Clearing Up Confusion About Schizophrenia Vs Psychosis
Elpidio Heart
It is essential in the ED not to confuse the thought and behavioral disturbances of organically based acute delirium with any of the psychotic disorders. Many medical conditions can cause the acute delirium that be confused with an acute schizophrenic psychotic episode. The avoidance of this confusion is the primary reason for "medical clearance" examinations and drugs-of-abuse screening.
Because of the variability of symptom expression, diagnostic requirements of chronicity, and lack of pathognomonic features, an ED diagnosis of schizophrenia should be made cautiously. As a diagnosis-by-exclusion, schizophrenia must be distinguished from the numerous psychiatric and organic disorders that also can lead to psychotic disturbances in thinking and behavior. The diagnosis is best made by a psychiatrist who has throughly evaluated the patient, including historical episodes and corroborating information from family and friends.
Psychosis and schizophrenia are not equivalent, although they are commonly mistaken as such. Psychosis is a disorder of thinking and perception in which information processing and reality testing are impaired, resulting in an inability to distinguish fantasy from reality (delusions and hallucinations). Psychosis is a major feature of schizophrenia, as it is in several other psychiatric disorders. Other psychiatric disorders with psychotic features that can be mistaken for schizophrenia include the following:
The most common etiologies for severe acute mental status changes in the ED are organic, not psychiatric. They include medications, drug intoxication, drug withdrawal syndromes, and general medical illnesses causing delirium.
The onset of schizophrenia is insidious in approximately one half of all patients. The prodromal phase can begin years before the full-blown syndrome and is characterized by decreasing ability to function based on societal norms of one's home, social interactons, and occupation. Patients will potentially display poor school or work performance, deterioration of hygiene and appearance, decreasing emotional connections with others, and/or behaviors that would have been atypical or strange for the individual in the past.
A gradual onset indicates a more severe and prolonged course of illness. An abrupt onset of hallucinations and delusional, bizarre, or disorganized thinking in patients who previously functioned normally may result in a better intermediate and long-term outcome. Patients arriving in an acute psychotic crisis that requires immediate management may not have been previously diagnosed with a psychiatric illness. These patients often present diagnostic dilemmas involving organic versus psychiatric etiology and primary psychotic versus affective disorder diagnosis. Treatment may be complicated further by the presence of acute or chronic alcohol or drug use.
Often, the visit to the ED relates to a complication of treatment (medication adverse effects, noncompliance), a crisis arising from socioeconomic factors secondary to schizophrenia (poverty, homelessness, social isolation, failure of support systems), or intoxication from substance abuse (drugs or alcohol).
While the primary diagnosis of schizophrenia rarely is made de novo in the ED, several historical features can be helpful in distinguishing the illness from the many medical and psychiatric conditions that can mimic it. Typically, the first episode will present in the patient's early 20's.
Two or more of the following must have been present over the prior month for a significant period (less than a month if treated with medication). Only one is required if the patient has a delusion of a voice providing a running commentary or two voices conversing. [4]
Presence of an affective disorder (eg, major depression, bipolar disorder, schizoaffective disorder) must be excluded; these conditions can be mistaken for schizophrenia and have very different prognoses and therapies. They may be present, but only for a brief period of time and are not the majority of symptoms. Additionally, an organic etiology (eg, drug intoxication, medical illness, or medication side effect) must be ruled out.
Acute dystonia (muscle rigidity and spasm), oculogyric crisis (bizarre and frightening upward gaze paralysis and contortion of facial and neck musculature), akathisia (dysphoric sense of motor restlessness)
Dry mouth, fatigue, sedation, visual disturbance, inhibited urination, and sexual dysfunction, which can be adverse reactions to antipsychotic medication or to anticholinergic drugs taken for prophylaxis of dystonia
Find out about threats made to others, expressions of suicidal intent, and possession of weapons at home or on the person. A paranoid schizophrenic, in response to delusions and command hallucinations, can be extremely dangerous and unpredictable.
Depending on the reason for ED presentation, the patient with schizophrenia may present with wildly agitated, combative, withdrawn, or severely catatonic behavior. Conversely, the patient may appear rational, cooperative, and well controlled (perhaps with only some blunting of affect). The person also could be subtly odd, unkempt, or frankly bizarre in manner, dress, and/or affect.
Pay particular attention to fever, tachycardia (which, in association with rigidity, can be a sign of neuroleptic malignant syndrome), heatstroke (antipsychotics inhibit sweating), and other medical illness.
Mental status testing should typically reveal clear sensorium and orientation to person, place, and time. Assess attention, language, memory, constructions, and executive functions. Absence of clear sensorium and/or orientation may indicate the presence of acute delirium, a medical condition.
No specific laboratory findings are diagnostic of schizophrenia. However, performing some studies may be necessary to rule out possible organic etiologies for psychosis or to uncover complications of schizophrenia and its treatment.
Blood levels of certain psychiatric drugs, such as lithium and antiseizure medications used as mood-stabilizers (eg, valproic acid, carbamazepine), can be used to confirm compliance or rule out toxicity.
Interpreting the results of a fingerstick blood glucose determination is a rapid and inexpensive method of ruling out a diabetic emergency masquerading as an exacerbation of a psychotic illness. Similarly, measuring oxygen saturation levels can help to disclose hypoxia resulting in behavioral or central nervous system (CNS) disturbance.
Electrolyte measurements may reveal various abnormalities that can cause altered mental status. Additionally, it would evaluate for hyponatremia secondary to water intoxication (ie, psychogenic polydipsia). This is common in undertreated or refractory schizophrenia.
Laboratory abnormalities observed in neuroleptic malignant syndrome may include leukocytosis with left shift and elevated skeletal muscle creatinine kinase (CK) and aldolase levels. Some antipsychotics may also cause leukopenia with long-term use.
Computed tomography (CT) scanning, magnetic resonance imaging (MRI), and positron emission tomography (PET) scanning can disclose abnormalities of brain structure and function in schizophrenia. Although these studies are of interest for research, they have limited clinical relevance. Various psychological and neurobiologic tests, such as absence of smooth eye-tracking, may be helpful in studying schizophrenia but are not useful in the ED setting. A CT scan can be helpful to evaluate after a trauma and for masses, lesions, or areas of ischemia that may present as acute psychosis. Electrocardiograph prior to the use of antipsychotics is helpful as some can cause QT prolongation.
Safe transport of a patient with acute psychosis may require physical or chemical restraints. Be familiar with restraint and sedation protocols in your local emergency medical service (EMS) area and hospitals.
The deinstitutionalization of patients with schizophrenia has had a major impact on emergency medicine. This process developed from the efficacy of modern antipsychotic medications but also the subsequent widespread budget cutting of psychiatric services over the past 2 decades, Patients with schizophrenia are frequently seen in the emergency department. These patients present with problems ranging from exacerbation of symptoms to medication noncompliance, adverse effects to medications, or a socioeconomic crisis that arises from either substance abuse, poverty, homelessness, or a failed support system.
Patients with schizophrenia may require care that is limited to diagnosis and treatment of an urgent or nonurgent medical complaint. Other visits are a brief medical evaluation followed by consultation with psychiatric, crisis, or social service personnel. Many visits are for evaluation and treatment of an adverse reaction to a psychiatric drug. The more concerning visit is the one requiring physical and chemical restraint of a patient with acute psychosis in coordination with a workup to rule out organic etiologies.
Remember that psychiatric and organic illness can coexist at the same time in the same patient. An acute medical diagnosis may be clouding the diagnosis or excerbating underlying psychiatric symptoms. Furthermore, acute psychiatric symptoms may create difficulty in obtaining a reliable history from the patient and can mask serious organic illness. A brief medical clearance examination is limited in its usefulness and is insufficient to rule out organic etiologies.
Proper physical restraints and individuals trained in their application should be available at all times. [8] Documentation should include reasons for restraining a patient such as patient/staff safety and protection, the type of restraint used (eg, locked room vs 4-point leather), the maximum duration of restraint, and reasons for involuntary commitment. [9]
Follow all Consolidated Omnibus Budget Reconciliation Act (COBRA) regulations when transferring patients to another facility for psychiatric care. Be familiar with hospital and ED specific regulations, Health Insurance Portability and Accountability Act (HIPAA) rules, regional statutes, and Emergency Medical Treatment and Labor Act (EMTALA) requirements regarding the use of medical screening exams, physical restraints, involuntary psychiatric commitment, and facility transfer. [10]
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