Schizophrenia case discussion

Table of Contents

Introduction:

For a child , one minute they’ll be having an elegant tea party with the queen or the next , flying a spaceship into outerspace. Imagination allows us to explore a wide array of scenarios and influnces everything around us. As we get older we learn how to use this creative imagination to create goals and dreams . Albert Einstein believed that imagination is very much important because imagination embraces the entire world.

But how much is too much? Where exactly would you draw the line and address it as a cause for concern?

This seems to be the case for 42 year old Jacob Hayes who walks into the emergency room complainig that “the men are following me”. He also complains of hearing a voice telling him to hurt others. When questioned further he mentions to the medical examiner that the news anchorman gives him special messages about the state of the world every night through the TV .

This case report presents a patient who demonstrated symptoms that are relative to schizophrenia.

This gives rise to the following questions ; what is schizophrenia or how can schizophrenia be described? What are the symptoms that led to the diagnosis of this particular patient? Are there any differential diagnosis? what are the signs and symptoms of schizophrenia? How can it be treated?

The following extract delves deeper into this topic

What is Schizophrenia?

Schizophrenia is a chronic and severe psychiatric syndrome affecting more than 21 million people worldwide which is characterized by distortions in thinking, perception, emotions, language, sense of self, and behaviour. Common experiences include hallucinations mostly involving hearing voices or seeing things that are not there and delusions which involve having fixed, false beliefs

According to the DSM-5 criteria, a diagnosis of schizophrenia is made if the presence of at least two of the following five items, each present for a clinically significant portion of time during a 1-month period (or less if successfully treated), with at least one of them being items 1), 2), or 3) :

1) delusions,

2) hallucinations,

3) disorganized speech,

4) grossly disorganized or catatonic behavior, and

5) negative symptoms (e.g., decreased motivation and diminished expressiveness).

Therefore according to the basis of the patients report of symptoms the diagnosis can be determined as schizophrenia .

What are the differential diagnosis for schizophrenia?

Bipolar 1 disorder with psychotic features;

Bipolar positive symptoms of schizophrenia resemble symptoms in maniac episodes especially those wih psychotic features and the negative symptoms can resemble the depressive episodes in bipolar.

Delusional Disorder

Here patients have a variety of paranoid or persecutary beliefs but not as bizarre and not accompanied by other symptoms of schizophrenia.

Psychoses secondary to organic causes

There are several psychoses that are secondary to organic causes. Behavioural changes like confusion ,irritabiltity and psychosis bought about by metabolic ,endocrine disorders and symptoms of delirium like confusion and reduced awareness looks a lot like schizophrenia.

Schizoaffectitive disorder

In schizophrenia, mood symptoms are not expected to occur without psychotic symptoms. The psychotic symptoms are almost always present, but the mood symptoms come and go.

In schizoaffective disorder, the psychotic symptoms may or may not be present during the times when a person is experiencing depression or mania.

Psychotic Depression;

Here patients have symptoms of depression and pyschosis . The negative symptoms in schizophrenia is similar to the the symptoms in a major depressive disorder but the features of low mood are prominent here and are associated with mood congruent depression ,delusions and hallucinations

Heavy metal toxicity

Here it may cause changes in personality thinking and mood .

What are the signs and symptoms of schizophrenia ?

Onset

Schizophrenia is typically diagnosed in the late teen years to the early thirties and tends to emerge earlier in males (late adolescence – early twenties) than females (early twenties – early thirties) and often follows the first episode of psychosis, when individuals first display symptoms of schizophrenia and begin before the first episode of psychosis, usually starting in mid-adolescence.

Some common early warning signs inclide social withdrawal , insomnia or oversleeping, lack of hygeine,flat personality or an inability to show emotion or even a the ability to show emotion in inapropriate situations.

Positive symptoms

They are highly exaggerated ideas, perceptions, or actions that show the person can’t tell what’s real from what isn’t. They can include:

1. Hallucinations:

Seeing or hearing people or things that do not exist. The person may also have the experience of tasting, touching or smelling something that isn’t there. Most people also report they hear voices speaking to them, commanding or abusing them. The types of hallucinations in schizophrenia include:

Auditory: Often hears voices in their head. They might be angry or urgent and demand that they do things. It can sound like one voice or many. They might whisper, murmur, or be angry and demanding.
Visual: Seeing lights, objects, people, or patterns, loved ones or friends who are no longer alive. They may also have trouble with depth perception and distance.

Olfactory and gustatory: This can include good and bad smells and tastes. Someone might believe they’re being poisoned and refuse to eat.
Tactile:This creates a feeling of things moving on your body, like hands or insects.

2. Delusions:

These are beliefs that can persist even after they have been proved to be false or unreasonable. Types of delusions include:

Somatic delusions. The person thinks they have a terrible illness or bizarre health problem.This centres around the body. For example they will complain in the belief that there are worms under their skin or damage from cosmic rays.
Persecutory delusions. The patient may feel that they are The being stalked, hunted, framed, or tricked. That there they will be treated with malicious intent.

Referential delusions.When a person believes that public forms of communication, like song lyrics or a gesture from a TV host, are a special message just for them.
Grandiose delusions. The patient may think that they are an important figure or somone who is held in high regard or is famous.
Religious delusions. The patient might think they have a special relationship with a deity or that they’re possessed
Erotomanic delusions. A person might be convinced a celebrity is in love with them or that their partner is cheating. Or they might think people they’re not attracted to are pursuing them.

3. Disorganized behavior :

A decline in overall daily functioning and unpredictable or inappropriate emotional responses .Patients present with behaviors that appear bizarre and have no purpose.These can appear as :

Disorganized speech. Schizophrenia can cause trouble concentrating and maintaining r train of thought, which may manifest itself in the way that you speak. The patient may respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, speak incoherently, or say illogical things.

Common signs of disorganized speech include:

Loose associations – Rapidly shifting from topic to topic, with no connection between one thought and the next.
Neologisms – Made-up words or phrases that only have meaning to you.
Perseveration – Repetition of words and statements; saying the same thing over and over.
Clang – Meaningless use of rhyming words

Disorganized thinking. Sometimes, the person is unable to think clearly. Their talk appears illogical, irrelevant or disconnected and this makes no logical sense to people around them. The person may stop abruptly before finishing a sentence, give irrelevant answers to questions, or occasionally they make up their own nonsensical words.

2.Negative Symptoms

Negative symptoms refer to an absence or lack of normal mental function involving thinking, behavior, and perception such as:

Speech difficulties and abnormalities – The patient shows an inability to carry a conversation,they may start speaking in a monotone nd the conversation is disconnected or short. They might not talk much or show any feelings. Doctors call this alogia,their voice can sound flat, like they have no emotions. (Affective flattening).
Lack of interest or enthusiasm – Problems with motivation; lack of self-care and seeming lack of interest in the world – Apparent unawareness of the environment; social withdrawal.
Lack of emotional expression – They may have a dull or inexpressive,blank or restricted facial expressions . They have a flat voice and lack of eye contact

Withdrawal – This might include no longer making plans with friends. To get an answer out of them may be quite a difficult task. This is also known as apathy .
Lack of pleasure – No pleasure is felt or that they cannot enjoy anything (anhedonia) .
No follow-through – Cannot or have trouble with staying on schedule .They cannot follow through with the tasks they have begun.

3. Cognitive Symptoms & Thinking Problems

These symptoms reflect how well the person’s brain learns, stores, and uses information.These include :

Difficulty processing information to make decisions
Problems using information immediately after learning it
Trouble focusing or paying attention

What are the symptoms seen in this particular patient?

1. Persecutary delusions (previously called paranoid delusions).

Where one believes that they are treated with malicious intent hostility and harrasment , harmed, or otherwise watched by others.Similar to this paptient who complains that he is followed.

2.Auditory hallucinations .

It includes hearing voices and sometimes these voices may seem angry,arrogant and often makes demands .Since the hallucinations he hears is a voice telling him to hurt others which is addressed in second person it is an auditory hallucination.

3. Delusions of reference.

A person believes that messages are for them, such as something on a billboard, on the television, or in a movie. It might occur when someone watches a form of media and believes there is a message in the media that is meant specifically for them, again this is exceedingly similar to this patient who says he receives special meesges from the anchorman about the state of the world.

What are the investigations done?

An assesment or a psychiatric evaluation may be performed where a series of structured questions will be asked by a physician or psychologist or a mental health proffesionall ; which will be helpful in gathering information.Information may be taken from an account with the patient, an observation of the patient and also from the patients family or the people they associate or someone who is familiar with the patients history so that a diagnosis can be formed.

Diagnosis is usually arived by exclusion as there isnt many clinical diagnostic tests to confirm a diagnosis.

CT(computed tomography), MRI (magnetic resonance imaging),EEG (electroencephalogram) may be done to further aid a diagnosis by exclusion , most importantly to rule out diseases like stroke, brain injuries, epilepsy, tumors and other ailments that change the the brain structure.

Complete blood cell (CBC) count ,CSF(cerebrospinal fluid) tests and urine tests as well as liver, thyroid, and renal function tests are measured. Electrolyte, glucose, vitamin B-12, serum methylmalonic acid, folate, and calcium levels are also checeked to exclude any other underlying diseases.

How is this disease managed?

Schizophrenia is usually treated with an individually tailored combination of psychotherapy and medicine.

Schizophrenia treatment will center on managing the patients symptoms. The patient may need to stay on medication for a long time, possibly even for life. Psychological treatment can help people with schizophrenia cope with the symptoms of hallucinations or delusions better.They can also help treat some of the negative symptoms of schizophrenia, such as apathy or a lack of enjoyment and interest in things they used to enjoy.

Types of Psychotherapy

1. Individual psychotherapy. During sessions, a therapist or psychiatrist can teach the person how to deal with their thoughts and behaviors. They’ll learn more about their illness and its effects, as well as how to tell the difference between what’s real and what’s not. It also can help them manage everyday life.

2. Cognitive behavior therapy (CBT). This can help the person change their thinking and behavior and help them deal with the voices and hallucinations. With a combination of CBT sessions and medication, they can eventually tell what triggers their psychotic episodes and how to reduce or stop them.

3. Cognitive enhancement therapy (CET). Also called cognitive remediation and it teaches people how to better recognize social cues, or triggers, and improve their attention, memory, and ability to organize their thoughts. It combines computer-based brain training and group sessions.

Types of Psychosocial Therapy

If a person with schizophrenia sees improvement during psychotherapy sessions, it’s likely they’ll need more help learning how to become part of a community.

1. Social skills training. This type of instruction focuses on improving communication and social interactions.

2. Rehabilitation. Schizophrenia usually develops during the years we are building our careers. So rehabilitation may include job counseling, problem-solving support, and education in money management.

3. Family therapy and education. It is a way of helping the patients family cope better. It involves a series of informal meetings that may include discussing information about schizophrenia, educating the family and surrounding on psychosis and schizophrenia, exploring ways of supporting somebody with schizophrenia, and deciding how to solve practical problems that can be caused by the symptoms of schizophrenia.

4. Self-help groups. Encourage patients and loved ones to participate in community care and outreach programs to continue working on their social skills.

5. Coordinated specialty care (CSC). This is for people experiencing an episode of psychosis for the first time. It’s a team approach that combines medication and psychological therapies. It includes social and employment services and tries to include the family whenever possible. The aim is to change the direction and prognosis for the disease by catching it in its earliest stages.

6. Assertive community treatment (ACT). This offers highly personalized services to help people with schizophrenia meet life’s daily challenges, like taking medications.

7.Social recovery therapy and arts therapy . This treatment puts the focus on helping the person set and achieve goals and building a sense of optimism and positive beliefs about themselves and others. and encouraging the patient to use their creative expression through art.

Medications:

There are 2 main types of antipsychotics.These can be taken orally or given as an injection .

Typical antipsychotics

These are also called second-generation.They generally cause fewer side effects. Medications include:Aripiprazole (Abilify), Asenapine (Saphris), Brexpiprazole (Rexulti), Cariprazine (Vraylar), Clozapine (Clozaril), Iloperidone (Fanapt Lumateperone tosylate (Caplyta), Lurasidone (Latuda), Olanzapine (Zyprexa ), Paliperidone (Invega) ,Olanzapine/samidorphan (Lybalvi), clozapine, which is effective against schizophrenia that doesn’t respond to other treatments.

Atypical Antipsychotics:

Also known as first-generation antipsychotics where they are more likely to cause significant movement disorders like intense muscle stiffness or tardive dyskinesia. Drugs in this group include Chlorpromazine (Thorazine),Fluphenazine (Proxlixin),Haloperidol (Haldol),Loxapine (Loxitane) and Perphenazine (Trilafon).

Additional Treatment

Electroconvulsive Therapy (ECT)
Transcranial Magnetic Stimulation (TMS)
Deep Brain Stimulation (DBS)

Vagus Nerve Stimulation (VNS)

Magnetic Seizure Therapy (MST)

Of course the best possible treatment and the management strategies is a personal choice that can be made only between the patients doctor and the patient themselves.

Summary

There is no cure when it comes to schizophrenia but it is often treatable and rarely some do recover . Research has shown that the earlier a person can get a correct diagnosis and treatment for schizophrenia, the better the long-term outcome.It is imminent that the general public be eduacated on such mental illnesses.The goal is to encourage people to be empathetic toward such patients .This also means not judging them for what they can’t control.

Quiz

A woman had an onset of illness 10 months ago where she had a speech disorder.People found it hard to understand her. She also scolded people and destroyed things. Her speech gradually reduced and eventually she was unable to communicate properly with people around her. In the past 3 months she believed that she has voices in her head and someone was planning to harm her.On examination she presented with a clear consciousness,dull eye expression and also had imperative auditory hallucination,persecutary delusion,sense of insight and thought interruption.What is her diagnosis?

A. tumor

B. paranoid mental disorder

C. depression

D.Mental disorders caused by endocrine diseases.

E.Schizophrenia

Answer

A. tumor

B. paranoid mental disorder

C. depression

D.Mental disorders caused by endocrine diseases.

E.Schizophrenia

9 . References: