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PS4.1 | Psychotic Disorders — Practice Quiz
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A 24-year-old male is brought to a rural primary health centre by his family. Over the past 6 weeks he has become increasingly withdrawn, stopped attending work, and is now talking about 'government agents putting thoughts into his head.' His speech is coherent. He has no history of substance use or medical illness. Physical examination and basic investigations are normal. Which symptom domain does 'thought insertion' best represent?
Correct. Thought insertion is a first-rank (Schneiderian) symptom and a positive symptom of schizophrenia — representing an aberrant addition to normal mental experience. Positive symptoms include delusions, hallucinations, thought disorder, and disorganised behaviour.
Positive symptoms of schizophrenia (delusions, hallucinations, thought disorder including insertion/withdrawal/broadcasting) represent aberrant additions to normal mental experience and are the hallmark features used for diagnosis.
Thought insertion is a positive symptom — it represents something added to normal experience (an alien thought 'inserted' from outside). Negative symptoms reflect losses (avolition, alogia, anhedonia, affective flattening, asociality). Cognitive symptoms affect memory, attention, and executive function.
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A 28-year-old woman presents with a 2-month history of auditory hallucinations (third-person voices commenting on her actions), persecutory delusions, and significant social withdrawal. She has no prior psychiatric history. Which minimum duration of symptoms is required to diagnose Schizophrenia according to ICD-11?
Correct. ICD-11 requires symptoms to be present for at least 1 month. This distinguishes it from DSM-5, which requires 6 months (including prodrome and residual phases). This distinction is clinically important in India, where ICD coding is standard.
ICD-11 minimum duration for schizophrenia is 1 month; DSM-5 is 6 months. India follows ICD coding — use ICD-11 criteria in primary care practice.
ICD-11 requires a minimum duration of 1 month for core symptoms. DSM-5 requires 6 months (which includes prodromal/residual phases). Knowing this difference is essential for primary care certification exams and clinical practice in India.
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A 32-year-old male with a 4-year history of schizophrenia, currently on risperidone 4 mg/day, develops rhythmic, involuntary writhing movements of his tongue and lips that persist even when he is relaxed. He is not distressed. Which adverse effect is most likely?
Correct. Tardive dyskinesia (TD) is a late-onset, persistent movement disorder characterised by oro-facial choreiform movements — chewing, lip-smacking, tongue protrusion — emerging after months to years of antipsychotic use. It is less common with second-generation antipsychotics but still occurs.
Tardive dyskinesia presents as late-onset (months–years), involuntary, repetitive oro-facial or limb movements. It is more common with first-generation (typical) antipsychotics but occurs with SGAs too. Regular monitoring using AIMS is part of long-term antipsychotic management.
The key features pointing to TD are: involuntary oro-facial movements, long duration of antipsychotic use (4 years), and persistence at rest. Acute dystonia occurs within hours to days; akathisia is a subjective motor restlessness; NMS is a life-threatening emergency with hyperthermia and rigidity.
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A primary care physician initiates pharmacotherapy for a newly diagnosed 27-year-old male with schizophrenia. He has no cardiovascular risk factors or metabolic comorbidities. Which of the following is the most appropriate first-line drug class?
Correct. Second-generation antipsychotics (SGAs) are the preferred first-line agents for schizophrenia due to a lower risk of extrapyramidal side-effects (EPS) compared to first-generation antipsychotics (FGAs). Risperidone is a commonly initiated SGA in Indian primary care settings.
First-line treatment for schizophrenia = second-generation (atypical) antipsychotics. Clozapine is reserved for treatment-resistant cases only, because of mandatory WBC monitoring for agranulocytosis.
SGAs (risperidone, olanzapine, quetiapine, aripiprazole) are first-line for schizophrenia. FGAs (haloperidol, chlorpromazine) carry higher EPS risk and are no longer first-choice. Clozapine is reserved for treatment-resistant schizophrenia (≥2 antipsychotic failures) due to agranulocytosis risk. Mood stabilisers alone are not antipsychotic.
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A 30-year-old female with schizophrenia on olanzapine 10 mg/day for 8 months presents to your clinic with her mother for a routine review. Her psychotic symptoms are well-controlled. Her fasting blood glucose today is 7.4 mmol/L (133 mg/dL), and she has gained 12 kg since starting olanzapine. Which category of adverse effects is most responsible for these findings?
Correct. Olanzapine and clozapine carry the highest metabolic burden among SGAs: significant weight gain, hyperglycaemia/type 2 diabetes, and dyslipidaemia. Routine monitoring of weight, BMI, fasting glucose, and lipid profile is essential during SGA therapy.
SGAs — especially olanzapine and clozapine — cause metabolic syndrome: weight gain, hyperglycaemia, and dyslipidaemia. Monitor BMI, fasting glucose, and lipid profile at baseline and regularly throughout treatment.
The triad of weight gain + hyperglycaemia points clearly to metabolic adverse effects, the hallmark SGA concern. EPS (tremor, rigidity, dystonia) is primarily a FGA concern. Anticholinergic effects cause dry mouth, constipation, urinary retention, blurred vision. Hyperprolactinaemia causes galactorrhoea, amenorrhoea, sexual dysfunction.
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A 26-year-old man with schizophrenia on haloperidol 10 mg/day is brought to the emergency room with high-grade fever (40.2°C), severe generalised rigidity, sweating, blood pressure 160/100 mmHg, and confusion. Serum CK is markedly elevated. Which is the most likely diagnosis?
Correct. NMS is a rare but life-threatening reaction to antipsychotics, classically presenting with the tetrad: Hyperthermia, Rigidity ('lead-pipe'), Autonomic instability (labile BP, tachycardia, sweating), and altered consciousness (confusion/coma). Markedly elevated CK from rhabdomyolysis is characteristic.
NMS is a psychiatric emergency. Immediately STOP the antipsychotic, provide supportive care, and transfer urgently. Key features: hyperthermia + lead-pipe rigidity + autonomic instability + elevated CK. Mortality risk is high without prompt treatment.
NMS is identified by its tetrad: hyperthermia + 'lead-pipe' rigidity + autonomic instability + altered consciousness, in a patient on antipsychotics. Elevated CK confirms rhabdomyolysis. Serotonin syndrome features clonus/myoclonus and is linked to serotonergic drugs. Malignant hyperthermia follows inhalational anaesthetics. Acute dystonia has no fever and no CK rise.
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A primary care physician in a district hospital evaluates a 35-year-old male who has been treated with two different antipsychotics (risperidone for 8 weeks and olanzapine for 10 weeks, both at adequate doses) with minimal improvement in his positive symptoms. He remains functionally impaired. Which pharmacological option should now be considered?
Correct. Treatment-resistant schizophrenia (TRS) is defined as inadequate clinical response to ≥2 different antipsychotics at adequate dose and duration. Clozapine is the only evidence-based treatment for TRS. It requires specialist supervision and mandatory haematological monitoring (weekly WBC for the first 18 weeks) due to agranulocytosis risk.
Treatment-resistant schizophrenia = failure of ≥2 antipsychotics at adequate dose/duration. Clozapine is the evidence-based treatment — but requires specialist supervision and mandatory WBC monitoring for agranulocytosis. Primary care role: recognise TRS, refer promptly.
After failure of two adequate antipsychotic trials, the diagnosis is treatment-resistant schizophrenia, and clozapine is the indicated next step. At primary care level, the key role is to recognise TRS and initiate timely specialist referral for clozapine initiation.
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A 42-year-old man with a 15-year history of schizophrenia is brought to your primary care clinic by his wife. He stopped his antipsychotic 3 months ago. He is floridly psychotic — shouting, threatening his wife, and refusing examination. He has no physical co-morbidities. His wife asks if she can take him home and try to persuade him to restart medication. What is the most appropriate immediate action?
Correct. A patient who is floridly psychotic with threatening behaviour is a safety risk to himself and others. Urgent psychiatric referral or hospital admission is the primary care physician's essential role in this situation. Do not send a dangerous, unwell patient home with family.
At primary care level, the key roles for schizophrenia are: recognise, initiate (stable cases), monitor, and REFER urgently when: florid psychosis with safety risk, treatment resistance, serious AEs, or non-compliance with risk.
Florid psychosis with threatening behaviour constitutes a psychiatric emergency. The primary care physician's role is to ensure safety and arrange urgent psychiatric referral or inpatient admission. Restarting an outpatient prescription and sending the patient home would be unsafe. A cognitive assessment is not the priority here.
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The family of a 29-year-old male patient newly diagnosed with schizophrenia asks the primary care physician: 'What can we do at home to help him?' Which of the following is the most evidence-based non-pharmacological intervention you should recommend as part of the overall management?
Correct. Family psychoeducation is a cornerstone of schizophrenia management. It reduces expressed emotion (EE) in the household, improves medication adherence, and reduces relapse rates. A structured daily routine supports functional recovery. These are evidence-based components of psychosocial rehabilitation.
Psychosocial interventions for schizophrenia: family psychoeducation (reduces expressed emotion and relapse), structured daily routines, vocational rehabilitation, and social skills training. These complement pharmacotherapy and improve long-term outcomes.
Family psychoeducation — educating the family about schizophrenia, communication, expressed emotion, and medication adherence — is a key non-pharmacological intervention. Social isolation and bed rest are counterproductive. Discontinuing medication without psychiatric guidance is dangerous.
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