Schizophrenia: Recognition and Management in the ED

Schizophrenia has a heterogeneous presentation including both positive and negative symptoms. It is a relatively common disorder, affecting 0.7% of the world’s population.^1,2 Schizophrenia is defined by abnormalities in two or more of five domains:³

• Delusions,
• Hallucinations,
• Disorganized thinking/speech (eg, frequent derailment or incoherence),
• Grossly disorganized or abnormal motor behavior (including catatonia), or
• Negative symptoms (ie, diminished emotional expression or avolition).

Schizophrenia is defined as having two or more of the above domains. Each must present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be delusions, hallucinations, or disorganized speech. This must cause dysfunction in a major area, such as work, interpersonal relations, or self-care. Signs of the disturbance persist for at least 6 months. If mood symptoms exist, they may only be present for a minority of the total duration of symptoms. Symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.³

If symptoms are present for less than 1 month, then the diagnosis is brief psychotic disorder. If symptoms are present between 1 month and 6 months, then the diagnosis is schizophreniform disorder. If a patient has only delusions but does not hallucinate; possesses disorganized speech, grossly disorganized, or catatonic behavior; and negative symptoms, then the diagnosis is delusional disorder.

The exact pathophysiology of schizophrenia is not known at this time. However, it is theorized to be a mix of biological and environmental factors leading to dysfunction of the neurotransmitters dopamine and glutamate, as well as structural changes to the brain.²

Methods

There is an abundance of research on schizophrenia in the psychiatry literature; however, much of this deals with chronic management in patients with established diagnoses, thus this may be hard to translate into the realities of emergency practice. At the same time, although schizophrenia is discussed in the emergency medicine literature, most ED-based research is performed in patients with undifferentiated agitation and not specifically on one diagnostic subset. Therefore, a narrative review was utilized in order to focus in on studies that are relevant to emergency practice.

A narrative literature search was performed utilizing PubMed, the Cochrane database, and American Psychiatric Association Practice Alerts for the past 3 years; bibliographies of major psychiatric textbooks; and reviews and clinical policies in the National Guidelines Clearinghouse.

Epidemiology

The lifetime prevalence of schizophrenia is approximately 0.3% to 0.7%.² In addition, schizophrenia is a frequently deadly disease as one meta-analysis found lifetime suicide to be 4.9 %, which is far higher than the average risk in the United States,⁴ which is approximately 0.5%. From 1992 to 2000 there has been a 15% increase in ED visits for psychiatric problems.⁵ Patients with schizophrenia have been found to be significantly more likely to be “high utilizers” of ED services in comparison to those with other psychiatric diagnoses.⁶