Physician Assistant Exam: How to Diagnose and Treat Schizophrenia

Schizophrenia is a psychosis on the Physician Assistant Exam (PANCE) in which the person has significant problems with thinking. The symptoms become so bad they can overtake a person’s life, and the person experiences a detachment from reality. In addition to confused thinking, the affected person often experiences delusions and/or hallucinations. Even though the Greek word schizophrenia means “split mind,” schizophrenia isn’t the same as dissociative identity disorder.

Paranoia may be present. Broadly, paranoia is an irrational belief in a threat or conspiracy directed against the person, the idea that “they’re out to get me.”

What causes schizophrenia? Welcome to the wonderful medical term multi-factorial — a combination of DNA, environmental exposures, and/or social stressors seem to contribute. In addition, the variety of symptoms that can be present have produced a debate about whether a diagnosis of schizophrenia represents a single disorder or a number of different syndromes.

Delusions and hallucinations

You need to know the difference between a delusion and a hallucination. A delusion is a false belief that the patient is absolutely convinced is true. For example, a person believing he or she can fly has a delusion. Delusions are associated with many mental illnesses, including schizophrenia and even Alzheimer’s disease.

Here are a few examples of delusions:

  • Persecutory: Persecutory delusions are common in schizophrenia. The person may think that harm is happening right now or that it’s going to come soon from a persecutor. Wearing an aluminum foil hat to fend off the mind-controlling rays of space aliens likely falls into this category.

  • Grandiose: Grandiose delusions are delusions in which the sufferer believes he or she has special powers or talents. This is the arena where thinking you’re Napoleon resides. It’s a grandiose delusion unless, of course, you are Napoleon.

  • Delusions of love: In this delusion, the affected person thinks that someone or some people are in love with him or her. The affected person believes that he or she is the special recipient of messages that only the affected person can see. The person with delusions of love may give gifts or send messages of love to that unsuspecting person.

A hallucination, by contrast, is a sensory perception in which the person sees or hears things that aren’t there. That is, there’s no external basis for the perception. Actually, any sense can be the vehicle for hallucination — sight, hearing, touch, smell, or taste. The hallucinations in schizophrenia are mostly auditory.

How to diagnose schizophrenia

There are different types of schizophrenia, and the diagnosis is in the clinical presentation. The affected person needs to have at a minimum two symptoms present for at least 6 months. Symptoms can include the following:

  • Delusions alone: Delusions may be enough for you to make a judgment, especially if the delusions strike you as really strange. Remember, evaluating diseased minds is often a highly subjective process.

  • Hallucinations alone: Hallucinations may be enough to help you render a judgment, especially if the person describes the voice as not his or her own and if the voice speaks from outside of his or her head.

  • Disorganization of speech or behavior: Disorganized speech patterns such as incoherence, flight of ideas, word salad, and frequent derailment may be clinical signs that illustrate the thinking and cognitive problems present in schizophrenia. Basically, what comes out of the person’s mouth doesn’t make sense. Disorganized behavior can also be a symptom.

  • Problems with activities of daily living (ADL): Schizophrenia can affect the ability of the affected person to do routine everyday tasks, to hold down a job, to engage socially with peers and colleagues, and to be in a relationship. As the condition continues, it negatively impacts the patient and leads to a downward social drift.

  • Negative symptoms: Negative symptoms can include lack of motivation, social withdrawal, and diminished affective responsiveness, speech, and movement. People with catatonic schizophrenia, for examples, can exist in an almost permanent stupor.

How to treat schizophrenia

In addition to behavioral or cognitive therapy, the use of antipsychotic medications is inherent in the treatment of schizophrenia. In general, antipsychotics may be typical or atypical. The typical meds are used sparingly in deference to the newer atypical antipsychotics. Here are the main side effects you should know:

  • Typical antipsychotics: Typical antipsychotics, such as haloperidol and thioridazine, are called typical because of the extrapyramidal side effects associated with them. These side effects occur when you block the dopamine receptors in the brain. A common example of an extrapyramidal side effect is tardive dyskinesia, or lip-smacking. For test-taking purposes, you should be familiar with the side effects of these commonly prescribed medications.

  • Atypical antipsychotics: Here are some of the atypical antipsychotics the PANCE may ask you about:

    • Clozapine (Clozaril) is a very effective medication for treating psychoses. You’ll likely be asked about clozapine’s bone marrow effects, particularly agranulocytosis.

    • Olanzapine (Zyprexa) has the common side effect of weight gain. It can also cause hyperglycemia and can affect cholesterol and triglyceride levels.

You’re evaluating a 30-year-old man with a history of delusions, hallucinations, and “weird thinking patterns” that have been occurring over the past 3 months, according to the patient’s wife. What psychiatric condition does this person likely have?

(A) Schizophrenia
(B) Schizoaffective disorder
(C) Schizophreniform disorder
(D) Bipolar disorder
(E) Generalized anxiety disorder

The answer is Choice (C), schizophreniform disorder. The key to this question is being aware of time. Schizophreniform disorder has the same features as schizophrenia but requires only 3 months of symptoms for a diagnosis to be made, whereas schizophrenia, Choice (A), requires 6 months for a diagnosis.

As for the other choices, schizoaffective disorder, Choice (B), has the features of schizophrenia combined with the features of a mood disorder. Choice (D), bipolar disorder, is a mood disorder, not a psychotic disorder. Generalized anxiety disorder, Choice (E), is an anxiety disorder, and hallucinations and delusions aren’t features of generalized anxiety disorder.

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