Clinical Case 5 of 15 · ~721 words
Clinical Case No. 5. A First Psychotic Episode in a Young Adult
Changes before the first contact
Raj is 22. He lives in Surrey with his mother and older sister, attends college and works part-time in an electronics shop. The latest semester begins with missed classes. His family attributes this to gaming at night; Raj says the instructors deliberately make assignments ambiguous. He increasingly checks the window and tapes over his laptop camera, then tells his sister that classmates are sending comments about his thoughts through his phone.
Over several weeks, sleep decreases, hygiene deteriorates and voices begin discussing him. Frightened, Raj mostly stays at home. One evening, he refuses food because he believes it has been switched. His sister helps him reach emergency care.
The initial record describes a psychotic syndrome with persecutory delusions, auditory hallucinations and functional decline. Assessment clarifies duration, earlier development, mood episodes and physical signs. Raj reports regular high-potency cannabis use; its role will be assessed through timing and the subsequent course after cessation.
In the department, Raj is oriented, attention is broadly sustained and consciousness does not fluctuate. There is no fever, new headache, seizure or focal neurological symptom. Basic investigations, substance use history and examination guide further work; clinical indications determine neuroimaging and specialized tests. Continuing observation is also needed to assess risk, nutrition and his ability to agree to treatment.
Acute treatment and early intervention
After several discussions, Raj agrees to a brief voluntary admission. He is offered risperidone at a low initial dose with gradual titration. They discuss drowsiness, motor adverse effects, prolactin and metabolic changes. Weight, blood pressure, glucose and lipid measures are recorded before treatment. These provide a baseline when, a month later, the patient says he feels "different."
Response to the first antipsychotic is assessed over an adequate course while actual use and tolerability are checked. With a partial response, the team clarifies these factors before changing medication. [124]
Contact with Fraser Health Early Psychosis Intervention is established before discharge. The program accepts people aged 13 to 30 with a first psychotic episode, including family referrals, and provides care for up to three years. Assessment also covers co-occurring substance use. [4]
The first outpatient contact occurs soon after discharge. Raj knows his coordinator's name, and his sister has her contact details. The discharge summary records symptoms, medication, risks, Raj's greatest fears and ways of building trust.
Clarifying the diagnosis
The voices become less frequent; the belief that he is being watched recedes more slowly. Raj stops cannabis and restores sleep. Psychotic symptoms persist beyond intoxication; the overall duration, functional decline and absence of a dominant mood episode later allow the diagnosis to be clarified as schizophrenia.
His mother asks about returning to education. The psychiatrist discusses retained abilities, attention difficulties and gradual increases in workload. Raj's main concern is confidentiality. Together, they decide what he is willing to share with the college to obtain support.
Several months later, akathisia develops. Raj describes being unable to sit still; his sister interprets it as renewed agitation. Subjective inner tension, the need to move and examination help identify the adverse effect. The dose is reviewed, and later they agree to switch antipsychotics while monitoring psychotic symptoms.
Education, family and continuing support
An occupational therapist helps rebuild a daily schedule. Raj returns to one course; attention, stamina and pace are assessed through actual classes. Another course will be planned once he has adjusted to this workload.
Family meetings address early changes in sleep, tension and suspiciousness. His mother learns to respond to his fear calmly and briefly. Raj, his sister and the coordinator share responsibility for arranging appointments and agree on what information can be given to the family.
A year later, Raj studies part-time and works several shifts a week. Negative symptoms and cognitive difficulties still limit his pace. Appointments address the antipsychotic, sexual adverse effects, physical activity, relationships and contact with friends.
They separately consider a long-acting injectable formulation: visit frequency, convenience and Raj's preferences. Any reduction in maintenance treatment will require assessment of the previous course and relapse risk, with closer follow-up.
Preparation for transition after the three-year program begins early. Together with Raj and the psychiatrist, the coordinator will identify the necessary level of continuing support and the receiving team. [4]