Psychiatry · Year 2 · from Psychiatry
Case 2: First-Episode Psychosis - MSE in Acute Psychosis
Patient Presentation
Demographics: 22-year-old male
Chief Complaint: Brought by parents who state "He's been acting strange and says people are watching him."
History of Present Illness: A 22-year-old college senior was brought to the emergency department by his parents after they received a call from campus security. The patient was found wandering in the library at 3 AM, talking to himself and attempting to disconnect security cameras because he believed "they" were using them to monitor his thoughts. His parents report a gradual change over the past 6 months: declining grades, social withdrawal, dropping out of his fraternity, and increasingly bizarre statements about being "chosen for a special mission." He has not slept more than 2-3 hours per night for the past week and has been eating poorly. He has no psychiatric history and no substance use other than occasional alcohol. Family history is significant for a maternal uncle with schizophrenia.
Mental Status Examination:
- Appearance: Young male appearing stated age, disheveled with unkempt hair and soiled clothes, malodorous, appears not to have bathed in days
- Behavior: Psychomotor agitation with restless pacing, frequently looking toward the door and windows, guarded posture
- Cooperation: Initially guarded and suspicious, became more cooperative with calm reassurance
- Speech: Pressured rate, normal volume, somewhat disorganized with occasional tangential responses
- Mood: "I'm fine, they're the ones with the problem" (patient's words)
- Affect: Restricted range, inappropriate at times (laughed when discussing surveillance), anxious
- Thought Process: Tangential with loose associations; circumstantial at times; some thought blocking observed
- Thought Content: Paranoid delusions (believes government agents are monitoring him through cameras and his phone); grandiose delusions (believes he has been chosen for a special mission); ideas of reference (believes news anchors are sending him coded messages); denies suicidal or homicidal ideation
- Perceptions: Endorses auditory hallucinations - two male voices commenting on his actions and occasionally commanding him to "stay alert"; denies visual hallucinations
- Cognition: Alert and oriented to person and place, disoriented to date (off by one week); attention impaired; unable to complete serial 7s
- Insight: Poor - does not believe he is ill, attributes symptoms to real external threats
- Judgment: Poor - attempted to "escape" through window, has not been attending to self-care
Workup:
- Urine drug screen: Negative for all substances
- Blood alcohol level: Undetectable
- TSH: Normal
- CBC, CMP: Normal
- RPR: Non-reactive
- HIV: Negative
- MRI brain: No structural abnormalities
- EEG: No epileptiform activity
Diagnosis: Schizophrenia spectrum disorder, likely schizophrenia (first episode, acute)
Treatment:
- Admitted to inpatient psychiatric unit on voluntary status after much discussion
- Started on risperidone 2 mg at bedtime
- Sleep hygiene measures implemented
- Daily supportive therapy
- Family psychoeducation initiated
- Duration of untreated psychosis estimated at 6 months - early intervention emphasized
- Discharged after 10 days with significant improvement in positive symptoms
- Enrolled in first-episode psychosis early intervention program
Clinical Pearl: First-episode psychosis requires thorough medical workup to exclude organic causes. The MSE in psychosis typically reveals disorganized thought process, impaired insight and judgment, and often incongruent or inappropriate affect. Auditory hallucinations, particularly voices commenting or conversing, are characteristic of schizophrenia. Early intervention programs for first-episode psychosis improve long-term outcomes.