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PS4.1 | Psychotic Disorders — PBL Case

CLINICAL SETTING

Setting: A semi-urban Community Health Centre (CHC) in Tamil Nadu. You are the duty medical officer. Time: Tuesday, 10:30 AM. Mrs Kavitha, a 52-year-old woman, enters the consultation room with her 25-year-old son, Rajan. Rajan sits rigidly in the chair, staring at the floor, and does not respond to your greeting. Mrs Kavitha speaks for him: 'Doctor, please help us. Rajan has not spoken properly for 3 months. He has stopped going to the printing press where he works, barely eats, and I found him standing at the window at 3 AM last night, muttering to himself. Yesterday he told me the machines at his workplace are sending electric signals into his brain. Two weeks ago he threw a cup at the wall saying 'they' were watching him through it.'

Trigger 1: First Presentation — Gathering the History

You invite Mrs Kavitha to wait outside and gently attempt to engage Rajan directly. After several minutes he makes eye contact. In a flat, monotonous voice he tells you: 'The machines started sending signals 3 months ago. I can hear them — two voices — they talk about everything I do. They told me not to eat the food at home because it has chemicals.' He denies wanting to harm himself or anyone else. He admits he has 'no energy for anything' and has lost 6 kg over 3 months. He has no personal or family history of psychiatric illness. He uses no tobacco, alcohol, or drugs. He was a bright student; completed his 12th standard exams. His last medical check-up was 2 years ago — normal. Mental Status Examination findings: - Appearance: Dishevelled, psychomotor slowing - Speech: Sparse, low volume, monotonous (poverty of speech) - Mood: 'Empty' (subjective); affect blunted - Thought content: Persecutory delusions (machines sending signals, food poisoned), thought alienation (signals controlling his mind) - Perception: Auditory hallucinations — third-person voices commenting on his actions - Insight: Absent - Cognition: Appears grossly intact; oriented in time, place, person Vitals: BP 110/70 mmHg, HR 82/min, Temp 37.0°C, RR 16/min. Basic investigations: FBC normal; RBS 5.4 mmol/L; TFTs normal; urine toxicology negative.

DISCUSSION POINTS

Categorise Rajan's symptoms into the three core symptom domains of schizophrenia (positive, negative, cognitive). Which symptoms in this case belong to each domain?
Apply ICD-11 criteria for schizophrenia to Rajan's presentation. What minimum duration of symptoms is required? How does this differ from DSM-5? Does Rajan meet the ICD-11 threshold?
Why is it important to exclude organic causes (medical illness, substance use, thyroid disease) before diagnosing schizophrenia? Which investigations have already been done, and are they sufficient?
What additional history would you want from Mrs Kavitha that Rajan cannot or will not provide? How does the family history and premorbid functioning inform your diagnosis and prognosis?

Click to reveal Trigger 2: Diagnosis Confirmed — Initiating Management (discuss previous trigger first!)

Trigger 2: Diagnosis Confirmed — Initiating Management

You confirm a diagnosis of Schizophrenia (ICD-11 6A20) based on: third-person auditory hallucinations, persecutory delusions, thought alienation, negative symptoms (poverty of speech, blunted affect, avolition, anhedonia, social withdrawal), and a 3-month duration. Organic causes have been excluded. You discuss the diagnosis with Mrs Kavitha and explain the nature of the illness. Rajan is cooperative, not at imminent risk to himself or others, and Mrs Kavitha is willing and able to supervise his care at home. You decide to initiate pharmacotherapy at the CHC level and arrange psychiatric referral. You initiate risperidone 1 mg at night, to be uptitrated to 2 mg after 1 week if tolerated. You counsel Mrs Kavitha on medication adherence and arrange a review in 1 week. At the 1-week review, Mrs Kavitha reports Rajan slept better in the first 3 days but now complains of stiffness in his arms and a fine tremor of his hands. He also seems more restless — 'he can't sit still, doctor, he keeps pacing.' He has not had any fever. On examination: Mild cogwheel rigidity at the wrists bilaterally; resting tremor; no fever; BP 118/74 mmHg.

DISCUSSION POINTS

Identify the extrapyramidal side effects (EPS) present at the 1-week review. Name each EPS category, its mechanism, and the appropriate management step for each.
Why is risperidone preferred over haloperidol as first-line? Under what circumstances (symptom pattern, patient profile, resource availability) might haloperidol still be chosen?
What is the role of the primary care physician in initiating versus continuing antipsychotic therapy? At what point should Rajan be seen by a psychiatrist, and what information should the referral letter include?
Mrs Kavitha asks: 'Will he need to take these tablets forever?' How do you counsel her about the duration of antipsychotic maintenance therapy for a first episode of schizophrenia? What are the consequences of abrupt discontinuation?

Click to reveal Trigger 3: Six Months Later — Monitoring, Adverse Effects, and the Relapse Question (discuss previous trigger first!)

Trigger 3: Six Months Later — Monitoring, Adverse Effects, and the Relapse Question

Six months have passed. Rajan has been on risperidone 3 mg/day. His positive symptoms are largely resolved — he no longer hears voices, and the delusions have faded. However, Mrs Kavitha reports he is still not back at work, shows little interest in activities he used to enjoy (cricket, listening to music), and his mood seems 'flat'. His weight has increased by 5 kg. At today's review: Fasting blood glucose: 6.4 mmol/L (impaired fasting glucose) Fasting lipids: Total cholesterol 5.9 mmol/L; triglycerides 2.1 mmol/L (elevated) Body weight: +5 kg since baseline Blood pressure: 124/80 mmHg Prolactin (checked by referral psychiatrist last month): Elevated at 2.8× upper limit of normal Rajan's wife (newly married, 3 months): Reports he has lost interest in sexual activity and she is worried. Rajan himself asks you: 'The voices are gone. Can I stop the medicine now?' He has no EPS. His insight has partially returned. He now attends the outpatient psychiatry clinic monthly. News update: His psychiatrist's letter notes he has had no adverse response to two antipsychotics previously (he had a 2-year-old episode treated briefly with an unknown antipsychotic at a private clinic — records not available). The psychiatrist wants you to co-manage his metabolic monitoring.

DISCUSSION POINTS

Interpret Rajan's current metabolic findings (impaired fasting glucose, dyslipidaemia, weight gain). Which antipsychotic side-effect category is responsible? Which antipsychotics carry the highest and lowest metabolic burden?
The elevated prolactin and sexual dysfunction are linked to risperidone. Explain the mechanism of risperidone-induced hyperprolactinaemia and list its clinical consequences. What management options are available?
Rajan's persistent negative symptoms (flat affect, anhedonia, avolition) have not resolved on risperidone. How do you distinguish residual negative symptoms from a depressive episode? What does this mean for his management?
Rajan asks to stop the antipsychotic. Construct the counselling argument you would make to Rajan and his family about why maintenance therapy should continue. What would constitute a valid reason to discuss dose reduction with his psychiatrist?
The treatment gap for schizophrenia in India exceeds 70%. Using Rajan's case, describe three practical barriers that would prevent a typical patient in your district from receiving the care Rajan has received, and one strategy to address each.

Learning Issues

Research these questions and bring your findings to the discussion.

[PS4.1] How does a primary care physician diagnose and manage a case of schizophrenia — from recognising the first psychotic episode through initiating pharmacotherapy, monitoring adverse effects, coordinating psychiatric referral, and engaging the family in long-term psychosocial rehabilitation?