Treatment of First-Episode Schizophrenia in a Young Woman

Abstract

A 20-year-old woman was referred by her family physician to a community mental health team in London, United Kingdom. Her mental state had deteriorated progressively over the previous 12 months, following the death of her father. After a period living alone, she had returned to the family home 4 months prior to her presentation and had beennotedtobesociallywithdrawn,preoccupied,anddistractible.Herfamilyphysician,suspectingadepressiveepisode, had prescribed citalopram up to a dosage of 40 mg once daily, to no effect. Her family subsequently sought advice from the family physician when the patient was noted to be speaking to herself, expressing concerns about people meaning her harm, and professing the belief that she could hear other peoples' thoughts.The patient had been born in Sierra Leone after a complicated delivery and had traveled to the United Kingdom as a child with her family, who were fleeing from a civil war. On arrival in the UnitedKingdom,herfamilyclaimedasylumandmovedintoasmallapartmentinahigh-risebuilding in central London. Although there was no reported developmental delay, she had struggled academically at school and was bullied for having overweight. She left school without qualifications at age 16 years and worked as a shop assistant. She left this job about a year prior to her referral to psychiatry after a period of sick leave following the death of her father. She was a nonsmoker, did not drink alcohol, and denied illicit drug use. A paternal relative was reported to have a diagnosis of schizophrenia. There was no comorbid physical illness.On review, the patient was kempt and had overweight. Eye contact was fleeting, and she presented as anxious, with a degree of psychomotor agitation. Her speech was normal in rate, volume, and tone, although tangential. There was no other evidence of thought disorder. She denied feeling low in mood or suicidal and was objectively euthymic. There was some sleep disturbance, with the patient reporting being fearful to go to sleep owing to persecutory beliefs regarding her neighbors. She reflected that over the preceding few months, she had experienced a sensation of detachment from her immediate environment, as though it was not real, making her world similar to that of a video game. She reported that in the apartment where she had previously been living, she had realized that something was amiss and had become convinced that the door number of her neighbor's flat, number 6, signified that they meant her harm. She explained this was because 6 was associated with the number of the devil. She reported hearing her neighbors commenting negatively about her appearance. These distressing experiences prompted her to return to her family home, but she continued to hear her neighbors' voices making derogatory comments about her appearance and began to hear them commentingonheractionsandthoughtsinthethirdpersonaswell.Onreturninghome,herparanoia regarding her previous neighbors worsened, resulting in her rarely leaving the house. The volumeandfrequencyofderogatoryaudito...

Schizophrenia—An Overview

“…There is also evidence consistent with disrupted early neurodevelopment, such as skin markers of altered ectodermal development and mild cognitive and motor impairments in childhood . Such impairments may manifest as falling behind peers in schoolwork, as is the case with the patient in the Clinical Challenge …”

“…Schizophrenia typically develops in early adulthood, as was seen in the Clinical Challenge case; it is rare before age 16 years. This highlights that, in addition to the genetic and early developmental factors discussed above, other factors act later to lead to the disorder (Figure 1 and Figure 2).…”

“…The Clinical Challenge in this issue of JAMA Psychiatry describes a patient who clinicians will be familiar with: a young woman who develops auditory hallucinations, unusual beliefs, and a deterioration in cognitive abilities and social function and is diagnosed with schizophrenia in early adulthood. The diagnosis of schizophrenia is based on a clinical assessment.…”

“…The patient in the Clinical Challenge case has a history of perinatal complications. Although schizophrenia typically appears in early adulthood, multiple strands of evidence indicate that its pathogenesis begins early in neurodevelopment .…”

“…This highlights that, in addition to the genetic and early developmental factors discussed above, other factors act later to lead to the disorder (Figure 1 and Figure 2). The patient in the Clinical Challenge reported that she began to drop behind in her school work during early adolescence and noticed increasing memory difficulties in the run-up to her first psychotic episode. The cognitive deficits and negative symptoms observed in schizophrenia may attract less clinical attention than the positive symptoms, but they are responsible for a large proportion of the morbidity associated with the disorder .…”