Schizophrenia
A group of psychotic disorders characterized by disturbances in thought, perception, affect, behavior, and communication that last longer than 6 months.
Symptoms. For a material part of at least one month (or less, if effectively treated) the patient has had 2 or more of:
Delusions (only one symptom is required if a delusion is bizarre, such as being abducted in a space ship from the sun)
Duration. For at least 6 continuous months the patient has shown some evidence of the disorder. At least one month must include the symptoms of frank psychosis mentioned above. During the balance of this time (either as a prodrome or residual of the illness), the patient must show either or both:
Dysfunction. For much of this time, the disorder has materially impaired the patient's ability to work, study, socialize or provide self-care.
Mood exclusions. Mood and Schizoaffective Disorders have been ruled out, because the duration of any depressive or manic episodes that have occurred during the psychotic phase has been brief.
Other exclusions. This disorder is not directly caused by a general medical condition or the use of substances, including prescription medications.
Developmental Disorder exclusion. If the patient has a history of any Pervasive Developmental Disorder (such as Autistic Disorder), only diagnose Schizophrenia if prominent hallucinations or delusions are also present for a month or more (less, if treated).
After at least 1 year as passed since onset, classify the course of psychosis. Until a year has passed, you cannot assign any of these course specifiers.
Continuous. There has been no remission of "A" symptoms (first bullet). If negative symptoms stand out, you can also add "With Prominent Negative Symptoms."
Episodic With Interepisode Residual Symptoms. During episodes, "A" criteria are met. Between episodes the patient has clinically important residual symptoms. If negative symptoms stand out, you can also add "With Prominent Negative Symptoms."
Episodic With No Interepisode Residual Symptoms. During episodes, "A" criteria are met. Between episodes the patient has remissions with no clinically important symptoms.
Single Episode in Partial Remission. There has been one episode during which "A" criteria are met. Now there are some clinically important residual symptoms. If negative symptoms stand out, you can also add "With Prominent Negative Symptoms."
Single Episode in Full Remission. No clinically important symptoms remain.
Other or Unspecified Pattern.
Clinical Types
Paranoid type
The patient meets the basic criteria for Schizophrenia.
The patient is preoccupied with delusions or frequent auditory hallucinations.
None of these symptoms is prominent:
Disorganized speech
Disorganized behavior
Inappropriate or flat affect
Catatonic behaviorAll of these symptoms are prominent:
Disorganized behavior
Disorganized speech
Affect that is flat or inappropriateThe patient does not fulfill criteria for Catatonic Schizophrenia
At least 2 catatonic symptoms predominate:
Stupor or motor immobility (catalepsy or waxy flexibility)
Hyperactivity that has no apparent purpose and is not influenced by external stimuli
Mutism or marked negativism
Peculiar behavior such as posturing, stereotypes, mannerisms or grimacing
Echolalia or echopraxia
The patient does not meet criteria for Paranoid, Disorganized, or Catatonic types.
The patient at one time met criteria for Catatonic, Disorganized, Paranoid or Undifferentiated Schizophrenia.The patient no longer has pronounced catatonic behavior, delusions, hallucinations or disorganized speech or behavior.
The patient is still ill, as indicated by either:
1) Negative symptoms such as flattened affect, reduced speech output or lack of volition, or
2) An attenuated form of at least 2 characteristic symptoms of schizophrenia, such as odd beliefs (related to delusions), distorted perceptions or illusions (hallucinations), odd speech (disorganized speech) or peculiarities of behavior (disorganized behavior).
Associated FeaturesLearning Problem
Hypoactivity
Psychosis
Euphoric Mood
Depressed Mood
Somatic or Sexual Dysfunction
Hyperactivity
Guilt or Obsession
Sexually Deviant Behavior
Odd/Eccentric or Suspicious Personality
Anxious or Fearful or Dependent Personality
Dramatic or Erratic or Antisocial PersonalityDifferential Diagnosis:
Some disorders have similar or even the same symptom. The clinician, therefore, in his/her diagnostic attempt has to differentiate against the following disorders which he/she needs to rule out to establish a precise diagnosis.Psychotic Disorder Due to a General Medical Condition, delirium, or dementia;
Substance-Induced Psychotic Disorder;
Substance-Induced Delirium;
Substance-Induced Persisting Dementia;
Substance-Related Disorders;
Mood Disorder With Psychotic Features;
Schizoaffective Disorder;
Depressive Disorder Not Otherwise Specified;
Bipolar Disorder Not Otherwise Specified;
Mood Disorder With Catatonic Features;
Schizophreniform Disorder;
Brief Psychotic Disorder;
Delusional Disorder;
Psychotic Disorder Not Otherwise Specified;
Pervasive Developmental Disorders (e.g., Autistic Disorder);
Childhood presentations combining disorganized speech (from a Communication Disorder) and disorganized behavior (from Attention-Deficit/ Hyperactivity Disorder);
Schizotypal Disorder;
Schizoid Personality Disorder;
Paranoid Personality Disorder.Cause:
The cause of schizophrenia is unknown and schizophrenia cannot be cured, but it can be treated. Predictors for good treatment outcomes are normal adjustment before the onset of the disease and little or no family history of schizophrenia, confusion, paranoia, depression, or catatonic behavior. Some predictors for a poor outcome are: earlier age of onset, a family history of the illness, withdrawal, apathy, and prior history of a thought disorder. There are various theories to explain the development of this disorder. Genetic factors may play a role, as close relatives of a person with schizophrenia are more likely to develop the disorder. Psychological and social factors, such as disturbed family and interpersonal relationships, may also play a role in development.
Treatment:
Hospitalization, psychotherapy and drug treatment:
Counseling and Psychotherapy
Psychotherapy may be helpful in certain situations. Family therapy is often helpful to assist relatives in coping with the affected individual. Behavioral techniques used in a therapeutic setting, or in the home can help a person learn behaviors that will lead to social acceptance.
Hospitalization is often required to prevent self-inflicted harm or harm to others, and to provide for the person's basic needs such as food, rest, and hygiene.
First psychotic episode. Typical antipsychotic chosen based on side effects the patient will tolerate best (see examples below). Need 6 to 8 weeks at a therapeutic dose for adequate trial. If no response, consider switching to another typical antipsychotic class. If two typical antipsychotic trials fail, consider atypical antipsychotics(usually risperidone first, then olanzapine, and then clozapine). Prophylactic treatment is recommended for at least 6 months to 1 year. The above is usually done in consultation with a psychiatrist.
Relapsing psychosis. Requires long-term treatment with antipsychotics. Minimize dose to prevent long-term complications of antipsychotics (tardive dyskinesia).
Supportive psychotherapy Individual or family counseling may be a helpful adjunct to reduce risk for relapse.
Community programs Beneficial in providing support, social skills training, and vocational rehabilitation.Pharmacotherapy
Antipsychotics: Doses and Side Effects for Chronic UseAntipsychotics (typical).
Chlorpromazine (Thorazine).
Thioridazine (Mellaril).
Trifluoperazine (Stelazine).
Thiothixene (Navane).
Fluphenazine (Prolixin).
Haloperidol (Haldol).Antipsychotics (atypical).
Risperidone (Risperdal).
Olanzapine (Zyprexa).
Clozapineł (Clozaril).Special Antipsychotic Adverse Reactions
Neuroleptic Malignant Syndrome. May occur at any point during the course of treatment. Includes symptoms of autonomic instability, altered mental status, which may progress to hyperthermia, stupor, and muscle hypertonicity. Death may occur. Cause: Neuroleptics (phenothiazines, etc.) Characteristics. Same symptoms as malignant hyperthermia (see below) but generally develops over days instead of minutes. Treatment: As per malignant hyperthermia.
Malignant Hyperthermia. Cause. 1:20,000 in response to a muscle-relaxing agent (such as succinylcholine) or an inhaled anesthetic (such as halothane). Is hereditary. May also be secondary to physical or emotional stress. Characteristics. Hyperthermia, muscle rigidity, tachycardia, acidosis, shock, coma, rhabdomyolysis. Treatment includes IV dantrolene 1 to 10 mg/kg IV titrated to effect, management of acidosis and shock, peripheral cooling (see management of heat stroke below).
Tardive Dyskinesia. Involuntary movements of the tongue, face, mouth, or jaw associated with long-term administration of antipsychotics. Elderly females at highest risk. May be irreversible.