Clinical Cases

• Case 1: First‑episode psychosis in a young adult

  • A 21‑year‑old college student is brought by his parents because over the past 3 months he has become socially withdrawn, stopped attending classes, and spends most of his time in his room.

    • Over the last 6 weeks he has begun saying that his roommates are “implanting cameras” in the apartment and that a “voice” comments on his actions and sometimes tells him that he is “pathetic” and “shouldn’t be here.”

    • He occasionally laughs to himself.

    • There is no known substance use.

    • He sleeps poorly but denies depressed mood or elevated mood.

    • There is no confusion or fluctuation in attention.

    • Medical and neurologic exams are normal.

  • Questions

    • What is the most likely syndrome/diagnostic category at this point (at the level of “type of psychotic disorder,” not yet final DSM label)?

    • What are the key positive and negative symptoms in this case?

    • What additional information do you need to distinguish schizophrenia, schizophreniform disorder, and mood disorder with psychotic features?

    • What baseline investigations should you order in this first‑episode psychosis?

    • Identify two prognostic factors in this case that you would explore further.

  • Explained Answers

    • Syndrome/diagnostic category

      • This is a probable non‑affective primary psychotic disorder, presented as a first‑episode psychosis with prominent persecutory delusions and third‑person commenting/insulting auditory hallucinations, in the absence of mood episodes or medical/substance causes.

      • At this early stage, you should think in terms of “first‑episode psychosis, likely schizophrenia‑spectrum” rather than prematurely locking into schizophrenia; duration and evolution will determine whether the diagnosis ultimately becomes schizophreniform vs schizophrenia vs other specified psychotic disorder.

    • Positive and negative symptoms :

      • Positive Symptoms

        • Persecutory delusions (“roommates implanting cameras”).

        • Third‑person auditory hallucinations (voices commenting on his actions, insulting him).

        • Possible subtle disorganization (laughing to himself could reflect response to internal stimuli).

      • Negative symptoms

        • Social withdrawal (marked isolation)

        • Avolition (stopping classes, decreased goal‑directed activity).

    • Additional information for diagnostic differentiation:

      • Duration

        • Total duration of psychotic symptoms and of the entire disturbance (including prodrome).

        • Schizophreniform: 1–6 months total; schizophrenia: ≥6 months with ≥1 month active symptoms.

      • Mood symptoms and temporal relationship

        • Characterize any depression or mania in detail (duration, severity, functional impact).

        • Determine whether psychosis occurs exclusively during major mood episodes (suggesting mood disorder with psychotic features) or persists outside them (favoring schizophrenia or schizoaffective).

      • Course and functioning

        • Longitudinal premorbid functioning and any pattern of episodic vs continuous psychosis.

      Baseline investigations

      • Standard first‑episode psychosis workup would include:

        • Physical and neurologic exam (already normal, but must be documented).

        • Labs:

          • CBC, CMP, thyroid function, B12/folate, ± vitamin D, calcium, fasting lipids/glucose (also for medication baseline), HIV/syphilis where appropriate, urine toxicology, pregnancy test if relevant.

        • Brain imaging:

          • CT or MRI at least once to exclude structural lesions, particularly in a first‑episode.

        • Consider EEG if there is any suggestion of seizures, episodic confusion, or atypical features.

    • Prognostic factors to explore

      • Duration of untreated psychosis (DUP):

        • Get precise timing of onset of frank psychotic symptoms and when antipsychotic treatment is started.

        • Shorter DUP predicts better remission and functional outcomes.

      • Premorbid/early functioning:

        • Academic performance prior to onset, social functioning, and level of impairment at presentation.

        • Better premorbid functioning correlates with higher likelihood of recovery.

      • Explore substance use, family history, and presence of negative/cognitive symptoms, but DUP and premorbid functioning are two key, modifiable or highly predictive factors.
        

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