Master the board step 3

Master the Boards: USMLE Step 3
When symptoms are present for < 1 month and the question states that there
is a return to baseline, the diagnosis is brief psychotic disorder (look for a
stressful life event that precipitates it).
Basic Science Correlate
L-Phenylalanine → L-Tyrosine → L-DOPA → Dopamine
Schizophrenia is not
diagnosed if symptoms of
pervasive developmental
disorder are present, unless
accompanied by prominent
delusions or hallucinations.
When there is a history of symptoms for many years with no impairment of
baseline functioning, think of:
··
Delusional disorder (key is that delusions are nonbizarre)
··
Personality disorders
These patients do not respond to antipsychotics. Psychotherapy is the preferred
therapy.
Rule out medical illness and other forms of psychosis that aren’t schizophrenia:
The first step in management
of any acute
psychiatric condition is to
determine if the patient
needs hospitalization.
Hospitalize if the patient
is at risk of harm to self
or to others. Hospitalize
against the patient’s will if
the patient has suicidal or
homicidal ideation.
When the case describes
any of the following
features, the prognosis
is poor:
• Early age of onset
• Negative symptoms
• Poor premorbid
functioning
• Family history of
schizophrenia
• Disorganized or deficit
subtype
··
Check TSH for hypo- or hyperthyroidism.
··
Check basic electrolytes and calcium to rule out metabolic disorders.
··
Test serology to rule out HIV.
··
Test VDRL to rule out syphilis.
··
Drug screen is the best initial test in a patient with psychosis.
··
Temporal lobe epilepsy can present with hallucinations (auditory and olfactory
distortions), feeling of déjà vu, or dissociation from surroundings.
Watch out for suicidal ideation in schizophrenia patients and schizophreniform
patients. Fifty percent of schizophrenia patients attempt suicide in their lifetimes,
and 10 percent of these attempts are successful. Schizophreniform patients are at
greater risk of depression and suicide after the episode of psychosis resolves. The
first step in management is always to hospitalize if there is any risk of suicide.
What is the greatest risk factor for progression to schizophrenia?
Answer: Schizophreniform disorder. Two thirds eventually progress to schizophrenia.
Prognosis
In general, females have a better prognosis and respond better to treatment
than males.
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