A 17-Year-Old With Hallucinations About Martians and Paranoia

Raheel I. Shaikh; Neal T. Patel; Alexander Martinek; Imran Shaikh, MD

Disclosures

September 28, 2021

After all other causes were ruled out, schizophrenia was determined to be the primary illness in this patient. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, characterizes schizophrenia as a mental disorder with episodes of psychosis involving positive and negative symptoms.[1] Positive symptoms include hallucinations, delusions, and disorganized forms of speech. Hallucinations can involve any of the senses, including visual, auditory, and taste. Delusions are characterized as paranoid and persecutory, with bizarre elements, such as "aliens" or "FBI agents." The negative symptoms are characterized as a deficiency in normal emotions and may include flat affect, alogia, anhedonia, and apathy.[2]

Initially, it was suspected that long-term drug use may have contributed to the early onset of schizophrenia in this patient. However, the results of the urine drug test demonstrated that the use of marijuana had probably not continued. A detailed history supported this finding. It was determined that the one-time use of marijuana had no direct relation to the sudden development of psychotic symptoms that persisted well beyond the use of the psychogenic drug. The marijuana use was simply an acute event and did not result in the patient's development of schizophrenia, which was most likely hereditary, owing to a family history of mental health disorders.

Whereas long-term cannabis use has been noted to increase the likelihood of schizophrenia onset, one-time use would most likely not cause the abrupt psychotic symptoms seen in this patient. Thus, the presentation of drug-induced psychosis did not fit, because most drug-induced psychotic disorders require the chronic use of a psychogenic drug to cause permanent changes in the brain signaling pathways.[3,4] These permanent changes, most notably in the dopamine pathway, lead to the development of schizophrenia.[5]

The initial presentation determines the overall prognosis of schizophrenia, which is generally poor in many patients. Patients with a sudden onset of initial symptoms have a better overall prognosis, whereas those with a slow onset of symptoms over time have a worse prognosis. In addition, schizophrenia is known to have a "downward drift" progression, with symptoms worsening over time into adulthood and the patient becoming more withdrawn.[1] Medication and therapy help slow the downward drift but do not stop it entirely. Schizophrenia is also associated with a decreased life expectancy, owing primarily to poor lifestyle management but also to an increased risk for suicide. Poor lifestyle management results from reduced activity in many patients with schizophrenia, which leads to obesity and increases the risk for diabetes and hypertension.[6]

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