# Clinical Cases: Psychotic Disorders ## 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. --- ## Case 2: Treatment-Resistant Schizophrenia - Clozapine Indication ### Patient Presentation **Demographics:** 38-year-old female **Chief Complaint:** "The CIA is still monitoring me. The medications don't work." **History of Present Illness:** A 38-year-old woman with an 18-year history of schizophrenia is referred for evaluation of treatment-resistant disease. She was first hospitalized at age 20 for a psychotic episode with persecutory delusions and command auditory hallucinations. Since then, she has been hospitalized 12 times and tried multiple antipsychotics: haloperidol (caused severe akathisia), risperidone (partial response, elevated prolactin with galactorrhea), olanzapine (significant weight gain of 40 lbs, developed diabetes), and aripiprazole (inadequate response). Most recently, she completed an 8-week adequate trial of paliperidone 12 mg daily with only partial improvement. She continues to hear voices commanding her to hurt herself (though she has never acted on commands), believes the CIA is monitoring her through her television, and believes her thoughts are being broadcast to others. She lives in a supervised group home and has not been able to work in 15 years. Her current paliperidone has reduced the intensity of hallucinations but has not eliminated them. **Mental Status Examination:** - Appearance: Obese female, casually dressed, appropriate hygiene (with supervision) - Behavior: Calm, cooperative - Speech: Low volume, reduced spontaneity - Mood: "Okay" - Affect: Blunted, restricted range - Thought process: Concrete, mildly circumstantial - Thought content: Persistent persecutory delusions (CIA monitoring), thought broadcasting; command AH present but not acted upon; denies SI/HI - Insight: Partial - takes medications because told to, not because believes she is ill - Judgment: Fair with significant support **Previous Medication Trials:** 1. Haloperidol 20 mg - discontinued due to akathisia 2. Risperidone 6 mg x 12 weeks - partial response, prolactin elevation 3. Olanzapine 20 mg x 10 weeks - partial response, significant metabolic effects 4. Aripiprazole 30 mg x 10 weeks - inadequate response 5. Paliperidone 12 mg x 8 weeks (current) - partial response **Diagnosis:** Schizophrenia, continuous, treatment-resistant (failed 2+ adequate antipsychotic trials) **Treatment:** - Meets criteria for treatment-resistant schizophrenia - indicated for clozapine trial - Discussed unique risks of clozapine: agranulocytosis (requires REMS monitoring), seizures, metabolic effects, constipation, sialorrhea - Obtained baseline: CBC with ANC, metabolic panel, HbA1c, lipid panel, ECG - Cross-tapered from paliperidone to clozapine with slow titration: - Started clozapine 25 mg at bedtime - Increased by 25-50 mg every 3-4 days - Target dose 300-450 mg/day - Registered in Clozapine REMS program; weekly ANC monitoring initially - At 8 weeks on clozapine 350 mg: Significant improvement in positive symptoms - Voices reduced in frequency and intensity; no longer feels monitored - First time in 10 years with meaningful symptom reduction - At 6 months: Able to volunteer at local library, first structured activity in years - ANC monitoring decreased to biweekly, then monthly as per REMS schedule - Manages constipation with bowel regimen, sialorrhea with nighttime towel **Clinical Pearl:** Clozapine is the only antipsychotic with demonstrated efficacy for treatment-resistant schizophrenia (defined as failure of 2+ adequate antipsychotic trials). It should be offered to all patients meeting this criterion despite monitoring requirements. The REMS program mandates ANC monitoring due to 1% risk of agranulocytosis. Beyond positive symptoms, clozapine is also the most effective antipsychotic for reducing suicidality in schizophrenia. Response rates to clozapine in treatment-resistant patients are approximately 30-60%. --- ## Case 3: Brief Psychotic Disorder with Postpartum Onset ### Patient Presentation **Demographics:** 28-year-old female **Chief Complaint:** "She's talking about the baby being special and hasn't slept in days." (per husband) **History of Present Illness:** A 28-year-old woman, gravida 1 para 1, is brought to the emergency department by her husband 5 days postpartum. She had an uncomplicated pregnancy and vaginal delivery of a healthy baby boy. Her husband reports that she seemed normal for the first 2 days but then stopped sleeping entirely despite exhaustion. She became increasingly agitated and began making statements that their baby was "chosen by God for a special mission" and that she could communicate with him telepathically. She believes she can hear angels singing around the baby. She has been unable to care for the infant appropriately - she attempted to keep the baby awake through the night because "he needs to receive the messages." Last night, she tried to take the baby outside in freezing weather because "the angels told me the stars would bless him." Her husband intervened and brought her to the ED. She has no prior psychiatric history and was psychiatrically healthy throughout her pregnancy. No substance use. Family history is negative for psychiatric illness. **Physical Examination:** - Vital signs: BP 140/90, HR 110, T 37.8C - General: Agitated, sleep-deprived appearance, pressured speech - Neurological: No focal deficits - Postpartum exam: Normal uterine involution, no signs of infection **Mental Status Examination:** - Appearance: Disheveled, appears exhausted but hyperactive - Behavior: Agitated, pacing, intrusive - Speech: Pressured, rapid, difficult to interrupt - Mood: "Blessed, chosen" - Affect: Elevated, labile, incongruent at times - Thought process: Tangential with flight of ideas - Thought content: Grandiose delusions (baby is special, chosen), religious delusions; denies SI but judgment severely impaired - Perceptions: Auditory hallucinations (angels singing), possible visual hallucinations (sees "light" around the baby) - Insight: Absent - Judgment: Severely impaired - endangered infant **Workup:** - **TSH:** Normal - **CBC:** Mild leukocytosis (may be normal postpartum) - **CMP:** Normal - **Urinalysis:** Normal, no infection - **B12, folate:** Normal - **Urine drug screen:** Negative **Diagnosis:** Brief Psychotic Disorder with peripartum onset (also known as postpartum psychosis) **Treatment:** - Admitted to inpatient psychiatry with mother-baby unit capabilities - Started olanzapine 10 mg at bedtime (addresses psychosis, aids sleep) - Added lorazepam 1 mg Q6H PRN for agitation - Infant cared for by husband and nursing staff; supervised mother-baby contact only - Supportive care emphasizing sleep restoration - Rapid improvement over 3-4 days as sleep normalized - At 1 week: Psychotic symptoms resolved, appropriate maternal behavior - Transitioned to quetiapine for maintenance - Discharged at 10 days with close outpatient follow-up - Plan for medication continuation for at least 6-12 months - Discussed risk of recurrence with future pregnancies (approximately 25-50%) **Clinical Pearl:** Postpartum psychosis is a psychiatric emergency with onset typically within the first 2 weeks postpartum. It occurs in approximately 1-2 per 1000 deliveries and is distinct from postpartum depression. Risk of infanticide is approximately 4%, necessitating thorough safety assessment and often supervised infant contact initially. Most cases resolve relatively quickly with treatment, but there is significant recurrence risk with future pregnancies. The presentation often resembles mania with psychotic features, and there is a strong association with underlying bipolar disorder (approximately 50% will be diagnosed with bipolar disorder on follow-up). --- ## Clinical Image ![Schizophrenia brain imaging](case_01_image.jpg) **Image Description:** MRI comparison showing ventricular enlargement in schizophrenia. The image demonstrates enlarged lateral ventricles in a patient with schizophrenia (right) compared to an age-matched healthy control (left), a consistent structural finding in schizophrenia research. **Attribution:** Structural brain imaging in schizophrenia demonstrating ventricular enlargement. For educational use. **Image Source:** Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Schizophrenia_MRI.jpg - Search for "schizophrenia MRI" or "ventricular enlargement schizophrenia"