Former "A" Student Now Failing and Behaving Oddly

Anne McBride, MD; Glen Xiong, MD


July 25, 2023

Childhood-onset schizophrenia is rare.[3] Late-onset cases (onset > 40 years of age) are more common in women than in men.[1]

Suicide is a significant risk in individuals with schizophrenia. Approximately 5%-6% of individuals with schizophrenia die by suicide, and approximately 20% attempt suicide on one or more occasions.[1]

The etiology of schizophrenia is thought to be due to a multifactorial neurodevelopmental model involving multiple genes and environmental exposures that play roles in the development of the disorder. A genetic and environmental contribution to patients developing schizophrenia has been documented. Brain CT or MRI may show ventricular enlargement and reduced cortical volume in schizophrenia. Brain imaging studies cannot establish a diagnosis of schizophrenia but may be helpful to rule out other causes of psychotic symptoms and may be especially helpful if the patient does not respond to treatment.

The initial acute therapy for persons with schizophrenia includes treatment with antipsychotic medication. Baseline vital signs, weight, height, and body mass index should be obtained. Individuals should be assessed for extrapyramidal signs and abnormal involuntary movements, which will be monitored over time with use of antipsychotic drugs. First-generation antipsychotic medications are associated with extrapyramidal symptoms. Baseline and regular laboratory studies include screening for diabetes and a lipid panel. With some antipsychotics, an ECG can be obtained when cardiac risk factors are present.[4]

However, the side effects of second-generation and third-generation antipsychotic medications, including extrapyramidal signs, abnormal involuntary movements, and tardive dyskinesia, are much less significant than with the earlier drugs.[4] However, atypical antipsychotics often include more significant weight gain and metabolic side effects. Published effectiveness trials suggest that typical and atypical antipsychotics may be equally effective.[4] In a landmark comparative effective study among second-generation antipsychotics (CATIE), it was found that patients often switch from one antipsychotic medication to another for various reasons, including efficacy; tolerability; and side effects, such as weight gain. Olanzapine may be more efficacious than other medications (with the exception of clozapine).[5]

Long-acting injectable formulations are available for some antipsychotic medications and should be considered when adherence is an issue or according to patient preference.[4]

Adjunctive medications may be used to treat comorbid conditions, associated symptoms, or sleep disturbances, or to treat side effects of the antipsychotic medications.[3]

Clozapine is an atypical antipsychotic that is generally more effective than other antipsychotic medications but often has more side effects and potentially life-threatening risks. Clozapine can be considered for individuals with clinically inadequate response to two antipsychotics, persistent suicidality, or persistent violent behaviors.[6,7] However, clozapine use requires registry in a national database and frequent (initially weekly) complete blood count monitoring to monitor for signs of agranulocytosis.

Electroconvulsive therapy, although rarely used for patients with schizophrenia, may be considered for individuals with persistent severe psychosis and/or suicidal ideation or behaviors that are refractory to prior treatments, including clozapine. Electroconvulsive therapy is also considered for those with prominent catatonia that has not responded to a benzodiazepine trial.[4] Severe catatonia may constitute a medical emergency in which electroconvulsive therapy may be indicated.

Treatment of co-occurring conditions includes substance use disorder, and medical disorders in patients with schizophrenia also require special attention and management strategies. Suicide and violence risk assessment should also be routinely conducted.

Early diagnosis and treatment is associated with improved outcomes.[8] As patients with chronic psychosis lose the ability to work and their family members experience various forms of stigma (eg, guilt, shame, and isolation), the clinician should consider a comprehensive treatment plan that includes facilitation and referral to psychological support and social services. Psychosocial treatments are important and effective and include family interventions, supported employment, assertive community treatment, social skills training, and cognitive behaviorally oriented psychotherapy, among other treatments.[9]

This patient's presentation and symptoms met the diagnostic criteria for schizophrenia. The diagnosis was discussed with the student and his family. The risks, benefits, and alternatives to antipsychotic therapy, which was recommended, were also discussed. Outpatient treatment was indicated, given his insight, family support, low risk of harm, and willingness to accept the diagnosis and take medications.

The patient agreed to take an antipsychotic medication and expressed interest in choosing a medication that is available as a monthly injection, because he does not like to take pills daily. He was started on an oral antipsychotic, which was well-tolerated, and then was quickly transitioned to monthly injections.

The patient was also referred to a local program that targets newly diagnosed psychotic disorders for more comprehensive treatment. Within 1 month, he no longer showed signs of hallucinatory behavior, and within several months, his delusional beliefs improved. He enrolled in the local community college for summer classes, with a plan to try to transition back to college in the fall.


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