For Mr. J, years of uninterrupted hallucinations, longstanding paranoid delusions, and absence of prominent affective symptoms suggest schizophrenia. His hallucinations are typical of those reported in schizophrenia. Voices giving a running commentary on a person’s thoughts and actions and derogatory comments are two of the most common auditory hallucinations.
Somatic concerns are also prominent in schizophrenia. Patients may describe symptoms in bizarre terms, such as “electric shocks in my head” or “there’s a fire in my spleen.”
Supporting evidence for a schizophrenia diagnosis would include a history of social isolation, lack of interest in work, and poor social interaction. Mr. J has a supportive partner, and we are told he appears to be high-functioning and active as a guitarist in a band. These factors might support an alternate diagnosis of affective psychosis. Finally, his past drug use and somatic symptoms raise the possibility of active substance abuse.
Table 2
Differential diagnosis of primary psychosis: Typical features
| Affective disorder | Schizophrenic spectrum disorder | |
|---|---|---|
| Symptom onset | Acute or subacute | Prolonged period (months to years) of self-neglect, social isolation, odd beliefs, eccentric behaviors |
| Course | Episodic, with periods of normal social and occupational functioning between episodes | Chronic, with exacerbations superimposed on gradually deteriorating social and occupational functioning |
| Associated symptoms | Mania (irritability, insomnia, rapid speech, labile mood, psychomotor agitation, racing thoughts) | Flat or inappropriate affect, thought blocking, apathy |
| Depression (anhedonia, psychomotor retardation, sleep problems, poor appetite) |
Suicide risk. Ask psychotic patients if they think about harming themselves. Lifetime risk of suicide in schizophrenia is 10% to 15%, and rates in bipolar disorder are higher. If patients deny suicidality, ask them why. Reassuring responses include religious prohibition, hopefulness about the future, concern about suicide’s effect on a loved one, fear of dying, or lack of means.
Candidates for emergent psychiatric consultation or hospitalization include patients with violent or homicidal thoughts and any patient who has attempted suicide, has a family history of suicide, has access to means, and lacks compelling reasons against suicide. Consider immediate psychiatric evaluation and admission of patients whose delusions or behaviors put them at risk for harm.
Abdominal pain workup. Although Mr. J’s abdominal pain may be functional, also seek an organic cause. His first-time disclosure of psychotic symptoms suggests that a serious medical stressor may be exacerbating a chronic psychiatric illness. Because the elevated lipase may indicate pancreatitis, consider an endoscopic or MRI examination of the pancreas and bile ducts. In consultation with a gastroenterologist, evaluate other causes such as peptic ulcer disease, ischemic bowel (perhaps as a result of cocaine use), inflammatory bowel disease, vasculitis, porphyria, and abdominal migraine.
Managing psychosis
Psychiatric consultation is strongly recommended for patients beginning therapy for psychotic disorders who have shown a particularly high risk for suicide. Uncontrolled symptoms, unanticipated psychiatric side effects, and the humiliation that results from the insight gained through treatment may contribute to this risk.
Assuming that Mr. J does not meet criteria for acute psychiatric hospitalization, the primary care clinician can stabilize the psychotic symptoms while awaiting psychiatric referral. Any atypical antipsychotic would be appropriate (Table 3).
Table 3
Starting an atypical antipsychotic* for primary psychosis
| Drug | Starting and maintenance dosages1 | Most-common adverse effects |
|---|---|---|
| Aripiprazole | 7.5 to 15 mg daily; 15 to 30 mg daily | EPS (+), agitation (++) |
| Olanzapine | 5 to 15 mg nightly; 10 to 20 mg nightly | Sedation (+++), weight gain (++++) hyperglycemia (++++), anticholinergic |
| Quetiapine | 50 to 100 mg bid; 600 to 800 mg nightly | Sedation (++++), weight gain (+++), hyperglycemia (++) |
| Risperidone | 0.5 to 2 mg bid; 2 to 4 mg bid | EPS (++), sedation (++), weight gain (++), hyperglycemia (++), elevated prolactin |
| Ziprasidone | 20 to 40 mg bid; 60 to 80 mg bid | EPS (+), agitation (++), sedation (+), QTc prolongation2 |
| EPS: Extrapyramidal symptoms | ||
| + small risk ++ moderate risk +++ high risk ++++ most risk | ||
| * All atypical antipsychotics have been associated with rare cases of neuroleptic malignant syndrome. Tardive dyskinesia is estimated to occur in 0.5% of adults and 2.5% of geriatric patients for each year on therapy. FDA requires a warning on increased risks of hyperlipidemia, hyperglycemia, and diabetes mellitus on the labels of all atypical antipsychotics. Monitoring weight, glucose, and lipids is recommended. | ||
| 1 In clinical practice, dosages may be increased beyond maximum dosages listed. Doses may be given solely at night or bid, depending on sedation and agitation. Low dosages are recommended in geriatric patients or those with renal or hepatic disease. Review potential drug-drug interactions before dosing. | ||
| 2 Despite earlier concerns, no cases of torsade de pointes or sudden death have been reported with ziprasidone. Not recommended for patients with cardiac risk. | ||
| Source: Adapted from reference 4. | ||
Patients who refuse treatment pose a quandary. If the patient is not acutely ill, try to establish an alliance over several visits rather than endangering the therapeutic relationship through confrontation or overzealous persuasion (Table 4).