Schizophrenia is a common psychiatric condition encountered by EMS professionals that is characterized by disturbances in the patient's perceptions, thoughts, behaviors and affect that last for more than six months. Although in Greek the word schizophrenia means "split mind," it does not mean split personality. Because schizophrenia is commonly mistaken for various other psychiatric conditions, it is important for EMS providers to know what it is and how to assess and manage patients who have or display signs and symptoms associated with this condition.

EPIDEMIOLOGY

   Schizophrenia is a debilitating brain disorder that affects 2.4 million American adults, or 1.1% of the population.¹ Schizophrenia usually occurs in late adolescence or early adulthood, although it can occur at any age. Typically, the psychotic symptoms associated with this disorder appear earlier in males than in females, but the disorder usually affects both genders equally.² Schizophrenia is more common than multiple sclerosis, insulin-dependent diabetes, muscular dystrophy and Huntington's disease.³ Life expectancy associated with this condition is reduced by 20% compared with the general population. The reasons for this include an increased risk of suicide, increased risk of coronary heart disease, cardiovascular disease, hypertension, obesity, cigarette smoking, and insulin resistance and diabetes.⁴

CAUSES

   Unlike many medical conditions, there is no known cause for schizophrenia, although the majority of researchers believe it is caused by interaction of a number of biological and environmental factors. Some of the most commonly cited factors are listed below:⁵

   • Genetic factors

   Genetic factors are believed to play a significant role in the development of schizophrenia. Patients who have a family history of schizophrenia have an increased chance of developing this condition.

   • Structural brain changes

   Abnormalities within the frontal, temporal, limbic and basal ganglia areas of the brain have been identified via CT, MRI, PET scan and postmortem studies. Atrophy and reduced brain volume have also been attributed to this condition.

   • Neurochemical and neurophysical changes

   Changes in dopamine, norepinephrine, serotonin, cholinergic glutamatergic, neuropeptide and GABAergic have been implicated. Neuronal loss in the thalamus has also been cited.

   • Endocrine factors

   Changes in prolactin, melatonin and thyroid function have been cited.

   • Viruses and immune factors

   Although a specific virus has not been identified, it is suspected that perinatal viral infections may be a cause. Immune changes have also been found in schizophrenic patients.

   • Environmental factors

   Difficult birth or obstetrical trauma resulting in hypoxia can play a role. Some also link winter births as a predisposing factor.

   • Psychosocial factors

   Once believed to be the cause of schizophrenia, these factors are now believed to only have a role in the illness itself.

SIGNS AND SYMPTOMS

   The signs and symptoms seen in patients with schizophrenia vary with each individual and can impair personal, social and occupational functioning.⁶ Most frequently, the signs and symptoms will continuously wax and wane throughout the patient's lifetime. During active periods, the signs and symptoms are classified as positive or negative.

POSITIVE SYMPTOMS

   • Delusions

   Delusions are false beliefs that are not shared by others within a culture. Many delusions are bizarre, religious, somatic or persecutory in nature and often involve loss of control over the mind or body.⁷

   • Hallucinations

   Hallucinations are any type of sensory experience (auditory, visual, olfactory, gustatory or tactile) that does not exist, but is very real to the patient. Auditory hallucinations are the most common symptom. Patients may hear unpleasant sounds, words, phrases or voices. Sometimes, the voices command or suggest that a patient do things that may be dangerous to himself or others.⁸

   • Disorganized speech

   Patients with disorganized speech may jump randomly from one subject to another. Their speech may lack content. Some may use neologisms, or meaningless made-up words, or may frequently repeat words or phrases. Some patients' speech may be totally incoherent and disorganized, referred to as word salad.⁷

   • Catatonic or disorganized behavior

   Patients with schizophrenia often display unorganized behavior. Some may display negativism, doing or saying things that are completely opposite of what is appropriate for the situation, while others may automatically obey anything they are told despite the consequences of their actions.

   Many patients with disorganized behavior may appear improperly dressed and walk about aimlessly talking to themselves. Their behavior is often bizarre, and they may appear agitated or aggressive. Others may be completely unaware of their surroundings and maintain a rigid posture, resisting any type of movement. This positioning is usually referred to as catatonia.⁷ These types of unusual behaviors often lead to 9-1-1 calls from bystanders or family members for medical and sometimes police assistance.

NEGATIVE SYMPTOMS

   • Flat affect or decreased emotional reactivity

   This is one of the most common symptoms associated with schizophrenia. While some patients with schizophrenia may be depressed, many just have a lifeless facial expression and speak in monotone.

   • Alogia or poverty of speech

   Patients talk, but there is no real content to their conversation.

   • Avolition or lack of purposeful action

   Patients lack purpose when performing any activity.

DIAGNOSIS OF SCHIZOPHRENIA

   Diagnosis of schizophrenia is based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria (see Figure 1 on page 66).⁷

   Various tests are performed, along with a thorough history, physical exam and neuropsychological assessment by physicians, to formulate the diagnosis. Part of this process includes ensuring that other medical conditions are not the cause of the patient's signs and symptoms. The following medical conditions can induce psychosis and may be mistaken for schizophrenia.⁵

• Huntington's or Parkinson's disease
• Head trauma
• Infections—encephalitis, abscess, neurosyphilis
• Endocrine disease—thyroid, Cushing's, Addison's, pituitary, parathyroid diseases
• Substance abuse and drug toxicity
• Central nervous system lesions, tumors, aneurysms
• Systemic lupus erythematosus and multiple sclerosis
• Cerebrovascular disease or stroke
• Withdrawal from alcohol and benzodiazepines
• Delirium or dementia
• Migraine headache and temporal arteritis
• Pellagra and pernicious anemia
• Porphyria
• Sensory deprivation or overstimulation states.

   Like physicians, it is imperative that the EMS provider thoroughly assess the patient to ensure that no underlying traumatic or medical condition is responsible for the presenting signs and symptoms in the field. When in doubt, it is best to err on the side of the patients and treat them as if they have an underlying medical or traumatic cause (if suspected) for their behavior.

TYPES OF SCHIZOPHRENIA

   According to the DSM-IV, there are four major types of schizophrenia: paranoid, disorganized, catatonic and undifferentiated.⁹ Knowing the types may help you understand the behaviors usually associated with the patient's condition.

   • Paranoid

   Patient is preoccupied with one or more delusions or auditory hallucinations.

   • Disorganized

   Patient displays all of the following: disorganized speech, disorganized behavior, flat or inappropriate affect.

   • Catatonic

   At least two of the following: motor immobility as evidenced by catalepsy or stupor, excessive motor ability, extreme negativism or mutism, peculiarities in voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms or grimacing, echolalia or echopraxia.

   • Undifferentiated

   Symptoms meeting the first general criteria for schizophrenia are present, but criteria for other types are not met.

ADDITIONAL CONCERNS

   Patients with schizophrenia by itself pose a challenge to EMS providers. When it's coupled with alcohol or substance abuse, they prove even more challenging. Alcohol intoxication and use of other substances can mimic or alter psychiatric symptoms and can impair the patient's ability to make medical decisions.¹⁰ Consider the possibility that substances are causing the patient's signs and symptoms.

   Violence and suicidal tendencies are other considerations for EMS. Patients with schizophrenia are usually not overly prone to violence, and most do not commit violent crimes; however, substance abuse always increases the chance of violent behavior.² In a study conducted over a period of 15 years, older male patients with schizophrenia were more likely to be violent than other groups within the study. This study also identified that the risk of assault was greatly increased if patients had a previous history of violence, personal victimization and substance abuse.¹¹

   Approximately 40% of schizophrenia patients attempt suicide at some point in their lifetimes, and 10%a–20% of them are successful.⁵ This is a higher risk than that of the general population. EMS providers should acknowledge these concerns and make sure they provide for their safety and their patient's safety as well.

TREATMENT OF SCHIZOPHRENIA

   Schizophrenia affects virtually all aspects of the patient's life. Personal and social interactions are often impaired, and many do not have appropriate resources for help. Many patients require help with daily activities and personal hygiene, thus placing additional demands on their families or support networks. It is estimated that one-third to one-half of homeless patients have schizophrenia.³

   The goals of treating schizophrenia usually include reducing or eliminating symptoms, maximizing quality of life and adaptive functioning, and enabling recovery by assisting patients in attaining personal life goals (e.g., in work, housing and relationships).¹² Treatment usually includes a combination of psychotherapy, group therapy, use of a token economy, skills training and use of antipsychotic medications. These medications may be found during the scene size-up or may be provided by the patient or his family. It is important to attempt to identify if and when the patient began taking the medication, or if he stopped suddenly.

   There are two types of medication normally used to treat this condition: typical and atypical. Some typical, or first-generation, antipsychotic medications include haloperidol (Haldol), fluphenazine or chlorpromazine. Some atypical, or second-generation, medications include clozapine (Clozaril), olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify).⁸

   Although these medications are used to help treat patients with schizophrenia, they have side-effects that may potentially cause life-threatening complications.¹³ Some of the more dangerous side effects you should be aware of include: extrapyramidal symptoms that affect the nervous system, tardive dyskenesia, which involves uncontrolled facial and bodily movements, orthostatic hypotension, respiratory depression, prolonged QT syndrome and neuroleptic malignant syndrome, which involves autonomic instability and can present with hyperthermia, hypertension and extremity rigidity.⁷

   If signs and symptoms indicating a life-threatening complication occur, treat them appropriately based on your local protocols. It is not important to diagnose what may have caused the life threat, but appropriate assessment and management is crucial to patients' survival.

ASSESSMENT AND MANAGEMENT

   Assessment and management of the schizophrenic patient pose additional challenges for EMS. You may need to adjust portions of your assessment to meet a patient's special needs. It is imperative that you focus on identifying, ensuring, maintaining and supporting vital functions of the patient's ABCs. Reversible causes that can result in agitation, such as infection, metabolic, endocrine, traumatic and all other medical abnormalities, should be ruled out before you attribute the patient's presenting signs and symptoms to schizophrenia.¹³ These patients will require additional communication skills, patience and compassion.

SCENE SIZE-UP

   Safety of both provider and patient is paramount. Look for hazards within the scene that may indicate suicidal or homicidal intentions. Patients may listen to and obey perceived forces that are out of their control and may be violent in nature. Identify suspected traumatic injury.

   If necessary, utilize police or additional resources to ensure a safe environment. The use of both physical and chemical restraints for patients displaying violent behavior is heavily dependent on local protocol. If restraints are required, ensure that they are used appropriately and you retain respect for the patient. Remember, patients with schizophrenia may have no indication of what is truly happening in their environment; others may be overly suspicious and falsely believe that harm will come to them if they cooperate with emergency responders.

GAINING CONSENT FOR TREATMENT

   Gaining informed consent for treatment may pose a challenge with these patients. As with all patients, a pre-existing diagnosis does not exempt them from making an informed medical decision or refusing care; however, patients with schizophrenia may require greater in-depth analysis of decisional capacity before doing so.¹³ Patients with an altered mental status should be evaluated in the emergency department. A patient suspected of being under the influence of a substance, such as alcohol, must be evaluated by a physician who can identify if he is medically stable.¹⁰ Always err on the side of the patient.

ASSESSMENT

   Assess the patient's mental status and identify his response to the environment. If the patient has a suspected head or spinal injury, apply cervical and spinal immobilization.

   Establish and maintain an open airway. If the patient is unable to provide for his own airway, utilize mechanical devices or endotracheal intubation as directed by your protocol. Have suction devices available.

   Determine if the patient is breathing adequately and if bilateral breath sounds are present. If breathing is inadequate, provide a high concentration of oxygen via positive pressure ventilation. If it is adequate, provide supplemental oxygen. Use pulse oximetry and patient presentation to identify and maintain oxygen saturation higher than 95%.

   Assess the patient's pulse and circulation, identify major bleeding and manage any life-threatening conditions. Utilize ECG monitoring and establish IV access if necessary. If the patient's condition warrants, treat for shock.

   Obtain vital signs and a glucose reading to help rule out hypoglycemia or hyperglycemia as a cause for the patient's presentation.

   Perform a complete head-to-toe assessment. Remember, you must rule out all other possible causes before concluding that the signs and symptoms are from schizophrenia. Identify and treat findings as you would for other medical or trauma patients.

   In addition to the usual assessment, note the patient's mood, affect and speech (pattern, words, tone, rate and volume), as well as any expressed or viewed impairments in judgment, impulse control or memory. Document all findings objectively.

VERBAL INTERVIEW

   For patients without life-threatening findings, the verbal interview will provide a significant amount of information that will be utilized throughout the patient's care. Conduct the interview in a quiet, non-threatening environment, reduce external noise and stimuli, and be an active listener. Speak with a calm, non-threatening voice and focus on what and how the patient describes what is happening to him. Build a good rapport with the patient. Do not argue with or agitate him, and do not give in to his delusions. Some patients understand that what they experience is not real, but they operate in both their perceived world and the real world. It may be necessary to obtain some information from family or bystanders about the patient's history, medications, behaviors or norms. Take into consideration what information is disclosed and from whom the information is received.

   • Chief complaint

   Ask the patient for his chief complaint and have him describe any signs or symptoms associated with the complaint. If the patient was not the person who called for help, identify who and why EMS was called. Note the patient's overall presentation, demeanor, affect and behavior.

   • History

   Ask the patient about his medical and psychological history. Remember, many patients with schizophrenia are at risk for other medical problems and may have underlying conditions contributing to their current situation. Ask about the onset of symptoms. Obtain information about the patient's allergies and medications, and identify when the medications were last taken and last adjusted.

   • Signs and symptoms

   Ask the patient if he has had any delusions, hallucinations, or suicidal or homicidal thoughts or tendencies. Look for bizarre behaviors or unusual posturing. Document all findings objectively. Never pretend to interact in the patient's reality. If necessary, you can say you understand what he thinks or feels, but kindly direct him back to the current situation without any arguments.

   Tell the patient what to expect. Try to alleviate any fears regarding treatments or people who will be helping him.

TREATMENT

   Treatment for a patient with schizophrenia will depend on the signs and symptoms associated with his presenting condition. Life threats should be managed immediately and illnesses or injuries should be identified and treated appropriately. Schizophrenia should be a secondary consideration to any underlying cause presented by the patient. If there is no illness or injury, prehospital management will be primarily supportive.

BEYOND THE AMBULANCE

   EMS providers are often the first of many medical professionals with whom schizophrenic patients will interact during an emergency. Care for these patients in the prehospital environment is limited. Comprehensive care and treatment involves many healthcare providers at and often beyond the hospital environment. Many of these patients will need rehabilitation, counseling and outpatient treatment, and some may require hospitalization.

   Even with appropriate treatment, patients may relapse due to lack of compliance with medications or inability to afford appropriate treatment. Other causes may include substance abuse, alcoholism, attitude or medical changes. Regardless of the reason for a patient's relapse, it is the responsibility of EMS providers to respond and provide appropriate medical care in the patient's best interest.

Figure 1: Summary of DSM-IV Criteria for Schizophrenia

1. Presence of two (or more) characteristic symptoms for 1 month (or more) unless treated

   1. Delusion
   2. Hallucination
   3. Disorganized speech (derailment or incoherence)
   4. Grossly disorganized or catatonic behavior
   5. Negative symptoms: affect flattening, alogia (poverty of speech), avolition (unable to perform goal-directed activities)

   Note: Only one symptom above is required if delusions are bizarre or hallucinations consist of a running commentary.

2. Sharp deterioration from prior level of functioning (e.g., work, self-care, interpersonal relations)
3. Continuous signs of disturbance for 6 months (or more)
4. Schizoaffective disorder and mood disorder when psychotic features have been ruled out
5. Not caused by substance abuse, medication, or a general medical condition

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice chart: Modified from Diagnostic and Statistical Manual of Mental Disorders, ed 4-TR, Washington, DC, 2000, American Psychiatric Association.

References

1. National Institute of Mental Health. The Numbers Count: Mental Disorders in America (2008), www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml#Schizophrenia.

2. National Institute of Mental Health, March 2008, www.nimh.nih.gov/health/publications/schizophrenia/what-is-schizophrenia.shtml.

3. Stuart GW, Laraia MT. Neurobiological responses and schizophrenia and psychotic disorders. Principles and Practice of Psychiatric Nursing, 8th ed., Chapter 21, Mosby, 2005.

4. Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 150(6): December 2005.

5. Jacobson. Schizophrenia and schizoaffective disorders. Psychiatric Secrets, 2nd. Ed., Chapter 10. Hanley and Belfus, 2001.

6. Flashman LA, Green MF. Review of cognition and brain structures in schizophrenia: Profiles, longitudinal course, and effects of treatment. Psych Clin N Am 27(1): March 2004.

7. Marx. Thought disorders. Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., Chapter 108. Mosby, Inc., 2006.

8. Moore and Jefferson, eds. Handbook of Medical Psychiatry, 2nd ed., Chapter 67, Schizophrenia (DSM-IV-TR#295.1–295.3, 295.90), Mosby, 2004.

9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed. 4, text revision, Washington, DC, 2000.

10. Lukens TW, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med 47(1): January 2006.

11. Flannery RB, Jr. Repetitively assaultive psychiatric patients: Fifteen-year analysis of the Assaulted Staff Action Program (ASAP) with implications for emergency services. Int J Emerg Mental Health 10(1):1–8, Jan. 1, 2008.

12. American Psychiatric Association Practice Guidelines-Treatment of Patients with Schizophrenia, 2nd ed. https://www.psychiatryonline.com/pracGuide/pracGuideChapToc_6.aspx.

13. Marco CA, Vaughan JV. Emergency management of agitation in schizophrenia. Am J Emerg Med 23(6): October 2005.

   Cornelia A. Bryan, BSAS, NREMT-P, is an adjunct faculty member at Youngstown (OH) State University.

   Joseph J. Mistovich, MEd, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University.

   William S. Krost, MBA, NREMT-P, is an adjunct assistant professor of emergency medicine at The George Washington University.

Daniel Limmer, AS, EMT-P, has been involved in EMS for 31 years. He is active as a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. A passionate educator, Dan teaches basic, advanced and continuing education EMS courses throughout Maine.