# Clinical Cases: Psychotic Disorders ## 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Patient Demographics - **Age:** 21 years old - **Sex:** Male - **Occupation:** College student (junior year, currently withdrawn) ### Chief Complaint "The voices won't stop and people are following me."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 She describes an initial prodromal period where he became increasingly socially withdrawn, stopped attending classes, and spent hours alone in his room.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:** 1. 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) 2. Level of functioning markedly decreased from premorbid baseline in multiple domains (academic, social, self-care) 3. Continuous signs of disturbance for at least 6 months (8 months total - prodromal plus active phase) 4. Schizoaffective disorder and mood disorder with psychotic features ruled out 5. 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 --- ## Case 2: Schizoaffective Disorder, Bipolar Type ### Patient Demographics - **Age:** 34 years old - **Sex:** Female - **Occupation:** Unemployed, formerly worked as graphic designer ### Chief Complaint "I haven't slept in 5 days because I've been chosen to redesign the universe." ### History of Present Illness The patient is a 34-year-old female with a known psychiatric history presenting to the ED after being found by police directing traffic at a busy intersection at 3 AM while wearing a bathrobe. She has a 10-year history of psychiatric illness with multiple hospitalizations. Per records, she has experienced episodes of psychosis both during mood episodes and during periods of relative mood stability. Current episode began 2 weeks ago with decreased need for sleep, increased energy, pressured speech, and grandiose delusions that she has been selected by a divine entity to "restructure reality." She believes she can communicate with historical figures through her artwork and that her designs are transmitted to world leaders through "quantum channels." She has spent $15,000 in the past week on art supplies and electronics to build a "cosmic transmitter." She also reports hearing the voice of Leonardo da Vinci guiding her work. Per family, she stopped taking her medications 6 weeks ago, stating she was "cured." ### Mental Status Examination **Appearance:** Disheveled woman in bathrobe, bright makeup applied asymmetrically, multiple pieces of costume jewelry, carrying a notebook with drawings **Behavior:** Psychomotor agitation, pacing, unable to sit still, animated, invading personal space, showing drawings to interviewer **Speech:** Pressured rate, increased volume, difficult to interrupt, flight of ideas, occasional rhyming (clang associations) **Mood:** "Transcendent and powerful" **Affect:** Euphoric, expansive, labile (brief tears when discussing past hospitalizations) **Thought Process:** Flight of ideas, tangential, loose associations, word salad at times **Thought Content:** - Grandiose delusions (chosen by divine entity, special powers) - Delusions of reference (believes art contains messages for world leaders) - Denies suicidal ideation - Denies homicidal ideation but expresses frustration with "those who can't see the truth" **Perceptions:** - Auditory hallucinations: Voice of Leonardo da Vinci providing artistic guidance - Visual phenomena: Reports seeing "energy patterns" around people - No command hallucinations **Cognition:** Alert, oriented to person, partially oriented to place (knows hospital but not city), disoriented to time; attention severely impaired; unable to complete cognitive testing due to distractibility **Insight:** Absent - believes she has special mission and does not need medication **Judgment:** Severely impaired - reckless spending, unsafe behavior, stopped medications ### Psychiatric Workup **Screening Tools:** - Young Mania Rating Scale (YMRS): 42 (severe mania) - PANSS: Positive subscale 28 (significant psychotic symptoms) - Columbia Suicide Severity Rating Scale: Negative **Laboratory Studies:** - Urine drug screen: Negative - TSH: 1.9 mIU/L (normal) - CBC: Within normal limits - CMP: Within normal limits - Lithium level: <0.1 mEq/L (undetectable, consistent with nonadherence) - Valproic acid level: <10 mcg/mL (undetectable) - Pregnancy test: Negative ### Diagnosis **Schizoaffective Disorder, Bipolar Type, Current Episode Manic with Psychotic Features (F25.0)** **DSM-5 Criteria Analysis:** 1. Major mood episode (manic) concurrent with Criterion A symptoms of schizophrenia (delusions, hallucinations) 2. Delusions and hallucinations have been present for 2+ weeks in the absence of a major mood episode during illness lifetime (per prior records documenting psychotic symptoms between mood episodes) 3. Mood episode symptoms present for majority of total illness duration 4. Not attributable to substance use or medical condition **Distinguishing from Bipolar I with Psychotic Features:** - In bipolar disorder, psychotic symptoms occur exclusively during mood episodes - This patient has documented history of persistent psychotic symptoms between mood episodes, meeting criteria for schizoaffective disorder ### Treatment Plan **Acute Management:** - Involuntary psychiatric hold (danger to self due to impaired judgment) - Restart lithium 600 mg BID, titrate to therapeutic level (0.8-1.0 mEq/L) - Add olanzapine 10 mg at bedtime for acute psychosis and mood stabilization - PRN olanzapine 5 mg IM for agitation **Pharmacotherapy Rationale:** - Combination mood stabilizer plus antipsychotic optimal for schizoaffective disorder - Lithium for long-term mood stabilization and suicide risk reduction - Olanzapine for acute mania and psychosis **Monitoring:** - Daily lithium levels until therapeutic - Metabolic panel, renal function at baseline and periodically - Fasting glucose and lipids (olanzapine metabolic risks) - Weight monitoring **Psychoeducation:** - Discuss diagnosis and the chronic nature requiring maintenance treatment - Medication adherence counseling with exploration of barriers - Discuss warning signs of relapse - Financial counseling referral for spending recovery **Discharge Planning:** - Structured outpatient program - Consider long-acting injectable antipsychotic for adherence - Family involvement in treatment planning - Return to work program with vocational rehabilitation --- ## Image Attribution ![Schizophrenia Brain Imaging](case_01_image.jpg) *Image: PET scan comparison of brain activity in schizophrenia showing altered metabolic patterns. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*