Case studies · Psychiatry · 26 October 2026

Schizophrenia case study

The case

Patient: A 22‑year‑old male, college student, unmarried, living in a shared hostel.

Presenting complaint: “I hear voices telling me to do things” – duration 6 months.

History of presenting illness:

• Onset: Insidious; the patient first noticed that his friends were “laughing at him” even when they were not.
• Positive symptoms: Auditory hallucinations (multiple male voices commenting on his actions, sometimes commanding him to “take the pills”). Visual hallucinations (seeing shadows moving in the corner of the room) started 3 months ago. Delusions of reference (“the TV is sending me secret messages”) and persecutory delusions (“my professors are plotting to fail me”) appeared 4 months ago.
• Negative symptoms: Over the past 2 months he has become socially withdrawn, speaks less, shows reduced facial expression, and neglects personal hygiene.
• Cognitive symptoms: Difficulty concentrating on studies, poor short‑term memory, and reduced goal‑directed activity.
• Course: Symptoms have been continuous with gradual worsening; there are no clear periods of remission.

Past psychiatric history: None documented. No prior psychiatric treatment.

Medical history: Unremarkable. No known chronic illnesses.

Family history: Mother has a history of major depressive disorder; paternal uncle diagnosed with schizophrenia.

Substance use: Occasional cannabis use (≈1 joint/week) for the past 2 years; denies alcohol, tobacco, or other illicit drugs.

Social history: Lives in a hostel, attends engineering college, average academic performance before symptom onset.

Review of systems: No headache, fever, weight loss, or seizures. No recent infections or trauma.

Examination

Initial investigations

The patient is admitted to the psychiatry ward for further evaluation and management.

Questions

1. What is the most likely diagnosis?
2. Which clinical findings in the history and examination point toward this diagnosis, and why are alternative diagnoses less likely?
3. List the essential investigations that should be performed to confirm the diagnosis and rule out mimics, and explain the relevance of each.
4. Outline a comprehensive management plan (pharmacological and non‑pharmacological) for this patient, including acute, stabilization, and maintenance phases.
5. Discuss the potential short‑ and long‑term complications of the illness and its treatment, and strategies to monitor and prevent them.

Answers

1. Diagnosis

Schizophrenia, chronic type (DSM‑5‑TR 2022 criteria).

• Duration ≥6 months with at least 1 month of active‑phase symptoms (hallucinations, delusions, disorganized speech/behavior).
• Presence of both positive (auditory/visual hallucinations, delusions) and negative (affective flattening, avolition) symptoms.
• Functional decline (social withdrawal, academic deterioration).

The diagnosis aligns with the International Classification of Diseases, 11th Revision (ICD‑11, 2022) “Schizophrenia spectrum disorder”.

2. Clinical findings supporting the diagnosis

3. Essential investigations

These investigations satisfy the NICE Clinical Guideline NG221 (2023) for psychosis and schizophrenia which recommends a minimum “basic screen” plus targeted tests based on clinical suspicion.

4. Comprehensive management plan

A. Acute phase (first 2–4 weeks)

1. Pharmacotherapy

   • First‑generation antipsychotic (FGA): Haloperidol 2–5 mg PO BID, titrate to 10 mg/day as needed, monitoring extrapyramidal symptoms (EPS).
   • Or second‑generation antipsychotic (SGA) – preferred per NICE 2023: Risperidone 2 mg PO daily, titrate to 4–6 mg/day.
   • Rationale: SGAs have lower EPS risk and treat both positive and negative symptoms. Risperidone has robust evidence in young adults.
   • Baseline metabolic monitoring: Fasting glucose, lipid profile, weight, waist circumference.

2. Adjunctive medication

   • Benztropine 1 mg PO BID if EPS develop (e.g., parkinsonism).
   • Low‑dose lorazepam 0.5 mg PO q6h PRN for severe agitation, not exceeding 2 mg/day.

3. Non‑pharmacological

   • Safe environment: Remove potential self‑harm objects, ensure 1‑to‑1 observation if risk of acting on command hallucinations.
   • Psychoeducation: Brief session with patient and family about illness, medication, and expected course.
   • Sleep hygiene & regular meals to stabilize circadian rhythm.

B. Stabilization phase (weeks 4–12)

1. Medication optimization

   • Aim for the lowest effective dose; switch to an SGA with favorable metabolic profile (e.g., aripiprazole 10–15 mg daily) if weight gain or hyperglycemia emerges.
   • Therapeutic drug monitoring (plasma levels) is optional for clozapine but not for risperidone/haloperidol.

2. Psychosocial interventions

   • Cognitive‑behavioral therapy for psychosis (CBTp): 12‑weekly sessions focusing on reality testing of hallucinations and coping strategies.
   • Supported employment / educational assistance: Liaise with college disability services to arrange a reduced workload and tutoring.

3. Family interventions

   • Family psychoeducation (6–8 sessions) to improve expressed emotion, reduce relapse risk (per McFarlane model, 2022).

4. Physical health monitoring (every 4 weeks)

   • Weight, BMI, fasting glucose, lipid panel, blood pressure.

C. Maintenance/long‑term phase (≥12 weeks)

1. Continuation of antipsychotic at the maintenance dose (usually 50–75 % of the acute dose).

2. Relapse‑prevention strategies

   • Adherence support: Pill boxes, SMS reminders, depot formulation (e.g., Risperidone long‑acting injection 25 mg IM every 2 weeks) if oral adherence is poor.
   • Regular follow‑up: Every 3 months for the first year, then 6 monthly if stable.

3. Rehabilitation

   • Social skills training, vocational rehabilitation, and peer‑support groups.

4. Monitoring for treatment‑emergent side effects

   • EPS: Use the Simpson‑Angus Scale; treat with anticholinergics or switch to a lower‑risk SGA.
   • Metabolic syndrome: Follow American Diabetes Association (ADA) 2023 criteria – weight gain ≥5 % of baseline, fasting glucose ≥100 mg/dL, triglycerides ≥150 mg/dL, HDL‑C <40 mg/dL (men).

5. Consideration of clozapine

   • Indicated if treatment‑resistant schizophrenia (failure of ≥2 antipsychotics at adequate doses for ≥6 weeks).
   • Baseline ANC ≥1500 cells/µL, then weekly for first 6 months, bi‑weekly for next 6 months, then monthly.

5. Complications and prevention

Key learning points

• Schizophrenia requires ≥6 months of symptoms with at least 1 month of active psychosis (hallucinations, delusions, disorganized speech/behavior).
• Positive, negative, and cognitive domains together differentiate schizophrenia from mood disorders, substance‑induced psychosis, and delusional disorder.
• A basic laboratory and neuroimaging screen is mandatory to exclude organic causes before confirming a primary psychotic disorder.
• Second‑generation antipsychotics (e.g., risperidone, aripiprazole) are first‑line; monitor for metabolic side effects and EPS.
• Early psychosocial interventions (CBTp, family psychoeducation, supported education) improve functional outcomes and reduce relapse.
• Clozapine remains the gold standard for treatment‑resistant schizophrenia but requires stringent hematologic monitoring.
• Regular assessment for suicidality, EPS, metabolic syndrome, and substance use is essential throughout the illness course.
• Long‑term prognosis improves with adherence, early rehabilitation, and integrated physical‑mental health care.

Practice MCQs

1. A 22‑year‑old man presents with auditory hallucinations for 7 months, delusions of persecution, and marked social withdrawal. Which of the following is the most appropriate next step in management?

A. Start high‑dose haloperidol (20 mg/day) immediately.
B. Order a full metabolic panel, thyroid function, and urine

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