Schizophrenia

1. In adolescents presenting with problem behaviours, consider schizophrenia in the differential diagnosis.
2. In “apparently” stable patients with schizophrenia (e.g., those who are not floridly psychotic), provide regular or periodic assessment in a structured fashion e.g., positive and negative symptoms, their performance of activities of daily living, and the level of social functioning at each visit:
   • seeking collateral information from family members and other caregivers to develop a more complete assessment of symptoms and functional status;
   • competency to accept or refuse treatement, and document specifically;
   • suicidal and homicidal ideation, as well as the risk for violence;
   • medication compliance and side effects.
3. In all patients presenting with psychotic symptoms, inquire about substance use and abuse.
4. Consider the possibility of substance abuse and look for it in patients with schizophrenia, as this is a population at risk.
5. In patients with schizophrenia, assess and treat substance abuse appropriately.
6. In decompensating patients with schizophrenia, determine:
   • if substance abuse is contributory.
   • the role of medication compliance and side-effect problems.
   • if psychosocial supports have changed.
7. Diagnose and treat serious complications/side effects of antipsychotic medications (e.g., neuroleptic malignant syndrome, tardive dyskinesia).
8. Include psychosocial supports (e.g., housing, family support, disability issues, vocational rehabilitation) as part of the treatment plan for patients with schizophrenia.

General Overview

• Delusions
  • Persecutory
  • Grandiose
  • Erotomanic (eg. movie star is in love with them)
  • Somatic (eg. sinuses infested by worms)
  • Delusions of reference (eg. dialogue on TV directed towards patient)
  • Delusions of control (eg. thoughts/movements controlled by others)
• Hallucinations
  • Auditory (most common)
  • Visual
  • Tactile
  • Olfactory
  • Gustatory
• Thought disorganization
  • Alogia/poverty of content – Very little information conveyed by speech
  • Thought blocking – Suddenly losing train of thought, exhibited by abrupt interruption in speech
  • Loosening of association
  • Tangentiality – (circumstantiality if content eventually returns to original topic)
  • Clanging or clang association – Using words in a sentence that are linked by rhyming or phonetic similarity (eg, “I fell down the well sell bell.”)
  • Word salad – Real words are linked together incoherently, yielding nonsensical content
  • Perseveration – Repeating words or ideas persistently, often even after interview topic has changed

DSM-5 Diagnosis

• ≥2 for most of the month (with one of the first three)
  • Delusions (eg. perscution, passivity [thoughts/actions controlled by external force])
  • Hallucinations
  • Disorganized Speech
  • Grossly disorganized or catatonic behavior
  • Negative symptoms (eg. avolition, diminished emotional expression)
• Marked dysfunction
• r/o schizoaffective, depression, bipolar

DDx Psychosis

• Psychiatric
  • Brief psychotic disorder >1d-1mo
  • Schizophreniform >1mo - <6mo
  • Schizophrenia >6mo
  • Schizoaffective (major mood episode, and >2w of delusions/hallucination in absence of mood)
  • Bipolar I with psychotic features
  • Major depressive disorder with psychotic features
  • Personality disorder (schizotypal, borderline)
  • PTSD
  • ADHD, CD, ODD
• Substance-induced psychotic disorder
• Medical
  • Autoimmune (SLE, MS)
  • Infection (HIV, Neurosyphilis, HSV encephalitis, Lyme, Prion disorders)
  • Endocrine (Thyroid, parathyroid, adrenal)
  • Metabolic (Wilson's disease, acute intermittent porphyria)
  • Dementia
  • Neurologic (trauma, lesion, seizure, stroke)
  • B12 deficiency
  • Malignancy
  • Medication
• Delirium

Screening

• Do you ever hear voices when you are alone? What do these voices say to you?
• Do you ever feel that people are talking about you behind your back? Or that they are out to get you?
• Do you ever think that people can pick up on or control what you are thinking?

History

• Symptoms
• Function
• Suicide
• Head trauma (r/o subdural hematoma)
• Recent stressors and Supports
• Substance use
• Medication and adherence
• Family Hx
• Collateral

Investigations

• CBC +/- blood culture
• Electrolytes
• LFT
• TSH
• Syphilis screen
• HIV
• UA +/- urine culture
• Urine drug screen
• B12
• Consider Head CT/MRI
• Consider baseline EKG, lipids

Management

• Family intervention and CBT
• Housing, vocational, financial support, social worker
• Admission, day-time inpatient care
• Detoxification
• Agitation PRN Cocktail (LAB) - can mix all three in one syringe
  • Loxapine 25-50mg PO/IM q1-2h or Haldol 5mg IM q1-2h (max 4/24h)
  • Ativan 1-2mg PO/IM q1-2h
  • Benadryl 25-50mg PO/IM q1-2h
• Atypical antipsychotic
  • Risperidone 1-6mg/day smallest risk for metabolic side effects
  • Clozapine for non-responders
    • Adverse: agranulocytosis, seizure, myocarditis, cardiomyopathy
• Follow q3 months until stable
  • Signs/symptoms
  • Function
  • Suicidal/aggressive thoughts/behaviour
  • Substance use
  • BMI
  • Labs: Fasting glucose/Lipids baseline, 3mo, then yearly

Follow-up

• Positive and negative symptoms
• Suicidal, homicidal ideation
• Function (social, home, ADLs)
• Psychosocial supports
• Medication adherence
• Medication side effects
  • EPS, hyperprolactinemia, cardiometabolic risk (weight gain, diabetes, dyslipidermia), anticholinergic, antihistamine (sedation), antiadrenergic (orthostatic hypotension)
• Substance use

Extrapyramidal Symptoms (EPS)

• Consider antipsychotic dose reduction
• Consider switching to agent with less EPS
• Consider dystonia prophylaxis if treating with haloperidol or high risk
• Acute Dystonia (hours-5days, involuntary contractions of major muscle groups)
  • Severe - Benztropine 1-2mg IM/IV or Diphenhydramine 25mg IM
  • Mild - Benztropine 1-2mg PO daily
• Akathisia (restlessness, most common EPS)
  • Beta-blocker - Propranolol 10mg (to 40mg) PO BID
  • Anticholinergic - Benztropine 1-2mg PO BID
  • Benzodiazepine - Lorazepam 0.5mg PO BID
• Parkinsonism (mask facies, resting tremor, rigidity, shuffling gait, bradykinesia)
  • Anticholinergic - Benztropine 1-2mg PO BID
  • Non-anticholinergic - Amantadine 100mg PO BID-TID
• Tardive dyskinesia (years of treatment - lip smacking, facial grimace, jaw movements, choreiform movements of extremities/trunk)
  • Switch to antipsychotic with low risk TD (quetiapine, clozapine)
  • Benzodiazepine - Clonazepam
  • Other - Botox injections, tetrabenazine, anticholinergic, deep brain stimulation

Neuroleptic Malignant Syndrome

• Altered mental status, rigidity, hyperthermia (>38-40C), dysautonomia (tachycardia, hypertension, tachypnea)
  • In the setting of neuroleptic use of dopamine withdrawal
  • r/o infection (eg. meningitis) or drug-induced
  • r/o serotonin syndrome (shivering, hyperreflexia, myoclonus, ataxia, GI symptoms)
• Treatment
  • Stop neuroleptic
  • ICU - aggressive supportive therapy
  • Treat hyperthermia
  • Follow serum CK
  • Consider benzodiazepines, dantrolene, bromocriptine, amantadine if no response to supportive care within 1-2d