Schizophrenia

Patient is a _____-year old male, married/single, with _____ children, college

graduate/undergraduate (educational attainment), presently working as
_____/housewife/homebound, residing in _______, with chief complaint of _________.
According to the patient: “______________.” This is apparently his ____th admission.

HPI:

​Patient has had multiple admissions in the past, approximately ____ admissions
in a span of _____years.

[Then, go on to discuss his first ever admission.] Patient was apparently well
(give patient’s premorbid), working as______ until _____years PTA , when patient
began manifesting with s/sx of _______. His condition eventually worsened which led to
his first admission at ________. He was admitted for ____ weeks/months and
discharged improved with the following medications: ________, with poor/good
compliance and follow-up. He was able/not able to go back to work, stayed at
home….until….

The patient had several more admission after his first with similar signs and
symptoms as the first admission. In general, these admissions would usually last for
______months/weeks with the patient being discharged improved/partially improved. He
reportedly had good/poor compliance with medications and follow-ups. He was/was not
able to go back to work; able/not able to achieve previous level of functioning.
[Note: especially with multiple admissions, ask for compliance to meds and
follow-up; effects of these meds; side effects of meds]

His most recent admission began ____ PTA, when he was working
as/student________. He had an argument/personal loss/occupational problem/other
stressors_______. He manifested with the following: ___________. Condition
worsened, hence, he was brought in by his ________. Patient was admitted
voluntarily/involuntarily.

[Pertinent positives and negatives]. At the time of admission, patient was

positive/negative for [ROS- fever, headache, dizziness, convulsions, weakness, loss of
consciousness, feeling of faintness…]
Recent medications included the following:

Past Psychiatric/Medical Hx:

 - Px is positive/negative for psychiatric illness. [Name them; with or without previous
admission; meds given; with or without relief; side effects from meds;
compliance]
- positive/negative for medical illness [thyroid problems, HPN, DM…] and
neurological disorder [head trauma, seizure, stroke, loss of consciousness…]
- history of alcohol and/or illicit substance use- last use?
- intake of other medications?
- positive/negative for drug allergies

Family Hx:

- Px’s family has a positive/negative hx for ________. [name the psychiatric illness
and relationship of px to the relative; any admissions; outpx consultation; meds
given; with or without relief]
- Px’s family is positive/negative history for _______ [medical illness, neurological
illness]
- Mother and father’s ages, any medical/psychiatric illnesses; how about in siblings

Personal and Social Hx:

Patient is the ___ of ____siblings. He describes himself as _______

[PREMORBID personality]. He was born via NSD/C-section, with apparently no
complications during pregnancy or delivery.

He was raised by [name caregiver and describe his relationship with caregiver,
work of caregiver, time given to him]. Discipline was primarily given by __________.
He was raised in a strict/lenient environment [Describe the kind of discipline.]. (+) /(-)
history of physical or emotional abuse. [Any separations or rejections at a young
age.]
He started schooling at the age of ____. [Educational history: How were his
grades, relationships with peers, superiors; extracurricular activities; leader or a follower;
transfers and why]. [Same with high school and college education]
- Ask the following:
o Occupational history
o various relationships, how they ended, his reaction, how he coped with
end of relationships, how long or short relationships were
o marriage- how many children, relationship with wife and children; how he
juggles family life and work
o Current living situation- who is the provider; what px does, how long in
his line of work; how he feels about his work
o his plans for the future [test judgment]

Mental Status Exam:

- Patient is seen fairly kempt and groomed (other descriptions) with no/+
psychomotor agitation/retardation. +/- involuntary movements, tremors. He looks
 guarded with sharp looks. He is +/- for hallucinatory behavior- shifting glances.
He is cooperative/not cooperative with the examiner with good/poor/fair eye
contact.
- Speech is of normal/increased rate; normal rhythm, volume (soft or loud); of normal
content. Spontaneous, clear, and audible.
- Mood is euthymic/depressed/elevated/irritable/labile, with broad-ranged appropriate
affect; constricted/blunted inappropriate affect [range, intensity, lability,
appropriateness]
- positive/negative for hallucinations/illusions (auditory, visual, olfactory, gustatory)
- +/- for delusions: paranoid delusions, del of reference, del of thought broadcasting,
del of thought withdrawal, del of thought insertion; bizarre delusions; +/- for
suicidal ideations/homicidal ideations; +/- for preoccupations
- thought process is + for looseness of association/tendency to be derailed; +/- for
flight of ideas (although directable, can be brought back to focus), circumstantial
with overinclusiveness of ideas; tangential; goal-directed; coherent; disorganized
thought process, and difficult to be engaged in a logical conversation
- he is oriented to time, place, and person (ask orientation to day, date, month, year,
place where he is)
- has good/impaired immediate recall and delayed recall (do formal MMSE)
- with good concentration/attention span/+ inattention (easily distractible) (count
backwards by seven from 100 or spell “mundo” backwards
- fund of knowledge- identify the present president, the president before gma, and
before erap
- good abstraction/ poor abstracting abilities- similarities and differences between
orange and apple
- good/poor insight- do you sick you are sick in any way? what is your understanding
of your condition?
- good/poor judgment- do you think you need treatment? what is your plan for the
future? How does your future look to you?

Physical Exam:

Patient’s vital signs are within normal limits; BP at___ , HR at_____, RR at ______

Normocephalic, no visible wounds on the scalp or head

He has anicteric/icteric/dirty sclerae with pink/pale conjunctivae; pupils equal and briskly
reactive to light
Equal chest expansion with clear breath sounds/no or + rales/wheezes
heart rate with normal rate and regular rhythm, +/- murmurs
no abdominal pain on palpation; -/+ masses
extremities with no edema/cyanosis/no deformity

Neurological Exam:

Conscious, coherent, oriented to three spheres/(date, date, month, and year); no visual
field cuts
Can smell coffee; intact sense of smell
+ pupillary light reflex; on fundoscopy, + red-orange reflex, normal cup/disc ratio,
normal A/V ratio, no hemorrhages
full and conjugate EOMs
equal sensation on the face, with equal masseter ms. contraction
no facial asymmetry
intact gross hearing
+ gag reflex/with elevation of uvula
good shoulder shrug
tongue midline, normal in appearance with no atrophy or fasciculations

Motor: good muscle bulk, strength, and tone [Me: bst]; strength equal [symmetrical] on
both sides; tone: +/- paratonia; +/- cogwheel rigidity; +/- spasticity

Sensory is intact and equal on both sides; position sense (propioception): good position
sense (evidenced by negative romberg’s)

Reflexes: equal and symmetrical on both sides, on all extremities; no babinski sign

Patient has normal/good station and gait [Me: gait- base, stride, posture, arm swing, turn]

Postural stability: good postural reflexes/ + or – mild postural instability [good postural
stability]

Cerebellar: Patient can do tandem walk and rapid alternating movements

Differential Diagnosis:

​As with any other psychiatric conditions, I would first like to rule out an organic-
based psychotic disorder [the possibility of an organic basis for the px’s
symptomatology]. Is this psychosis secondary to substance or medication, or secondary
to a general medical condition. I would indeed like to rule-out any treatable and
reversible causes of psychosis.

​ Is the px on any medications, including nonpsychotropic meds? Does he have a

hx of substance abuse/dependence? I would further explore this by getting collateral
information and ordering a urine toxicologic screen. Does his history and/or physical
examination reveal a significant medical condition that may cause psychosis [seizure do,
infections, endocrinopathies, electrolyte imbalance, nutritional deficiencies; heavy metal
exposure; neurologic disorder]. I would order the following to check the medical
condition of the patient and identify reversible causes of psychosis: complete blood
count with differentials, electrolytes, kidney function test, liver enzymes, glucose, calcium,
thyroid function test, B12, folate, HIV when indicated [choose which ones are most
pertinent to the case; obtain EEG, brain imaging when indicated]. [My recent case: Even
if px has a past history of hypothyroidism, her present magnitude of symptoms seems to
be in excess of what we normally see in hypothyroidism. Clinically, hypothyroidism
commonly presents with psychomotor retardation, low enery rather than overt and florid
psychosis. Moreso, patients first episode of psychosis preceded her diagnosis of
hypothoyroidism. Hence, I would rule-out the possibility of psychosis secondary to
gmc. She has no history of substance use, hence, I would also rule this out as the cause
of psychosis, although, would want to explore more on this by ordering UDD for
methamphetamine and cannabinoids and get more collateral information to as the
veracity of her substance use data] [In terms of baseline labs, I would like to refer patient
to an OB and order ultrasound to confirm the claim of patient that she is 5 mos. AOG.]

​OR, based on the history reported by the patient, physical, and neurological
exams, there seems to be no basis for a psychotic disorder secondary to a general medical
condition or psychotic disorder induced by substance or medications. [There seems to be
no basis for a consideration of psychosis secondary to gmc or substance.]

​Psychotic sxs are identical over a wide range of psychotic disorders; hence, I
would like to rule out other psychotic disorders. I am also considering other psychotic
disorders in the differential dx because of the major implications for short- and long-
term treatment planning.

​Schizophreniform do warrants that psychotic disturbance lasts for at least four

weeks but less than six months. [My recent case: her psychosis has been recurrent and
has lasted more than six months.]

​Brief psychotic do necessitates that psychotic episode lasts less than four weeks;
psychotic sxs must remit within four weeks and patient should go back to previous level
of functioning.

​Further down the line are mood disorders. [Me: not all psychotic symptoms
are part of a primary psychotic disorder; psychotic symptoms can be part and
parcel of an underlying primary mood disorder. Hence, the inclusion of mood
disorders in my differential diagnoses.] Mood symptoms are commonly present in a
psychotic disorder, hence the inclusion of mood disorders in my differential diagnoses.
This differential is particularly important because of the availability of specific and
effective treatments for mood disorders. [My recent case: patient claims to have felt
depressed with associated social withdrawal, low self-esteem, psychomotor retardation,
low energy and an apparent event of suicidal attempt. Hence, I would also like to discuss
the possibility of the px having mood disorder. Is this a case of Bipolar d/o with
psychotic features? Patient has no clear manic signs and symptoms based on history and
MSE; hence, I would rule this out. Although, I would still like to explore more on this by
getting collateral information to verify the presence or absence of mania. [Me: as it is
not possible to completely rule out the possibility of Bipolar Disorder based on
clinical interview of the patient, as loss of insight is part and parcel of Bipolar
Disorder.] Does she have MDD with psychotic symptoms? She specifically mentioned
in her history that she got depressed with other associated signs of depression after her
first admission. I am suspecting that she might have had post-schizophrenic depressive
disorder. As to whether she had other episodes of depression was unclear. I would like
to get more collateral information as to the prominence of her mood symptoms, in
this case, depressive symptoms, as opposed to the prominence of her psychosis.
Have there been events when mood and psychosis were concurrently prominent? If
so, then I would also like to consider Schizoaffective disorder, depressive type.
However, I will rule this out as based on her present history and MSE, psychosis was
markedly more prominent than a mood disturbance and psychosis seems to have been
more significantly substantial in her clinical picture. Even if I rule this out,
Schizoaffective disorder is high in my list of differential and is next to my primary
working impression.

​[My recent case: Based on the prominence of psychosis on history, MSE; the
presence of poor premorbid functioning, and social and occupational deterioration, my
working impression is schizophrenia, paranoid type.]

Is this a case of bipolar disorder with psychotic features? In this mood

disorder, mood episodes are more prominent than psychosis and psychosis occurs only in
the context of a mood episode. Psychosis disappears once patient becomes euthymic.
Does the patient’s psychosis persist beyond the mood episode? If so, I would like to
consider schizoaffective disorder. In this disorder, at some time during the illness,
mood sxs that meet criteria for a mood episode and psychotic sxs occur concurrently,
although psychosis must have occurred [for at least two weeks] even in the absence
prominent mood sxs. Indeed, how prominent are mood sxs relative to psychotic sxs? In
schizoaffective do, even with the presence of psychosis, mood symptoms are prominent
and are present for a substantial portion of the duration of the illness. [If however, mood
sxs are just brief relative to the total duration of the illness, with prominence of psychotic
sxs, I then consider schizophrenia, which is a diagnosis of exclusion. The patient must
have had a deterioration of level of functioning.] Other factors that help differentiate
mood disorders from schizophrenia:
i. Family history
ii. premorbid hx [Me: social and occupational functioning]
iii. course (age of onset)
iv. prognosis (absence of residual deterioration following psychotic
episode in mood do; presence of residual deterioration after a
psychotic episode in schizophrenia)
v. response to treatment

​Is this a case of delusional disorder? In this disorder, delusions are nonbizarre-
are capable of happening in real life and the patient’s functioning is not markedly
impaired nor does his behavior look obviously odd. The disturbance lasts for at least one
month in the context of an intact, relatively well-functioning personality, in the absence
of prominent hallucinations.

​Specific personality disorders may also resemble some symptoms of

schizophrenia. The important ones are schizotypal, schizoid, paranoid, and borderline.
However, generally, there are no psychotic symptoms; however, if present, they are
transient and not prominent.

​Pervasive developmental disorders are usually recognized before the age of 3.

Although behavior may be bizarre and deteriorated, there are no delusions or
hallucinations, or clear formal thought disorder.

​Mental retardation is also a consideration as intellectual, behavioral, and mood

disturbances may suggest schizophrenia. However, MR involves no psychotic sxs and
involves a constantly low level of functioning rather than a deterioration. If psychotic
sxs are present, a dx of schizophrenia may be made concurrently.

​Psychotic d/o not otherwise specified is also a consideration if psychosis is

atypical with a confusing clinical picture [e.g. persistent auditory hallucinations as the
only sx]. This category is considered when there are psychotic sxs; however, there is 1)
inadequate information to make a specific dx or there is 2) contradictory information, or
the 3) history doesn’t meet the criteria for any specific psychotic disorder. This diagnosis
is also made when one had concluded that a 4) psychotic disorder is present, but is
unable to determine whether it is primary, due to a general medical condition, or
substance-induced.
​
​[My recent case:

My DSM-IV multi-axial diagnoses are:

​Axis I: Schizophrenia, paranoid type; post-schizophrenic depressive d/o
​Axis II: None
​Axis III: Hx of hypothyroidism [pending laboratory results]
​Axis IV:
​Axis V:

Etiology:

Biologic consideration:
​Patient has a family history of mental illness. Mother and brother are….specific
mental illness is unknown to the px. Given this history, using the stress-diathesis model
of schizophrenia, patient has a biologic vulnerability which when
superimposed/triggered by stress, can lead to a psychotic episode. Superimposed stress
may come in various forms- biologic, genetic, psychosocial, and environmental. With the
history gathered, it is not clear what specific stress may have led to patient’s psychotic
episodes earlier on and what may have perpetuated recurrences. I would like to get more
information regarding this. With regard to present psychotic exacerbation, even if patient
denies psychosocial stress, I am suspicious that one of her stressors may be her
impending motherhood (if this is at all true and not part of her psychosis; do abdominal
examination- (+) everted umbilicus). She may have ambivalent feelings and fears about
this, given the responsibility it entails. Concomitantly, the hormonal changes involved in
pregnancy may also have superimposed some degree of biological stress. Both these
stressors may have eventually triggered another psychotic episode.

Psychodynamic consideration
​Patient during her younger years may have had a poor object relations which led
to early developmental fixations and ego deficit. This vulnerability of ego deficit, when
superimposed by some stress like interpersonal difficulties or harsh realities may cause
her psychotic episode. History taken from her is not clear about any specific identifiable
stressor which I would like to delve more having given more time or if with relatives
around. I surmise that interpersonal difficulties, conflicts with others, or harsh realities
regarding the real world caused her to decathect from the real outside world→ and
regress into her own world of fantasy, that she deems as safe, reliable, and secure. She
employs psychotic denial, projection, and reaction formation. With regard to her
present psychosis, maybe, the impending motherhood which she so desires and fears and
is ambivalent about caused her overwhelming stress that led her to regress again to her
own fantasy which is all-soothing and safe, unlike the real world of responsibilities,
obligations, and uncertainties which her ego finds hard to integrate. [Me: real world-
harsh realities, responsibilities, obligations, uncertainties, interpersonal
difficulties/conflicts]

Cognitive-behavioral issues
​As per history and during interview, the patient keeps stating her self-perception
of uselessness, inadequacy, and low self-esteem. She has a negative view of her
experiences and a negative anticipation of her future, which she perceives as bleak.
Along her life experiences and also, with her repeated admissions, she most likely
(another way: she mostly likely experienced repeated multiple failures, rejections, and
abandonment) developed some cognitive beliefs about herself, her environment and
experiences, and her future. These negative distorted cognitions further fuel her negative
symptoms of social withdrawal and paranoia, contributing to the negative deficit of her
illness.
​
Socio-cultural consideration
​With the brief interview, I was not able to elicit any significant present
psychosocial stressor that led to her recent admission. I am suspicious though that some
social and environmental triggers may have been present. Could it be the social demands
of being wife to her new husband? Could it be the impending social demands of being a
good mother? She recently began living-in with her boyfriend she newly met. This
seems to have been a hurried decision as she has always wanted to have a boyfriend or
husband to love her. This is a major role transition for her which she may not have been
ready for. Interpersonal disagreements and arguments may easily overwhelm her. And,
indeed, the impending demands of being a mother is also something that is most likely
overwhelming her at this stage. [Me: in other cases, for socio-cultural, may also
consider social background, family and religious backgrounds]

Treatment:
- Regardless of cause (or as any psychiatric patient), schizophrenia occurs in a person
with unique individual, familial, social psychological profile; hence, treatment must be
individualized. [My recent case: I would like to adopt a holistic approach, that of a
biopsychosocial approach on this patient. I would integrate psychosocial interventions
into the pharmacotherapeutic regimen as schizophrenia is a complex, multi-faceted
disorder; hence, a single therapeutic approach is inadequate. I would like to divide my
management of this patient into three phases, namely, acute, stabilization, and stable
phase…]

A. Pharmacologic
a. Use of antipsychotic meds should follow certain principles
i. clinicians should carefully define target symptoms to be treated
ii. an antipsychotic that has worked well in the past for a px should
be used again. [In the absence of such information, choice of
antipsychotic is usually based on adverse effect.]
iii. the length of antipsychotic trial is 4 to 6 weeks at adequate
dosages
iv. patients should be maintained on the lowest possible effective
dose of medication. The maintenance dose is often lower than that
used to achieve sx control during the acute psychotic episode.
B. Psychosocial
a. Antipsychotic medication alone is not as effective in treating schizophrenic
patients as are drugs coupled with psychosocial interventions. The
complexity of schizophrenia renders any single therapeutic approach
inadequate to deal with this multifaceted disorder.
b. although anti-psychotic medications are the mainstay of treatment,
psychosocial interventions must be in place to augment the clinical
improvement. They must be carefully integrated into the drug treatment
regimen and should support it.
c. Types:
i. Individual (supportive tx):
1. include advice, reassurance, limit-setting, modeling,
psychoeducation, reality testing; adjustment to the
illness
2. work with pxs to recognize early sxs of relapse in order to
prevent full-blown illness exacerbations
3. Acceptable goal is as much insight as a px desires and can
tolerate
4. One must establish therapeutic relationship that is safe,
reliable, and secure for px to stay in therapy and to enhance
compliance with medications
ii. Group tx
1. focus is support and social skills
development/improvement- work on poor eye contact,
lack of relatedness, social inappropriateness, and inaccurate
perception of others
2. helpful in decreasing social isolation and increasing reality
testing
iii. Behavior tx
 1. desired behaviors are positively reinforced by rewarding
them with specific tokens, like trips or privileges
2. the goal is to generalize reinforced behavior to the world
outside the hospital setting
iv. Family therapy/work: can significantly decrease relapse rates
1. high-EE family interaction can be diminished through family
therapy; development of coping strategies to diminish
relapses [Me: to diminish stress of family members]
2. educate relatives to recognize early sxs of relapse in order to
prevent full-blown illness exacerbations
3. should be educational and supportive; focusing on
understanding the nature of the illness and development of
realistic expectations

- Treatment of comorbid conditions, especially major depression, substance use

disorders [My recent case: As I continue to follow-up patient longitudinally, I
will watch out for signs and symptoms of mood disturbance; continually revisit
my diagnosis and correspondingly, update my treatment plan. I should also watch
out for other comorbid psychiatric conditions and medical conditions and treat
accordingly. I would also continue to monitor for adverse effects of medications.]

- Acute Phase [Me: ave. of 8-12 weeks]

o Goals:
▪ prevent harm
▪ control disturbed behavior
▪ reduce the severity of psychosis and associated sxs (e.g. agitation,
aggression, negative sxs, affective sxs)
▪ determine and address factors that led to the occurrence of the acute
episode
▪ effect a rapid return to the best level of functioning
▪ develop an alliance with the px and family

o initiate anti-psychotics as soon as it is feasible

o identify target sxs and side effects [Me: I would identify target symptoms
and start anti-psychotics, and watch out for side effects]

- Stabilization Phase (six months)

o Goals:
▪ minimize stress on the px and provide support to minimize the
likelihood of relapse [add: rate of relapse is 40% in two years for
those on medications and 80% in two years for those off
medications]
▪ facilitate continued reduction in sxs and consolidation of remission,
and promote the process of recovery
▪ enhance the px’s adaptation to life in the community through realistic
goal setting
- Stable Phase
o Goals:
▪ ensure that sx remission or control is sustained
▪ maintain or improve the patient’s level of functioning and quality of
life
▪ continue to monitor for adverse effects
▪ [Add: one should strive to keep patient in remission as recurrences
are associated with an increased risk of chronic residual symptoms
and evidence of neuroanatomical changes.]