Which form is the least common

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Paranoid. They also tend to be slightly older at onset, and have prominent hallucinations and delusions, with a lesser component of disorganization.

Catatonic. Prior to the development of antipsychotics, this form was more common.

What is catalepsy and waxy flexibility?

What is the most predictive of overall prognosis in schizophrenia?

Overall, schizophrenia is associated with repeated psychotic episodes, and a chronic downhill course. What features are associated with a somewhat better prognosis?

Are patients with schizophrenia at risk of suicide?

What is the primary treatment for schizophrenia?

What is the difference between typical and atypical antipsychotics?

What is EPS?

How do you treat EPS? What is tardive dyskinesia?

How do you treat tardive dyskinesia?

Catalepsy is the ability of a catatonic patient to hold a seemingly uncomfortable position for extended periods of time. Waxy flexibility is the slight resistance given to moving the limbs, after which the patient will often hold the new position given.

Level of premorbid function

Abrupt onset, female gender, presence of mood symptoms, and old age at onset

Yes! Over half of schizophrenics will attempt suicide at some point in their lives, and 10% will die from it.

Antipsychotics.

Typical antipsychotics are older and tend to work by antagonizing dopamine. Comparatively they have higher rates of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD). Atypical antipsychotics are newer, have complex mechanisms, have less EPS and TD, are more expensive, and have more metabolic side effects.

This includes tremor, rigidity, akathisia (inner restlessness), and acute dystonias (muscle spasm).

Anticholinergics (eg, diphenhydramine and benztropine)

Abnormal movements of the face, trunk, extremities, and mouth that may happen after prolonged exposure to antipsychotic medications.

Early identification and removal of the offending antipsychotic drug. With early recognition, remission rates are reasonably high. Benzodiazepines can be used for mild persistent cases.

What are some differences between EPS and TD to remember?

EPS can develop quite quickly, whereas TD tends to come on after prolonged exposure to medicines—months to years. TD is not helped by anticholinergics and may become worse. TD is also more often permanent.

What is a potentially fatal side effect of antipsychotic treatment?

Neuroleptic malignant syndrome (NMS). This is an idiosyncratic reaction that is more common in young men, usually after recently starting a new antipsychotic. Mortality is nearly 20%.

How does NMS present?

Fever, muscle rigidity, altered mental status, and autonomic instability

What is the first thing you should do if a patient presents to the ER with NMS?

Stop the antipsychotic! Then care is primarily supportive.

Other Psychotic Disorders

What is the DSM-IV-TR criteria for Schizoaffective Disorder?

What are the two types of schizoaffective disorder?

How could you differentiate between a mood disorder with psychotic symptoms (eg, major depressive disorder [MDD] with psychosis or Bipolar Mania) from schizoaffective disorder?

Must meet criteria for either a major depressive episode, a manic episode, or a mixed episode at the same time as meeting characteristic symptoms of schizophrenia. The schizophrenic symptoms must persist in the absence of mood symptoms.

1. Bipolar

2. Depressed

A person that has a mood disorder with psychotic symptoms will not have psychosis without a mood disturbance. Schizoaffective patients have psychosis at some point even when they are not experiencing an affective disturbance. Tip: Look at the names! For example, in schizoaffective disorder, the emphasis is on the schizo. The primary problem is a psychotic disorder that sometimes has a mood component, whereas in MDD with psychosis, the emphasis is on MDD. The main problem is a mood disorder that when severe, may have a component of psychosis.

Patients with delusional disorder tend to have an isolated, fixed, nonbizarre delusion (eg, the Internal Revenue Service [IRS] is after them, or their partner is cheating). Even if the delusion is unfounded, it is plausible. They are not disorganized in thoughts or affect, and patients do not meet criteria for schizophrenia.

1. Erotomanic: Someone is in love with patient.

2. Somatic.

3. Grandiose.

4. Jealous: Wife/husband is cheating.

5. Persecutory: Patient is being mistreated.

What is a shared psychotic disorder? A rare disorder where the patient believes the delusions of another person with a primary psychotic disorder.

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