Core Diagnosis
A patient presents with hallucinations and delusions for 1 month. What additional element is required before diagnosing schizophrenia?
What is evidence of ≥6 months total illness duration?
Active symptoms alone aren’t enough ... timeline is important!
A patient reports hearing two voices discussing his behavior in real time, causing him distress and interfering with concentration at work.
What are auditory hallucinations?
Functional impact helps distinguish pathologic vs benign experiences.
A patient’s hallucinations are attributed to increased dopamine activity in this pathway, contributing to impaired reality testing and daily functioning.
What is the mesolimbic pathway?
Positive symptoms disrupt perception of reality.
A newly diagnosed patient with schizophrenia and impaired functioning is started on this first-line medication class.
What are second-generation antipsychotics?
Always monitor metabolic health!
A 19-year-old male develops schizophrenia with significant functional decline. Is his age a good or poor prognostic factor?
What is poor prognostic factor?
Earlier onset is linked to worse long-term functioning
A patient has 7 months of hallucinations and delusions but continues to function well at work and socially. Do they meet criteria for schizophrenia?
What is no?
Must have significant functional decline as well!
During an interview, a patient gives answers that shift rapidly between unrelated topics, making it impossible to follow their reasoning. This has impaired their ability to communicate at work.
What is loose associations (disorganized speech)?
Disorganized speech is both diagnostic and functionally impairing.
A patient’s lack of motivation and impaired executive function are linked to reduced dopamine activity in this pathway, contributing to inability to work.
What is the mesocortical pathway?
Explains persistent functional deficits.
A patient repeatedly stops oral medications, leading to relapse and hospitalization with functional decline. What is an option for them?
What are long-acting injectable antipsychotics?
Improves adherence → better functional outcomes.
A 57 year old patient develops symptoms gradually over several years before diagnosis, with worsening social and occupational impairment. Does he have a good or poor prognosis?
What is poor prognosis?
Insidious onset is strongly linked to poorer recovery.
A patient has disorganized speech and negative symptoms for 8 months but no hallucinations or delusions. Why do they not meet criteria?
What is missing a positive symptom?
Must include ≥1 of: delusions, hallucinations, or disorganized speech.
A patient has stopped engaging in hobbies, rarely speaks, neglects hygiene, and is unable to maintain employment due to lack of motivation.
What are negative symptoms?
These symptoms drive long-term disability, not positive symptoms.
Antipsychotic medications improve symptoms primarily by blocking this receptor, helping reduce hallucinations and delusions.
What is the D2 receptor?
Balance efficacy vs side effects.
A patient continues to have hallucinations and cannot maintain employment despite two adequate medication trials. Next option?
What is clozapine?
Gold standard for treatment resistance.
A patient with schizophrenia dies prematurely due to chronic illness after years of metabolic complications and poor healthcare access. The leading cause of mortality in schizophrenia patients is?
What is cardiovascular disease?
A patient has hallucinations for 1 month, followed by 5 months of only negative symptoms and decline. Do they meet criteria for schizophrenia?
What is yes?
Residual symptoms still count toward the 6 month duration!
A patient believes news anchors are sending them personal messages and has stopped leaving home out of fear.
What is a delusion of reference?
Delusions often lead directly to behavioral impairment.
Dysfunction in this neurotransmitter system, particularly NMDA receptor hypofunction, is thought to contribute to both positive and negative symptoms.
What is glutamate?
Expands beyond dopamine hypothesis.
A hospitalized patient on antipsychotics develops rigidity, fever, and autonomic instability, requiring ICU care.
What is neuroleptic malignant syndrome?
Life-threatening, stop medication immediately.
Strongest predictor of long-term functional outcome.
What are negative symptoms.
Often persist despite treatment.
A 28-year-old patient has had auditory hallucinations and paranoia for 10 months with clear decline in work and social functioning. They also report recurrent depressive episodes, but describe a 3-week period of persistent hallucinations when their mood was “completely normal.” No substance use. What is the diagnosis?
What is schizophrenia?
Psychosis independent of mood symptoms + functional decline + duration → schizophrenia.
A hospitalized patient remains motionless for hours, resists repositioning, and repeats staff speech. They require assistance with basic care.
What is catatonia?
Severe functional impairment; treat with benzodiazepines first.
Decreased activity in this brain region is associated with impaired planning, motivation, and social functioning.
What is the prefrontal cortex?
Correlates with negative + cognitive symptoms.
A patient’s positive symptoms are controlled on antipsychotics, but they remain unable to work due to avolition and social withdrawal. Increasing the antipsychotic dose has not helped. What is the best next step?
What is add psychosocial interventions rather than increasing medication?
Negative symptoms are poorly responsive to dopamine blockade, so more meds ≠ better outcomes.
Most common substance used in schizophrenia.
What is nicotine?
May transiently enhance cognition via nicotinic receptors.