Hospital Medicine

Schizophrenia

I. What every physician needs to know.

Schizophrenia is a common mental illness that is typically characterized by positive symptoms such as hallucinations or delusions, disorganized speech; and negative symptoms such as a flat affect or poverty of speech, and impairments in cognition including attention, memory and executive functions. Patients with a first onset of psychosis may frequently present for medical care.

II. Diagnostic Confirmation: Are you sure your patient has schizophrenia?

In order to meet DSM IV criteria for schizophrenia, two or more of the following symptoms must be present a significant portion of time during a one-month period (unless being treated): delusions, hallucinations, disorganized speech, disorganized behavior, catatonic behavior or negative symptoms such as flat affect, poverty of speech or decreased executive functioning. In addition to the presence of the symptoms above, there must also be at least six months of social or occupational dysfunction.

The differential diagnosis includes: schizophreniform disorder, schizoaffective disorder, bipolar disorder, major depression with psychotic features, and substance-induced psychotic disorders. Less common diagnoses include encephalitis, delirium, Wilson’s disease, and brain tumor.

A. History Part I: Pattern Recognition:

Key features of schizophrenia are auditory hallucinations and delusions. A typical patient in the midst of an acute psychotic episode or a relapse may include an dishelved agitated patient responding to internal stimuli.

B. History Part 2: Prevalence:

Approximately 1% of the US population suffers from schizophrenia. The disease typically manifests itself in the late teens and early twenties although it can occur at any age.

C. History Part 3: Competing diagnoses that can mimic schizophrenia.

The differential diagnosis includes other psychiatric illness including schizophreniform disorder, schizoaffective disorder, bipolar disorder, major depression with psychotic features, and substance-induced psychotic disorders. Less common diagnoses include encephalitis, delirium, Wilson’s disease and brain tumor.

E. What diagnostic tests should be performed?

There is no diagnostic study for schizophrenia. Diagnostic studies are primarily to rule out other diagnoses and should include basic chemistries, complete blood count, thyroid function studies, urinalysis, and urine drug screen. Brain imaging may be considered for patients with concurrent neurological symptoms. Additional testing, such as electroencephalogram (EEG), lumbar puncture or urine copper studies, should be based on initial assessment.

III. Default Management.

Immediate management of acute psychosis should focus on safety and stabilization. Patients can be started initially on short-acting anti-psychotics. Short-acting intramuscular (IM) injectable formulations such as haloperidol, olanzapine, aripiprazole and ziprasidone. Olanzapine IM (5-10mg) is a good first line agent. Haloperidol IM (2-10mg) is also a good initial choice, and should be given with benztropine or diphenhydramine to reduce the risk of dystonias or other extrapyramidal symptoms. Initiation of maintenance medications is often done in consultation with a psychiatrist.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

Most antipsychotic treatment can be initiated prior to labs. Clonazapine requires an initial CBC and frequent monitoring due to its association with agranulocytosis. Because of its risks, clonazapine is typically not a first-line agent.

D. Long-term management.

Patients with a diagnosis of schizophrenia on maintenance medication should be counseled about tobacco cessation, and offered pharmacologic therapy to assist. In addition, patients on antitypical antipsychotics should also have a fasting lipid profile and be screened for diabetes.

Cardiovascular disease is a leading cause of death for people with schizophrenia. This is likely due to a combination of poor preventative care, high rates of tobacco use and obesity and glucose intolerance from medication. As a result of a sedentary lifestyle and the metabolic effects of the atypical anti-psychotics, patients with schizophrenia are often obese and have impaired glucose tolerance.

K. Dementia or Psychiatric Illness/Treatment

Suicide is a leading cause of death for people with schizophrenia. There may also be a high rate of concomittent substance abuse disorders.

V. Transitions of Care

A. Sign-out considerations While Hospitalized.

Sign-out considerations should include the patient’s list of PRN medications for acute agitation or psychosis as well as the patient’s current mental status: are they actively delusional, agitated, violent, or catatonic? It should also include whether the patient is considered competent and is able to consent for medical procedures or sign-out against medical advice. If the patient is not deemed able to consent for themselves, then the patient designated medical decision-maker or court appointed designee should also be listed on the sign-out.

B. Anticipated Length of Stay.

Length of stay depends on the presenting complaint. For a patient presenting with a first psychotic episode, they may only have a short stay until alternative medical diagnoses are excluded and they are medically cleared for to transfer to an inpatient psychiatric facility.

D. Arranging for Clinic Follow-up

Patients should be discharged to a psychiatric unit or have close follow-up with a psychiatrist within two weeks of discharge.

VI. Patient Safety and Quality Measures

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Patients and family members should be counseled about medication side effects. It should also be stressed that this condition is chronic and medications should be continued even when the patient feels well.

What's the evidence?

Andreasen, NC. "Symptoms, signs, and diagnosis of schizophrenia". Lancet. vol. 346. 1995. pp. 477-81.

Buchanan, RW, Kreyenbuhl, J, Kelly, DL, Noel, JM, Boggs, DL, Fischer, BA, Himelhoch, S, Fang, B, Peterson, E, Aquino, PR, Keller, W. "The 2009 Schizophrenia PORT Psychopharmacological Treatment Recommendations and Summary Statements". Schizophrenia Bulletin. vol. 36. 2009. pp. 71-93.

Goff, DC, Cather, C, Evins, AE, Henderson, DC, Freudenreich, O, Copeland, PM, Bierer, M, Duckworth, K, Sacks, FM. "Medical morbidity and mortality in schizophrenia: guidelines for psychiatrists". J Clin Psychiatry. vol. 66. 2005. pp. 183-94.

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