Schizophrenia

Background

A heterogeneous clinical syndrome characterized by a constellation of signs and symptoms associated with impaired occupational or social functioning involving a range of cognitive, behavioral, and emotional dysfunctions

Clinical Features

• A. Two (or more) of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
  • 1. Delusions
  • 2. Hallucinations
  • 3. Disorganized speech (e.g., frequent derailment or incoherence)
  • 4. Grossly disorganized or catatonic behavior
  • 5. Negative symptoms (i.e., diminished emotional expression or avolition)
• B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
• C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Cri­terion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
• D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1 ) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
• E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
• F. If there is a history of autism spectrum disorder or a communication disorder of child­hood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated)

Differential Diagnosis

Psychiatric Disorders with Psychotic Symptoms

• Acute psychosis
• Schizophrenia
• Schizoaffective disorder
• Delusional disorder
• Schizotypal personality disorder
• Schizoid personality disorder
• Bipolar disorder with psychotic features

Organic Causes

• Meningitis
• Encephalitis
• Thyroid (Main)
• Toxin ingestion
• Medication effect

Nonorganic Causes

• Mood Disorder

Evaluation

Rule out other organic causes including substance abuse, medication effect or other medical conditions. Consider emergency psychiatric evaluation in addition to medical evaluation.

General ED Psychiatric Workup

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)

Management

General ED Psychiatric Management

• Non-pharmacologic
  • Verbal de-escalation
  • Offer comforting items: blanket, meal, pillow, etc
  • Quiet room
  • Physical restraints (should administer medications if restraints used, as decreases restraint time)
• Pharmacologic: Goal is to calm patient without oversedation
  • No history of psychosis
    • Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
    • Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
  • Known or suspected underlying psychotic illness
    • Continue treatment with previous antipsychotic or
    • PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
    • IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
    • (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)

Disposition

• Home with outpatient psychiatric services if stable, versus inpatient psychiatric admission if unstable

See Also

• Acute psychosis
• Schizophreniform disorder
• Meningitis
• Encephalitis
• Schizoaffective disorder

References

Authors

Matin Shah, Aaron Snyder, Ross Donaldson, Daniel Ostermayer, Neil Young