A chronic psychiatric disorder characterized by episodes of psychosis – including delusions, hallucinations, disorganized speech/behavior – along with longer-term negative symptoms (flat affect, avolition) and functional decline.
Schizophrenia is relatively common (~1% prevalence worldwide) and among the top causes of disability. It typically strikes adolescents and young adults at the start of their productive years, causing profound personal and socioeconomic impact. Boards frequently test distinguishing schizophrenia from related psychotic disorders and understanding its management. It's also life-threatening: about 5% of patients die by suicide, and many suffer reduced lifespan from comorbid health issues.
Classically presents in late teens to 20s (earlier in males than females) with a prodromal phase of social withdrawal, odd thinking, or decline in school/work functioning. This precedes the first psychotic break (acute active phase).
During active psychosis, patients experience positive symptoms: e.g. auditory hallucinations (often voices commenting or commanding), delusions (often paranoid or bizarre beliefs), and severely disorganized speech or behavior. They may have trouble with reality testing and exhibit inappropriate affect or catatonic behavior.
Negative symptoms dominate the residual phase and throughout the illness: diminished emotional expression (flat affect), lack of motivation (avolition), paucity of speech (alogia), social withdrawal, and poor self-care. Cognitive impairment (poor attention, executive dysfunction) is also common. Even in residual periods, some mild psychotic symptoms or odd beliefs can persist.
Confirm the time course meets DSM-5: at least 6 months of continuous illness (including prodromal and residual periods) with ≥1 month of active-phase psychotic symptoms. Diagnostic Criterion A requires ≥2 of the 5 key symptoms – delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms – with at least one from the first three.
Rule out other causes of psychosis: obtain a toxicology screen and relevant labs to exclude substance-induced psychosis or medical conditions (e.g. brain tumor, delirium). A first psychotic episode warrants evaluation to eliminate organic causes.
Differentiate from mood disorders with psychosis: If hallucinations/delusions occur exclusively during mood episodes, the diagnosis is a mood disorder (e.g. bipolar depression with psychotic features) rather than schizophrenia. If significant mood symptoms are present but psychosis also occurs outside those mood episodes, think schizoaffective disorder.
Gather collateral history and assess insight and safety. Patients often lack insight into their illness, which can impair treatment adherence. Evaluate for suicidal ideation or dangerous command hallucinations (telling the patient to harm self/others); these are red flags necessitating urgent intervention (e.g. hospitalization).
Fixed delusions but no other major psychotic features; functioning relatively preserved outside the impact of the delusions.
Mood disorder with psychotic features
Psychosis occurs only during episodes of major depression or mania (no psychotic symptoms in the absence of mood episode).
Antipsychotic medications are the cornerstone. First-line are typically second-generation (atypical) antipsychotics (e.g. risperidone, quetiapine, olanzapine) for their efficacy on positive symptoms and lower risk of extrapyramidal side effects. Be mindful of metabolic side effects (weight gain, diabetes, dyslipidemia) with atypicals.
First-generation (typical) antipsychotics (e.g. haloperidol, fluphenazine) are effective, especially for acute agitation, but carry higher risk of EPS (acute dystonia, akathisia, Parkinsonism, tardive dyskinesia) and can cause NMS (fever, rigidity, mental status change). Monitor for these serious adverse effects.
For treatment-resistant cases (failure of ≥2 antipsychotics) or persistent suicidality, clozapine is the most effective antipsychotic. Clozapine requires regular WBC monitoring due to risk of agranulocytosis and can cause seizures and metabolic syndrome.
Psychosocial interventions are essential adjuncts: CBT for psychosis, family therapy/psychoeducation, social skills training, and supported employment improve functional outcomes. Ensure a structured support system to enhance medication adherence and social integration.
If catatonia is present (e.g. immobility or extreme negativism), add a benzodiazepine (like lorazepam) and/or consider ECT (electroconvulsive therapy), as catatonic features often respond to these measures more than to antipsychotics.
Mnemonic: "Schizo" has 6 letters → needs ≥6 months of symptoms for schizophrenia diagnosis (if <6 months: schizophreniform; <1 month: brief psychotic disorder).
Auditory hallucinations (hearing voices) are the most common hallucination in schizophrenia (seen in ~75% of patients).
Command auditory hallucinations instructing harm (to self or others), or any expression of intent to act on delusional beliefs (e.g. violence) → require emergent safety measures (hospitalization, emergency psychiatry consult) to prevent injury.
Poor prognostic indicators: early age of onset, insidious (gradual) symptom development, predominantly negative symptoms, and lack of social support are associated with worse outcomes. (Conversely, later onset, acute trigger, and mostly positive symptoms predict a more favorable prognosis.)
Young patient with hallucinations or delusions → rule out medical or substance causes (tox screen, labs, neuroimaging as needed).
If primary psychotic disorder is suspected, assess duration of illness: <1 month = Brief Psychotic Disorder; 1–6 months = Schizophreniform Disorder; ≥6 months with functional decline = Schizophrenia.
Distinguish schizophrenia spectrum from mood disorders: if psychosis extends beyond mood episodes → schizoaffective; if psychosis occurs only during mood episodes → mood disorder with psychotic features.
Initiate antipsychotic treatment promptly for schizophrenia. For first episodes, a low-to-moderate dose atypical antipsychotic is often chosen. Ensure close follow-up for response and side effects.
Provide psychotherapy and social support. Monitor for medication adherence and side effects (EPS, metabolic). If patient is a danger to self or others or gravely disabled by psychosis, initiate appropriate safety interventions (hospitalization, involuntary treatment if necessary).
A 21‑year‑old man has become increasingly withdrawn over the past year and believes the TV is broadcasting his thoughts. He hears multiple voices commenting on his actions. He neglects college and self-care → Schizophrenia (typical first-episode psychosis in a young adult with paranoid delusions and auditory hallucinations over >6 months).
A 32‑year‑old woman with a history of depression presents with 2 months of persecutory delusions and hallucinations, along with low mood. Her psychotic symptoms continue for several weeks even after her depressive episode resolves → Schizoaffective disorder (psychosis beyond mood disturbances, contrasted with mood disorder with psychotic features).
An agitated 40‑year‑old schizophrenic patient on high-dose haloperidol develops rigidity, high fever, autonomic instability, and altered consciousness → Neuroleptic Malignant Syndrome (life-threatening reaction to antipsychotic therapy).
Case 1
A 19‑year‑old college student has progressively deteriorated academically and socially over the last year. He rarely leaves his dorm, neglects hygiene, and believes classmates are conspiring to harm him. He reports hearing a man's voice narrating his daily activities for months.
Case 2
A 28‑year‑old woman is brought in by family due to bizarre behavior. Over the past 8 months she became increasingly isolated, speaking very little. She often stops midsentence and giggles to herself. She exhibits poor eye contact and flat facial expression. She occasionally mutters to herself about "shadows" but denies voices when asked. Urine toxicology is negative.
Brain MRI illustrations comparing a normal brain vs. a schizophrenic brain, highlighting **enlarged lateral ventricles** in schizophrenia (a common structural finding).
