Schizophrenia

- Managing adverse effects of antipsychotics - Dystonic reaction (especially of head and neck): Give diphenhydramine 25 to 50 mg IM or benztropine 1 to 2 mg IM. - Akathisia: propranolol 10 mg BID or lorazepam 0.5 mg BID - Pseudoparkinsonism: trihexyphenidyl 2 mg BID (may be increased to 15 mg/day if needed) or benztropine 0.5 BID (range 1 to 4 mg/day) - Akathisia (restlessness): propranolol (30 to 60 mg in divided doses) or lorazepam (range 1 to 2 mg/day) - Neuroleptic malignant syndrome: hyperthermia, autonomic dysfunction, and extrapyramidal symptoms; requires hospitalization and supportive management (IVF and cessation of offending neuroleptic)

- Geriatric considerations: All antipsychotics carry a black box warning for increased mortality risk in elderly dementia patients. - Adjunctive treatments - Benzodiazepines - May be effective adjuncts to antipsychotics during acute phase of illness - Useful for the treatment of catatonia - Withdrawal reactions with psychosis or seizures

- Mood stabilizers (valproic acid lithium, lamotrigine, carbamazepine): may be effective adjuncts for those with agitated/violent behavior (7,9)[A] - Antidepressants: if prominent symptoms of depression are present - Metformin: helps minimize risk of metabolic SE with use of AP (10)[A]

para>All antipsychotics are associated with weight gain and carry the risk of metabolic SE and tardive dyskinesia.

Managing adverse effects of antipsychoticsDystonic reaction (especially of head and neck): Give diphenhydramine 25 to 50 mg IM or benztropine 1 to 2 mg IM.Akathisia: propranolol 10 mg BID or lorazepam 0.5 mg BIDPseudoparkinsonism: trihexyphenidyl 2 mg BID (may be increased to 15 mg/day if needed) or benztropine 0.5 BID (range 1 to 4 mg/day)Akathisia (restlessness): propranolol (30 to 60 mg in divided doses) or lorazepam (range 1 to 2 mg/day)Neuroleptic malignant syndrome: hyperthermia, autonomic dysfunction, and extrapyramidal symptoms; requires hospitalization and supportive management (IVF and cessation of offending neuroleptic)
Geriatric considerations: All antipsychotics carry a black box warning for increased mortality risk in elderly dementia patients.
Adjunctive treatmentsBenzodiazepinesMay be effective adjuncts to antipsychotics during acute phase of illnessUseful for the treatment of catatoniaWithdrawal reactions with psychosis or seizuresMood stabilizers (valproic acid lithium, lamotrigine, carbamazepine): may be effective adjuncts for those with agitated/violent behavior (7,9)[A]Antidepressants: if prominent symptoms of depression are presentMetformin: helps minimize risk of metabolic SE with use of AP (10)[A]

ISSUES FOR REFERRAL

Consider in cases of suicidality, coexistence of an addiction, difficulty in engagement, or poor self-care.
Patients with schizophrenia should receive multidisciplinary care from both a primary care physician and a psychiatrist.
Family members often benefit from referral to family advocacy organizations such as NAMI (11)[A].

ADDITIONAL THERAPIES

Family and patient education and psychotherapy. These include specific treatments to reduce the impact of psychotic symptoms and to enhance social functioning. Cognitive-behavioral therapy has been shown to be effective for specific symptoms of schizophrenia (12)[C].

COMPLEMENTARY & ALTERNATIVE MEDICINE

No alternative therapies are validated.

SURGERY/OTHER PROCEDURES

Electroconvulsive therapy (ECT): For patients presenting with catatonic features, the option of ECT should be considered early when insufficient response to benzodiazepines is observed (7)[B].
Surgical interventions are not available.

INPATIENT CONSIDERATIONS

Initial stabilization focuses on maintaining a safe environment and reducing acute psychotic symptoms and agitation through the initiation of pharmacologic treatment.

Admission Criteria/Initial Stabilization

The decision to admit is usually based on the patient 's risk of self-harm or harm to others and the inability to care for self as governed by local legal statute.

Nursing

Monitor for safety concerns and establish a safe and supportive environment.

Discharge Criteria

Based on the patient 's ability to remain safe in the community. It reflects a combination of suicide risk, level of psychotic symptoms, support systems, and the availability of appropriate outpatient services.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Long-term symptom management and rehabilitation depend on engagement in ongoing pharmacologic and psychosocial treatment.
Monitoring is based on evaluation of symptoms (including safety and psychotic symptoms), looking for the emergence of comorbidities, medication side effects, and prevention of complications.

DIET

Newer atypical antipsychotics confer a higher risk of metabolic side effects such as diabetes, hypercholesterolemia, and weight gain.
Although there are no specific dietary requirements, attention should be paid to the high risk of development of obesity and metabolic syndrome in individuals with schizophrenia.

PATIENT EDUCATION

National Institute of Mental Health: Schizophrenia, at www.nimh.nih.gov/health/topics/schizophrenia/index.shtml
Helping a Family Member with Schizophrenia: www.aafp.org/afp/20070615/1830ph.html
National Alliance on Mental Illness (NAMI): www.NAMI.org

PROGNOSIS

Typical course is one of remissions and exacerbations. Although uncommon, there are known cases of complete remission and of refractory illness
Negative symptoms are often most difficult to treat.
Excessive mortality occurs due to suicide, accidents, coronary artery disease, pulmonary disease, or substance use disorders; guarded prognosis

COMPLICATIONS

Side effects from antipsychotic medications including tardive dyskinesia, orthostatic hypotension, QTc prolongation, and metabolic syndrome
Self-inflicted trauma and suicide
Combative behavior toward others
Comorbid addictions, including nicotine (13)[A]

REFERENCES

11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association;2013.22 McGrath JJ. Variations in the incidence of schizophrenia: data versus dogma. Schizophr Bull. 2006;32(1):195 " 197.33 Riecher-R Άssler A, H €fner H. Gender aspects in schizophrenia: bridging the border between social and biological psychiatry. Acta Psychiatr Scand Suppl. 2000;102(407):58 " 62.44 Laruelle M, Kegeles LS, Abi-Dargham A. Glutamate, dopamine, and schizophrenia: from pathophysiology to treatment. Ann N Y Acad Sci. 2003;1003:138 " 158.55 Norman RM, Manchanda R, Malla AK, et al. The significance of family history in first-episode schizophrenia spectrum disorder. J Nerv Ment Dis. 2007;195(10):846 " 852.66 Fagerstr Άm K, Aubin HJ. Management of smoking cessation in patients with psychiatric disorders. Curr Med Res Opin. 2009;25(2):511 " 518.77 Hasan A, Falkai P, Wobrock T, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry. 2012;13(5):318 " 378.88 Shenton ME, Dickey CC, Frumin M, et al. A review of MRI findings in schizophrenia. Schizophr Res. 2001;49(1 " 2):1 " 52.99 Essali A, Al-Haj Haasan N, Li C, et al. Clozapine versus typical neuroleptic medication for schizophrenia. Cochrane Database Syst Rev. 2009;(1):CD000059.1010 Mizuno Y, Suzuki T, Nakagawa A, et al. Pharmacological strategies to counteract antipsychotic-induced weight gain and metabolic adverse effects in schizophrenia: a systematic review and meta-analysis. Schizophr Bull. 2014;40(6):1385 " 1403.1111 Mojtabai R, Nicholson RA, Carpenter BN. Role of psychosocial treatments in management of schizophrenia: a meta-analytic review of controlled outcome studies. Schizophr Bull. 1998;24(4):569 " 587.1212 Grant PM, Huh GA, Perivoliotis D, et al. Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Arch Gen Psychiatry. 2012;69(2):121 " 127.1313 Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64(10):1123 " 1131.

ADDITIONAL READING

Saks E. The Center Cannot Hold: My Journey Through Madness. New York, NY: Hyperion; 2007.

CODES

ICD10

F20.9 Schizophrenia, unspecified
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.5 Residual schizophrenia
F20.3 Undifferentiated schizophrenia
F20.81 Schizophreniform disorder
F20.89 Other schizophrenia

ICD9

295.90 Unspecified schizophrenia, unspecified
295.30 Paranoid type schizophrenia, unspecified
295.10 Disorganized type schizophrenia, unspecified
295.20 Catatonic type schizophrenia, unspecified
295.40 Schizophreniform disorder, unspecified
295.80 Other specified types of schizophrenia, unspecified
295.60 Schizophrenic disorders, residual type, unspecified
295.70 Schizoaffective disorder, unspecified
295.50 Latent schizophrenia, unspecified
295.00 Simple type schizophrenia, unspecified

SNOMED

58214004 Schizophrenia (disorder)
64905009 Paranoid schizophrenia (disorder)
35252006 Disorganized schizophrenia (disorder)
191542003 Catatonic schizophrenia (disorder)
26025008 Residual schizophrenia (disorder)

CLINICAL PEARLS

A debilitating chronic mental illness that affects all cultures
Schizophrenia is characterized by positive symptoms, including hallucinations such as voices that converse with/about the patient, delusions that are often paranoid, and negative symptoms, including flattened affect, loss of a sense of pleasure, loss of will/drive, and social withdrawal.
Multidisciplinary teams to enhance patient and family coping with serious and persistent mental illness, to prevent and treat comorbidities, and to promote recovery