Schizophrenia

Question 1

DSM-5 key diagnostic criteria

Answer 1

A 2 or more of the following

• —each present for a significant portion of time during a 1 month period:

1. delusions
2. hallucinations
3. disorganised speech (at least one of these first three)
4. grossly disorganised or catatonic behaviour
5. negative symptoms, e.g. flat effect

B social, learning or occupational dysfunction

C continuous sign of disturbance at least 6 mths

D no evidence of other psychoses, e.g. bipolar

E not attributable to other disorders

Remember explanation and support to family and patient.

Question 2

Treatment of acute phase of psychosis (schizophrenia and related psychoses)

Answer 2

Hospitalisation usually necessary

Drug treatment for the psychosis

When oral medication possible, first-line Rx is one of the second generation (atypical) antipsychotics:

• olanzapine 5–10 mg (o) nocte or
• risperidone 0.5–1 mg (o) nocte titrated gradually to 2–4 mg (o) bd (beware hypotension) or
• quetiapine 50 mg (o) bd ↑ as tolerated to 200 mg bd (by day 5) or other

Note:First generation (typical) antipsychotics include haloperidol and chlorpromazine.

When parenteral medication required:

• haloperidol 2.5–10 mg IV or IM, initially, ↑ 20 mg in 24 h, depending on response or
• zuclopenthixol acetate 50–150 mg IM as a single dose add
• benztropine 1–2 mg (o) bd (to avoid dystonic reaction)

If dystonic reaction:

• benztropine 1–2 mg IV or IM

If very agitated:

• diazepam 5–20 mg (o) or 5–10 mg IV

Question 3

Chronic phase of schizophrenia

Answer 3

Long-term antipsychotic medication recommended to prevent relapse.

Examples of oral medication regimens:

• olanzapine 5–10 mg initially up to max. 20 mg (o) nocte or
• quetiapine 150 mg (o) bd or
• risperidone 0.5–1 mg (o) bd, up to 2–4 mg (o) bd

Use depot preparations if compliance is a problem (use test dose first):

• fluphenazine decanoate 12.5–50 mg IM, every 2–4 wks or
• haloperidol decanoate 50–200 mg IM, every 4 wks or
• flupenthixol decanoate 20–40 mg IM, every 2–4 wks or
• zuclopenthixol deconate 100–400 mg IM every 2–4 wks

Question 4

Resistant schizophrenia (options)

Answer 4

clozapine 12.5 mg (o) bd initially

• increasing up to 300–600 mg/d

olanzapine 5–20 mg (o)/d