer B:
The cause is unknown, but evidence for a genetic component is strong. Stressors may be primarily biochemical (eg, substance abuse, especially marijuana) or social (eg, becoming unemployed or impoverished, leaving home for college, breaking off a romantic relationship, joining the Armed Forces). Symptoms usually begin in adolescence or early adulthood. One or more episodes of symptoms must last ≥ 6 months before the diagnosis is made. Treatment consists of drug therapy, psychotherapy, and rehabilitation.
Clozapine is the neuroleptic of choice for schizophrenia when:
Second-generation antipsychotics - SGA’s (eg Clozapine) act by blocking both dopamine and serotonin receptors (serotonin-dopamine receptor antagonists). SGAs tend to alleviate positive symptoms; may lessen negative symptoms to a greater extent than do conventional antipsychotics (although such differences have been questioned); may cause less cognitive blunting; are less likely to cause extrapyramidal (motor) adverse effects; have a lower risk of causing tardive dyskinesia; and for some SGAs produce little or no elevation of prolactin.
Clozapine is the only SGA demonstrated to be effective in up to 50% of patients resistant to conventional antipsychotics. Clozapine reduces negative symptoms, produces few or no motor adverse effects, and has minimal risk of causing tardive dyskinesia, but it produces other adverse effects, including sedation, hypotension, tachycardia, weight gain, type 2 diabetes, and increased salivation. It also may cause seizures in a dose-dependent fashion. The most serious adverse effect is agranulocytosis, which can occur in about 1% of patients. Consequently, frequent monitoring of WBCs is required, and clozapine is generally reserved for patients who have responded inadequately to other drugs.
Which of the following symptoms of schizophrenia responds best to anti-psychotic medication?
Correct Answer C:
In schizophrenia symptoms are categorized as positive or negative. Positive symptoms are characterized by an excess or distortion of normal functions; negative symptoms, by diminution or loss of normal functions. Positive symptoms can be further categorized as delusions and hallucinations or thought disorder and bizarre behavior. Negative symptoms include blunted affect, poverty of speech, anhedonia, and asociality.
Antipsychotic drugs can be effective in reducing or eliminating positive symptoms, such as delusions, hallucinations, and disorganized thinking. After the immediate symptoms have cleared, the continued use of antipsychotic drugs substantially reduces the probability of future episodes.
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