Psychiatry · Year 3 · from Psychiatry
Case 1: First-Episode Schizophrenia
Patient Demographics
- Age: 21 years old
- Sex: Male
- Occupation: College student (junior year, currently withdrawn)
Chief Complaint
"The voices won't stop and people are following me."
History of Present Illness
The patient is a 21-year-old male brought to the psychiatric emergency department by his mother who reports progressive behavioral changes over the past 8 months. She describes an initial prodromal period where he became increasingly socially withdrawn, stopped attending classes, and spent hours alone in his room. Over the past 3 months, symptoms have escalated dramatically. He believes his professors are part of a government surveillance program monitoring his thoughts, and that his laptop webcam records him even when turned off. He reports auditory hallucinations consisting of two distinct male voices that comment on his actions and occasionally argue with each other. He has stopped showering, eating regular meals, and his sleep-wake cycle is severely disrupted. He has covered his room with aluminum foil "to block the signals." His academic performance has declined from a 3.7 GPA to failing all courses. No substance use history per patient and family, though urine drug screen will be obtained.
Mental Status Examination
Appearance: Thin young man with poor hygiene, disheveled clothing, appears malnourished, avoiding eye contact, wearing a baseball cap pulled low over eyes
Behavior: Hypervigilant, frequently looking toward corners of room, appears to be responding to internal stimuli (pausing mid-sentence, tilting head as if listening), guarded posture
Speech: Decreased rate, soft volume, poverty of content, occasional neologisms ("They use thoughtwaves to infiltrate")
Mood: "Scared and confused"
Affect: Flat with restricted range, incongruent (occasional inappropriate smiling when discussing persecution)
Thought Process: Tangential with loose associations, circumstantial at times, occasional thought blocking
Thought Content:
- Paranoid delusions (government surveillance, professors monitoring him)
- Ideas of reference (believes TV news contains hidden messages directed at him)
- Thought broadcasting (believes others can hear his thoughts)
- Denies suicidal or homicidal ideation
Perceptions:
- Auditory hallucinations: Two distinct male voices providing running commentary, occasionally command hallucinations (non-violent commands like "don't eat that")
- Denies visual, tactile, olfactory, or gustatory hallucinations
Cognition: Alert, oriented to person and place, disoriented to date (off by 3 weeks); attention impaired; serial 7s: 100, 93, 84, "I can't concentrate"; memory impaired for recent events
Insight: Poor - believes his experiences are real and that he is being targeted
Judgment: Poor - has isolated himself, stopped self-care, not seeking help voluntarily
Psychiatric Workup
Screening Tools:
- PANSS (Positive and Negative Syndrome Scale): Total score 98 (Positive: 32, Negative: 28, General: 38) - indicating severe illness
- Columbia Suicide Severity Rating Scale: Negative for suicidal ideation
- Calgary Depression Scale for Schizophrenia: 4 (minimal depressive symptoms)
Laboratory Studies:
- Urine drug screen: Negative
- TSH: 2.1 mIU/L (normal)
- CBC: WBC 6.8, Hgb 13.2 (normal)
- CMP: Within normal limits
- Prolactin: 12 ng/mL (normal baseline)
- HIV: Negative
- RPR: Non-reactive
- B12: 380 pg/mL (normal)
- Folate: 14 ng/mL (normal)
Neuroimaging:
- MRI Brain: No structural abnormalities
- Notable: Research would show enlarged ventricles and decreased gray matter volume in prefrontal cortex typical of schizophrenia
Diagnosis
Schizophrenia, First Episode, Currently in Acute Episode (F20.9)
DSM-5 Criteria Met:
- Two or more of the following, each present for significant portion of 1-month period:
- Delusions (paranoid, thought broadcasting, ideas of reference)
- Hallucinations (auditory - commentary type)
- Disorganized speech (tangential, loose associations)
- Negative symptoms (diminished emotional expression, avolition)
- Level of functioning markedly decreased from premorbid baseline in multiple domains (academic, social, self-care)
- Continuous signs of disturbance for at least 6 months (8 months total - prodromal plus active phase)
- Schizoaffective disorder and mood disorder with psychotic features ruled out
- Not attributable to substance use or medical condition
Treatment Plan
Acute Management:
- Voluntary psychiatric hospitalization accepted
- Start risperidone 2 mg at bedtime, titrate to 4 mg over 1 week
- PRN lorazepam 1 mg for acute agitation
- Nutritional support and hydration
Pharmacotherapy Rationale:
- Second-generation antipsychotic chosen for better tolerability profile
- Risperidone effective for positive symptoms
- Monitor for EPS, weight gain, metabolic effects, hyperprolactinemia
Psychoeducation:
- Family meeting to discuss diagnosis, neurobiology, treatment, and prognosis
- Discuss importance of medication adherence (relapse rates without medication)
- Connect with NAMI family support group
Psychosocial Interventions:
- Refer to Coordinated Specialty Care (CSC) first-episode psychosis program
- Cognitive Behavioral Therapy for psychosis (CBTp)
- Social skills training
- Supported education program for eventual return to school
Follow-up:
- Discharge planning to include outpatient psychiatrist within 1 week
- Case management services
- Consider long-acting injectable if adherence concerns