Schizophrenia is a chronic mental illness in which a person loses touch with reality, with hallucinations, fixed false beliefs and disorganized thinking. It usually begins in the late teens or twenties, and early treatment with medicine and support improves the long-term outcome.
Key symptoms
- Hearing voices or other hallucinations
- Delusions, such as feeling watched or controlled
- Disorganized speech or behavior
- Negative symptoms: flat emotions, low motivation, social withdrawal
- Decline in school, work or self-care over months
What you find on exam
- Mental status exam: appearance, thought process, perceptions, insight
- Ask about command hallucinations and thoughts of harming self or others
- Neurological exam and signs of drug intoxication or withdrawal
- Assess decision-making capacity when treatment is refused
Tests
- Urine drug screen to rule out substance-induced psychosis
- Blood count, metabolic panel, thyroid tests, HIV and syphilis testing
- Brain imaging if neurological signs or an atypical course
- Baseline weight, glucose, lipids and ECG before antipsychotics
- Diagnosis needs symptoms for at least 6 months
Treatment basics
- A second-generation antipsychotic such as risperidone or aripiprazole
- Long-acting injectable antipsychotics when adherence is a problem
- Clozapine for illness that does not respond to two antipsychotics
- Therapy, family education, supported housing and work
- Monitor weight, glucose and lipids; watch for movement side effects
Red flags
- Command hallucinations to harm self or others
- Fever, rigidity and confusion on antipsychotics (neuroleptic malignant syndrome)
- Unable to care for basic needs such as food or shelter
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.