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
  • Suicide risk is higher in[1]:
    • Males < 30 years of age
    • Earlier in course of schizophrenia
    • Higher IQ, higher achiever as teen or young adult
    • More insight and higher executive functioning
    • Presence of depression, hopelessness, anxiety, insomnia, etc
    • Substance abuse, alcohol
    • Family history of suicide
    • Prior attempt
  • Be wary of diagnostic overshadowing (e.g. erroneously attributing symptoms to psychiatric disorder when etiology is in fact organic)
    • Patients with schizophrenia have significantly higher rates of stroke[2], CAD[3], DM[4], cancer[5], HIV, HCV[6]
    • All cause mortality rate is 200-250% higher for patients with schizophrenia than general population[7]

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):[8]
    • 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

Organic Causes

Evaluation
  • Rule out other organic causes including substance abuse, medication effect or other medical conditions
  • Consider whether acute medical condition may be exacerbating psych symptoms
  • Consider emergency psychiatric evaluation in addition to medical evaluation.

General ED Psychiatric Workup

Management

General ED Psychiatric Management

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

See Also

References
  1. K Hor and M Taylor. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol. 2010 Nov; 24(4_supplement): 81–90.
  2. Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333
  3. Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333.
  4. Mai Q, D’Arcy C, Holman J, Sanfilippo FM, Emery JD, et al. (2011) Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 9: 118.
  5. https://www.cdc.gov/mentalhealth/data_stats/mental-illness.htm
  6. Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People with Learning Disabilities and/or Mental Health Problems. Disability Rights Commission. London.
  7. https://www.who.int/mental_health/management/info_sheet.pdf
  8. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
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