Schizophrenia

1. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
   1. delusions
   2. hallucinations
   3. disorganized speech (e.g., frequent derailment or incoherence)
   4. grossly disorganized or catatonic behavior
   5. negative symptoms, i.e., affective flattening, alogia, or avolition

   Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

2. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
3. Duration: 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 two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
4. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
5. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
6. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Diagnostic Criteria of Schizophrenia Subtypes

Paranoid Type

A type of Schizophrenia in which the following criteria are met:

1. Preoccupation with one or more delusions or frequent auditory hallucinations.
2. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor
2. excessive motor activity (that is apparently purposeless and not influenced by external stimuli)
3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism
4. peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures),
5. stereotyped movements, prominent mannerisms, or prominent grimacing
6. echolalia or echopraxia

Disorganized Type

A type of Schizophrenia in which the following criteria are met:

1. All of the following are prominent:
   
   1. disorganized speech
   2. disorganized behavior
   3. flat or inappropriate affect
2. The criteria are not met for Catatonic Type.

Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Residual Type

A type of Schizophrenia in which the following criteria are met:

1. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.
2. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Treatment

• The Expert Consensus Guideline Series on Schizophrenia (very extensive desription of treatment options)
• Results of the Schizophrenia Policy Survey

1. 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.
2. Relapsing psychosis. Requires long-term treatment with antipsychotics. Minimize dose to prevent long-term complications of antipsychotics (tardive dyskinesia).
3. Supportive psychotherapy Individual or family counseling may be a helpful adjunct to reduce risk for relapse.
4. Community programs Beneficial in providing support, social skills training, and vocational rehabilitation.

Antipsychotics: Doses and Side Effects for Chronic Use

Antipsychotics (typical)	Dose mg/day	Anti- cholineric¹	EPS²	Sedation	Hypotension (orthostatic)
Chlorpromazine (Thorazine)	100-2000	++++	++	+++++	+++++
Thioridazine (Mellaril)	100-600	+++++	+	++++	+++++
Trifluoperazine (Stelazine)	5-60	++	++++	+	++
Thiothixene (Navane)	5-60	++	++++	++	++
Fluphenazine (Prolixin)	5-30	++	+++++	++	++
Haloperidol (Haldol)	2-200	+	+++++	++	+

Antipsychotics (atypical)	Dose mg/day	Anti- cholineric¹	EPS²	Sedation	Hypotension (orthostatic)
Risperidone (Risperdal)	1-6	+	+	+	++
Olanzapine (Zyprexa)	5-20	+	+	++	+
Clozapine³ (Clozaril)	5-60	+++++	+	+++++	+++++

¹ Dry mouth, constipation, blurred vision, urinary retention.
² Extrapyramidal side effects (dystonia, parkinsonism, akathisia, tardive dyskinesia).

³ Requires weekly White Blood Cell (WBC) count because of risk of agranulocytosis.
Adapted from Bernstein JG: Handbook of drug therapy in psychiatry, ed 3, St. Louis, 1995, Mosby.

Special Antipsychotic Adverse Reactions

1. 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).
2. 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.

Learning Problem
Hypoactivity
Psychosis
Euphoric Mood
Depressed Mood
Somatic or Sexual Dysfunction
Hyperactivity
Guilt or Obsession
Sexually Deviant Behavior
Odd/Eccentric or Suspicious Personality
Anxious or Fearful or Dependent Personality
Dramatic or Erratic or Antisocial Personality

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.

• Psychotic Disorder Due to a General Medical Condition, delirium, or dementia;
• Substance-Induced Psychotic Disorder;
• Substance-Induced Delirium;
• Substance-Induced Persisting Dementia;
• Substance-Related Disorders;
• Mood Disorder With Psychotic Features;
• Schizoaffective Disorder;
• Depressive Disorder Not Otherwise Specified;
• Bipolar Disorder Not Otherwise Specified;
• Mood Disorder With Catatonic Features;
• Schizophreniform Disorder;
• Brief Psychotic Disorder;
• Delusional Disorder;
• Psychotic Disorder Not Otherwise Specified;
• Pervasive Developmental Disorders (e.g., Autistic Disorder);
• Childhood presentations combining disorganized speech (from a Communication Disorder) and disorganized behavior (from Attention-Deficit/ Hyperactivity Disorder);
• Schizotypal Disorder;
• Schizoid Personality Disorder;
• Paranoid Personality Disorder.