USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 49-year-old man comes to the emergency department because of hallucinations. He is admitted to the inpatient psychiatric ward and is awaiting transport from the emergency department. He has a long history of schizophrenia and alarmed his family with talks about aliens from outer space. He often has ruminations about different galaxies and their particular alien species, but he has remained functional in terms of day-to-day life as a custodian. The patient describes with vivid detail a green alien in the room that does not speak but simply stands in the corner and observes the patient. The patient denies distress and finds the alien interesting and justifies its action by stating they are peaceful and observatory creatures. He is in no acute distress and denies suicidal thoughts, homicidal thoughts, or any other hallucinations or delusions. Which of the following is the most appropriate physician response to the patient's current condition?
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Tanner Marshall, MS
Schizo means split, and phrenia, in this case refers to the mind.
Even though schizophrenia can be interpreted to mean “splitting of the mind”, it does not refer to a split personality, like some media sources might portray, but rather schizophrenia describes a scattered or fragmented pattern of thinking.
Schizophrenia’s actually a syndrome, meaning there’re all sorts of symptoms that might be associated with it and different patients might experience different symptoms, although the symptoms can be broadly categorized into three major areas: positive symptoms, negative symptoms, and cognitive symptoms.
Alright taking a step back, most human symptoms from any illness are extreme versions of a normal physiologic process (for example everyone has a heartbeat and tachycardia is a fast heartbeat, everyone has a normal body temperature, but during a fever that temperature is higher).
In schizophrenia, patients have positive symptoms which aren’t positive in the sense that they’re helpful, but positive in the sense that they’re some new feature that doesn’t have some “normal” or physiologic counterpart.
These are the psychotic symptoms, so delusions, hallucinations, disorganized speech, and disorganized or catatonic behavior; none of which occur physiologically.
Delusions are false beliefs that the patient might feel very strongly about, so much so that they won’t change their mind, even if you give them evidence against it.
There are all sorts of different delusions, like, for example, a delusion of control, where somebody thinks that some outside force or person or thing is controlling their actions.
They could also be delusions of reference, where someone might think that insignificant remarks are directed at them, like a newscaster is speaking directly to them through the TV.
Hallucinations are a second type of positive symptom, and can be any kind of sensation that’s not actually there, including visual but also including auditory sensations, like hearing voices or commands.
A third type is disorganized speech An example being something like a “word salad”, which seems like just a random jumbling of words or phrases, like “pencil dog hat coffee blue”.
Disorganized behavior on the other hand could be like if they exhibit bizarre or silly behavior that’s out of context and doesn’t seem to have much of a purpose, like for example wearing multiple layers of jackets on a hot summer day.
Also sometimes the behavior is described as “catatonic”, which has to do with their movements, posture, and responsiveness.
So like they might be super resistant to moving, or be in an unresponsive stupor.
Negative symptoms, are like when there’s this reduction or removal of normal processes, and this is like a decrease in emotions they can express, or a loss of interest in things they once found interesting.
One type of a negative symptom is called flat affect, where they don’t respond with an emotion or reaction that would seem appropriate, like if they saw something very unexpected like a small monkey playing in their living room, they might simply sit and watch idly as if nothing was happening.
Another type is alogia, or poverty of speech, which is a lack of content in speech, so like if somebody asked them “do you have any children?”, they might respond with “yes”, instead of “yes, one boy and two girls”.
A third type of negative symptom is avolition, which is this decrease in motivation to complete certain goals, so someone might stay at home for long periods of time, without trying to reach out to friends or find work.
Cognitive symptoms include things like not being able to remember things, learn new things, or understand others easily.
These symptoms are more subtle though, and more difficult to notice and might only be detected if they have really specific tests performed.
An example might be somebody not being able to keep track of several things at once, like a phone number and an address.
People with schizophrenia seem to cycle through three phases, typically in order.