Psychiatry · Year 2 · from Psychiatry
Case 1: Schizophrenia - First Episode Psychosis
Patient Presentation
Demographics: 20-year-old male
Chief Complaint: "They're putting thoughts in my head through the radio."
History of Present Illness: A 20-year-old college sophomore is brought to the emergency department by campus police after his roommate called concerned about bizarre behavior. The roommate reports that over the past 6 months, the patient has become increasingly isolated, stopped attending classes, and developed poor hygiene. Over the past 2 months, the patient began making strange statements about the radio "sending him messages" and covered his dorm room windows with aluminum foil "to block the transmissions." Last night, he was found standing in the hallway at 3 AM, talking to himself and appearing frightened. When approached, he stated, "They're putting thoughts in my head - thoughts that aren't mine." The patient has no prior psychiatric history. He used marijuana occasionally (monthly) until 8 months ago but stopped when "it started making things worse." Family history is significant for schizophrenia in his maternal aunt. He dropped out of high school briefly during 10th grade due to "anxiety" but eventually graduated. His grades in college declined from B's to failing over the past two semesters.
Physical Examination:
- Vital signs: BP 124/78, HR 96, T 37.2C
- General: Thin young male, malodorous, unkempt
- Neurological: No focal deficits
Mental Status Examination:
- Appearance: Disheveled, poor hygiene, suspicious eye contact
- Behavior: Guarded, internally preoccupied, occasionally appears to respond to internal stimuli
- Cooperation: Marginally cooperative, suspicious
- Speech: Normal rate but vague, circumstantial
- Mood: "Scared"
- Affect: Blunted, occasionally inappropriate (laughed when discussing frightening content)
- Thought process: Circumstantial with tangential elements, loose associations at times
- Thought content: Persecutory delusions (believes "they" are monitoring him), thought insertion delusion (thoughts being placed in his mind), ideas of reference (radio messages directed at him); denies SI/HI
- Perceptions: Auditory hallucinations - hears two voices discussing him in the third person ("He's going to figure it out, then we'll have to stop him")
- Cognition: Alert and oriented x3, attention impaired
- Insight: Poor - believes experiences are real
- Judgment: Poor - not attending to basic needs
Workup:
- Urine drug screen: Negative
- TSH: Normal
- CBC, CMP: Normal
- RPR: Non-reactive
- HIV: Negative
- MRI brain: Mildly enlarged lateral ventricles, no focal lesions
- EEG: No epileptiform activity
Diagnosis: Schizophrenia, first episode, currently in acute episode
Duration of untreated psychosis (DUP): Approximately 6 months
Treatment:
- Admitted to inpatient psychiatry for stabilization and workup
- Started risperidone 2 mg at bedtime (low starting dose for antipsychotic-naive patient)
- Titrated to 4 mg over 5 days with good response
- Sleep hygiene measures, low-stimulation environment
- Individual supportive therapy
- Family meeting for psychoeducation about schizophrenia
- After 2 weeks: Positive symptoms significantly improved, more organized, better hygiene
- Discharged on risperidone 4 mg to first-episode psychosis early intervention program
- Plan for at least 1-2 years of antipsychotic treatment
- Psychosocial interventions: supported education program, family intervention, CBT for psychosis
Clinical Pearl: First-episode psychosis requires thorough medical workup to exclude organic causes. Duration of untreated psychosis (DUP) is a predictor of outcome - shorter DUP is associated with better prognosis. First-episode patients often respond to lower antipsychotic doses and are more sensitive to side effects. Early intervention programs that provide comprehensive care (medication, family involvement, psychosocial support) improve long-term outcomes. Third-person voices commenting or discussing the patient are characteristic of schizophrenia.