The diagnosis of a primary psychotic disorder may be revised weeks or years after the initial diagnosis. Thorough documentation of symptoms (see Table 1) improves diagnostic accuracy.
The core symptoms of schizophrenia are:
- Positive symptoms—Additional symptoms that people with schizophrenia experience which most other people do not commonly experience. These include auditory hallucinations, ideas of reference, thought broadcasting, thought insertion, thought withdrawal, paranoia and delusions. The intensity and quality of these symptoms are unique to each person. They can all be present in one person and are usually consistent with the person's cultural background, values and temperament.
- Negative symptoms—Qualities that people with schizophrenia do not have that other people have. Negative symptoms include lack of energy, lack of ambition, limited spontaneous speech and difficulties initiating activities (avolition).
- Cognitive symptoms—Memory problems, such as poor concentration and difficulties carrying out activities that require planning (i.e., executive functioning deficits).
- Mood symptoms—Characterized by depressive mood, hopelessness, helplessness, suicidal ideation and a lack of enjoyment of pleasurable activities. These symptoms must be primarily due to psychosis rather than a distinct depressive disorder.
Psychotic Symptoms Typology
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Clients' general appearance and behaviour may indicate overarousal and hostility or irritability suggestive of elevated mood. Catatonia is usually rare in developed countries. However, in cities like Toronto that have large multicultural and immigrant populations from developing countries, primary health care practitioners may encounter catatonia across the population. Altered consciousness is highly unusual in non-organic psychoses and, if present, may indicate delirium, which requires urgent medical investigation. When speech is disorganized, it is likely due to thought dysfunction. When negative symptoms are significant, a conversation will be difficult. Random changes of the subject, loosening of associations and creation of new words (neologisms) are not uncommon.
Fast or pressured speech suggests mania. Mood should be noted as normal, depressed or elevated. Affect, the outward expression of mood, is unlikely to be normal in these clients. A restricted to flat affect may be the most obvious sign of negative symptoms, but there may be other causes. An anxious or perplexed affect may impact actual behaviour.
Suicidal ideation (thoughts, intentions, actions) must always be assessed by asking questions such as, "Have the voices suggested you hurt yourself or others?" Other abnormalities of thought (e.g., obsessions, overvalued ideas) and perception (e.g., illusions, misinterpretations) are common. Screening for cognitive impairment (using the mini-mental status exam) can further inform the approach to client care.
Cognitive impairment may be present in the early stages of psychosis, but significant cognitive abnormalities may be due to a learning disability or organic pathology; concentration may be subjectively normal (i.e., the client is unaware of any impairment) but objectively impaired (e.g., the client cannot recite the months of the year backwards). Insight can change considerably over the course of a psychotic illness and its treatment.
Screening and Assessment
According to the Diagnostic and Statistical Manual of Mental Disorders ([DSM-IV-TR], American Psychiatric Association, 2000), a diagnosis of schizophrenia requires the presence of three characteristics:
- Characteristic symptoms—Two or more of the following, each present for a significant portion of time during a one-month period (or less, if successfully treated): delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour and negative symptoms. Only one characteristic symptom is required if (a) delusions are bizarre, (b) hallucinations consist of a voice keeping up a running commentary on the person's behaviour or thoughts or (c) hallucinations consisting of two or more voices conversing with each other.
- Social/occupational dysfunction—For a significant portion of the time since onset of the illness, one or more major areas of functioning, such as work, relationships or self-care, are significantly reduced.
- Duration—Continuous signs of the disturbance are apparent for at least six months, with or without prodromal or residual phases.
Gathering a comprehensive history of the client, with a focus on his or her functioning at home, school, work and with other daily living activities, is indispensable. Obtaining supporting information from family members, partners and teachers is also crucial. Such a comprehensive assessment is more likely to be completed if there is a well-functioning interprofessional team (social worker, nurse practitioner and occupational therapist, among others).
It is also important to rule out substance-induced psychosis. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is a brief, psychometrically sound and easy-to-administer screening questionnaire that can help in making this determination.
There are two major types of antipsychotics.
- First-generation antipsychotics (FGAs)
- The first antipsychotic was chlorpromazine.
- Among the FGAs are fluphenazine, pimozide, triofluoperanzie, haldol and loxapine. There is no difference in the efficacy of these antipsychotics, but they differ in their side-effect profiles.
- Overall, these antipsychotics are known to cause extrapyramidal side-effects, such as akathisia, parkinsonism and dystonias, in addition to tardive dyskinesia and prolactinemia (high prolactin levels).
- Second-generation antipsychotics (SGAs)
- Introduced with clozapine (which is indicated for treatment-refractory clients), followed by risperidone, olanzapine, quetiapine, paliperidone and, more recently, ziprasidone and aripriprazole.
- The introduction of SGAs offered a benign extrapyramidal side-effect profile, or even no extrapyramidal sideeffects, compared with FGAs.
- On the other hand, SGAs have unique side-effects related to weight gain, hypercholesterolemia, hypertension and significant risk of diabetes and cardiovascular problems.
- SGAs are better tolerated than FGAs, but their efficacy is about the same as that of FGAs. However, their direct cost is five to 10 times that of FGAs. Moreover, the indirect cost associated with treating the side-effects of SGAs increases their cost significantly (Marian & Meyboom-de Jong, 2009).