Schizophrenia — clinical viva (first episode, antipsychotics, clozapine)

Opening stem

"A 22-year-old man has third-person auditory hallucinations, persecutory delusions and 5 months of social withdrawal. Discuss diagnosis and management."

Q1: Diagnosis (2 min)

• Core features: delusions, hallucinations, disorganised speech/behaviour, negative symptoms, with functional decline and duration criteria met.^[1]
• Domains: positive, negative (5 As), cognitive, affective.
• Schneiderian first-rank symptoms (classic exam list): third-person commentary, running commentary, thought insertion/withdrawal/broadcast, passivity, delusional perception — supportive but not pathognomonic.
• Differentials: substance, bipolar, psychotic depression, delirium/encephalitis, temporal lobe epilepsy, SLE, B12, tumour.

Q2: Acute management (2 min)

• Risk: suicide (especially early years), violence (minority), self-neglect, exploitation.^[3]
• Medical work-up and baseline metabolic/ECG panel before antipsychotics.
• Low-stimulus environment; short-term benzodiazepine if severely agitated.
• Capacity/Mental Health Act if insight lacking and risk high.

Q3: Antipsychotics — mechanism, choice, monitoring (3 min)

• Mechanism: D2 receptor antagonism (mesolimbic) reduces positive symptoms; 5-HT2A antagonism (many SGAs) modulates EPS and negative symptoms somewhat.^[2]
• First-episode example regimens:
  • Risperidone 2 mg nocte, titrate (watch prolactin, EPS)
  • Olanzapine 5–10 mg nocte (metabolic risk)
  • Aripiprazole 10–15 mg daily (akathisia; more weight-neutral)
• Adequate trial: therapeutic dose for 4–6 weeks.
• Monitoring: weight/BMI, waist, fasting glucose/HbA1c, lipids, BP, EPS, prolactin, QTc as indicated.
• EPS spectrum: acute dystonia (procyclidine/benztropine), akathisia (reduce dose/propranolol/benzo), parkinsonism, tardive dyskinesia (minimise dose; consider switch/VMAT2 inhibitors in specialist care).
• NMS: rigidity, fever, autonomic instability, raised CK — stop antipsychotic, supportive care, ICU, bromocriptine/dantrolene considered.

Q4: Treatment resistance, special populations, prognosis (1–2 min)

• Treatment-resistant schizophrenia: failure of ≥2 adequate antipsychotic trials → clozapine with weekly then spaced FBC (agranulocytosis), watch myocarditis, seizures, metabolic effects, hypersalivation, constipation (can be fatal).
• Pregnancy: do not stop effective antipsychotic solely for pregnancy; avoid clozapine if possible; monitor neonate for EPS/withdrawal.
• Elderly/dementia psychosis: increased stroke/mortality risk with antipsychotics — extreme caution.
• Prognosis: rule of thirds (approx) — recovery / relapsing / chronic; early intervention and adherence improve outcome; cognitive/negative symptoms drive disability more than positive symptoms alone.

Key phrases examiners want

• "Positive, negative and cognitive domains."
• "Lowest effective dose of one antipsychotic for four to six weeks."
• "Metabolic and ECG baseline before starting."
• "Two failed trials, then clozapine with blood monitoring."
• "Suicide risk is highest in the early years after onset."

References3ShowHide

1. [1]Lieberman JA, First MB. Psychotic Disorders. N Engl J Med, 2018.PMID 30021088
2. [2]Leucht S, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs. Lancet, 2013.PMID 23810019
3. [3]Palmer BA, et al. The lifetime risk of suicide in schizophrenia. Arch Gen Psychiatry, 2005.PMID 15753237