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)
Hallucinations (only one symptom is required if hallucinations
are of at least two voices talking to one another or of a voice
that keeps up a running commentary on the patient's thoughts or
actions).
Speech that shows incoherence, derailment or other disorganization
Severely disorganized
or catatonic behavior Any negative symptom such as flat affect,
reduced speech or lack of volition.
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:
Negative symptoms as mentioned above.
In attenuated form,
at least 2 of the other symptoms mentioned above (example: deteriorating
personal hygiene plus an increasing suspicion that people are
talking behind one's back).
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.
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 behavior
Disorganized
type
The patient meets the basic criteria for Schizophrenia
All
of these symptoms are prominent:
Disorganized behavior
Disorganized speech
Affect that is flat or inappropriate
The
patient does not fulfill criteria for Catatonic Schizophrenia
Catatonic
Type
The patient meets the basic criteria for 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
Undifferentiated Type
The patient meets the basic criteria for Schizophrenia
The
patient does not meet criteria for Paranoid, Disorganized, or
Catatonic types.
Residual
Type
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 Features
Differential
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.
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:
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.
Antipsychotics:
Doses and Side Effects for Chronic Use
Antipsychotics
(typical).
Chlorpromazine (Thorazine).
Thioridazine (Mellaril).
Trifluoperazine (Stelazine).
Thiothixene (Navane).
Fluphenazine (Prolixin).
Haloperidol (Haldol).
Antipsychotics
(atypical).
Risperidone (Risperdal).
Olanzapine (Zyprexa).
Clozapine (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.
