Questions Expected During a Schizophrenia Case Presentation
Be prepared to present a comprehensive diagnostic assessment that addresses symptom presentation, course of illness, differential diagnosis, and treatment planning, as these form the core of any schizophrenia case presentation. 1
Core Clinical History Questions
Symptom Presentation and Characterization
- What specific psychotic symptoms are present? You must detail hallucinations (type, content, frequency), delusions (type, content, systematization), disorganized speech patterns, disorganized or catatonic behavior, and negative symptoms (avolition, anhedonia, alogia, affective flattening). 1, 2
- How do you distinguish true psychotic symptoms from developmental phenomena? Be ready to explain how you differentiated genuine psychosis from overactive imagination, trauma-related phenomena, or developmental delays—this is a common pitfall. 1, 2
- What is the timeline of symptom onset and progression? Document whether onset was acute (less than 4 weeks) or insidious (more than 4 weeks), as insidious onset predicts greater disability. 3
Course of Illness and Duration
- What phase of schizophrenia is the patient in? Be prepared to identify whether the patient is in prodromal (social isolation, bizarre preoccupations, academic decline), acute (florid positive symptoms), recovery (remitting psychosis with confusion), or residual phase (minimal positive symptoms, persistent negative symptoms). 1, 2
- Has the duration criterion been met? You must demonstrate continuous disturbance for at least 6 months, including at least 1 month of active symptoms. 2, 3
- What was the premorbid functioning level? Document social, academic, and occupational functioning before illness onset, as marked deterioration from baseline is required. 2, 3
Differential Diagnosis Questions
Medical Rule-Outs
- What medical causes have you excluded? Be ready to discuss your workup for acute intoxication, delirium, CNS lesions, tumors, infections, metabolic disorders, and seizure disorders. 1, 2
- What laboratory and imaging studies were obtained? Expect questions about complete blood count, chemistry panel, thyroid function, toxicology screening, and whether neuroimaging or EEG were clinically indicated. 2, 4
- Did you perform a thorough physical and neurological examination? Document any abnormal findings that could suggest organic etiology. 1, 2
Psychiatric Differential
- How did you rule out bipolar disorder with psychotic features? This is critical—approximately 50% of adolescents with bipolar disorder may be initially misdiagnosed as schizophrenia, and mood disorders with psychosis are the most common diagnostic dilemma. 1, 4
- What is the temporal relationship between mood and psychotic symptoms? In schizophrenia, mood symptoms must be brief relative to the total duration of psychotic illness; in schizoaffective disorder, psychotic symptoms must persist for at least 2 weeks in the absence of prominent mood symptoms. 3, 4
- Have you ruled out substance-induced psychotic disorder? Document substance use history and whether psychotic symptoms persisted beyond one week after documented detoxification. 2, 4
Risk Assessment Questions
Safety Evaluation
- What is the suicide risk? Be prepared to discuss specific risk factors, as 4-10% of persons with schizophrenia die by suicide, with highest rates among males in early course. 1
- What is the risk of aggressive behavior? Document any history of violence and current risk factors. 1
- Can the patient care for themselves? Assess ability to maintain hygiene, nutrition, and basic safety. 1
Comorbidity and Confounding Factors
Associated Conditions
- What substance use is present? Assess tobacco use (extremely common) and other substance use disorders, which significantly contribute to morbidity and mortality. 1
- What developmental problems exist? Document any history of developmental delays, speech and language disorders, or intellectual disability, as these can complicate diagnosis. 1, 2
- What is the trauma history? A comprehensive trauma assessment is required in the initial evaluation. 1
Family History
- What is the family psychiatric history? Focus specifically on psychotic illnesses and mood disorders—increased family history of mood disorders may suggest schizoaffective or bipolar disorder rather than schizophrenia. 1, 2, 3
Mental Status Examination Questions
Cognitive and Functional Assessment
- What cognitive deficits are present? Document findings from cognitive assessment, as cognitive impairment is a core feature requiring evaluation. 1
- What is the degree of functional impairment? Quantify social and occupational dysfunction using standardized measures. 1
- Did you use quantitative measures? Be prepared to present scores from standardized instruments to identify and determine severity of symptoms. 1
Treatment Planning Questions
Pharmacological Approach
- What antipsychotic medication will you initiate? Antipsychotic medication is first-line treatment and should be started with monitoring for effectiveness and side effects. 1
- Would you consider clozapine? Be ready to discuss indications for clozapine: treatment-resistant schizophrenia (after failure of at least two other antipsychotics), substantial suicide risk despite other treatments, or substantial risk of aggressive behavior. 1, 3
- Would long-acting injectable antipsychotics be appropriate? Consider if the patient prefers such treatment or has a history of poor or uncertain adherence. 1
Comprehensive Treatment Plan
- What nonpharmacological treatments are included? Document your comprehensive, person-centered treatment plan that includes evidence-based psychosocial interventions. 1
- What are the patient's goals and preferences? The initial assessment must include the patient's own treatment goals and preferences. 1
Common Pitfalls to Address
Diagnostic Accuracy Concerns
- Why are you confident this is schizophrenia and not another disorder? Misdiagnosis is extremely common at onset—be prepared to justify your diagnosis and acknowledge the need for longitudinal follow-up with periodic reassessment. 1, 2
- Have you considered cultural and developmental factors? Cultural or religious beliefs may be misinterpreted as psychotic symptoms when taken out of context, and developmental factors must be considered. 1
- Are you aware of potential clinician biases? Studies show diagnostic disparities, with African-American youth more likely to receive psychotic diagnoses and less likely to receive mood or anxiety diagnoses. 1