Southern Philippines Medical Center

Institute of Psychiatry and Behavioral Medicine

Davao City

A Case
Of

Schizophrenia

Submitted By:
Salonga, Cindy Claire
Te, Jhoanna Myles
San Pedro Hospital
September 8, 2016

General Data:
Name: J.A
Age: 22 years old
Sex: Male
Address: Purok 1, Sitio Lorenzo, Pangyan, Calinan, Davao City
Civil Status:

Single

Date of Birth: 08/14/1993

Nationality:

Filipino

Birthplace: Davao City

Occupation: None
Religion: Roman Catholic
Educational Attainment: High School Graduate
Number of previous admissions: 1
Psychiatric History
Date of interview: September 5, 2016
Informant: Mother & Patient

Reliability: 90%

Chief Complaint: Difficulty of Sleeping

Patient's words: Maglisod ko ug tulog usahay doc
Companion's words: okay man siya doc kaso usahay dili siya katulog
Premorbid Personality:
The patient was noted to be nervous very easily and was a shy kind of person. He had
difficulty sharing his problems with anyone. However, patient had many friends mostly boys and
they love going out. As a son, he was an obedient and loving child. As a brother, he took care of
his younger brother when the parents are away.

History of Present Illness:

Patient is a diagnosed case of schizophrenia last march 2016. He was compliant to
his medication (olanzapine 10mg/tab bid -> was tapered to od last june 2016) and has
been having monthly check-ups in our institution.
However, 2 months PTC, his mother stopped him from taking the medications
since his lower extremities suddenly became swollen and affected his ambulation. During
this time of non-compliance, patient felt dizzy and had occasional headaches. He began
to have bizarre thoughts such as bad things against his family members. Also, he had
difficulty sleeping and was feeling nervous.
Persistence of these symptoms prompted the patient to seek consult at our
institution.

Past Medical History:

Psychiatric
Last March 10-23, 2016, the patient was admitted at SPMC-IPBM with a
diagnosis of schizophrenia. He was brought in at our institution because for 7 months, he
was observed to be staring blankly, talking to himself, laughing alone, had difficulty
sleeping, had loss of appetite and didnt talk to anyone else. Also, there was presence of
auditory hallucinations, persecutory and grandiose delusions. He was given olanzapine
10mg/ODT bid.
At the time of discharge, patient recovered and was maintained on the same
medication. According to his mother, he went back to his pre-morbid state because he had
good compliance to medication. He had good sleep, helps at household chores, socializes
with friends and looks happy.
Non-psychiatric
Patient was admitted in a local hospital for 1 week due to dengue fever when he
was 7 years old.

With unrecalled medications, his condition improved and was

subsequently discharged.

Patient is a non- hypertensive, non- diabetic and non- asthmatic. He has no

history of seizure disorder, head trauma or thyroid problems.

He has no previous

surgeries. Patient has no known food and drug allergies.

Family History:
No known heredofamilial diseases. No known psychiatric illness in the family.
Family Dynamics:
His parents have been married for more than 20 years and their relationship was
not perfect. They often have misunderstanding, mostly financial. However, despite these issues,
they find time to talk about it and settle it immediately. In the family, both parents were involved
in decision making. Family set-up was more on the democratic type.
The patient was very close to his younger brother. He was more close to his mom
because his father was busy working. However, he did not feel distant to his father when he was
around.
Social and Personal History:
Infancy
Patient is the seventh child among 8 siblings. The pregnancy was wanted and
planned.

He was delivered via normal spontaneous delivery, full term, with no

maternal/birth complications at home assisted by a traditional birth attendant.

Childhood
As claimed by his mother, his developmental milestones were at par with age. He
loved playing with his siblings and other kids in the neighbourhood. He started attending
Grade 1 at the age of 7 years old, and had good performance in school. Method of
discipline was through corporal punishment usually done by the father.

Adolescence
At the age 13, patient started to have group of friends. He did not smoke cigarettes, drink
alcoholic beverages nor take illegal drugs. Together with his friends, they play basketball
and watch television. Patient has not been called for disciplinary action at school.
Adulthood
The patient took a vocational course on automotive servicing for less than a year.
He was not able to finish it because he preferred to work and earn money. He worked for
5 months as a security guard. He resigned because the work was tiresome. Since then,
the patient is unemployed.
Patients gender preference is female. He wasnt involved in any intimate
relationship. He denied history of any sexual intercourse with the opposite sex.
Substance Use History:
At the age of 21, he started smoking cigarettes approximately 1-2 sticks per day.
This was due to peer pressure. However, after in less than a month, he stopped smoking
because he didnt like it anymore.
He denied intake of alcoholic beverages and use of illegal drugs.
Legal History:
Patient has no history of imprisonment or incarceration.

Hopes and Dreams:

Patient dreamed of being healed from his condition so that he could earn a living
to help his family.
Religious Practices:
Patient is a Roman Catholic. Regularly, he prays to god and asks for healing and
guidance. However, he seldom attends mass at the church.

Review of Systems

General: (-) weight loss, (-) fatigue

Skin: (-) hyperpigmentation, (-) urticaria, (-) bruising
Endocrine: (-) heat or cold intolerance, (-) excessive thirst
HEENT: (-) headache (-) vertigo (-) changes in visual acuity (-) ear pain
Neck: (-) stiff neck (-) neck movement limitation
Pulmonary: (-) cough, (-) dyspnea, (-) wheeze
Cardiovascular: (-) palpitations, (-) chest pain
Breasts: (-) breast pain, (-) nipple discharge (-) masses
Gastrointestinal: (-) dysphagia, (-) odynophagia, (-) hemorrhoids
Urinary: (-) anuria, (-) hematuria
Genital tract: (-) discharge, (-) lesions
Musculoskeletal: (+) edema on lower extremities, (-) joints pains, (-) limitation of motion
Neurologic: (-) loss of consciousness, (-) headache (-) seizures, (-) tremors, (-) dizziness
Hematology: (-) easy bruising or bleeding

Physical Examination

General Survey: Awake, alert, coherent and not in respiratory distress. Well-groomed, shirt,
pants and slippers
Vital signs:

BP: 110/80 mmHg

RR: 21 cpm

HR: 74 bpm

Temp: 36.6 C

Weight: 62 kg

Height: 175 cm

BMI: 20.2 (Normal)

Skin:
Inspection: brown complexion; No laceration, skin discolorations, or lesions.
Palpation: Skin is dry, warm to touch and with good skin turgor.

HEENT:
Head: atraumatic; No deformities or masses.
Eyes: anicteric sclerae; pink palpebral conjunctiva, pupils are equally round and reactive to
light and accommodation
Ears: Symmetric; No ear discharge
Nose: Nasal septum is in midline; No polyp or nasal dripping noted.
Throat: Lips are moist and pink in color. Buccal mucosa is moist. No lesions and ulcerations
noted. No gingivitis or bleeding.

Neck:
No anterior masses. No palpable thyroid gland; no lymphadenopathies. Tracheal
deviation is not noted.

Chest & lungs:

Inspection: Symmetrical chest expansion; No use of accessory muscles of respirations;
No retractions
Palpation: Equal tactile and vocal fremitus felt on both lung fields
Percussion: Resonance heard on both lung fields
Auscultation: Clear breath sounds heard on both lung fields

Cardiovascular:
Inspection: Adynamic precordium
Palpation: Point of maximal impulse is noted on the left 5th intercostal space, midclavicular
line. No heaves and lifts.
Auscultation: Heart rate and rhythm is regular. Distinct S1 and S2. No murmurs heard.

Abdomen:
Inspection: flabby; No visible lesions or scars noted
Auscultation: Normoactive bowel sounds
Percussion: Tympany is heard on all quadrants
Palpation: Soft, No tenderness or masses

Genitourinary:
The patients bladder is not distended. No costovertebral angle tenderness

Extremities:
Inspection: Both upper and lower extremities are symmetrical; Nails beds are pink. No
deformities, cyanosis, edema or lesions noted. Full range of motion and muscle strength of 5/5
observed on all extremities.
Palpation: Strong peripheral pulses felt on both upper and lower extremities. Nail beds
are pink; with a capillary refill time of less than 2 seconds.

Cranial Nerves
CN1 able to smell cologne on left and right nostrils
CN2 can read letters without glasses on both eyes
CN3,4,6 able to move both his eyes and follow the pen up, down, right and left laterally
and obliquely. Pupils are reactive to light and accommodation on both eyes
CN5 able to clench jaw, and squint symmetrically with good muscle tone; intact facial
sensation
CN7 able to smile symmetrically with good muscle tone
CN8 good hearing on both ears able to hear whispered words. Can stand on one foot on
both feet
CN9, 10 able to swallow and intact gag reflex
CN11 Able to shrug both shoulders against resistance and was able to turn head to both
sides without difficulty
CN 12 able to protrude the tongue and move side by side, up and front without twitching
and tremors

Involuntary movements:
(-) tremors
Muscle tone:
(-) flaccidity, spasticity nor atrophy
Muscle Strength:
(-) hemiplegia nor hemiparesis
5/5 motor strength in all except left arm (immobile)
Gait:
able to stand and walk without assistance
(-) meningeal signs

Mental Status Examination

Appearance:
Patient appeared well groomed, appropriately dressed for age & sex. No body odor noted.
He is accompanied by his mother.
Behaviour and Psychomotor Activity:
Patient was not restless, no psychomotor retardation, not agitated, with no muscle
rigidity. He has good eye contact.
Mood and affect:
Euthymic mood with appropriate affect
Neurovegetative Function:
No changes in appetite, although patient had mixed insomnia. Occasionally, he wakes up
in the middle of the night and had a hard time going back to sleep. He also gained weight.
He is more active during the day and has libido to live his life. Attention is good.
Speech:
He talks in a spontaneous speech with normal rate and clear understandable words
Perception:
Denies any auditory, visual or tactile hallucinations
Thought process and content:
Patient had no looseness of association, flight of ideas, tangentiality, thought blocking,
circumstantiality or neologism. However, last week, patient claimed to have grandiose
delusion (Makalupad ko ato). Also, he had no suicidal/homicidal ideation and ideas of
reference.

Sensorium and cognition:

Patient is oriented to 3 spheres. Remote, recent past, recent and immediate memory were
intact. He has good attention and concentration. Patient has abstract thought and fund of
knowledge.
Judgment and insight:
Social and test judgment is unimpaired. Patient had partial insight about his condition.

Salient Features

History

Physical Examination

22 year old

Unremarkable physical findings during the

Male

time of examination

Lives in a rural area

Gets nervous easily, has difficulty
sharing his problems to others
diagnosed case of schizophrenia last
march 2016
non-compliant to medications x 2
months
patient felt the following signs and
symptoms:
staring blankly
talking to himself
laughing alone
had difficulty sleeping
had loss of appetite

 didnt talk to anyone else

(+) auditory hallucinations
(+)

persecutory

and

grandiose

delusions
Dizziness & occasional headaches
bizarre thoughts such as bad things
against his family members
(+) nervousness

Mental Status Examination

(+) mixed insomnia
(+) grandiose delusions
(+) partial insight

ADMITTING IMPRESSION: Schizophrenia

DIFFERENTIAL DIAGNOSES
Major Depressive Disorder
Diagnostic Criteria
A. Five (or more) of the
following symptoms have
been present during the same
2-week
period and represent a
change from previous
functioning: at least one of the
symptoms
is either (1) depressed mood
or (2) loss of interest or
pleasure.
1. Depressed mood most of
the day, nearly every day, as
indicated by either
subjectivereport or
observation made by others.
2. Markedly diminished
interest or pleasure in all, or
almost all, activities most of
the day, nearly every day.
3. Significant weight loss
when not dieting or weight
gain (e.g., a change of more
than5% of body weight in a
month), or decrease or
increase in appetite nearly
every day.
4. Insomnia or hypersomnia
nearly every day.
5. Psychomotor agitation or
retardation nearly every day.
6. Fatigue or loss of energy
nearly every day.
7. Feelings of worthlessness
or excessive or inappropriate
guilt nearly every day.
8. Diminished ability to think
or concentrate, or
indecisiveness, nearly every
day.
9. Recurrent thoughts of
death (not just fear of dying),

Rule In

Rule Out

recurrent suicidal ideation

withouta specific plan, or a
suicide attempt or a specific
plan for committing suicide.
B. The symptoms cause
clinically significant distress or
impairment in social,
occupational,
or other important areas of
functioning.
C. The episode is not
attributable to the
physiological effects of a
substance or to another
medical condition.
D. The occurrence of the
major depressive episode is
not better explained by
schizoaffective
disorder, schizophrenia,
schizophreniform disorder,
delusional disorder, or
other specified and
unspecified schizophrenia
spectrum and other psychotic
disorders.
E. There has never been a
manic episode or a
hypomanie episode.
Note: This exclusion does not
apply if all of the manic-like or
hypomanic-like episodes
are substance-induced or are
attributable to the
physiological effects of
another medical
condition.
Schizoaffective Disorder
Diagnostic Criteria
A. An uninterrupted period of
illness during which there is a
major mood episode (major
depressive or manic)
concurrent with Criterion A of
schizophrenia.

Rule In

Rule Out

B. Delusions or hallucinations
for 2 or more weeks in the
absence of a major mood
episode (depressive or manic)
during the lifetime duration of
the illness.
C. Symptoms that meet
criteria for a major mood
episode are present for the
majority of the total duration of
the active and residual
portions of the illness.
D. The disturbance is not
attributable to the effects of a
substance (e.g., a drug of
abuse, a medication) or
another medical condition.

Bipolar I Disorder w/ psychotic features

Manic Episode
Rule In
Diagnostic Criteria
A. A distinct period of
abnormally and persistently
elevated, expansive, or
irritable mood and abnormally
and persistently increased
goal-directed activity or
energy, lasting at least 1 week
and present most of the day,
nearly every day (or any
duration if hospitalization is
necessary).
B. During the period of mood
disturbance and increased
energy or activity, three (or
more) of the following
symptoms (four if the mood is
only irritable) are present to a
significant degree and
represent a noticeable change
from usual behavior:
1. Inflated self-esteem or
grandiosity.
2. Decreased need for sleep
(e.g., feels rested after only 3
hours of sleep).

Rule Out

3. More talkative than usual or

pressure to keep talking.
4. Flight of ideas or subjective
experience that thoughts are
racing.
5. Distractibility (i.e., attention
too easily drawn to
unimportant or irrelevant
external stimuli), as reported
or observed.
6. Increase in goal-directed
activity (either socially, at work
or school, or sexually) or
psychomotor agitation (i.e.,
purposeless non-goal-directed
activity).
7. Excessive involvement in
activities that have a high
potential for painful
consequences (e.g., engaging
in unrestrained buying sprees,
sexual indiscretions, or foolish
business investments).
C. The mood disturbance is
sufficiently severe to cause
marked impairment in social
or occupational functioning or
to necessitate hospitalization
to prevent harm to self or
others, or there are psychotic
features.
D. The episode is not
attributable to the
physiological effects of a
substance (e.g., a drugof
abuse, a medication, other
treatment) or to another
medical condition.

Schizophrenia
Diagnostic Criteria
A. Two (or more) of the
following, each present for a
significant portion of time

Rule In

Rule Out

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 (e.g.,
frequent derailment or
incoherence).
4. Grossly disorganized or
catatonic behavior.
5. Negative symptoms (i.e.,
diminished emotional
expression or avolition).
B. 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).
C. Continuous signs of the
disturbance persist for at
least 6 months. This 6month period must include
at least 1 month of
symptoms (or less if
successfully treated) that
meet Criterion A (i.e., activephase 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 (e.g., odd

beliefs, unusual perceptual
experiences).
D. 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 activephase symptoms, they have
been present for a minority
of the total duration of the
active and residual periods
of the illness.
E. The disturbance is not
attributable to the
physiological effects of a
substance (e.g., a drug of
abuse, a medication) or
another medical condition.
F. 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).

FINAL DIAGNOSIS: SCHIZOPHRENIA

CASE DISCUSSION
Schizophrenia is a chronic and disabling mental illness that affects men and women in
equal numbers. The disease is characterized by 3 types of symptoms: positive symptoms, which
include delusions and hallucinations; disorganized thought and speech; and negative or deficit
symptoms, which include reduced thought and speech, flattened affect, and decreased initiation
of

goal-directed

behavior.

The

alterations

in

psychological

processes--perception

(hallucinations), reality (delusions), thought, feeling (flat or inappropriate affect), behavior,

attention, concentration, motivation, and judgment--lead to such functional impairments as
learning problems, self-care deficits, and impaired working and interpersonal relationships.
Epidemiology
The lifetime prevalence of schizophrenia has generally been estimated to be
approximately 1% worldwide. However, a systematic review by Saha et al of 188 studies drawn
from 46 countries found a lifetime risk of 4.0 per 1000 population; prevalence estimates from
countries considered least developed were significantly lower than those from countries classed
as emerging or developed.
The prevalence of schizophrenia is about the same in men and women. The onset of
schizophrenia is later in women than in men, and the clinical manifestations are less severe. This
may be because of the antidopaminergic influence of estrogen.

Etiology
The causes of schizophrenia are not known. Most likely, there are at least 2 sets of risk
factors, genetic and perinatal. In addition, undefined socioenvironmental factors may increase the
risk of schizophrenia in international migrants or urban populations of ethnic minorities.
Increased paternal age is associated with a greater risk of schizophrenia.
The risk of schizophrenia in first-degree relatives of persons with schizophrenia is 10%.
If both parents have schizophrenia, the risk of schizophrenia in their child is 40%. Concordance
for schizophrenia is about 10% for dizygotic twins and 40-50% for monozygotic twins.

Pathophysiology
Anatomic, neurotransmitter, and immune system abnormalities have been implicated in
the pathophysiology of schizophrenia.
Anatomic Abnormalities
Neuroimaging studies show differences between the brains of those with schizophrenia
and those without this disorder. For example, the ventricles are somewhat larger, there is
decreased brain volume in medial temporal areas, and changes are seen in the hippocampus.
Interest has also focused on the various connections within the brain rather than on localization
in a single part of the brain. Magnetic resonance imaging (MRI) studies show anatomic
abnormalities in a network of neocortical and limbic regions and interconnecting white-matter
tracts. A meta-analysis of studies using diffusion tensor imaging (DTI) to examine white matter
found that 2 networks of white-matter tracts are reduced in schizophrenia.
Neurotransmitter System Abnormalities
Abnormalities of the dopaminergic system are thought to exist in schizophrenia. The first
clearly effective antipsychotic drugs, chlorpromazine and reserpine, were structurally different
from each other, but they shared antidopaminergic properties. Drugs that diminish the firing rates

of mesolimbic dopamine D2 neurons are antipsychotic, and drugs that stimulate these neurons
(eg, amphetamines) exacerbate psychotic symptoms.
Hypodopaminergic activity in the mesocortical system, leading to negative symptoms,
and hyperdopaminergic activity in the mesolimbic system, leading to positive symptoms, may
coexist. Moreover, the newer antipsychotic drugs block both dopamine D2 and serotonin (5hydroxytryptamine [5-HT]) receptors.
Clozapine, perhaps the most effective antipsychotic agent, is a particularly weak
dopamine D2 antagonist. Thus, other neurotransmitter systems, such as norepinephrine,
serotonin, and gamma-aminobutyric acid (GABA), are undoubtedly involved.
Inflammation and Immune Function
Immune function is disturbed in schizophrenia. Overactivation of the immune system (eg,
from prenatal infection or postnatal stress) may result in overexpression of inflammatory
cytokines and subsequent alteration of brain structure and function. For example, schizophrenic
patients have elevated levels of proinflammatory cytokines that activate the kynurenine pathway,
by which tryptophan is metabolized into kynurenic and quinolinic acids; these acids regulate
NMDA receptor activity and may also be involved in dopamine regulation.
Insulin resistance and metabolic disturbances, which are common in the schizophrenic
population, have also been linked to inflammation. Thus, inflammation might be related both to
the psychopathology of schizophrenia and to metabolic disturbances seen in patients with
schizophrenia.
Diagnosis
The symptoms of schizophrenia may be divided into the following 4 domains:

Positive symptoms - Psychotic symptoms, such as hallucinations, which are usually

auditory; delusions; and disorganized speech and behavior

Negative symptoms - A decrease in emotional range, poverty of speech, and loss of

interests and drive; the person with schizophrenia has tremendous inertia

Cognitive symptoms - Neurocognitive deficits (eg, deficits in working memory and

attention and in executive functions, such as the ability to organize and abstract); patients also
find it difficult to understand nuances and subtleties of interpersonal cues and relationships

Mood symptoms - Patients often seem cheerful or sad in a way that is difficult to
understand; they often are depressed
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5),
to meet the criteria for diagnosis of schizophrenia:
A. The patient must have experienced at least 2 of the following symptoms :

Delusions

Hallucinations

Disorganized speech

Disorganized or catatonic behavior

Negative symptoms
At least 1 of the symptoms must be the presence of delusions, hallucinations, or disorganized
speech.
Continuous signs of the disturbance must persist for at least 6 months, during which the patient
must experience at least 1 month of active symptoms (or less if successfully treated), with social
or occupational deterioration problems occurring over a significant amount of time. These
problems must not be attributable to another condition
B. 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 relationships, 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).
C. 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 (ie,
active phase symptoms) and may include periods of prodomal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbances may be manifested by only

negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated

form (eg, odd beliefs, unusual perceptual experiences).
D. 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.
E. The disturbance is not attributable to the physiological effects of a substance (eg, a drug of
abuse, a medication) or another medical condition.
F. 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).

Treatment
The APA Guideline stresses the importance of the initial work-up and the use of
antipsychotic medications.
Treatment begins with a thorough initial work-up to rule out conditions that may mimic
schizophrenia, to identify any comorbid conditions that can complicate diagnosis and/or
treatment, to establish a baseline for monitoring the course of illness and response to treatment,
and to initiate any routine medical care required--for example, to manage a chronic illness that
may have been neglected by the patient.

Acute Psychosis
Acute psychotic symptoms require immediate attention. Treatment during the acute phase
focuses on alleviating the most severe psychotic symptoms. This phase usually lasts from 4 to 8
weeks. Acute schizophrenia is typically associated with severe agitation, which can result from
such symptoms as frightening delusions, hallucinations, or suspiciousness, or from other causes
(including stimulant abuse). Patients with akathisia can appear agitated when they experience a
subjective feeling of motor restlessness. Differentiating akathisia from psychotic agitation can be
difficult, particularly when patients are incapable of describing their internal experience. If
patients are receiving an agent associated with extrapyramidal side effects, usually a firstgeneration antipsychotic, a trial with an anticholinergic anti-Parkinson medication,
benzodiazepine, or propranolol (Inderal) may be helpful in making the discrimination.
Clinicians have a number of options for managing agitation that results from psychosis.
Antipsychotics and benzodiazepines can result in relatively rapid calming of patients. With
highly agitated patients, intramuscular administration of antipsychotics produces a more rapid
effect. An advantage of an antipsychotic is that a single intramuscular injection of haloperidol
(Haldol), fluphenazine (Prolixin, Permitil), olanzapine (Zyprexa), or ziprasidone (Geodon) will
often result in calming effect without excessive sedation. Low-potency antipsychotics are often
associated with sedation and postural hypotension, particularly when they are administered
intramuscularly. Intramuscular ziprasidone and olanzapine are similar to their oral counterparts
in not causing substantial extrapyramidal side effects during acute treatment. This can be an
important advantage over haloperidol or fluphenazine, which can cause frightening dystonias or
akathisia in some patients.
Antipsychotic medications (also known as neuroleptic medications or major
tranquilizers) diminish the positive symptoms of schizophrenia and prevent relapses.
Approximately 80% of patients relapse within 1 year if antipsychotic medications are stopped,
whereas only 20% relapse if treated.The guideline states that second-generation agents should be
considered first-line options for patients in the acute phase, mainly because of the decreased risk
of extrapyramidal side effects and tardive dyskinesia, but acknowledges debate over the relative
advantages, disadvantages, and cost-effectiveness of first- and second-generation agents. The
guideline also states that for some patients, a first-generation agent may be an appropriate first-

line option. This latter recommendation has been strengthened by the results of several recently
published effectiveness studies that suggest that the first-generation antipsychotics perphenazine
and molindone may be equally effective as second-generation agents. In fact, the distinction
between first- and second-generation antipsychotics appearsto have limited clinical utility.
According to the results of a year-long randomized controlled trial, starting a long-acting
injectable (LAI) antipsychotic after a first episode of schizophrenia is more effective than
starting an oral antipsychotic. If the patient has not responded to a medication, physicians can
switch medications or add another one. Anticholinergic agents (eg, benztropine, trihexyphenidyl,
and diphenhydramine) and amantadine are often used in conjunction with the conventional
antipsychotic agents to prevent dystonic movements or to treat extrapyramidal symptoms.
Akathisia is particularly difficult to treat, but it occasionally responds to an anticholinergic agent,
a benzodiazepine, or a beta blocker.
As described in the guideline, psychosocial treatments such as family intervention,
supportedemployment, assertive community treatment, skills training, and cognitive-behavioral
therapy (CBT) can prevent relapse and enable recovery during the stable phase of treatment.
Some interventions, such as family psychoeducation, may also be initiated during the acute
phase.
Stabilization and Maintenance Phase
In the stable or maintenance phase, the illness is in a relative stage of remission. The
goals during this phase are to prevent psychotic relapse and to assist patients in improving their
level of functioning. As newer medications have been introduced with a substantively reduced
risk of tardive dyskinesia, one of the major concerns about long-term treatment has been
diminished. During this phase, patients are usually in a relative state of remission with only
minimal psychotic symptoms. Stable patients who are maintained on an antipsychotic have a
much lower relapse rate than patients who have their medications discontinued. Data suggest that
16 to 23 percent of patients receiving treatment will experience a relapse within 1 year, and 53 to
72 percent will relapse without medications. Even patients who have had only one episode have
a four in five chance of relapsing at least once over the following 5 years. Stopping medication
increases this risk fivefold.

Although published guidelines do not make definitive recommendations about the

duration of maintenance treatment after the first episode, recent data suggest that 1 or 2 years
might not be adequate. This is a particular concern when patients have achieved good
employment status or are involved in educational programs because they have a lot to lose if they
experience another psychotic decompensation.
It is generally recommended that multiepisode patients receive maintenance treatment for
at least 5 years, and many experts recommend pharmacotherapy on an indefinite basis.
Prognosis
The prognosis is guarded. Full recovery is unusual. Early onset of illness, family history
of schizophrenia, structural brain abnormalities, and prominent cognitive symptoms are
associated with a poor prognosis. The prognosis is better for people living in low-income and
middle-income countries.
Symptoms usually follow a waxing-and-waning course and their nature may change over
time. Positive symptoms respond fairly well to antipsychotic medication, but the other symptoms
are quite persistent.
Because of vocational difficulties, many patients with schizophrenia also have to cope
with the burdens of poverty. These include limited access to medical care, which may lead to
poor control of the disease; homelessness; and incarceration, typically for minor offenses.
People with schizophrenia have a 5% lifetime risk of suicide. Other factors that contribute
to increased mortality include lifestyle issues such as cigarette smoking, poor nutrition, and lack
of exercise, and perhaps poorer medical care and complications of medications. A study from
Britain shows that this mortality gap is increasing.
References: Kaplan N Sadocks Synopsis of Psychiatry, 11th ed
American Psychiatric Association CPG