Priority Topic: Schizophrenia

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.