Schizophrenia is one of the most common major mental diseases. Since it is a chronic illness, the prognosis involves multiple relapses and admissions, with a proportion of patients relying on long-term institutional care. The onset of schizophrenia in a majority of patients occurs in younger adults. Since genetics is a strong predisposing risk factor, the calculated risk of the offspring having schizophrenia when both parents also have schizophrenia is close to 37% [8]. When one parent has schizophrenia, the risk is closer to 14% [8]. The current hypothesis states that most cases of schizophrenia result from polygenic gene interaction and possible extrinsic factors including drug abuse and trauma. Studies have shown that specific candidate genes associated with schizophrenia include neuregulin, dysbindin, proline dehydrogenase, and catechol-O-methyltransferase [8]. Guanylate-binding protein 2 (GBP2) is another gene that was replicated and upregulated in five studies assessing gene expression in schizophrenia [9]. In our case, the patient was adopted, hence no conclusions could be made about her genetic predisposition to schizophrenia.

Our patient presented with symptoms that included delusions, hallucinations, disorganized speech/behavior, unusual thought processes, tangential thoughts, flight of ideas, lack of eye contact, distractibility, talkativeness, and neologism. As defined in the introduction, schizophrenia is a chronic mental illness that affects daily functioning. The symptoms can present as positive (hallucinations, delusions, disorganized speech/behavior), and negative (anhedonia, blunted affect, apathy). According to DSM-5, a patient can be diagnosed with schizophrenia if he/she has two or more of the active symptoms listed above for at least one month, with one being a positive symptom, lasting for over six months. Our patient exhibited these symptoms and their onset must have been at least six months before the diagnosis of schizophrenia. Impairment in one of the major areas of functioning must also be present. This was displayed through our patient's declining school performance, self-care, and interpersonal relations. To help reduce her current symptoms, she was started on Abilify (aripiprazole) 30 mg PO daily (started initially and then discontinued after two weeks), LAIs Aristada (aripiprazole lauroxil) 1064 mg and Aristada Initio (Aripiprazole lauroxil) 675 mg IM, and Depakote (valproate) 500 mg. Abilify (aripiprazole) is an atypical antipsychotic that acts as a dopamine D2 receptor (D2) and serotonin 5-HT1A receptor (5HT1A) partial agonist, and serotonin 5-HT2A receptor (5HT2A) antagonist [10]. A second-generation antipsychotic, aripiprazole blocks dopamine and serotonin receptors but has fewer extrapyramidal side effects (acute dystonia, akathisia, parkinsonism). Aristada, containing aripiprazole lauroxil, is a long-acting injection of the atypical antipsychotic agent. Our patient received Aristada (aripiprazole lauroxil) 1064 and 675 mg for nearly two months. She was initially started on oral Abilify (aripiprazole) for two weeks before being given IM Aristada (aripiprazole lauroxil) to establish medication tolerance. Depakote (valproate) was added a few weeks post-IM medication due to ongoing psychosis and manic episodes. Depakote (valproate) is a drug used to treat mood episodes in bipolar disorder. Its mechanism of action is unknown, but it is believed to increase the level of gamma-aminobutyric acid (GABA) in the central nervous system (CNS) and inhibit voltage-gated Na channels [11]. These medications were added progressively. We continued to monitor the improvement in the patient and also track for side effects from antipsychotic/mood stabilizer medications such as extrapyramidal symptoms.

Our patient refused medication initially. As time progressed, she slowly agreed to take the medication and eventually stated that she believed she was feeling better. Although she continued to display signs of disorganized speech/behavior during weekly updates, it was evident that the patient was becoming more cognizant of her behavior, her talkativeness, and her delusion of being pregnant that she carried consistently throughout her stay at the center. Upon further analysis of the patient’s progression, it was determined that although she was initially evaluated and diagnosed with schizophrenia, her symptoms of mania such as excessive talkativeness and flight of ideas can also indicate a diagnosis of schizoaffective disorder. Schizoaffective disorder, although similar to schizophrenia, also includes mood disorder. According to DSM-5, schizoaffective disorder is defined as a major mood episode (bipolar type-mania or depressive type) along with all the criteria for schizophrenia. However, the symptoms of schizophrenia (hallucinations, delusion) should be present for ≥2 weeks without any major mood episode [12].

Substance abuse in patients with schizophrenia has been studied extensively. Studies have shown cannabis abuse as a stressor that induced a relapse of psychosis in patients with schizophrenia [13]. People at risk of schizophrenia are more vulnerable to substance abuse due to multiple factors ranging from genetics to changes in their mesolimbic brain activity involving the reward pathway. Substance abuse has been correlated to poor outcomes for patients through low treatment compliance. In a study by Arscnault et al. [13], regular cannabis use in the younger adolescent population had an increased risk of schizophrenia in adulthood. In a longitudinal study in New Zealand, participants aged 15 to 18 were assessed for regular cannabis use. Results portrayed that participants who utilized cannabis in that age group showcased greater symptoms of schizophrenia at age 26 compared to those who did not use it. Research based on 1055 participants showed that cannabis users had a 1.6 to 1.8 times greater chance of exhibiting psychotic symptoms [13]. This idea of substance use and its link to schizophrenia is vital in the case of our patient since she began to engage in tetrahydrocannabinol (THC) during her adolescence. Her previous and recent medical reports revealed urine analysis positive for THC. We are unsure how long the patient may have been using cannabis and in what quantity as these are important factors in understanding the relationship between the drug's impact and her mental health and recovery. 

Due to the circumstances of the patient's disappearance and the suspicious identity of the perpetrator from the initial police encounter, the patient was suspected of being a victim of human sex trafficking. In the following portion of the discussion, we will discuss pseudocyesis and the Stockholm syndrome in relation to the patient and how they can be probable factors to consider in terms of human trafficking. At the time of the patient's arrival at the center, she had had no contact with her family for four years and was reported missing in her home state. She was noted to be hypersexual, asking for male escorts to be delivered to the center and preoccupied with the notion of sex. She also kept mentioning how she was pregnant and insisted on repetitive pregnancy testing. This condition is known as pseudocyesis. Multiple studies have suggested that biological factors are important in pseudocyesis development. Neuroendocrine changes or disturbances have been recognized as factors that play a role in its development. Disturbances in the hypothalamic-pituitary-ovarian axis, although not necessarily unique to pseudocyesis, are commonly seen in its pathology [14]. Studies examining neuroendocrine factors in pseudocyesis have suggested that women displaying this condition might encounter enhanced nervous system activity or CNS impairment. In addition, a lack of dopamine is frequently observed in pseudocyesis. Schizophrenia contributes to notable dopamine hypo-activity in various regions of the brain. Dopamine in the CNS increases the possibility of some neurochemical relationship between schizophrenia and pseudocyesis. As per the etiology of our patient’s pseudocyesis, there are many theories as to its exact origin. It could be related to sexual trauma she might have experienced as a possible sex trafficking victim or due to her schizophrenia diagnosis. Regardless, the treatment remains the same, a pregnancy test and an ultrasound which would confirm absence of fetal heartbeat. The patient was ordered numerous pregnancy tests during her time at the center which were all negative and after two weeks of treatment with antipsychotic medications, she began to realize that she was having delusions that she was pregnant, perhaps indicating an improvement in her mental status. 

With continued analysis of the patient, it was probable that she was a human trafficking victim as mentioned above. Whenever the patient was asked about her past residence she refused to make eye contact, became anxious, and made an effort to dismiss the subject. She was more willing to talk about the matter in the third person where she then mentioned that there was drug paraphernalia in the house and that she was not allowed to leave the house. She stated that she couldn’t talk much about her living conditions for the past four years as she was “not allowed to and has boundaries.” These signs and symptoms may be indicative of Stockholm syndrome, which includes affection for captors and empathy for their causes and objectives combined with animosity towards law enforcement or authorities, which is considered a coping mechanism for a captive or abusive situation [15]. People with Stockholm syndrome tend to form a psychological bond with their captors. These individuals also tend to empathize, connect, and identify with them. There is still a question about why this syndrome evolves in some captives but not with others. One proposition implies that this condition might be an example of a survival mechanism that was passed down from our ancestors where the threat of capture or death by alternative groups was typical and forming bonds with the captors could augment their chances of survival [15]. A different theory suggests that the intense emotional atmosphere and psychological climate of captivity or abuse can guide individuals to cultivate feelings of compassion for their abuser, particularly if they are exposed to kindness with time [15]. Victims might fine-tune their emotions to line up with their abuser, believing that cooperation and support rather than opposition could improve their safety [15]. When not harmed, victims might feel a sense of gratitude and even perceive their abuser as being compassionate [15]. 

It is crucial to debunk the myth that associates schizophrenia with violence. The reality is that most individuals with schizophrenia are not violent, and the stereotype perpetuated by media sensationalism is both misleading and harmful. Research proposes that around 10% to 15% of patients with schizophrenia display violent behavior, meaning anywhere from 85% to 90% do not [4]. Individuals with schizophrenia living in the community experience victimization rates that are 65 to 130% higher than the general population [16]. Particularly, the rate of these individuals being victims of violence is 75 to 120% greater than the general public [16]. The principal determinants of this heightened risk include those with more acute symptoms and elevated levels of substance use, with the severity of symptoms being the most crucial factor [16]. The fact that people with schizophrenia are more likely to be victims of violence than perpetrators underscores the need for greater empathy and support. Their heightened vulnerability can be attributed to several factors, including cognitive impairment and social isolation [16]. Tackling these issues involves not only advancing mental health care and support systems but also aiming to lessen stigma and discrimination [16]. Generating accurate and compassionate portrayals of mental health conditions in the media and cultivating awareness within communities can help transform perceptions and better the lives of those affected. The findings mentioned above highlight a crucial challenge for policymakers and service providers regarding patients with schizophrenia who face an increased risk of being harmed in the community compared to the risk they pose others. To address this issue, there needs to be an improved collaboration between the mental health sector and the law enforcement agencies. Police officers should gain specialized training and education about mental illness in order to handle such interactions with sensitivity and understanding [16]. In addition, integrating community-based crisis assistance from trained mental health professionals can improve responses to individuals in mental health crises and better protect those who are vulnerable. Also, early detection of these individuals who are deemed vulnerable can help prevent further detrimental effects to the prognosis of their mental health status due to stressors and trauma, ultimately disrupting this vicious cycle.