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Schizoaffective disorder
From WikEM
Contents
Background
Clinical Features
- A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia.[1]
- B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
- C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
- D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Differential Diagnosis
Psychiatric Disorders with Psychotic Symptoms
- Acute psychosis
- Schizophrenia
- Schizoaffective disorder
- Delusional disorder
- Schizotypal personality disorder
- Schizoid personality disorder
- Bipolar disorder with psychotic features
Organic Causes
- Meningitis
- Encephalitis
- Thyroid (Main)
- Toxin ingestion
- Medication effect
Nonorganic Causes
- Mood Disorder
Evaluation
Rule out other organic causes including substance abuse, medication effect or other medical conditions. Consider emergency psychiatric evaluation in addition to medical evaluation.
General ED Psychiatric Workup
- Point-of-care glucose
- CBC
- Chem 7
- LFTs
- ECG (for toxicology evaluation)
- ASA level
- Tylenol level
- Urine toxicology screen/Blood toxicology screen
- EtOH
- Urine pregnancy/beta-hCG (if female of childbearing age)
- Consider:
- Ammonia (see Hepatic encephalopathy)
- TSH (hypo or hyperthyroidism may mimic mental illness)
- CXR (for Tb screen or rule-out delirium in older patient)
- UA (for rule-out delirium in older patients)
- Head CT (to rule-out ICH in patients with AMS)
- Lumbar puncture (to rule-out meningitis or encephalitis)
Management
General ED Psychiatric Management
- Non-pharmacologic
- Verbal de-escalation
- Offer comforting items: blanket, meal, pillow, etc
- Quiet room
- Physical restraints (should administer medications if restraints used, as decreases restraint time)
- Pharmacologic: Goal is to calm patient without oversedation
- No history of psychosis
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Known or suspected underlying psychotic illness
- Continue treatment with previous antipsychotic or
- PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
- IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
- (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- No history of psychosis
Disposition
- Home with outpatient psychiatric services if stable, versus inpatient psychiatric admission if unstable
See Also
External Links
References
- ↑ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
