Schizophrenia Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is one of the most common reasons for psychiatric admission and a major cause of acute behavioural disturbance in the ED. You need to be able to assess, stabilise, and rule out organic causes quickly and safely.
High-Yield Definition (DSM-5): A chronic brain disorder characterised by ≥2 of the following, each present for a significant portion of time during a 1-month period (and at least one must be 1, 2, or 3): (1) Delusions, (2) Hallucinations, (3) Disorganised speech, (4) Grossly disorganised or catatonic behaviour, (5) Negative symptoms. This leads to significant social/occupational dysfunction with continuous signs of disturbance persisting for at least 6 months.
Clinical One-Liner: Basically, it's a chronic illness that fractures a person's perception of reality, affecting how they think, feel, and interact with the world.
II. Etiology & Risk Factors
Etiology: It's not fully understood, but we work with a multifactorial model. The key theory you must know is the Dopamine Hypothesis: positive symptoms are linked to excess dopamine activity in the mesolimbic pathway, while negative/cognitive symptoms are linked to reduced dopamine in the mesocortical pathway. There is a strong genetic component.
Risk Factors:
Non-modifiable:
Genetics (Family history is the single strongest risk factor; ~10% risk in first-degree relatives).
Male gender (tend to have earlier onset and poorer outcome).
Modifiable / Environmental:
Cannabis use, especially high-potency types during adolescence.
Perinatal factors (e.g., obstetric complications, maternal malnutrition/infection).
Urban upbringing.
Migration.
III. Quick Pathophysiology
Think of it as a circuit problem. The mesolimbic pathway (ventral tegmental area to nucleus accumbens) becomes hyperactive, leading to the "positive" symptoms like hallucinations and delusions. Meanwhile, the mesocortical pathway (VTA to the prefrontal cortex) is hypoactive, causing the "negative" and cognitive symptoms like apathy, flat affect, and executive dysfunction. This is why our typical antipsychotics, which are pure D2 blockers, are great for positive symptoms but can sometimes worsen negative symptoms.
IV. Clinical Assessment
Red Flags & Immediate Actions:
Command hallucinations to harm self/others: Immediate 1-to-1 observation, alert senior, consider need for restraint and rapid tranquilisation.
Acute agitation/aggression: Ensure staff safety first. Attempt verbal de-escalation. If fails -> Alert senior/security, prepare for rapid tranquilisation (RT).
Catatonia (immobility, mutism, waxy flexibility): Rule out organic causes. This is a medical emergency. Alert senior, consider Lorazepam challenge.
Suspected Neuroleptic Malignant Syndrome (NMS): Fever, muscle rigidity, autonomic instability in a patient on antipsychotics -> Stop all antipsychotics, STAT bloods (CK, FBC, RP), alert senior immediately for transfer to medical ward.
History:
Presenting Complaint: Focus on the core symptoms (Positive, Negative, Cognitive). Get specific examples of delusions or hallucinations.
History of Presenting Illness: Clarify onset (acute vs. insidious) and duration. Crucially, ask about functional decline (work, studies, self-care).
Collateral History: This is non-negotiable. Speak to family or friends. Patients often have poor insight. You need to know their baseline personality and function.
Pertinent Negatives: Ask about mood symptoms (mania/depression) to rule out bipolar/schizoaffective disorder. Ask about substance use (especially cannabis, methamphetamines). Ask about medical history to rule out organic causes (epilepsy, thyroid disease, autoimmune conditions).
Physical Examination:
The main tool is the Mental State Examination (MSE):
Appearance & Behaviour: Dishevelled, bizarre clothing, poor rapport, psychomotor agitation or retardation.
Speech: Disorganised (e.g., thought blocking, tangentiality, word salad).
Mood & Affect: State mood (e.g., "depressed," "anxious"). Describe affect (e.g., blunted, flat, incongruent).
Thought Content: Delusions (persecutory, grandiose, bizarre). Assess for suicidal/homicidal ideation.
Perception: Hallucinations (auditory are most common; third-person running commentary is classic).
Cognition: Assess orientation, attention. Formal cognitive testing is for later.
Insight: Often impaired (rated from 1-6, where 1 is complete denial of illness).
Perform a full physical and neurological exam to rule out organic pathology. Look for signs of substance use or toxidromes.
Clinical Pearl: When a patient is acutely psychotic, your first priority is not a deep, psychoanalytic history. It is to ensure safety (yours, theirs, and others'), complete a focused assessment to rule out immediate medical emergencies, and get collateral information.
V. Diagnostic Workflow
Differential Diagnosis: Your primary job is to exclude things that look like schizophrenia but aren't.
Substance-Induced Psychotic Disorder:
Points For: Recent use of cannabis, methamphetamines, ketamine, or withdrawal from alcohol/benzos.
Points Against: Psychosis persists >1 month after cessation of substance.
How to Differentiate: Urine drug screen (UDS), good collateral history.
Psychosis due to a General Medical Condition (Organic Psychosis):
Points For: Atypical age of onset (>40), fluctuating consciousness, abnormal vitals, presence of neurological signs.
Points Against: Normal physical exam, clear sensorium, typical age of onset (late teens/early 20s).
How to Differentiate: Blood tests, CT brain, EEG if suspecting epilepsy. Think: infections, metabolic disturbance, CNS lesions, autoimmune (e.g., anti-NMDA receptor encephalitis).
Bipolar I Disorder, Manic Episode with Psychotic Features:
Points For: Prominent mood symptoms (elation, grandiosity, reduced need for sleep), psychosis is typically mood-congruent.
Points Against: Psychosis occurs in the absence of a major mood episode. Prominent negative symptoms.
How to Differentiate: A longitudinal history is key. Functioning often returns to baseline between bipolar episodes.
Schizoaffective Disorder:
Points For: Patient meets criteria for schizophrenia, but also has discrete, prominent major mood episodes (depressive or manic).
Points Against: Mood symptoms are brief relative to the total duration of the psychotic illness.
How to Differentiate: The key is timing: there must be a period of at least 2 weeks of delusions or hallucinations in the absence of a major mood episode.
Investigations Plan: This is a workup to exclude differentials.
Bedside / Initial (First 15 Mins):
Vital Signs: Tachycardia, hypertension, or fever can point to an organic cause or NMS.
Urine Drug Screen (UDS): Essential for all first-episode psychosis.
First-Line Labs & Imaging:
Full Blood Count (FBC): To rule out infection/anemia.
Renal Profile (RP) & Liver Function Test (LFT): Baseline before starting antipsychotics.
Thyroid Function Test (TFT): Hypo/hyperthyroidism can mimic psychiatric disorders.
Syphilis Serology (VDRL/RPR): Neurosyphilis is a classic organic cause.
CT Brain: Indicated for first-episode psychosis, late-onset, or presence of neurological signs to rule out a structural lesion.
VI. Staging & Severity Assessment
We don't "stage" schizophrenia like cancer. We describe its course and severity.
Course Specifiers (DSM-5):
First episode, currently in acute episode: The initial presentation.
Multiple episodes, currently in acute episode: A relapse.
Continuous: Symptoms persist for the majority of the illness course.
In partial/full remission: Symptoms are present but sub-threshold, or absent.
Severity Assessment: This is clinical. It's based on a quantitative assessment of the primary symptoms (delusions, hallucinations, etc.) on a 5-point scale from 0 (not present) to 4 (present and severe). For practical purposes, your assessment of functional impairment (self-care, social, occupational) is the most important measure of severity.
VII. Management Plan
Immediate Stabilisation (The ED / On-Call Plan):
A (Airway), B (Breathing), C (Circulation): Usually not an issue unless there is substance intoxication or NMS.
D (Disability/De-escalation):
Verbal De-escalation: Use a calm, non-threatening approach. Maintain personal space. Do not argue about their delusions.
Rapid Tranquilisation (RT): If verbal de-escalation fails and the patient is a danger to self/others. A common regimen in our setting is:
IM Haloperidol 5mg + IM Midazolam 2.5-5mg.
OR IM Olanzapine 10mg.
Caution: Monitor for respiratory depression (with benzos) and acute dystonia (with haloperidol).
E (Environment): Move patient to a quiet, safe area. Remove any potential weapons. Ensure adequate staff are present.
Definitive Treatment (The Ward Round Plan):
First-Line (Pharmacological):
Second-Generation Antipsychotics (SGAs / Atypicals): Preferred due to lower risk of Extrapyramidal Side Effects (EPS).
Risperidone: Start 1-2mg ON. Titrate up. Common brand: Risperdal.
Olanzapine: Start 5-10mg ON. Potent, but high risk of metabolic side effects (weight gain, dyslipidemia). Common brand: Zyprexa.
Paliperidone: Active metabolite of risperidone. Fewer drug-drug interactions.
Second-Line / Treatment-Resistant Schizophrenia (TRS):
Clozapine: The gold standard for TRS (defined as failure of two different antipsychotic trials). Requires mandatory weekly FBC monitoring initially due to risk of agranulocytosis. This is strictly consultant-led.
Non-Pharmacological (Crucial for Recovery):
Psychoeducation: For patient and family.
Cognitive Behavioural Therapy for psychosis (CBTp).
Family Intervention/Therapy.
Supported Employment & Social Skills Training.
Long-Term & Discharge Plan:
Long-Acting Injectable (LAI) Antipsychotics: Consider for patients with poor medication adherence. Examples: Paliperidone Palmitate (Xeplion), Aripiprazole Maintena.
Discharge Medications: Ensure clear instructions and adequate supply.
Follow-up: Arrange appointment with community psychiatric clinic / Klinik Kesihatan mental health team.
VIII. Complications
Immediate (From Treatment):
Acute Dystonia: Painful muscle spasms (e.g., torticollis, oculogyric crisis) within hours/days of starting an antipsychotic (especially typicals like Haloperidol). Management: IM/IV Benztropine 2mg or Diphenhydramine 25-50mg.
Short-Term:
Akathisia: Unpleasant inner restlessness. Management: Reduce antipsychotic dose, consider Propranolol.
Metabolic Syndrome: Weight gain, hypertension, dyslipidemia, insulin resistance (highest risk with Olanzapine and Clozapine). Management: Baseline and regular monitoring of weight, BP, fasting glucose, and lipids.
Long-Term:
Tardive Dyskinesia (TD): Involuntary, repetitive body movements (e.g., grimacing, lip-smacking). Can be irreversible.
Suicide: Risk is significantly elevated (~5-10% lifetime risk).
Co-morbid Substance Use & Physical Illness: High rates of smoking, diabetes, and cardiovascular disease contribute to a ~15-20 year reduction in life expectancy.
IX. Prognosis
The classic "rule of thirds" is a useful simplification: about 1/3 achieve significant recovery, 1/3 have persistent symptoms with relapses, and 1/3 are severely affected and refractory to treatment.
Good Prognostic Factors: Late/acute onset, female, good premorbid function, obvious precipitating factor, prominent mood symptoms.
Poor Prognostic Factors: Early/insidious onset, male, poor premorbid function, prominent negative symptoms, strong family history.
X. How to Present to Your Senior
Use the SBAR format. Be concise.
"Dr, for your review please. This is [patient name], a [age]-year-old [gender] in the ED, brought in by police for [reason e.g., aggressive behaviour at home]. This is their first presentation.
Situation: He is acutely agitated and responding to unseen stimuli.
Background: Collateral from his mother suggests a 3-month history of social withdrawal and talking to himself, with functional decline from his job. No significant past medical history.
Assessment: My initial MSE findings are [e.g., blunted affect, persecutory delusions, third-person auditory hallucinations]. Vitals are stable. My primary differential is a first episode of psychosis, likely Schizophrenia Spectrum Disorder, versus substance-induced psychosis.
Recommendation: I have sent off the initial bloods and a urine drug screen. I need your guidance on starting an antipsychotic and for admission to the psychiatric ward."
XI. Summary & Further Reading
Top 3 Takeaways:
Safety first, rule out organic causes second. Your first job with any new psychosis is to be a physician, not a psychiatrist.
Collateral history is not optional. It is essential for diagnosis and management.
Start with a Second-Generation Antipsychotic (SGA). Monitor closely for both therapeutic effects and side effects, especially metabolic changes.
Key Resources:
Malaysian CPG: Management of Schizophrenia in Adults (2nd Edition, 2020) - This should be your primary reference. Look for it on the MOH website.
UpToDate: Search for "Schizophrenia in adults: Epidemiology and pathogenesis" and "Schizophrenia in adults: Clinical features, diagnosis, and course".
NEJM Review: Tandon, R., Gaebel, W., Barch, D. M., Bustillo, J., Gur, R. E., Heckers, S., Malaspina, D., Owen, M. J., Schultz, S., Tsuang, M., Van Os, J., & Carpenter, W. (2013). Definition and description of schizophrenia in the DSM-5. Schizophrenia research, 150(1), 3–10. (This is a foundational paper on the modern definition).
