schizophrenia case study video

• Audiocassette Recordings on Schizophrenia
• Educational Films and Videos on Schizophrenia
• Advanced Science/Biology of Schizophrenia Internet-based Videos (free)

NEWS: The latest news on new movies, plays, books, etc. related to schizophrenia

Archive: Full List of News on New Books, Movies, etc. on schizophrenia

Audiocassettes on Schizophrenia

An audiocassette reading of "The Quiet Room" by Lori Schiller. The second recording is "Schizophrenia" - From the award-winning public radio program The Infinite Mind. What is schizophrenia? What's it like to experience its symptoms? Dr. Goodwin and several top researchers and advocates discuss the most recent developments in our understanding of schizophrenia and how to treat it. Psychologist Fred Frese, who himself has schizophrenia, explains that for the schizophrenic, life can be dreamlike. The ability to determine what is true, to control one's actions, to distinguish between internal and external aspects of one's experience -- all can be altered. The Quiet Room: A Journey Out of the Torment of Madness By Lori Schiller, Publisher: Time Warner Audio Books; Abridged edition (June 1994) ISBN: 1570420386 Schizophrenia: Voices of an Illness Publisher: Lichtenstein Creative Media; (May 1, 1994) ISBN: 1888064021 Voices of an Illness radio documentary series has provided millions with an extraordinary window on serious mental illness since the series premiere in 1992. The series was the first to feature people who had recovered from serious mental illness, telling their own stories in their own words. The National Institute of Mental Health hailed the series as having "truly set new standards of creativity and scientific accuracy in broadcast journalism about mental illness." Mental Illness and the Media - (2002) Publisher: Lichtenstein Creative Media Schizophrenia; Second Chances - (2001) Publisher: Lichtenstein Creative Media Double Jeopardy: Mental Illness and Addiction - (2001) Publisher: Lichtenstein Creative Media The Insanity Defense - (2001) Publisher: Lichtenstein Creative Media PSYCHOSIS - (2000) Publisher: Lichtenstein Creative Media Managing Madness - (1999) Publisher: Lichtenstein Creative Media Schizophrenia - (1998) Publisher: Lichtenstein Creative Media Are Mentally Ill People More Violent? - (2000) Publisher: Lichtenstein Creative Media

Educational Films, Videos and DVDs on Schizophrenia (in no particular order)

Out of the Shadow - Up and down. Up and down. For years, that's how things went for Susan Smiley. Her 63-year-old mother suffers from paranoid schizophrenia. She's been in and out of psychiatric facilities in the Chicago area. She took, and then didn't take, her medication. "I was sort of at wit's end with all the trials and tribulations," said Smiley, 38. "I wanted to just channel my frustrations." One day Smiley, a filmmaker, picked up her camera and followed her mother around. She captured her pain, her unpredictability. What evolved was a nearly five-year odyssey - all caught on film - that became the subject of a cinematic exposé of the highs and lows of her mother's mental health care. More information: See " Out of the Shadow" Website Tarnation - a film done by a young film student (who has a mother who has schizophrenia) on his home Macintosh computer, don't expect a very refined production. "Tarnation" is an unsettling look into one man's shattered upbringing. The Movie Website: Tarnation "People Say I'm Crazy" - During his senior year in college, artist John Cadigan had a psychotic break. He dropped out of school and cycled through a number of drugs and doctors, then decided to film his agonizing battle with schizophrenia. People Say I'm Crazy is the first documentary ever photographed and directed by someone with schizophrenia. John invites viewers to tour the inside of his mind, a chaotic and creative universe, where he struggles to know what is real and what is not. An alumna of Stanford University's graduate program who profiled John in her 1994 thesis film, Out of My Mind [see below], Katie Cadigan reports that shooting People was much easier for her brother - since he controlled what got recorded - than editing." The Cadigans are collaborating on another documentary, about the hysterical and misleading portrayals of schizophrenia in popular culture. As its title (Wacko) suggests, it's intended to be funny as well as scathing. More information on "People Say I'm Crazy" - http://www.peoplesayimcrazy.org/ "Out of My Mind" - a film thesis by Katie Cadigan. Out of My Mind is an award-winning documentary about the onset of mental illness. A young artist's college career comes to a halt by a psychotic episode, signaling the onset of schizophrenia. The artist teams up with his sister - the filmmaker - to explore the nature of his psychosis, their agonizing search for care, and the family love that sustains him through crisis after crisis. Demystifying the frightening and stigmatized world of severe mental illness, Out of My Mind offers a rare first-person account of a family struggling to come to terms with schizophrenia. For purchase or rental, contact Filmaker's Library , {phone (212) 808-4980}. "It is one of the best and most useful films I have seen on this subject... especially for teaching and for families of individuals with serious mental illnesses." - E. Fuller Torrey, M.D., author of Surviving Schizophrenia Before They Fall Off the Cliff - This is an award-winning film is the story of a family where paranoid schizophrenia took its heavy toll, but also gave it the courage to forgive and to enlighten others about mental illness. In 1994, Matthew McBride, the youngest son of a suburban St., Louis family was fighting a difficult battle with paranoid schizophrenia. Imaginary voices convinced him that if he killed his parents, he could prevent World War III. He stabbed his parents to death hours after release from a mental hospital. Matt¹s brother and sister were left to deal with not only the violent death of their beloved parents but the well being of their younger brother who was not responsible for his actions. 60min. Video. Sale $350. Rental $75. - Order from Filmakers Library, 124 East 40th Street, NY, NY 10016, Phone 212-808-4980, fax 212-808-4983 Imaging Robert: My Brother, Madness and Survival - The book, Imagining Robert: My Brother, Madness & Survival, has been made into a one-hour documentary. Jay Neuborgen wrote the story about his brother and their family's experience with schizophrenia. The film is available for rental through Films for the Humanities & Sciences at www.films.com or by calling (800) 257-5126. Information about the filmmakers, Larry Hott and Diane Garey, is available at www.florentinefilms.org . For more information see the film web site at: http://www.imaginingrobert.org/ Dark Voices: Schizophrenia - Schizophrenia is a neurological brain disorder that affects 2.2 million Americans today. This program seeks to understand how schizophrenia touches the lives of patients and their family members while examining the disease’s etiology and pathology. Although there is currently no cure, schizophrenia is a highly manageable disorder—in fact, its treatment success rate is comparable to the success rate associated with heart disease. A Discovery Channel Production. (53 minutes, color). List Price: $129.95, Rental Price: $75.00, Ordering Website: www.films.com Drug/Alcohol Addiction and Schizophrenia - Many people who are mentally ill are also addicted to drugs and alcohol. These are separate problems that require separate treatments, yet few people have been diagnosed correctly for both conditions. This program from The Doctor Is In profiles a woman who is manic-depressive and alcoholic, and a man with schizophrenia who is also alcoholic. Dr. Fred Goodwin, director of the National Institute of Mental Health, explains ongoing research that may help identify and treat adolescents before they begin to experience problems. A Dartmouth-Hitchcock Medical Center production. (28 minutes, color). List Price: $149.95, Rental Price: $75.00, Ordering Website: www.films.com The Torment of Schizophrenia - (2000) Although one out of every hundred people in the world will likely wrestle with schizophrenia, the disease remains one of psychiatry’s greatest therapeutic challenges. Enhanced by computer animations of the brain, this poignant program uses several case studies and expert commentary to promote a better understanding of schizophrenia: its causes and warning signs, current treatments, and how it affects the lives of those who have it. The phases of a psychotic attack are described, and positive, negative, and cognitive symptoms are defined. In addition, approaches to mainstreaming patients are addressed. (53 minutes, color), List Price: $129.95, Rental Price: $75.00, Ordering Website: www.films.com Preventing Relapse in Schizophrenia - As of now, there is no cure for schizophrenia, but with a combination of proper medication, therapy, and group support, patients can gain more control over their lives. In this program, two psychiatric experts discuss the elusive nature of this devastating disorder, as well as various treatments available to prevent relapse. Both the benefits and side effects of antipsychotic drugs are weighed by doctors. Schizophrenia patients offer personal insights into how they avoid relapse and how a growing variety of treatment options are helping them lead more normal lives. (21 minutes, color), List Price: $129.95, Rental Price: $75.00. Ordering Website: www.films.com Schizophrenia - This specially adapted Phil Donahue program is widely regarded as a very helpful program on schizophrenia addressed to non-specialist audiences. The program offers basic information about this psychotic illness that affects nearly one million Americans, usually striking 17- to 25-year-olds. Dr. E. Fuller Torrey, author of Surviving Schizophrenia: A Family Manual, reviews the suspected causes, the symptoms, the prognosis for recovery, and the steps to be taken by supportive family members. (28 minutes, color), List Price: $89.95, Rental Price: $75.00, Ordering Website: www.films.com Schizophrenia and Depression - Mental illness, its forms, and the progress being made in its treatment are the focus of this program. First, Dr. David Pickar, of the National Institute of Mental Health, provides information on schizophrenia and its treatment. A patient with schizophrenia who has a history of suicide attempts and has benefited from drug therapies is profiled. Then, Dr. Frederick Goodwin, formerly of the NIMH, shares his knowledge of depression, an illness that affects millions of American adults. Of this group, most could benefit from medication, but only a fraction actually seek treatment. The program also explores the temporary chemical changes in the brain during winter, which can lead to seasonal affective disorder. (23 minutes, color), List Price: $99.95, Rental Price: $75.00, Ordering Website: www.films.com Schizophrenia: New Definitions, New Therapies - (1998) Using interviews with medical authorities including neuropsychiatrist Richard Petty, of the University of Pennsylvania Medical Center, and outstanding computer animation of the brain, this program provides an update on the causes and treatments of schizophrenia. NewsHour correspondent Susan Dentzer focuses on a young Philadelphia man trying desperately to control this devastating disorder. Although new atypical antipsychotic drugs such as Olanzapine, Risperidone, and Quetiapine are proving helpful—to those who can afford them—experts agree that a strong community support program is also essential to achieve lasting recovery. (29 minutes, color), List Price: $89.95, Rental Price: $75.00, Ordering Website: www.films.com PBS (Public Broadcasting Service) Videos West 47th Street Mental illness is a topic rife with stereotypes and misunderstanding. Made with depth and compassion, "West 47th Street" is an intimate cinema verite portrait of four people struggling to recover from serious mental illness. They've all come to Fountain House, a renowned rehabilitation center in New York City's Hell's Kitchen. Over three years, the film follows its subjects as they deal with drug regimens, health issues, group homes and work programs with courage and humor. Epic in scope, "West 47th Street" offers an unprecedented window onto the lives of people who are often feared and ignored, but seldom understood. An Active Voice Selection. Price: $49.98 for DVD, $39.98 for Video A Brilliant Madness - The Story of John Nash John Nash was an eccentric mathematical genius whose sudden youthful plunge into schizophrenia could have ended in obscurity or tragedy. Instead, his 30-year battle against crippling mental disease ended in triumph--and winning the 1994 Nobel Prize in economics, as recounted in the blockbuster 2001 film, A Beautiful Mind. This documentary features interviews with Nash, wife Alicia, friends, and colleagues. DVD Special Features include bonus interview with John Nash; out-takes of schizophrenia; Price: $14.95 Video, $19.95 DVD. Secret Life of the Brain: Part 3: The Teenage Brain: A World of Their Own This episode offers potential comfort to parents who believe teenagers are different from the rest of humanity by demonstrating that it's literally true. During puberty the brain is a work in progress, teeming with hormones, while the areas that direct reasoning and impulse control are still in development. Adolescence is also a period during which people are especially susceptible to schizophrenia and addiction, two areas currently under intensive study and benefiting from increased understanding of brain function. Price: $14.95 for Video. Other Documentary-type films related to schizophrenia "Managing Depression", "Depression and Relationships", "Treating Depression" and "Understanding Depression" from Glaxo Wellcome Inc, Pharmaceuticals Research, Triangle Park, N.C. 27709. "Negative Symptoms in Schizophrenia", 1995, Nancy Andreasen, M.D., Ph.D., University of Iowa Hospitals and Clinics. Contact NAMI for 60 minute video, www.nami.org . Notes from Video "Negative Symptoms of Schizophrenia (4 page PDF file) "Promise". Hallmark Hall of Fame, 1986. (Story of two brothers, one schizophrenic). 60 minutes. "Uncertain Journey." Dept. Of Psychiatry, Duke University Medical Center, Box 3173, Durham, N.C. 27710. (919) 684-3332, 50 minutes. $25.00. "Understanding and Communicating With a Person Who Is Experiencing Mania", "Understanding and Communicating With a Person Who is Hallucinating", "Understanding Relapse: Managing the Symptoms of Schizophrenia". Nurseminars, Inc., P.O. Box 540616, Omaha, NE, 68154-0616, (402) 496-2245. Each: 60 minutes, $89.00 "When the Music Stops: The Reality of Serious Mental Illness", The DuPont Co., 1987, NAMI, 200 N. Glebe Road, Suite 1015, Arlington, VA 22203-3754, (703) 524-7600. 20 minutes, $20.  

Recent Movies on Schizophrenia

Revolution #9 - VHS Version , Starring: Michael Risley, Adrienne Shelly, Director: Tim McCann, Format: Color, NTSC, Rated: NR, Studio: Wellspring Media, Inc. Revolution #9 - DVD Version , Starring: Michael Risley, Adrienne Shelly, Director: Tim McCann, Format: Color, NTSC, Rated: NR, Studio: Wellspring Media, Inc. Revolution #9 is an award-winning fictional movie that realistically documents a young man's descent into schizophrenia. Just as everything seems to be going right for Jackson and his girlfriend Kim, a shadow falls across their lives. Suddenly, Jackson begins to suspect that Kim's young nephew is sending him sinister messages over the Internet. Next, he becomes convinced a television commercial for a perfume called Revolution #9 is part of a systematic sensory attack by corporate media. Diagnosed as schizophrenic by his doctor, Jackson refuses to take his medication and rejects everyone around him, believing they are all part of a conspiracy against him. If you're looking for a realistic depiction of schizophrenia from a recent Hollywood production, Revolution #9 is perhaps a more accurate and representative movie than "A Beautiful Mind". A Beautiful Mind (The Awards Edition) VHS-Version , Starring: Russell Crowe, Ed Harris, Director: Ron Howard, ASIN: B00005JKQZ A Beautiful Mind (Widescreen Awards Edition) DVD-Version , Starring: Russell Crowe, Ed Harris, Director: Ron Howard, ASIN: B00005JKQZ Older Movies that involve people who have schizophrenia (as reviewed by Ian Chovil ) Benny & Joon is a happy film about romance, independence and schizophrenia. Movie Information: Starring: Johnny Depp, Mary Stuart Masterson, Director: Jeremiah S. Chechik, Format: Color, Closed-captioned, NTSC, Studio: Mgm/Ua Studio, Video Release Date: April 1, 1997 The Saint of Fort Washington is a sad (but well-done) movie about homelessness and schizophrenia. Click here for another person's review of the movie Through a Glass Darkly won an Academy award, "Best Foreign film", back in the sixties, very early for any film to mention schizophrenia by name. It is an Igmar Bergman film shot in black and white, a bit stark really about a young woman and some pretty strange family dynamics. Angel Baby (VHS) is a relatively recent Australian film about a young couple in love who both have schizophrenia. It's a very sad and brutally honest film. It is a little too realistic for comfort for people who have experience with schizophrenia. Movie Details: Starring: Michael Rymer, John Lync, Director: Michael Rymer, Format: Color, NTSC, Rated: R - Not for sale to persons under age 18. The Gingerbread Man is a bad movie. It has a central character with schizophrenia but his role is to illustrate our fear of people with schizophrenia. Rated: R - Not for sale to persons under age 18. Donnie Darko was recommended by several of my visitors. It's a film about adolescents, and the main character is being treated with medication for a mental illness. This film you're never too sure what is real and what are delusions. And in the same way the ending is inconclusive because you're not sure if what you're seeing is real or just what Donnie believes is real. Rated: R - Not for sale to persons under age 18. Advanced Science/Biology of Schizophrenia Videos - We have a lot of advanced Internet-based videos on schizophrenia at this link.  

Schizophrenia Videos Recommended by Dr. E. Fuller Torrey

I'm Still Here. The Truth About Schizophrenia; A Non-Fiction Film (1996) Real and compelling stories told by individuals struggling with schizophrenia, but who are able to lead lives of extraordinary courage and accomplishment. College Students, mental health professionals, and family members view this tape as moving and remarkable testimony. To Order: Direct Cinema, PO Box 10003, Santa Monica, CA 90410. Phone: 1-800-525-0000 or 310-636-8200. 67-min videotape, $20.95 (includes shipping). NOTE: We've received feedback from people that the following videos are more difficult to get. In a World Alone: Living with Schizophrenia (1997) William M. Glazer, MD and Peter M. Weiden, MD., discuss the history of deinstitutionalization, the history of treatment methods, and the advances in medications used today. The viewer is reminded that "stigma is caused by disease that cannot be precisely measured." Consumers express belief in recovery and cite importance of staying on medications. To Order: Lisa Rosas, WLIW Health Chronicles, 1790 Broadway, 16th Floor, New York, NY 10019, Phone: 212-974-2121 Ext. 3825. or 1-800-847-7793. 26 min videotape, $24.95 + $3.00 shipping = $27.95 Madness (Part 7, "The Brain" series) (1984) An excellent, detailed, informative and interesting introduction to schizophrenia used extensively by college students, professionals, and families to better understand schizophrenia. To Order: Produced by PBS. Annenberg CPB Project, P.O. Box 2345, South Burlington, VT 05407, Phone: 800-LEARNER, fax: 802-864-9846. 60 minute videotape, $29.95 + $2.40 shipping = $32.35. Mental Illness: Unraveling the Myths (1990) An impressive and provocative panel discussion explores the origins of the stigma surrounding people with serious mental illness. Host is Rutgers professor Richard Heffner; panelists are Alexander D. Brooks, law professor; Patricia Deegan, psychologist; Joanne Verbanic, founder of Schizophrenics Anonymous; Phyllis Vine, author; and Otto Wahl, psychology professor. To Order: Rutgers University, New Jersey, Electronic Communications, 6 Berrue Circle, Piscataway, NJ 08854. Phone: 732-445-3710, ext. 129. 60 min videotape, $35.00 + $5.00 Shipping = $40.00 No More Shame: Understanding Schizophrenia (1995) Videotape presents current findings and thinking in the area of research on schizophrenia. Symptoms of the illness and treatment options are brought to the forefront. Use of graphics and computer animations help to assist viewer to better understand the brain, the neurotransmitters, and what actually happens at the level of the neuron. Schools, colleges, families, and professionals will learn from and enjoy this videotape. To Order: Films for Humanities and Sciences, P.O. Box 2053, Princeton, NJ 08543, Catalog Number 5827, Phone: 800-257-5126, 20 min. videotape. $89.95 + $5.95 shipping = $95.90 The film " Nor More Shame " is also available from www.films.com Schizophrenia (1996) - A Three-part series enjoyed by families and useful as teaching tools 635.1 - Causation Discusses the epidemiology of schizophrenia and presents theories regarding the cause of this biologically-based disorder. Includes a discussion of genetic and environmental factors, as well as structural and functional changes in the brain, including biochemistry. Also discusses neurologic signs and information-processing deficits. 1995, 28 min., $280, 2-CE 635.2 - Symptomatology Discusses both positive and negative symptoms of schizophrenia and assists helpers in determining whether or not an individual has such symptoms. Also assists helpers interacting with individuals who are symptomatic and increases awareness of situations in which violence might occur. Discusses the DSM-IV criteria for schizophrenia. 1995, 31 min., $280, 2-CE 635.3 - The Community's Response Describes the deinstitutionalization movement and its impact. Discusses the community's response from several viewpoints including that of clients, parents, medical and nursing professionals, law enforcement personnel, psychiatric personnel in the penal system, and outreach workers. Examines issues such as importance of the family, adherence to medication regimens, stigmatization, dangerousness, and need for community outreach and support. Commentary by E. Fuller Torrey. 1995, 41 min., $280, 2-CE To Order: Concept Media, P.O. Box 19542, Irvine, CA 92623-9542, Tel (949) 660-0727, Fax: (949) 660-0206, Toll-Free 800-233-7078, www.conceptmedia.com "Schizophrenia: Surving in the World of Normals", and "A Love Story: Living with Someone with Schizophrenia" (1991) Frederick J. Frese, a psychologist and consumer, and his wife, Penny Frese, speak candidly about schizoprenia. Dr. Frese offers and insider's perspective and practicle approaches to the problems surrounding the illness; Penny Frese speaks from the perspective of a spouse. An iimpressive and inspiring model for "openness" about mental illness. A favorite among consumers and families, college students and professionals. To Order: Wellness Reproductions, 23945 Mercantile Road, Beachwood, OH 44122-5924, Phone: 216-831-9209, 120 minute videotape, $49.95 + $5.95 shipping = $55.90 A Mother's Search (1996) A mother's extraordinary journey to rescue her son, Mark, who has schizophrenia, is homeless and is in need of medical attention. The issues of medication non-compliance and involuntary treatment are addressed. Designed especially for families, professionals and law enforcement officers. To Order: CBS Video: "48 Hours" 10-24-96. CBS, P.O. Box 2284, So. Burlington, VT 05407, Phone: 800-542-5621. 45 minute video tape. $29.95 + $7.13 shipping = $38.08. Annick Holister's Story (1997) Annick's story is about living with schizophrenia. Determined to face mental illness and overcome the obstacles to recovery, Annick and members of her family relate their experiences. A heartwarming video to inspire and encourage other consumers and families to seek help. The importance of research is emphasized. To Order: CBS "60 Minutes" segment, 5-18-97. CBS, P.O. Box 2284, So. Burlington, VT 05407, Phone: 800-542-5621. (sM70518C) video tape. $29.95 + $7.13 shipping = $38.08. Critical Conections (1997) From the perspective of individuals who have schizophrenia, the viewer learns that treatment is not just a matter of medications; the individual must take control and build relationships of trust with others. The message the video conveys is: "see the individual first, then the illness." Video cites progress in science and medications with fewer side-effects. Suitable for families, consumers, mental health professionals, and concerned citizens. To Order Your Free Copy: American Psychiatric Association, Public Affairs, 1400 K Street NW, Washington, DC 20005, 28-min videotape, Call 202-682-6325 to obtain a free copy. Familes Coping with Mental Illness (1996) Families convey stories about their struggles and successes. A provocative tape that stimulates exellent discussions. Families will get a perspective that will help them cope more effectively. This is a powerful learning tool for social workers and other mental health professionals to use in training and when attempting to help families cope with mental disease. To Order: Bonnie Tapes. Mental Illness Education Project, 22-D Hollywood Avenue, Hohokus, NJ 07423. Phone: 201-652-1989. 22 minute or 43 minute videotape, $29.95 + $9 shipping = $38.95

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Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

Schizophrenia case studies: putting theory into practice

This article considers how patients with schizophrenia should be managed when their condition or treatment changes.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Treatments for schizophrenia are typically recommended by a mental health specialist; however, it is important that pharmacists recognise their role in the management and monitoring of this condition. In ‘ Schizophrenia: recognition and management ’, advice was provided that would help with identifying symptoms of the condition, and determining and monitoring treatment. In this article, hospital and community pharmacy-based case studies provide further context for the management of patients with schizophrenia who have concurrent conditions or factors that could impact their treatment.

Case study 1: A man who suddenly stops smoking

A man aged 35 years* has been admitted to a ward following a serious injury. He has been taking olanzapine 20mg at night for the past three years to treat his schizophrenia, without any problems, and does not take any other medicines. He smokes 25–30 cigarettes per day, but, because of his injury, he is unable to go outside and has opted to be started on nicotine replacement therapy (NRT) in the form of a patch.

When speaking to him about his medicines, he appears very drowsy and is barely able to speak. After checking his notes, it is found that the nurses are withholding his morphine because he appears over-sedated. The doctor asks the pharmacist if any of the patient’s prescribed therapies could be causing these symptoms.

What could be the cause?

Smoking is known to increase the metabolism of several antipsychotics, including olanzapine, haloperidol and clozapine. This increase is linked to a chemical found in cigarettes, but not nicotine itself. Tobacco smoke contains aromatic hydrocarbons that are inducers of CYP1A2, which are involved in the metabolism of several medicines [1] , [2] , [3] . Therefore, smoking cessation and starting NRT leads to a reduction in clearance of the patient’s olanzapine, leading to increased plasma levels of the antipsychotic olanzapine and potentially more adverse effects — sedation in this case.

Patients who want to stop, or who inadvertently stop, smoking while taking antipsychotics should be monitored for signs of increased adverse effects (e.g. extrapyramidal side effects, weight gain or confusion). Patients who take clozapine and who wish to stop smoking should be referred to their mental health team for review as clozapine levels can increase significantly when smoking is stopped [3] , [4] .

For this patient, olanzapine is reduced to 15mg at night; consequently, he seems much brighter and more responsive. After a period on the ward, he has successfully been treated for his injury and is ready to go home. The doctor has asked for him to be supplied with olanzapine 15mg for discharge along with his NRT.

What should be considered prior to discharge?

It is important to discuss with the patient why his dose was changed during his stay in hospital and to ask whether he intends to start smoking again or to continue with his NRT. Explain to him that if he wants to begin, or is at risk of, smoking again, his olanzapine levels may be impacted and he may be at risk of becoming unwell. It is necessary to warn him of the risk to his current therapy and to speak to his pharmacist or mental health team if he does decide to start smoking again. In addition, this should be used as an opportunity to reinforce the general risks of smoking to the patient and to encourage him to remain smoke-free.

It is also important to speak to the patient’s community team (e.g. doctors, nurses), who specialise in caring for patients with mental health disorders, about why the olanzapine dose was reduced during his stay, so that they can then monitor him in case he does begin smoking again.

Case 2: A woman with constipation

A woman aged 40 years* presents at the pharmacy. The pharmacist recognises her as she often comes in to collect medicine for her family. They are aware that she has a history of schizophrenia and that she was started on clozapine three months ago. She receives this from her mental health team on a weekly basis.

She has visited the pharmacy to discuss constipation that she is experiencing. She has noticed that since she was started on clozapine, her bowel movements have become less frequent. She is concerned as she is currently only able to go to the toilet about once per week. She explains that she feels uncomfortable and sick, and although she has been trying to change her diet to include more fibre, it does not seem to be helping. The patient asks for advice on a suitable laxative.

What needs to be considered?

Constipation is a very common side effect of clozapine . However, it has the potential to become serious and, in rare cases, even fatal [5] , [6] , [7] , [8] . While minor constipation can be managed using over-the-counter medicines (e.g. stimulant laxatives, such as senna, are normally recommended first-line with stool softeners, such as docusate, or osmotic laxatives, such as lactulose, as an alternative choice), severe constipation should be checked by a doctor to ensure there is no serious bowel obstruction as this can lead to paralytic ileus, which can be fatal [9] . Symptoms indicative of severe constipation include: no improvement or bowel movement following laxative use, fever, stomach pain, vomiting, loss of appetite and/or diarrhoea, which can be a sign of faecal impaction overflow.

As the patient has been experiencing this for some time and is only opening her bowels once per week, as well as having other symptoms (i.e. feeling uncomfortable and sick), she should be advised to see her GP as soon as possible.

The patient returns to the pharmacy again a few weeks later to collect a prescription for a member of their family and thanks the pharmacist for their advice. The patient was prescribed a laxative that has led to resolution of symptoms and she explains that she is feeling much better. Although she has a repeat prescription for lactulose 15ml twice per day, she says she is not sure whether she needs to continue to take it as she feels better.

What advice should be provided?

As she has already had an episode of constipation, despite dietary changes, it would be best for the patient to continue with the lactulose at the same dose (i.e. 15ml twice daily), to prevent the problem occurring again. Explain to the patient that as constipation is a common side effect of clozapine, it is reasonable for her to take laxatives before she gets constipation to prevent complications.

Pharmacists should encourage any patient who has previously had constipation to continue taking prescribed laxatives and explain why this is important. Pharmacists should also continue to ask patients about their bowel habits to help pick up any constipation that may be returning. Where pharmacists identify patients who have had problems with constipation prior to starting clozapine, they can recommend the use of a prophylactic laxative such as lactulose.

Case 3: A mother is concerned for her son who is talking to someone who is not there

A woman has been visiting the pharmacy for the past 3 months to collect a prescription for her son, aged 17 years*. In the past, the patient has collected his own medicine. Today the patient has presented with his mother; he looks dishevelled, preoccupied and does not speak to anyone in the pharmacy.

His mother beckons you to the side and expresses her concern for her son, explaining that she often hears him talking to someone who is not there. She adds that he is spending a lot of time in his room by himself and has accused her of tampering with his things. She is not sure what she should do and asks for advice.

What action can the pharmacist take?

It is important to reassure the mother that there is help available to review her son and identify if there are any problems that he is experiencing, but explain it is difficult to say at this point what he may be experiencing. Schizophrenia is a psychotic illness which has several symptoms that are classified as positive (e.g. hallucinations and delusions), negative (e.g. social withdrawal, self-neglect) and cognitive (e.g. poor memory and attention).

Many patients who go on to be diagnosed with schizophrenia will experience a prodromal period before schizophrenia is diagnosed. This may be a period where negative symptoms dominate and patients may become isolated and withdrawn. These symptoms can be confused with depression, particularly in younger people, though depression and anxiety disorders themselves may be prominent and treatment for these may also be needed. In this case, the patient’s mother is describing potential psychotic symptoms and it would be best for her son to be assessed. She should be encouraged to take her son to the GP for an assessment; however, if she is unable to do so, she can talk to the GP herself. It is usually the role of the doctor to refer patients for an assessment and to ensure that any other medical problems are assessed. 

Three months later, the patient comes into the pharmacy and seems to be much more like his usual self, having been started on an antipsychotic. He collects his prescription for risperidone and mentions that he is very worried about his weight, which has increased since he started taking the newly prescribed tablets. Although he does not keep track of his weight, he has noticed a physical change and that some of his clothes no longer fit him.

What advice can the pharmacist provide?

Weight gain is common with many antipsychotics [10] . Risperidone is usually associated with a moderate chance of weight gain, which can occur early on in treatment [6] , [11] , [12] . As such, the National Institute for Health and Care Excellence recommends weekly monitoring of weight initially [13] . As well as weight gain, risperidone can be associated with an increased risk of diabetes and dyslipidaemia, which must also be monitored [6] , [11] , [12] . For example, the lipid profile and glucose should be assessed at 12 weeks, 6 months and then annually [12] .

The pharmacist should encourage the patient to attend any appointments for monitoring, which may be provided by his GP or mental health team, and to speak to his mental health team about his weight gain. If he agrees, the pharmacist could inform the patient’s mental health team of his weight gain and concerns on his behalf. It is important to tackle weight gain early on in treatment, as weight loss can be difficult to achieve, even if the medicine is changed.

The pharmacist should provide the patient with advice on healthy eating (e.g. eating a balanced diet with at least five fruit and vegetables per day) and exercising regularly (e.g. doing at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week), and direct him to locally available services. The pharmacist can record the adverse effect on the patient’s medical record, which will help flag this in the future and thus help other pharmacists to intervene should he be prescribed risperidone again.

*All case studies are fictional.

Useful resources

• Mind — Schizophrenia
• Rethink Mental Illness — Schizophrenia
• Mental Health Foundation — Schizophrenia
• Royal College of Psychiatrists — Schizophrenia
• NICE guidance [CG178] — Psychosis and schizophrenia in adults: prevention and management
• NICE guidance [CG155] — Psychosis and schizophrenia in children and young people: recognition and management
• British Association for Psychopharmacology — Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology

About the author

Nicola Greenhalgh is lead pharmacist, Mental Health Services, North East London NHS Foundation Trust

[1] Chiu CC, Lu ML, Huang MC & Chen KP. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit 2004;26(5):579–581. doi: 10.1097/00007691-200410000-00018

[2] de Leon J. Psychopharmacology: atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004;55(5):491–493. doi: 10.1176/appi.ps.55.5.491

[3] Mayerova M, Ustohal L, Jarkovsky J et al . Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018;14:1535–1543. doi: 10.2147/NDT.S163839

[4] Ashir M & Petterson L. Smoking bans and clozapine levels. Adv Psychiatr Treat 2008;14(5):398–399. doi: 10.1192/apt.14.5.398b

[5] Young CR, Bowers MB & Mazure CM. Management of the adverse effects of clozapine. Schizophr Bull 1998;24(3):381–390. doi: 10.1093/oxfordjournals.schbul.a033333

[6] Taylor D, Barnes TRE & Young AH. The Maudsley Prescribing Guidelines in Psychiatry . 13th edn. London: Wiley Blackwell; 2018

[7] Oke V, Schmidt F, Bhattarai B et al . Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis — a case report. Int Med Case Rep J 2015;8:189–192. doi: 10.2147/IMCRJ.S86716

[8] Hibbard KR, Propst A, Frank DE & Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: a literature review and two case reports. Psychosomatics 2009;50(4):416–419. doi: 10.1176/appi.psy.50.4.416

[9] Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. 2020. Available from: https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus (accessed April 2020)

[10] Leucht S, Cipriani A, Spineli L et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013;382(9896):951–962. doi: 10.1016/S0140-6736(13)60733-3

[11] Bazire S. Psychotropic Drug Directory . Norwich: Lloyd-Reinhold Communications LLP; 2018

[12] Cooper SJ & Reynolds GP. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 2016;30(8):717–748. doi: 10.1177/0269881116645254

[13] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available from: https://www.nice.org.uk/guidance/cg178 (accessed April 2020)

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90-Second Video Humanizing Schizophrenia Reduces Stigma in Young Adults

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In a direct and honest manner, a 22-year-old woman presents the story of a young adult with psychosis who has successfully engaged in treatment and lives a meaningful and productive life.

People who watched a 90-second video of a young woman describing her experience with schizophrenia had a lower rate of stigma toward people with schizophrenia than those who did not watch this video. The findings were published in  Schizophrenia Bulletin .

Targeting the 18- to 25-year-old age group for destigmatizing efforts is crucial since that age range overlaps with that young adults at risk for first-episode psychosis, says study author Doron Amsalem, M.D.

“Stigma creates a huge barrier for people with psychosis to getting care, and studies show that 70% of people with serious mental illness do not seek out treatment,” lead author Doron Amsalem, M.D., an associate research scientist at Columbia University, told  Psychiatric News .

The length of time that people with psychosis go without treatment impacts their long-term outcome. “Before we talk about treatments, let’s help people be comfortable with seeking out care,” Amsalem said.

Amsalem and colleagues used a crowdsourcing tool to recruit 1,203 individuals aged 18 to 30 who were living in the United States. The participants were randomly assigned to view the 90-second video, read a text version of the same patient’s story, or be part of a control group that did not see the video or read the text.

The video featured a 22-year-old woman with schizophrenia who talked not just about her symptoms and her treatment, but about how her condition affected her daily life. The 90-second video was an abbreviated version of an 11-minute video created by the Center for Practice Innovation at ONTrackNY, the coordinated first-episode psychosis (FEP) treatment program at NYSPI.

The researchers then assessed stigma among the three groups using a web-based questionnaire that looked at five domains of stigma:

Social distance  assesses whether someone would be willing to be friends with someone with psychosis or schizophrenia or have a person with schizophrenia marry into their family.

Social restriction  determines a participant’s perception of whether a person with schizophrenia should marry and have children.

Separateness  measures perceptions of whether and how much an individual with schizophrenia is different from other people.

Stereotyping  assesses perceptions of whether people with schizophrenia are able to perform certain functions (make treatment decisions or manage their own finances) or are capable of violence.

Perceived recovery  measures participants’ beliefs that a person with schizophrenia can follow through on a treatment plan and reach recovery goals.

The researchers found that across all five domains, the video-based intervention group had lower rates of stigma than the control group. The video group also had lower rates of stigma on measures of social distance, stereotyping, and social restriction than the group who read the patient vignette; there was no difference on measures of separateness and perceived recovery between these two groups.

The group who read the vignette had lower rates of stigma than the control group across all five domains.

In comments to Psychiatric News , Amsalem emphasized the emotionally appealing nature of the patient in the audiovisual presentation: In a direct and honest manner, she presents the story of a young adult with psychosis who has successfully engaged in treatment and lives a meaningful and productive life.

Lisa Dixon, M.D., director of OnTrackNY, said videos like the one used in the stigma trial overcome the objectification of people with mental illness by creating connection and identification.

Lisa Dixon, M.D., director of OnTrackNY and a co-author of the study, said OnTrackNY has many similarly powerful videos that highlight the lived experiences of people with mental illness. “Mental illness is so objectified, but these kinds of stories just break through that by [allowing others] to see them as human beings like the rest of us, struggling and trying their best.

“They don’t present a perfect world, or a perfect life,” Dixon said. “These videos present a regular person being a regular person, coping with challenges and trials. We think they work by creating connection and identification.”

Amsalem and colleagues also emphasized that the target audience to which the video was aimed is crucial, since its age range overlaps with that of the onset of FEP and includes the potential peer group of people with FEP. Targeting this group also “intervenes in addressing stigma-related experiences when people are still young, rather than letting stereotypical attitudes endure,” they wrote. “This age group also cares greatly about what their peers think of them.”

The researchers concluded, “This simple, brief, easy to disseminate video-based intervention has the potential to increase the likelihood of seeking services, improve access to care among people with FEP, and ultimately reduce DUP [duration of untreated psychosis].” ■

“Reducing Stigma Toward People With Schizophrenia Using a Brief Video: A Randomized Controlled Trial of Young Adults” is posted here .

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Case Study Illustrates How Schizophrenia Can Often Be Overdiagnosed

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Study author Russell Margolis, director of the Johns Hopkins Schizophrenia Center, answers questions on misdiagnosis of the condition and reiterates the importance of thorough examination.

It’s not uncommon for an adolescent or young adult who reports hearing voices or seeing things to be diagnosed with schizophrenia, but using these reports alone can contribute to the disease being overdiagnosed, says  Russell Margolis , clinical director of the Johns Hopkins Schizophrenia Center. 

Many clinicians consider hallucinations as the sine qua non, or essential condition, of schizophrenia, he says. But even a true hallucination might be part of any number of disorders — or even within the range of normal. To diagnose a patient properly, he says, “There’s no substitute for taking time with patients and others who know them well. Trying to [diagnose] this in a compressed, shortcut kind of way leads to error.”

A case study he shared recently in the  Journal of Psychiatric Practice  illustrates the problem. Margolis, along with colleagues Krista Baker, schizophrenia supervisor at Johns Hopkins Bayview Medical Center, visiting resident Bianca Camerini, and Brazilian psychiatrist Ary Gadelha, described a 16-year-old girl who was referred to the Early Psychosis Intervention Clinic at Johns Hopkins Bayview for a second opinion concerning the diagnosis and treatment of suspected schizophrenia.

The patient made friends easily but had some academic difficulties. Returning to school in eighth grade after a period of home schooling, she was bullied, sexually groped and received texted death threats. She then began to complain of visions of a boy who harassed her, as well as three tall demons. The visions waxed and waned in relation to stress at school. The Johns Hopkins consultants determined that this girl did not have schizophrenia (or any other psychotic disorder), but that she had anxiety. They recommended psychotherapy and viewing herself as a healthy, competent person, instead of a sick one. A year later, the girl reported doing well: She was off medications and no longer complained of these visions.

Margolis answers  Hopkins Brain Wise ’s questions.

Q: How are anxiety disorders mistaken for schizophrenia?

A:  Patients often say they have hallucinations, but that doesn’t always mean they’re experiencing a true hallucination. What they may mean is that they have very vivid, distressing thoughts — in part because hallucinations have become a common way of talking about distress, and partly because they may have no other vocabulary with which to describe their experience. 

Then, even if it  is  a true hallucination, there are features of the way psychiatry has come to be practiced that cause difficulties. Electronic medical records are often designed with questionnaires that have yes or no answers. Sometimes, whether the patient has hallucinations is murky, or  possible —  not yes or no. Also, one can’t make a diagnosis based just on a hallucination; the diagnosis of disorders like schizophrenia is based on a constellation of symptoms. 

Q: How often are patients in this age range misdiagnosed?

A:  There’s no true way to know the numbers. Among a very select group of people in our consultation clinic where questions have been raised, about half who were referred to us and said to have schizophrenia or a related disorder did not. That is not generalizable.

Q:   Why does that happen?

A:  There is a lack of attention to the context of symptoms and other details, and there’s also a tendency to take patients literally. If a patient complains about x, there’s sometimes a pressure to directly address x. In fact, that’s not appropriate medicine. It is very important to pay attention to a patient’s stated concerns, but to place these concerns in the bigger picture. Clinicians can go too far in accepting at face value something that needs more exploration. 

Q: What lessons do you hope to impart by publishing this case?

A:  I want it to be understood that the diagnosis of schizophrenia has to be made with care. Clinicians need to take the necessary time and obtain the necessary information so that they’re not led astray. Eventually, we would like to have more objective measures for defining our disorders so that we do not need to rely totally on a clinical evaluation. 

Learn more about Russell Margolis’ research regarding the challenges of diagnosing schizophrenia .

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• April 01, 2024 | VOL. 75, NO. 4 CURRENT ISSUE pp.307-398
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Schizophrenia on YouTube

• Matthew M. Nour , B.M.B.Ch. ,
• Murraih H. Nour , B.M.B.S. ,
• Olga-Maria Tsatalou , B.M.B.Ch., M.R.C.Psych. ,
• Alvaro Barrera , M.D., Ph.D.

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YouTube ( www.youtube.com ) is the most popular video-sharing Web site on the Internet and is used by medical students as a source of information regarding mental health conditions, including schizophrenia. The accuracy and educational utility of schizophrenia presentations on YouTube are unknown. The purpose of this study was to analyze the accuracy of depictions of psychosis in the context of a diagnosis of schizophrenia (referred to in this article as “acute schizophrenia”) on YouTube and to assess the utility of these videos as educational tools for teaching medical students to recognize the clinical features of acute schizophrenia.

YouTube was searched for videos purporting to show acute schizophrenia. Eligible videos were independently rated by two consultant psychiatrists on two separate occasions 22 days apart for diagnostic accuracy, psychopathology, and educational utility.

Videos (N=4,200) were assessed against predefined inclusion and exclusion criteria. The majority were not eligible for further analysis, mostly because they did not claim to show a patient with schizophrenia (74%) or contained duplicated content (11%). Of 35 videos that met the eligibility and adequacy criteria, only 12 accurately depicted acute schizophrenia. Accurate videos were characterized by persecutory delusions (83%), inappropriate affect (75%), and negative symptoms (83%). Despite the fact that 83% of accurate videos were deemed to have good educational utility compared with 15% of inaccurate videos, accurate and inaccurate videos had similar view counts (290,048 versus 186,124).

Conclusions:

Schizophrenia presentations on YouTube offer a distorted picture of the condition.

With a prevalence approaching 1%, schizophrenia is a leading contributor to overall world health burden ( 1 ). Understanding of schizophrenia by medical students is suboptimal, which may contribute to the stigmatization of patients ( 2 – 8 ). In recent years the Internet has been used increasingly as a primary source of information regarding medical conditions ( 3 , 9 ). The video sharing Web site YouTube ( www.youtube.com ) is the third most popular Web site on the Internet ( 10 ), with over a billion users worldwide ( 11 ). Although the Web site is used as a learning tool by the public, patients, and health care professionals ( 12 , 13 ), videos are uploaded by the online user community with no formal vetting of quality ( 13 ).

A number of studies have examined the quality and educational utility of YouTube videos relating to a wide variety of health conditions, with most concluding that YouTube videos are not adequate for use as educational tools in isolation ( 12 – 24 ). There has been no similar analysis of the accuracy or quality of YouTube videos relating to mental health conditions. This is an important omission, given that portrayals of mental illness in the media influence public understanding ( 25 , 26 ) and may contribute to the damaging stigma surrounding psychiatric diagnoses ( 8 ).

The purpose of this study was to analyze the accuracy of depictions of psychosis in the context of a diagnosis of schizophrenia (hereafter referred to as “acute schizophrenia”) on YouTube, with a specific focus on the depiction of the signs and symptoms of acute schizophreniform psychosis. An additional aim was to assess the educational utility of YouTube portrayals of acute schizophrenia, specifically for teaching medical students about the symptoms and signs of acute schizophrenia.

YouTube Search

YouTube was searched from March 1, 2015, to March 14, 2015, for all videos claiming to show footage of people exhibiting the signs and symptoms of acute schizophrenia. Search terms with good face validity were used to identify additional search terms by using Google Trends ( www.google.com/trends/ ) until no novel terms were generated. This search engine may be used to identify the most searched terms on the Internet. The final list of 21 search terms is as follows: “schizophrenia,” “schizophrenia experience,” “schizophrenia interview,” “schizophrenia patient,” “my schizophrenia,” “schizophrenia symptoms,” “untreated schizophrenia,” “schizophrenia case study,” “schizophrenia example,” “paranoid schizophrenia,” “catatonic schizophrenia,” “hebephrenic schizophrenia,” “undifferentiated schizophrenia,” “residual schizophrenia,” “simple schizophrenia,” “negative symptoms schizophrenia,” “positive symptoms schizophrenia,” “cognitive symptoms schizophrenia,” “thought disorder schizophrenia,” “hallucinations schizophrenia,” and “delusions schizophrenia.” YouTube searches were performed by using the default settings and were sorted by relevance. [A figure summarizing an outline of the study methodology is available in an online supplement to this article.]

A total of 2,820,272 videos were returned from all of the YouTube searches. For each YouTube search, the first 200 videos (ten pages) were assessed against predefined eligibility criteria (N=4,200). The search was restricted to the first ten pages, similar to the methodology of comparable studies, because it was deemed unlikely that medical students would continue searching after that point ( 14 , 22 ).

Eligibility Criteria

The main inclusion criterion was that a video claimed to show a presentation of acute schizophrenia. Exclusion criteria were videos that did not claim to show footage of a person exhibiting the signs and symptoms of acute schizophrenia, duplicated videos, non–English language videos, videos of children, videos with <10 seconds (s) of relevant footage, and performing arts videos made by students for school projects.

Eligible videos were defined as those meeting the inclusion criterion and not meeting any of the exclusion criteria. Within the sample of eligible videos, unique presentations of people with acute schizophrenia were defined as single cases for further analysis. If a single video contained more than one unique presentation of acute schizophrenia, each presentation was analyzed as a separate case. If unduplicated content of a single person with acute schizophrenia was shown in multiple videos, the presentations were analyzed as a single case.

Case Rating

Cases meeting eligibility criteria were independently assessed by two consultant psychiatrists (O-MT and AB) for probable psychiatric diagnosis, psychopathological content, and educational utility. All videos were watched on full-screen mode, such that raters were blinded to the video title, description, viewer comments, upload date, viewer ratings, and video author. Cases were rerated by both raters after 22 days.

Adequacy criteria and psychiatric rating.

Eligible cases were rated as to whether they contained sufficient information to make a probable diagnosis and to allow a rating of psychopathological content.

Options for psychiatric diagnosis rating were schizophrenia (any ICD-10 subtype), unspecified psychosis, nonpsychotic behavioral disturbance, mania with psychotic symptoms, mania without psychotic symptoms, factitious disorder, depressive episode, acute anxiety, and schizophrenia-like psychotic disorder due to psychoactive substance use. Raters could also indicate whether there was insufficient information to make a probable diagnosis, in which case the case would be deemed inadequate for further analysis.

Psychopathological content was assessed on 13 symptom domains of particular relevance to acute psychosis ( Table 1 ). For each symptom domain, raters could indicate whether the symptom or sign was present or absent or whether there was insufficient information in the video to provide a rating. A symptom or sign was deemed to be present if it was rated as being present by at least one rater. The symptom domains assessed overlap with the seven symptoms and signs that constitute the positive scale of the Positive and Negative Syndrome Scale (PANSS) for schizophrenia (delusions, conceptual disorganization, hallucinatory behavior, excitement, grandiosity, suspiciousness, and hostility) ( 27 ), which is a standard tool used in research for assessment of psychotic symptoms in schizophrenia.

a Psychopathology was assessed on 13 domains. These videos were considered by two independent raters to have sufficient information about an individual, or case, to make a probable diagnosis and to rate psychopathological content for at least two of the 13 domains. A case was considered to contain a symptom or sign if that symptom or sign was identified as present by at least one rater. Probable diagnosis was determined independently by two raters. Schizophrenia cases are those that received a diagnosis of schizophrenia by both raters. Cases of other probable diagnoses are those that received a diagnosis other than schizophrenia by both raters. Ten cases received a rating of schizophrenia by only one rater and are not analyzed further.

b Statistically significant after Bonferroni correction

TABLE 1. Signs and symptoms (domains) of schizophrenia contained in videos of 35 individuals purported to have a diagnosis of acute schizophrenia, by probable diagnosis a

Cases with insufficient information to make a probable diagnosis or to assess the presence or absence of symptoms for at least two of the 13 psychopathological domains were deemed to have inadequate content for further analysis (“inadequate cases”). Cases with sufficient information both to make a probable diagnosis and to assess the presence or absence of symptoms for at least two psychopathological domains were deemed to have adequate content for further analysis (“adequate cases”).

Educational utility.

Videos of adequate cases were further assessed for educational utility. The educational utility of the videos was defined pragmatically. For each adequate case, the raters answered a yes-or-no question, “Considering the quality and content of this video, would you consider using it in a medical student teaching session as an illustration of the signs and symptoms of acute psychosis in schizophrenia?” Videos receiving a “yes” response by both independent raters were considered to have good educational utility.

Original Video Features

Original video features used in further analyses included video duration, view counts, whether the video was made for medical education purposes (as stated in the video title or description), and the number of viewers who rated the video positively by using YouTube’s rating system (thumbs-up).

Statistical Analysis

For statistical analysis, adequate cases were grouped into those given a schizophrenia diagnosis by both raters or those given a diagnosis other than schizophrenia by both raters (cases that received a diagnosis of schizophrenia by only one rater were excluded from subgroup analysis). Differences in original video features and ratings by consultants between adequate and inadequate cases and between cases of schizophrenia and all other diagnoses were assessed by using independent-samples, two-tailed t tests (comparing means between groups) and Fisher’s exact test (comparing proportions between groups). Differences are deemed statistically significant for p values that are less than .05 after adjustment for the number of simultaneous statistical tests being performed on the sample (Bonferroni correction for multiple comparisons).

The comparison of original video features included three variables (view count, duration, and whether the video was originally made for medical education purposes), resulting in a significance threshold of p<.017. The comparison of consultant psychopathology ratings included 13 variables (persecutory delusions, grandiose delusions, nihilistic delusions, passivity phenomena, auditory-verbal hallucinations, visual hallucinations, formal thought disorder, flow-of-thought abnormality, mood disturbance [a domain encompassing one or more features, including anxiety, irritability, hostility, elation, and depression], inappropriate affect, bizarre behavior, negative symptoms, and cognitive symptoms), resulting in a significance threshold of p<.004.

Interrater and intrarater reliability was assessed by using Cohen’s kappa (κ) coefficient ( 28 ). Kappa values were interpreted according to criteria defined by Landis and Koch, with values from .00 to .20 indicating slight agreement; .21 to .40, fair agreement; .41 to .60, moderate agreement; .61–.80, substantial agreement; and .81–1.00, almost perfect agreement ( 28 ). Statistical analysis was conducted by using MatLab (MATLAB and Statistics Toolbox Release 2013b).

Video Properties

Of the initial 4,200 videos assessed, 55 videos met eligibility criteria. Videos were excluded because they did not claim to show footage of a person exhibiting the signs and symptoms of acute schizophrenia (N=3,106, 74%) or were duplicated videos (N=464, 11%), non–English language videos (N=125, 3%), videos of children (N=169, 4%), videos with <10 s of relevant footage (N=82, 2%), and performing arts videos (N=253, 6%).

The 55 videos varied widely in their view count (mean±SD=127,222±271,637 views; range 54–1,243,550), positive reviews (239±584 thumbs-up ratings; range 0–3,481), and duration of relevant footage (184.3±187.8 s; range 10–759 s).

Four eligible videos contained more than one unique case, and eight eligible videos contained unduplicated content of a single case, resulting in 58 unique cases. Thirty-five cases (60%) were deemed by both raters to meet adequacy criteria (κ=.346). Adequate cases were significantly longer than inadequate cases (227.3±203.4 s versus 83.9±120.8 s, p=.004) and had more views (193,962±330,569 versus 15,168±26,901, p=.013). There was no significant difference in the proportion of adequate and inadequate cases that were sourced from videos originally made for educational purposes (31% [N=11] versus 52% [N=12]).

The psychopathological content of adequate cases was largely nonspecific ( Table 1 ) . Thirty-seven percent (N=13) of the purported cases of acute schizophrenia did not portray even a single symptom or sign of the positive syndrome of schizophrenia (as defined by PANSS criteria [ 27 ], with agreement by both raters).

Diagnostic Accuracy

Of the 35 adequate cases, 12 (34%) were rated to have a probable diagnosis of schizophrenia by both raters, and 13 (37%) received diagnoses other than schizophrenia from both raters (κ=.444). The remaining ten cases received a diagnosis of schizophrenia from only one rater. All subsequent analysis was performed on the cases that received either a diagnosis of schizophrenia (N=12) or a diagnosis other than schizophrenia (N=13) from both raters.

Taking both consultant ratings into account, the prevalence of probable schizophrenia subtype diagnoses among schizophrenia cases was as follows: paranoid schizophrenia (59%), undifferentiated schizophrenia (13%), hebephrenic schizophrenia (8%), residual schizophrenia (4%), and unspecified schizophrenia (17%). Prevalence of probable diagnoses in the cases with diagnoses other than schizophrenia was as follows: unspecified psychosis (54%), nonpsychotic behavioral disturbance (23%), mania with psychotic symptoms (8%), factitious disorder (8%), depressive episode (4%), and schizophrenia-like psychotic disorder due to psychoactive substance use (4%). In total, 26 cases (74%) were consistent with a psychotic presentation (schizophrenia, mania with psychotic symptoms, drug-induced psychosis, or unspecified psychosis) by both raters (κ=.533).

There were no significant differences between the subgroups (schizophrenia and diagnosis other than schizophrenia) in length of video (209±124.2 s versus 299±287.7 s) or view counts (290,048±381,563 versus 186,124±366,200). Although a greater proportion of schizophrenia cases versus cases of other diagnoses were sourced from videos explicitly intended for medical education purposes (50% [N=6] versus 8% [N=1], p=.030), this difference did not remain significant at the significance threshold adopted for multiple comparisons (p<.017).

Psychopathology

Compared with cases with a diagnosis other than schizophrenia, schizophrenia cases had a significantly higher prevalence of persecutory delusions (83% [N=10] versus 15% [N=2], p=.001), inappropriate affect (75% [N=9] versus 8% [N=1], p=.001), and negative symptoms (83% [N=10] versus 15% [N=2], p=.001) ( Table 1 ) . Seventy-five percent (N=9) of schizophrenia cases presented at least one symptom or sign of the positive syndrome of schizophrenia, and 67% (N=8) presented multiple positive symptoms or signs (as defined by PANSS criteria [ 27 ]). No single psychopathological feature was able to significantly predict classification of schizophrenia versus cases of other diagnoses in a univariate logistic regression analysis.

Educational Utility

Of all adequate cases, 16 (46%) were deemed by both raters to have good educational utility (κ=.407). There was a significant difference between the proportions of cases of schizophrenia versus other diagnoses that were deemed to have good educational utility (83% [N=10] versus 15% [N=2], p=.001).

Intrarater Reliability

Importantly, intrarater reliability (day 1 versus 22) was substantial for both educational-utility (κ=.77) and diagnosis (κ=.76) ratings for adequate cases ( 28 ).

This study is the first to systematically assess the accuracy, psychopathological content, and educational quality of videos purporting to show acute schizophrenia on the video-sharing Web site YouTube. Our main findings were that eligible videos were largely inaccurate, containing psychopathological features not specific to schizophrenia; that only 21% of eligible cases were deemed to accurately represent acute schizophrenia; and that in the subset of cases that accurately depicted acute schizophrenia, the disorder was portrayed as a condition of persecutory delusions, inappropriate affect, and negative symptoms. Forty percent of eligible cases were deemed to contain inadequate information to make an assessment of psychopathological content, and in the subgroup that did permit an assessment of psychopathology, less than half of the cases were deemed to have good educational utility.

These findings are important for psychiatrists, given that the Internet has a vast amount of medical information that is easily accessible to medical students ( 9 , 13 ). Medical schools currently place increasing emphasis on self-directed learning, and many students turn to Web sites like YouTube as an alternative to textbooks ( 12 ). In addition to watching videos of clinical case presentations, students are likely to use YouTube for other educational resources, such as lectures and presentations. Analysis of these additional educational resources, as well as medical students’ Internet use patterns, is beyond the scope of this study and may warrant future investigation. Recent studies have warned that YouTube videos vary widely in their educational utility and medical accuracy in a number of clinical domains ( 12 – 24 ), yet no studies have assessed the quality of psychiatric content on the Web site.

Our study did not investigate how the quality and accuracy of YouTube videos affect understanding of schizophrenia among medical students or the public or how these effects may have a negative impact on patient experiences. Nevertheless, other work has highlighted that public sources of inaccurate information about psychiatric conditions may contribute to stigma and its negative effects on patients’ quality of life and treatment ( 8 ) and that portrayals of schizophrenia in popular media can influence public understanding of the condition ( 25 , 26 ). Recently it has been argued that many videos on YouTube that purport to relate to psychiatry are highly critical of the specialty ( 29 ). But more encouraging, it is also true that appropriately selected video footage of patients with schizophrenia may be helpful in improving understanding and reducing stigma among medical students ( 30 , 31 ).

A key strength of this study was the exhaustive nature of the YouTube search, resulting in 4,200 videos being considered for analysis against predefined inclusion and exclusion criteria. Moreover, videos were rated in a blinded manner by two independent expert raters on two occasions.

Our study had some key limitations. First, despite the exhaustive nature of our initial YouTube search, only a small number of videos met predefined inclusion and exclusion criteria, perhaps reflecting narrow eligibility criteria. The narrowness of the eligibility criteria, however, is a reflection of the fact that our study explicitly focused on videos depicting psychosis in the context of schizophrenia, rather than videos relating to schizophrenia more generally. Second, interrater agreement in the analysis of video adequacy and probable diagnosis was modest, likely due to the short duration of most case presentations (227.3 s and 83.9 s for adequate and inadequate cases, respectively). Third, although YouTube is the largest video-sharing Web site on the Internet, the fact is that whether our conclusions generalize to other similar Web sites remains an open question. Fourth, our study excluded videos of patients in remission. Consequently, it may be argued that the videos that we deemed eligible showed only the most severe cases and did not offer an optimistic or recovery-oriented picture of the disorder. Conversely, our exclusion criteria allowed us to exclude many irrelevant and inappropriately titled videos. Finally, our study did not examine to what extent YouTube videos affect the attitudes and understanding of viewers, although other studies provide evidence that similar videos can change attitudes about schizophrenia ( 30 , 31 ). The relationship between misrepresentations of mental illness on the Internet and public understanding of these conditions will be an important focus for future work.

Conclusions

Our study highlights that videos on YouTube that are labeled as showing schizophrenia are inaccurate and contain nonspecific psychopathology. This diagnostic confusion is unhelpful for medical students. Mental health professionals and medical schools should be aware of this source of inaccurate information when advising students and patients about sources of health information.

This article is based on work presented as a poster at the Royal College of Psychiatrists International Congress, Birmingham, United Kingdom, June 29–July 2, 2015. The work was awarded a commendation by the judging panel.

The authors report no financial relationships with commercial interests.

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• v.28(3); 2019 Nov

Language: English | French

Case Report of Childhood-Onset Psychosis in a Patient with a Known WNT10A Mutation

Alexandra o. kobza.

1 Department of Child and Adolescent Psychiatry, Children’s Hospital of Eastern Ontario, Ottawa, Ontario

Shuliweeh Alenezi

2 Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia

To report on a patient with childhood-onset psychosis at age 12 with a known WNT10A mutation.

Case report.

The patient is a 12-year-old male who presented with an acute onset of psychosis in the context of a known WNT10A mutation.

WNT genes have only been previously linked to schizophrenia on a theoretical basis. To our knowledge, this is the first case report of an association between a childhood-onset psychosis and a WNT10A mutation. We conclude that there is a possibility that WNT10A may be one of the many genes contributing to the development of childhood-onset schizophrenia.

Résumé

Faire rapport sur un patient chez qui la psychose est apparue à 12 ans et qui a une mutation connue du WNT10A.

Méthodes

Rapport de cas.

Résultats

Le patient est un garçon de 12 ans qui a présenté un début de psychose aiguë dans le contexte d’une mutation connue du gène WNT10A.

Les gènes WNT n’ont précédemment été liés qu’à la schizophrénie sur une base théorique. À notre connaissance, ceci est le premier rapport de cas d’une association entre une psychose apparue dans l’enfance et une mutation du WNT10A. Nous en concluons qu’il existe une possibilité que le WNT10A soit l’un des nombreux gènes qui contribuent au développement de la schizophrénie apparue dans l’enfance.

Introduction

Schizophrenia is one of the most disabling and economically catastrophic medical disorders; it contributes 13.4 million years of life lived with disability to burden of disease globally ( Charlson et al., 2018 ).

Childhood-onset schizophrenia is defined as beginning before the age of 13. Such an early presentation is exceedingly rare. A study in the United States of America estimated a prevalence of 0.04% ( McKenna, Gordon, & Rapoport, 1994 ; Rapoport & Gogtay, 2011 ); while another in Germany estimated 0.01% ( Kallmann & Roth, 1956 )no significant inter-group differences have been found either with respect to twin concordance rates or with respect to the schizophrenia rates for the parents (12.5% and 9.2%. This is in contrast with the overall prevalence of the disease, estimated to be about 1% worldwide. The pathogenesis of childhood-onset schizophrenia is not thought be much different from the adult-onset form of the disease; however, the illness has proven to be more severe and debilitating than the adult-onset type ( Ordóñez, Luscher, & Gogtay, 2016 ).

It has long been known that schizophrenia has a substantial genetic component; with heritability being estimated from ~65–80% ( Sullivan, Kendler, & Neale, 2003 ). Through the recent advent of Genome-Wide Association Studies (GWAS) over 100 different forms of DNA variation—including both SNPs (single nucleotide polymorphisms) and CNVs (copy number variants)—have been associated with schizophrenia ( Aberg et al., 2013 ; Ripke et al., 2013 , 2014 ; Shi et al., 2009 ; Stefansson et al., 2009 )a devastating psychiatric disorder, has a prevalence of 0.5–1%, with high heritability (80–85%; however, there are no confirmed causal mutations, nor families where schizophrenia segregates in a Mendelian fashion ( Harrison, 2015 ). Overall, GWAS has identified a large number of susceptibility loci each having a very small effect, meaning that schizophrenia has proven to be a highly complex, heterogeneous and polygenic disease ( Henriksen, Nordgaard, & Jansson, 2017 ). The WNT pathway has theoretically been thought to play a role in schizophrenia given its role in neuronal migration and programmed cell death during development, yet no WNT gene mutation has ever been associated with the development of schizophrenia ( Harrison, 2015 ; Panaccione et al., 2013 ). Epidemiologic and family studies looking at genetics in childhood-onset schizophrenia have been limited due to the low prevalence of this illness as described earlier. We report on a patient with a known WNT10A mutation who presented with psychosis at the age of 12. To our knowledge this is the first case of childhood-onset psychosis in a patient with a known WNT10A gene mutation.

Case Report

A 12-year-old male presented to our centre with a one-month history of odd beliefs and behaviour. He lived at home with his parents and ten-year-old sister. In the Emergency Room he began the interview by consistently repeating that he was “dead” and saying, “I don’t want to be here. I am not safe. I am drowning.” He tried to leave the room multiple times and required redirection. He was uncooperative, suspicious and guarded and his speech was often unintelligible. His thought content was consistent with paranoid delusions. No hallucinations were reported and the patient did not seem to be responding to any internal stimuli.

The patient was born post-term after an uncomplicated pregnancy except for antepartum fetal distress necessitating a C-section and concern for small birth weight. His mother was not on any medications during pregnancy and there was no exposure to alcohol, smoking, or drugs. Neonatal course was unremarkable except for jaundice requiring phototherapy. Motor milestones were normal, with walking at ten months, but the patient was drooling into his first year of life and had a language delay. He was found to have normal receptive language but considerable expressive language delay and articulation problems necessitating speech therapy from the age of two. At the time of presentation, he had a diagnosed reading disability and was in grade seven with an individualized education plan.

His past medical history was significant for asthma, eosinophilic esophagitis (well controlled for years with steroid medication), food protein enteropathy, and multiple IgE-mediated food allergies. He was evaluated by the Genetics Team for abnormal dentition in addition to developmental delay, failure to thrive, and feeding difficulties and was found to have two heterozygous mutations in WNT10A in trans, one of which is associated with tooth abnormalities and possibly hypohydrosis (variant p.F228I, Coding DNA c.682 T>A) and one of which is a variant of uncertain significance (variant p.G165R, Coding DNA c.493 G>A). His past psychiatric history was significant for being under the care of a community psychiatrist for generalized anxiety and social anxiety for the last two months.

His medications on presentation were: lansoprazole, inhaled budesonide (1mg/2mL inhalation suspension taken every three days), mometasone nasal spray, ciclesonide nasal spray, salbutamol and Co-enzyme Q10. Parents denied any substance use.

Parents had noticed a cognitive decline over the last three months. They described a more disrupted sleep cycle, and an increase in uncooperative behaviour that teachers were calling defiance but the parents felt was more consistent with confusion. For example, the patient would be walking in a familiar place and all of a sudden look around completely lost to his surroundings.

In the last month, he had started to voice a number of paranoid thoughts: the presence of hidden cameras, teachers putting ‘body parts’ in the closets, and snipers on the roof of the house. His parents also noticed new strange behaviours including waking up in the middle of the night screaming and hitting his mother and himself. At other times he seemed disconnected and parents found his emotional expression difficult to read. The night the family presented to the Emergency Room, the patient’s mother found him awake just after midnight packing a suitcase full of clothing and a kitchen knife. He was insisting on leaving the house (inappropriately dressed for the winter weather) because he felt unsafe.

Family history was significant for one episode of psychosis in the maternal uncle which had resolved with medication.

As this was a first presentation of childhood psychosis, our group adhered to the Canadian Schizophrenia Guidelines ( Pringsheim & Addington, 2017 ) and the NICE (National Institute for Health and Care Excellence) Psychosis and Schizophrenia in Children and Young People Guidelines ( National Institite for Health and Care Excellence, 2016 ) for a comprehensive diagnostic work-up. There were no significant abnormal findings found on blood work as seen in Table 1 or on brain MRI and EEG. The patient did have a slight hyperkalemia on presentation (K + 5.2) that normalized without treatment on subsequent bloodwork.

Laboratory values at presentation

All values are reported as the patient’s value (reference range)

Values outside of the normal range have been bolded .

With a negative neurological exam, cerebral spinal fluid testing (for toxicology and anti-NMDA receptor antibodies) was not pursued. The patient was started on Olanzapine and has achieved partial improvement one year later.

We described a patient, with a known WNT10A mutation, who presented with psychosis at age 12. Our assessment included a full psychiatric, medical, psychological, psychosocial, and developmental investigation. Given that our medical work-up was negative, our diagnosis of exclusion was that this was indeed a first presentation of psychosis of psychiatric origin. Possible etiological factors of this early onset psychosis include hypoxia at the time of birth and the WNT10A mutation. Although oral steroid medications are well known to cause neuropsychiatric side effects including psychosis ( Dubovsky, Arvikar, Stern, & Axelrod, 2012 ) these side effects have not been associated with inhaled corticosteroid use ( Toogood, 1998 ). Therefore, steroids were ruled out as the cause in our patient given that he had been maintained on a stable dose of inhaled budesonide over several years. The patient’s mild hyperkalemia on presentation that normalized without treatment was also ruled out as a potential cause as hyperkalemia is not known to have psychotic manifestations and there was no improvement in our patient’s behaviour upon normalization ( Shrimanker & Bhattarai, 2019 ).

Historically, mutations in the WNT10A gene have been associated with three syndromes: Tooth agenesis, Schopf-Schulz-Passarge syndrome, and Odonto-onycho-dermal dysplasia ( National Institute of Health, 2018 ). Classically, the WNT10A gene has not been associated with childhood-onset schizophrenia.

To our knowledge this is the first case of childhood-onset psychosis in a patient with a known WNT10A gene mutation. It is important to recognize that the specific mutations seen in our patient (variant p.F228I, Coding DNA c.682 T>A and variant p.G165R, Coding DNA c.493 G>A) have a frequency of 0.00599 and 0.00220 respectively in the population and there have been no cases thus far reporting psychosis (National Center for Biotechnology Information, n.d.-a, n.d.-b). Further, databases of human genetic variation demonstrate that there are individuals who are homozygous for these particular mutations, and they have not been reported to have psychosis (National Center for Biotechnology Information, n.d.-a, n.d.-b). In addition, the WNT10A gene has been shown to have a lack of intolerance to variation (pLI=0.000) meaning that a high amount of genetic disturbance is needed in order to produce a different phenotype (gnomAD browser, n.d.).

Therefore, we would like to emphasize that our finding does not imply causality. Rather, we are reporting on an association between a WNT10A gene mutation and childhood-onset psychosis. It is possible that our patient has an otherwise high genetic risk score for the development of childhood-onset schizophrenia. However, given the theoretical link between the WNT pathway and schizophrenia with its role in neuronal migration and programmed cell death during development, we cannot discount that these heterogeneous mutations in the WNT10A gene in our patient may be contributing to his presentation of childhood-onset psychosis. We conclude that there is a possibility that WNT10A may be one of the many genes contributing to the development of childhood-onset schizophrenia. Further research is needed to examine if there is truly a causal relationship and whether it can be attributed to one particular mutation. Given how rare childhood-onset schizophrenia is, future case reports and case series may provide insight into answering this question.

Acknowledgements / Conflicts of Interest

The authors have no known conflicts of interest in this case presentation.

Witnessed consent was obtained on March 15 th 2018 to present this case for academic purposes.

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