Schizophrenia and related disorders: Clinical sciences

Schizophrenia and related disorders are psychiatric conditions characterized by psychotic symptoms, including delusions, hallucinations, disorganized thoughts and disorganized speech. Schizophrenia is the primary condition within this group of psychiatric conditions, along with related disorders such as schizophreniform disorder and brief psychotic disorder which share similar symptoms but are shorter in duration; schizoaffective disorder, where mood symptoms occur alongside psychotic symptoms; and mood disorders with psychotic features.

When a patient presents a with concern suggesting schizophrenia or a related psychotic disorder, start with a focused history and physical examination. The patient may report psychotic symptoms such as delusions, which are fixed false beliefs; hallucinations, which are abnormal sensory experiences; disorganized speech, like loose associations or word salad; or disorganized behavior, such as agitation or possibly catatonia, which refers to a severe type of disorganized behavior, ranging from waxy flexibility to excessive movement.

With these findings, suspect schizophrenia or a related disorder, and assess the key features to differentiate between the causes.

Here’s your first clinical pearl! Psychotic symptoms are categorized as either positive or negative. Positive symptoms are experiences present in the affected patient but not in the general population. These include delusions, hallucinations, and disorganized speech or behavior. Negative symptoms, on the other hand, are experiences that are absent in the patient but present in the general population. So instead of social engagement, motivation, and goal-directed activity normally found in the general population, the patient will demonstrate social withdrawal, decreased motivation, and lack of affect.

And here’s another clinical pearl! A first psychotic break requires a thorough medical workup to rule out possible underlying physical conditions that could better explain the patient’s symptoms. This includes a laboratory panel including CBC, CMP, urine drug screen, and thyroid function tests; as well as a head CT. Additional tests can include Lyme titers, lumbar puncture, and urine metanephrines.

If your patient reports psychotic symptoms, without significant mood episodes, suspect either schizophrenia, schizophreniform disorder, or brief psychotic disorder. To differentiate between these conditions, assess the timing of symptom onset. If symptoms started six or more months ago, consider schizophrenia and evaluate DSM-5 criteria.

To meet the criteria, your patient must experience two or more of the following symptoms for a significant portion of time during a one-month period: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms. Moreover, at least one of these symptoms must be either delusions, hallucinations, or disorganized speech. In addition, your patient must demonstrate an impairment in functioning for a significant portion of time. If these criteria are met, diagnose schizophrenia.

Treatment for schizophrenia requires a coordinated special care program involving physicians, nurses, social workers, and therapists, and involves the use of medications, psychotherapy, and family interventions.

Medications mainly include antipsychotics, which can be divided into first-generation or typical neuroleptics, such as chlorpromazine; and second-generation or atypical neuroleptics, like clozapine. The selection of the specific agent depends on medical history, past failed medication trials, patient preferences, and potential side effects.

Here’s a high yield fact! After selecting a medication, periodically monitor for potential side effects that may affect treatment adherence and quality of life. Major side effects include abnormal movements, such as acute dystonic reactions, parkinsonian symptoms, or tardive dyskinesia; metabolic syndrome, presenting with features like increased weight; high cholesterol and fasting glucose; and anticholinergic symptoms like dry mouth and constipation.

And here’s another clinical pearl! Less common side effects of antipsychotics include QT prolongation, hyperprolactinemia, and gynecomastia. Many antipsychotics can also cause either psychomotor slowing due to sedation, or psychomotor agitation due to akathisia. Finally, neuroleptic malignant syndrome is a rare but serious condition associated with antipsychotic use, and presents as a classic triad of symptoms: hyperthermia, rigidity, and confusion.

Now, if your patient has poor medication adherence, switch to a long-acting injectable antipsychotic like haloperidol, risperidone, paliperidone, or aripiprazole. Additionally, consider engaging frequently relapsing patients in assertive community treatment teams, so they may benefit from personalized care through home visits and medication delivery.

For treatment-resistant cases, including those with a substantial risk of suicide or aggression, consider clozapine, a second-generation antipsychotic; or electroconvulsive therapy, also called ECT. Clozapine is highly effective but can cause serious side effects like agranulocytosis, seizures, cardiomyopathy, and paralytic ileus. ECT is also effective but may result in memory loss and anesthesia-related risks. Finally, all patients with schizophrenia should receive psychosocial interventions, including psychoeducation about symptoms and treatment, and cognitive behavioral therapy, or CBT, to improve reality testing and social functioning, and supported employment services for independence and financial stability.

Now, if your patient’s psychotic symptoms began one to six months ago, suspect schizophreniform disorder and assess the DSM-5 criteria. The criteria are the same as schizophrenia, except symptoms must be present for one month but less than six months. So, two or more of the following symptoms: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms; and at least one of these symptoms must be either delusions, hallucinations, or disorganized speech. In addition, there’s is no requirement for impaired functioning. If these conditions are met, diagnose schizophreniform disorder.

Since schizophreniform disorder is often a precursor to schizophrenia, treatment is the same. It involves antipsychotics, which can be augmented with psychotherapeutic techniques, such as psychoeducation and CBT.