Key Feature 8: Include psychosocial supports (ex: housing, family support, disability issues, vocational rehabilitation) as part of the treatment plan for patients with schizophrenia.
Skill: Patient Centered, Clinical Reasoning
Phase: Treatment

While pharmacotherapy is a mainstay of treatment for schizophrenia, there is more to be done than chemically treat. The UpToDate article, "Psychosocial interventions for schizophrenia" provides suggestions for how to provide psychosocial supports for patients with schizophrenia, and they include the following:

1. Family-based interventions
   1. "For individuals with schizophrenia who have had a recent psychotic relapse, have significant ongoing contact with family members and have not previously received the intervention, we recommend that the patient and family members receive a family psychoeducational intervention. The intervention is typically provided in monthly sessions with an individual family or a group of families for six to nine months as augmentation to antipsychotic medication and other treatment."
   2. "For individuals with schizophrenia who have experienced multiple psychotic relapses, and reside in a particularly stressful family environment, we suggest treatment with a more intensive problem-solving family therapy over other family psychoeducational interventions."
2. Cognitive-behavioural therapy
   1. "For individuals who experience persistent delusions or hallucinations despite adequate trials of antipsychotic medication, we recommend adjunctive treatment with cognitive behavioral therapy over medication alone."
3. Social-skills training
   1. "For individuals with schizophrenia who have deficits in skills needed for everyday activities, we recommend social skills training as an adjunct to antipsychotic medication over medication alone. Social skills training is generally conducted several times a week (either in training sessions with a clinician or in patient practice sessions) for three to six months. Manuals and other materials are available to support training and provision."
4. Assertive community treatment 
5. Supported employment
6. Supportive housing

​
Treatment of schizophrenia ought to include antipsychotic therapy, but therapy as a whole is not JUST about antipsychotic medications.

Key Feature 2: In “apparently” stable patients with schizophrenia (ex: those who are not floridly psychotic), provide regular or periodic assessment in a structured fashion ex: 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

Skill: Clinical Reasoning, Patient Centered
Phase: Follow-up, History

Key Feature 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

Skill: Clinical Reasoning, Patient Centered
Phase: History, Hypothesis generation

Key Feature 7: Diagnose and treat serious complications/side effects of antipsychotic medications (ex: neuroleptic malignant syndrome, tardive dyskinesia).
Skill: Clinical Reasoning
Phase: Treatment, Diagnosis

The DSM 5 diagnostic criteria for Schizophrenia are listed below. Note that much like the other psychiatric diagnoses that I have reviewed in previous posts, it is pertinent to remember the diagnostic criteria for diagnosis but also for follow-up assessment of how they are doing with respect to the nature and severity of the disease. 

1. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
   1. Delusions.
   2. Hallucinations.
   3. Disorganized speech (ex: frequent derailment or incoherence).
   4. Grossly disorganized or catatonic behaviour.
   5. Negative symptoms (i.e., diminished emotional expression or avolition).
2. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
3. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (ex: odd beliefs, unusual perceptual experiences).
4. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
5. The disturbance is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication) or another medical condition.
6. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Specify if: (The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.)

• First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
• First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
• First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
• Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
• Unspecified

Specify if:

• With catatonia (The clinical picture is dominated by three (or more) of the following symptoms)
  1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
  2. Catalepsy (i.e., passive induction of a posture held against gravity).
  3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
  4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
  5. Negativism (i.e., opposition or no response to instructions or external stimuli).
  6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
  7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
  8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
  9. Agitation, not influenced by external stimuli.
  10. Grimacing.
  11. Echolalia (i.e., mimicking another’s speech).
  12. Echopraxia (i.e., mimicking another’s movements).

Specify current severity:

• Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). Note: Diagnosis of schizophrenia can be made without using this severity specifier.

If a patient has already been started on a management plan for diagnosed schizophrenia, it is important, as for any chronic health condition, to evaluate adherence to the previously designed treatment plan. Particularly with psychiatric medications there can be many intolerable side effects, and it is not infrequent to hear that patients are not taking a medication as prescribed because of them. UpToDate provides a table of the adverse effects of antipsychotic medications as follows: 

UpToDate further describes the antipsychotic side effects and how to manage them in the article, "Pharmacotherapy for schizophrenia: Side effect management," as follows:

• Extrapyramidal symptoms (EPS), which include akathisia, parkinsonism, and dystonias:
  • "Akathisia presents with a subjective feeling of restlessness accompanied in more severe presentations with motor movements such as fidgeting, pacing, or difficulty sitting still (...) For patients with antipsychotic-induced akathisia, we suggest first-line treatment with a beta blocker such as propranolol. An anticholinergic medication such as benztropine is a reasonable alternative." The article also mentions using a benzodiazepine as another alternative agent.
  • "Secondary parkinsonism consists of mask-like facies, resting tremor, cogwheel rigidity, shuffling gait, and psychomotor retardation (...) For patients with antipsychotic-induced parkinsonism that is uncomfortable or disabling, we suggest first-line treatment with benztropine. Amantadine, a non-anticholinergic antiparkinsonian medication, is a reasonable alternative and may be preferable for patients already experiencing anticholinergic side effects."
  • "Acute dystonias are involuntary contractions of major muscle groups and are characterized by symptoms such as torticollis, retrocollis, oculogyric crisis, and opisthotonos. Severe dystonias can be treated with intramuscular or intravenous benztropine or diphenhydramine. Milder dystonias can be treated with lower, less frequent doses of benztropine."
• Tardive dyskinesia (TD)
  • "TD, a syndrome of characteristic involuntary movements of the lips, tongue, face, jaw, extremities, or trunk, occurs after chronic use of antipsychotic medications. TD seldom occurs prior to three months of antipsychotic use and usually after years of treatment. TD appears to be more common with first-generation antipsychotics rather than second-generation antipsychotics."
• Weight gain/diabetes mellitus/hypercholesterolemia
  • "Many antipsychotic medications cause weight gain, hyperlipidemia, hyperglycemia, and hypertension, collectively known as metabolic syndrome, a risk factor for cardiovascular disease (...) All patients receiving antipsychotic medication should receive regular measurements of body mass index, serum lipids, and either fasting blood glucose or hemoglobin A1c. These assessments should be performed at baseline when starting a new medication, more frequently during the first year, and subsequently at regular intervals (...) Strategies for managing weight gain and cardiovascular risk factors resulting from antipsychotic-induced metabolic syndrome include changing the patient’s antipsychotic regimen and medication and/or psychosocial interventions for individual metabolic risk factors."
• Prolactin elevation
  • "This elevation can lead to galactorrhea and menstrual disturbances in women as well as sexual dysfunction and gynecomastia in men. This side effect can usually be managed by changing to a medication that is less likely to elevate prolactin."
• "Less common side effects of antipsychotic drugs include seizures, orthostatic hypotension, neuroleptic malignant syndrome, QT prolongation, and sudden death. Some antipsychotics cause sedation and anticholinergic effects." Since they are more infrequent, I won't get into the management of these here, but you can check out the article for more info. For the urgent management of neuroleptic malignant syndrome, which is a rare but potentially fatal adverse effect, see this previous blog post on what to do.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Anticipate and develop a plan for possible violent or aggressive behaviour and recognize the warning sign
  

Difficult Patient

Key Feature 7: Take steps to end the physician-patient relationship when it is in the patient’s best interests.
Skill: Professionalism, Patient Centered
Phase: Treatment

Key Feature 8: With a difficult patient, safely establish common ground to determine the patient’s needs (ex: threatening or demanding patients).
Skill: Patient Centered, Professionalism
Phase: Treatment

Schizophrenia

Key Feature 1: In adolescents presenting with problem behaviours, consider schizophrenia in the differential diagnosis.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 3:  In all patients presenting with psychotic symptoms, inquire about substance use and abuse.
Skill: Clinical Reasoning
​Phase: History

Key Feature 4: Consider the possibility of substance abuse and look for it in patients with schizophrenia, as this is a population at risk.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 5: In patients with schizophrenia, assess and treat substance abuse appropriately.
Skill: Clinical Reasoning
Phase: Treatment

Violent/Aggressive Patient

Key Feature 1a: In certain patient populations (ex: intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Anticipate possible violent or aggressive behaviour.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 1b: In certain patient populations (ex: intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Recognize warning signs of violent/aggressive behaviour.
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 1c: In certain patient populations (ex: intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Have a plan of action before assessing the patient (ex: stay near the door, be accompanied by security or other personnel, prepare physical and/or chemical restraints if necessary).
Skill: Clinical Reasoning
​Phase: Treatment

Key Feature 2: In all violent or aggressive patients, including those who are intoxicated, rule out underlying medical or psychiatric conditions (ex: hypoxemia, neurologic disorder, schizophrenia) in a timely fashion (i.e., don't wait for them to sober up, and realize that their calming down with or without sedation does not necessarily mean they are better).
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation

Key Feature 3: In a violent or aggressive patient, ensure the safety (including appropriate restraints) of the patient and staff before assessing the patient.
Skill: Clinical Reasoning, Professionalism
Phase: Treatment

Key Feature 4: In managing your practice environment (ex: office, emergency department), draw up a plan to deal with patients who are verbally or physically aggressive, and ensure your staff is aware of this plan and able to apply it.
Skill: Professionalism
Phase: Treatment

Yesterday, I spent my first full day on call for Psychiatry in the Emergency Department of St Paul's Hospital. I was shown what the quiet rooms in the ED looked like when I was oriented to the Acute Behavioural Stabilization Unit (ABSU) on a tour of where I would be working at the start of my week, but yesterday was the first day I actually went in to interview patients in this area. At one point I had a mission to obtain some history from two patients with psychosis who were in quiet rooms; there were three security guards and the attending physician by my side. First of all, how intimidating is that for any patient, let alone one who is floridly psychotic?

Working at SPH means I have exposure to some very complex and unfortunate patient stories. Many of these patients have serious medical issues, perpetuated and exacerbated by their dire psychosocial circumstances. It feels as though patients without substance use disorders are the exception rather than the norm, and has helped me solidify asking about substance use as a routine part of all of my patient histories, especially those presenting with psychotic symptoms. It can be quite challenging to tease apart primary from secondary drug-induced psychosis, and many patients may have one or both. This fact is all the more true in a young patient presenting with psychosis, as this may be a newly evolving primary psychotic disorder such as schizophrenia, or it may also very well likely be a secondary drug-induced presentation. The possibility of primary psychosis and separate substance use that does not induce psychosis is also a possibility as well. (For example, I once encountered a patient with psychosis who had a substance use disorder but who was found to have neurosyphilis and psychosis secondary to that.) It is always important to ask, and obtain collateral information, which is generally important no matter the psychiatric presentation. It is also important to treat any substance use disorder much as treatment that may be offered to patients without a psychotic disorder (see this previous blog post). And, like with all my patients, I had hopes of gathering this information from the patients in the quiet room with psychosis.

I started in a gentle open-ended fashion, introducing myself, and asking if they could tell me a little about what had brought them into the ED. Instantly I was faced with irritable - and what could really have been quite violent - reactions had I not had the security presence hovering around me. One of the two patients started to make threats, and so my attending physician asserted that the team needed to be treated with respect, and if not, we would not be able to engage with the patient to help them. The conversations ended quicker than they started, and I left the quiet room area feeling entirely unproductive.

I looked at my attending once we were out of the area and bluntly said, "What the heck?" He responded by saying, "You have a lot to learn, little one!" He went on to explain to me that with particularly difficult patients, you have to start off by gaining their trust a little bit, of which they tend to have very little toward authority and healthcare figures. If you first focus on their primary needs being met, and in so doing building rapport, you're much more likely to get what you need to help them medically. I have learned this concept as it relates to pain in particular: In the patient who presents writhing in pain, you are just not going to be able to get a good history until you provide them with some pain relief. To do so is also just the humane thing to do. Much as these patients with poor self-care, with a string of unhealthy relationships, and who may be starving and exhausted from sleeping on concrete steps, they need their basic needs to first be met: to be fed, to be rested, to feel like their immediate suffering is the priority in the interaction. Of course, this would always have been my intention and hope, but I hadn't really thought about how, in these initial moments with such difficult patients, ones who are likely difficult because they are truly suffering, starting off by first making attempts to meet their basic needs is in fact the most patient-centered and productive way of helping them.

As I write this paragraph, it is now a day later than when I wrote the above parts. I have since been reflecting on boundaries of the physician-patient relationship. As part of my learning objectives, I am supposed to learn to "Take steps to end the physician-patient relationship when it is in the patient’s best interests." While I expect to infrequently encounter patients who are as challenging to work with as the ones I met in the quiet room the other day, I will certainly have patients who are challenging to work with. There may even be patients who make threats, which would warrant ending the physician-patient relationship for safety concerns to myself or other people in the place of care delivery. But it was stumping me to come up with a situation for which ending a physician-patient relationship could ever be in the patient's best interest. Today in clinic, I clarified with my attending psychiatrist that ending a physician-patient relationship in the context of a threatening patient is certainly on grounds of patient and staff safety, but also in consideration that a therapeutic relationship cannot take place for the patient in this context, and therefore it is in the patient's best interest to terminate this relationship. I hope I will never have this happen in my practice, and if it does, I hope there can be enough rapport built to establish common ground and create more effective communication. But, in the setting of serious risk of harm to myself or coworkers, it is in the best interest of all parties to end the physician-patient relationship. This might not mean forever, but while the patient is upset or unpredictable (such as when acutely intoxicated or experiencing psychosis), or if they have a past history of violence/aggression in the health care setting, it does mean at the very least anticipating that the encounter could trigger a violent/aggressive response.  It also means being able to recognize warning signs of impending violence/aggression (ex: increasing volume of voice, clenched fists, etc.) and having a plan of safety when engaging with a patient in whom you anticipate possible risk of physical harm (such as having security guards present in the ABSU, always having an exit that is not blocked by the patient's position, and if worst comes to worst, having the means to employ physical or chemical restraints as necessary). In the clinic setting, where there aren't security guards on stand-by, it's important to have policies in place to ensure all staff members are prepared to deal with verbally or physically aggressive patients.