Psychiatry · Year 3 · from Psychiatry
Case 2: Psychosis - Importance of Structured Assessment
Patient Demographics
- Age: 22 years old
- Sex: Male
- Occupation: College student (currently on medical leave)
Chief Complaint
"My roommate says I've been acting strange, but I think he's part of the conspiracy."
History of Present Illness
The patient is brought to the emergency department by his college roommate who reports increasingly bizarre behavior over the past 3 months. The patient has become progressively isolated, stopped attending classes, and has been heard talking to himself in his room. The roommate reports the patient has covered all mirrors and windows with aluminum foil and accused him of "recording my thoughts." The patient believes that a government agency has implanted a device in his brain that allows them to hear his thoughts and insert thoughts that are not his own. He reports hearing voices commenting on his behavior and occasionally giving commands. He has not slept more than 2-3 hours per night for the past several weeks, stating he needs to "stay vigilant." He denies drug use, though the roommate reports finding an empty marijuana edible package 4 months ago.
Mental Status Examination
Appearance: Disheveled young man, malodorous, wearing multiple layers of clothing, appears older than stated age, poor hygiene, aluminum foil hat visible under hood
Behavior: Hypervigilant, scanning the room frequently, guarded, occasionally appears to be responding to internal stimuli (tilting head as if listening, mouthing words)
Speech: Pressured rate at times, normal volume, occasional tangentiality, neologisms present ("They use thoughtweave technology")
Mood: "Fine, everyone else has the problem"
Affect: Suspicious, labile with periods of inappropriate laughter, incongruent with content
Thought Process: Tangential, loose associations at times, circumstantial, occasional thought blocking
Thought Content:
- Paranoid delusions: Believes government is monitoring and controlling his thoughts
- Thought insertion: "They put ideas in my head that aren't mine"
- Ideas of reference: Believes news broadcasts contain hidden messages for him
- Denies suicidal ideation
- Denies homicidal ideation but states he "might have to protect myself"
Perceptions:
- Auditory hallucinations: Running commentary on his behavior, occasional command hallucinations (to "stay quiet")
- Denies visual hallucinations
Cognition: Alert and oriented to person, partially oriented to place (knows he's in a hospital but unsure which one), disoriented to date (off by 2 weeks); attention impaired; memory testing limited by poor cooperation
Insight: Poor - does not believe he is ill, believes others are conspiring against him
Judgment: Poor - has not been eating regularly, has alienated support system, brought to ED by others
Psychiatric Workup
Screening Tools:
- BPRS (Brief Psychiatric Rating Scale): 62 (severe)
- Columbia Suicide Severity Rating Scale: Negative for current suicidal ideation
Laboratory Studies to Rule Out Medical Causes:
- Urine drug screen: Positive for THC
- TSH: 1.8 mIU/L (normal)
- CBC: WBC 7.2 (normal)
- CMP: Within normal limits
- Ammonia: 28 mcg/dL (normal)
- HIV: Negative
- Syphilis screen (RPR): Non-reactive
- CT Head without contrast: No acute abnormalities
Diagnosis
Schizophrenia, First Episode, Currently in Acute Episode (F20.9)
DSM-5 Criteria Met:
- Two or more of the following, each present for a significant portion of time during a 1-month period:
- Delusions (paranoid, thought insertion, ideas of reference)
- Hallucinations (auditory)
- Disorganized speech (tangentiality, loose associations)
- Level of functioning markedly below baseline (stopped attending school, self-care deteriorated)
- Continuous signs of disturbance for at least 6 months (3 months of active symptoms with prodromal period)
- Schizoaffective disorder and depressive/bipolar disorder with psychotic features ruled out
- Not attributable to substance use or medical condition
Treatment Plan
Acute Management:
- Voluntary psychiatric admission accepted after extended discussion
- Start risperidone 2 mg BID
- PRN lorazepam 1 mg for agitation
Pharmacotherapy (Ongoing):
- Titrate risperidone as tolerated
- Monitor for extrapyramidal symptoms, metabolic effects
Psychoeducation:
- Family meeting to discuss diagnosis, treatment, and prognosis
- Discuss importance of cannabis abstinence
Safety:
- 1:1 observation initially due to command hallucinations
- Environmental safety precautions
Follow-up:
- Coordinate with college counseling center for return-to-school planning
- Connect with early psychosis intervention program