Schizophrenia

Case study :

Patient: James, 25-year-old Male

Presenting Complaint:

James was brought to the emergency department by his mother due to increasingly bizarre behavior, auditory hallucinations, and social withdrawal over the past six months.

History of Presenting Illness:

• James reports hearing voices that criticize him and sometimes give commands.
• He believes that his neighbors are spying on him through hidden cameras in his home.
• He has become increasingly paranoid, refusing to leave his room or eat food prepared by his family, fearing it is poisoned.
• He has neglected personal hygiene and stopped engaging in social activities.
• He was previously an excellent university student but has failed exams due to difficulty concentrating.

Past Medical History:

• No prior psychiatric history.
• No history of substance abuse.

Family History:

• Paternal uncle diagnosed with schizophrenia.

Mental State Examination:

• Appearance: Disheveled, poor eye contact.
• Speech: Disorganized, with occasional derailment.
• Mood: Blunted affect.
• Thoughts: Delusions of persecution and reference.
• Perception: Auditory hallucinations (second-person voices).
• Insight: Poor—James does not believe he is unwell.

Diagnosis:

James meets the DSM-5 criteria for schizophrenia, given the presence of delusions, hallucinations, disorganized speech, social withdrawal, and functional impairment for over six months.

Management:

1. Pharmacological – Antipsychotic medication (e.g., Olanzapine or Risperidone).
2. Psychosocial Support – Cognitive Behavioral Therapy (CBT) for psychosis, family education, and social skills training.
3. Long-Term Care – Regular psychiatric follow-ups to monitor symptoms and medication adherence.

Definition

• Schizophrenia is a severe chronic psychiatric disorder characterised by psychotic symptoms (hallucinations, delusions), disorganised thinking, and negative symptoms that significantly impair functioning.

Symptoms typically develop in late adolescence or early adulthood and require long-term management.

Causes & Risk Factors

Pathophysiology

• Dopamine Hypothesis → Excess dopamine in the mesolimbic pathway (positive symptoms) & reduced dopamine in the prefrontal cortex (negative symptoms).
• Neurodevelopmental Model → Structural Brain Changes (Enlarged Ventricles, Reduced Grey Matter).

Glutamate & GABA Dysregulation → Impaired Neurotransmitter Signalling.

Risk Factors for Schizophrenia

🔹 Schizophrenia has a strong genetic and neurodevelopmental basis, with environmental triggers.

Clinical Features

Core Symptoms of Schizophrenia (ICD-10 Criteria)

Signs on Examination

🔹 Positive symptoms are often more prominent in early schizophrenia, while negative symptoms cause long-term impairment.

Referral Criteria (NICE Guidelines)

Urgent Referral (If High Risk to Self or Others)

• Suicidal Ideation or Self-Neglect.
• Acute Psychotic Symptoms (Command Hallucinations, Delusional Persecutory Beliefs).
• Severe Agitation or Aggression.
• First Episode of Psychosis (Refer to Early Intervention in Psychosis Service).

Routine Referral (If Symptoms Persist or Affect Functioning)

• Social Withdrawal, Apathy, and Functional Decline Suggesting Prodromal Schizophrenia.
• Mild Psychotic Symptoms Without Immediate Risk.
• Lack of Insight Leading to Medication Non-Adherence.

🔹 Early intervention improves long-term outcomes in schizophrenia.

Diagnosis

Clinical Diagnosis (ICD-10/DSM-5 Criteria)

“HIT-FD” → Hallucinations, Impairment, Thought disorder, First-rank symptoms, Duration

Each letter corresponds to a key criterion:

• H → Hallucinations (Auditory most common, persistent)
• I → Impairment (Significant functional decline in work, social life, self-care)
• T → Thought disorder (Disorganized thinking, derailment, catatonia, negative symptoms)
• F → First-rank symptoms (Auditory hallucinations, thought insertion/withdrawal, delusions of control, passivity phenomena)
• D → Duration ≥1 month (To rule out brief psychotic disorder)

Quick Recall Phrase:

“Schizophrenia HIT-FD (Hard to Function Daily)”

This should help recall the essential diagnostic features of schizophrenia easily! 🧠

Differential Diagnosis

🔹 Diagnosis is clinical, supported by collateral history from family and mental state examination.

Management (NICE Guidelines)

Acute Episode Management

Maintenance Therapy (To Prevent Relapse)

🔹 Clozapine is the most effective drug for treatment-resistant schizophrenia but requires blood monitoring due to agranulocytosis risk.

Psychological & Social Interventions

• Cognitive Behavioural Therapy (CBT) for Psychosis.
• Family Therapy to Improve Support Systems.
• Social Skills Training & Vocational Support.
• Assertive Community Treatment for High-Risk Patients.

🔹 Long-term management requires a combination of medication, therapy, and social support.

Prognosis & Complications

Prognosis

Complications of Schizophrenia

🔹 Early treatment and adherence to medication reduce the risk of relapse and suicide.

UKMLA Key Points

• Best first-line antipsychotic for first-episode psychosis: Risperidone or Olanzapine.
• Best treatment for treatment-resistant schizophrenia: Clozapine.
• When to refer urgently: Suicidal risk, violent behaviour, severe psychosis.
• Best psychological therapy for schizophrenia: CBT for psychosis.

Best long-term management strategy: Combination of medication, therapy, and social support.