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1952 SECTION 24: Psychosocial Disorders initial visit for a motor vehicle crash, or during return visits to the ED after serious trauma, patients should be questioned about persistent pain, coping strategies, general well-being, and follow-up plan to possibly avert development of acute stress disorder, PTSD, or chronic pain. DIAGNOSIS Initially, assess patients who present with anxiety for life-threatening medical conditions, such as myocardial infarction, pulmonary embolus, hypoglycemia, hypoxia, tachyarrhythmias, thyroid storm, and cerebro vascular accident. Also ask about suicidal and homicidal ideation, as there is a 10-fold greater suicide risk among patients with anxiety disorders compared with the general population, 67 and even greater risk when the patient also has both an anxiety disorder and a mood disorder.68 Tr y to identify current stressful situations that may have precipitated symptoms. Anxiety symptoms may also be caused by certain medications or substances of abuse, including corticosteroids, neuroleptics, broncho dilators, decongestants, caffeine, nicotine, cocaine, and amphetamines. Withdrawal from benzodiazepines, opiates, SSRIs/SNRIs, and alcohol may cause agitation and anxiety. One useful screening question for panic attacks is: “Have you experienced brief periods for seconds or minutes of an overwhelming panic or terror that was accompanied by racing heart, shortness of breath, or dizziness?” 69 Take care to identify victims of domestic violence, sexual abuse, or assault, because such past or present experiences can provoke panic attacks. TREATMENT OF ANXIETY DISORDERS Psychological treatment with cognitive-behavioral therapy and phar macologic therapy with antidepressants for long-term treatment have both been shown to be effective for anxiety disorders and may be more effective when used in combination. 70,71 Benzodiazepines for short-term use and low-dose β-blockers to mitigate physical symptoms may also be helpful. Benzodiazepine pharmacotherapy in the ED may be considered (Table 289-7) for acute panic attack, especially for patients who need rapid control of debilitating symptoms. The limitation of benzodiaz epines for anything but very short-term use is their potential for abuse and dependence. Use with caution in patients with a respiratory disorder or history of substance abuse or dependence. The use of benzodiaz epines is discouraged in the elderly because of concerns for falling, cognitive slowing, paradoxical agitation, and drug interactions due to polypharmacy. SSRIs and SNRIs are effective treatments for anxiety disorders and ideally administered in conjunction with a primary care or psychiatric practitioner with a follow-up plan in place. Starting doses may be lower than used when treating depression and may take longer to be effective.

rug interactions due to polypharmacy. SSRIs and SNRIs are effective treatments for anxiety disorders and ideally administered in conjunction with a primary care or psychiatric practitioner with a follow-up plan in place. Starting doses may be lower than used when treating depression and may take longer to be effective. Cognitive-behavioral therapy is not usually arranged in the ED, although one study in patients who presented to the ED with noncardiac TABLE 289-7 Pharmacotherapy for Anxiety Disorder Class of Drug Drug and Dosage FDA Approved for Which Anxiety Disorder Acute medication treatment Benzodiazepines Lorazepam (Ativan ), 0.5–1.0 milligram 3 times a day Clonazepam (Klonopin ), 0.5–1.0 milligram twice a day Alprazolam (Xanax ), 0.25–1.0 milligram 3–4 times a day Diazepam (Valium ) 2–10 milligrams 2–4 times a day All All All All Ongoing medication treatment Selective serotonin reuptake inhibitor Sertraline (Zoloft ), 50–200 milligrams daily (initial dose, 25 milligrams) Paroxetine (Paxil ), 40–70 milligrams daily (initial dose, 10–20 milligrams) Escitalopram (Lexapro ), 10–20 milligrams daily (initial dose 5–10 milligrams) Fluoxetine (Prozac ) 20–60 milligrams daily (initial dose 10 milligrams) PD, PTSD, SAD, OCD GAD, PD, PTSD, SAD, OCD GAD PD, OCD Serotonin-norepinephrine reuptake inhibitor Venlafaxine (Effexor ), 75–300 milligrams daily (initial dose, 37.5 milligrams) (Venlafaxine XR preferred in anxiety) Duloxetine (Cymbalta ) 20–120 milligrams daily (initial dose, 20 milligrams) GAD, PD, SAD GAD Abbreviations: FDA = U.S. Food and Drug Administration; GAD = generalized anxiety disorder; OCD = obsessive-compulsive disorder; PD = panic disorder; PTSD = posttraumatic stress disorder; SAD = social anxiety disorder. chest pain (thought to be panic disorder) demonstrated a decrease in panic disorder symptoms with a single session of cognitive-behavioral therapy within 2 weeks of discharge. 72 This may have return ED visit implications. DISPOSITION Once a diagnosis of anxiety disorder is considered, the next step is to educate patients and provide reassurance that they are not dying or “going crazy. ” Emphasize that this is an illness that can be treated effectively with cognitive-behavioral therapy and antidepressants. Choice of treatment is based on an individual assessment of risks, benefits, efficacy, availability, acuity, and patient preference. Although cognitivebehavioral therapy is not practiced in the ED, education regarding it is worthwhile. Therapy consists of patient education about the disorder, symptom and thought records, and learning anxiety management skills (e.g., breathing retraining) with the guidance of a trained therapist. After exclusion of a life-threatening medical condition, the need for admission or emergent psychiatric consultation is rare, except in patients expressing suicidal or homicidal ideation, or other psychiat ric or medical comorbidities that prohibit the patient from self-care. Medication changes or initiation of antidepressants should be done in conjunction with the primary care provider or psychiatrist. Acknowledgment: Special thanks to Dr. Shauna Garris, PharmD, BCPP , BCPS, for her assistance in preparing this chapter. REFERENCES The complete reference list is available online at www.TintinalliEM.com. CHAPTER Psychoses Adam Z. Tobias INTRODUCTION AND EPIDEMIOLOGY Psychosis has been defined as a “fundamental derangement of the mind characterized by defective or lost contact with reality. ” 1 The Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, 2 defines psychotic disorders as those that include abnormalities in one or more of five domains: hallucinations, delusions, disorganized or abnormal Tintinalli_Sec24_p1933-1966.indd 1952 8/2/19 5:19 PM

efective or lost contact with reality. ” 1 The Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, 2 defines psychotic disorders as those that include abnormalities in one or more of five domains: hallucinations, delusions, disorganized or abnormal Tintinalli_Sec24_p1933-1966.indd 1952 8/2/19 5:19 PM CHAPTER 290: Psychoses 1953 motor behavior, disorganized thinking, and negative symptoms. The hallmark of these psychoses, schizophrenia, has a worldwide preva lence of 0.5% to 1%3 and affects approximately 2.4 million adults in the United States.4 Schizophrenia is considered one of the leading causes of chronic incapacity.5-7 The assessment of the psychotic patient presenting to the ED can be challenging, because patients may be agitated, combative, uncooperative, or unable to provide any history. The goals of evaluation are multiple. First, minimize any potential harm to the patient and ensure the safety of the ED staff and other patients. In the case of an aggressive or violent patient, this may require the use of verbal de-escalation techniques, physical restraints, or chemical sedation. Second, assess for any coexisting or confounding medical or traumatic conditions. Emergency care providers are gatekeepers to the psychiatric world, because once the patient is funneled into the psychiatric treatment realm, organic conditions may become more difficult to identify and treat. Psychiatric conditions contribute to increased mortality from comorbid medical conditions as compared to the general population. 8 In fact, patients with schizophrenia have a life expectancy of approximately 20 years less than that of the general population.9 Finally, aim to optimize the treatment of the patient’s underlying psychiatric illness, either by connection with the appropriate inpatient or outpatient resources or by contacting their psychiatrist.  PATHOPHYSIOLOGY Both environmental and genetic factors contribute to the schizophrenia spectrum of disorders. 10,11 The disorders have been linked to a spectrum of risk alleles, with overlap between the alleles associated with schizo phrenia and those associated with other disorders such as autism and bipolar disorder. 12 It is thought that dopamine acts as the common final pathway of a wide variety of predisposing factors, either environmental, genetic, or both, that lead to the disease. Other neurotransmitters, such as glutamate and adenosine, may also collaborate with dopamine to give rise to the entire picture of schizophrenia. 13,14 CLINICAL FEATURES  HISTORY Features of psychoses include hallucinations, delusions, disorganized thinking, and negative symptoms. A hallucination is an “apparent, often strong subjective perception of an external object or event when no such stimulus or situation is present. ” 2 Although hallucinations may occur in any sensory modality, they are most commonly auditory in schizophrenia and other psychotic disorders. Typically these are experienced as voices distinct from the individual’s own thoughts. Not all hallucinations are considered to be pathologic; they may be a normal part of certain religious and cultural experiences. A delusion is “a false belief or wrong judgment, sometimes associ ated with hallucinations, held with conviction despite evidence to the contrary. ” 15 Delusions may be classified based on various themes, including grandiose (i.e., “when an individual believes that he or she has exceptional abilities, wealth, or fame”), persecutory, erotomanic (i.e., “when an individual believes falsely that another person is in love with him or her”), and referential or ideas of reference (i.e., “belief that certain gestures, comments, environmental cues, and so forth are directed at oneself ”). Delusions are considered bizarre if they are clearly implau sible.

, erotomanic (i.e., “when an individual believes falsely that another person is in love with him or her”), and referential or ideas of reference (i.e., “belief that certain gestures, comments, environmental cues, and so forth are directed at oneself ”). Delusions are considered bizarre if they are clearly implau sible. In the ED, a nonbizarre delusion may be difficult to distinguish from a strongly held idea. Typically, disorganized thinking is inferred from a patient’s speech. Commonly encountered patterns may include derailment or loose associations, wherein the individual switches from one topic to another; tangentiality, wherein answers to questions may be unrelated or loosely related; and word salad , wherein the individual’s speech becomes so disorganized that it becomes nearly incomprehensible. Negative symptoms associated with psychotic disorders include avolition (decreased motivation), diminished emotional expression, anhedonia (decreased ability to experience pleasure), asociality (decreased interest in social interaction), and alogia (decreased speech). Patients with negative symptoms often present with flat affect. These symptoms can be the most chronically impairing features of psychoses.  PHYSICAL EXAMINATION Aside from grossly disorganized or abnormal motor behavior (discussed below), there are no specific physical findings associated with the psy chotic disorders. The goal of physical examination is the exclusion of coexisting medical or traumatic conditions. For agitated patients, be particularly vigilant to assess for any self-inflicted injuries, environmental injuries such as frostbite, or injuries occurring as a result of combat ive behavior or the restraint process. Grossly disorganized or abnormal motor behavior may take on various forms, although it is likely most familiar to emergency practi tioners as unpredictable agitation. Catatonia is a “marked decrease in reactivity to the environment. ” Catatonic features may range from negativism, which is a resistance to instructions, to maintenance of a rigid or inappropriate posture, to complete lack of motor or verbal response. Catatonic behavior may occur in association with a variety of psychiatric and medical conditions. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS Psychotic symptoms may be caused by numerous medical conditions and often occur in conjunction with delirium. Consider medical causes before attributing psychosis to a primary psychiatric illness. Some of the many potential causes include infections such as encephalitis, men ingitis, or sepsis; CNS conditions such as stroke, seizure, Parkinson’s disease, 16 or brain tumor; and metabolic derangements such as hypoglycemia or hepatic encephalopathy. Additionally, various medications and illicit substances may give rise to psychotic symptoms (Table 290-1). 17-20 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, delineates specific diagnostic criteria for the schizophrenia spec trum and other psychotic disorders (see discussion below). However, such granular distinctions are typically not necessary or relevant for emergency assessment and treatment. Rather than making a specific psychiatric diagnosis, the ED provider’s focus should be on emergency treatment and stabilization, identification of comorbid conditions, and appropriate disposition. Diagnostic testing is directed by the history and physical examination. Routine extensive laboratory testing for otherwise stable, cooperative, and previously diagnosed psychiatric patients is of low yield and need not be performed in most cases. Similarly, urine toxicologic screening rarely affects ED management and need not be routinely obtained. Many psychotic patients presenting to the ED have been previ ously diagnosed with a psychiatric condition.

ative, and previously diagnosed psychiatric patients is of low yield and need not be performed in most cases. Similarly, urine toxicologic screening rarely affects ED management and need not be routinely obtained. Many psychotic patients presenting to the ED have been previ ously diagnosed with a psychiatric condition. In such cases, determine whether there has been an acute change from the patient’s baseline and whether the current presentation is confounded by another condition that requires medical treatment. In cases where the patient is unable to aid with providing history, use other resources, including past medical records, medication lists, family members, and case workers. For patients with new-onset psychosis, the ED is a common point of first contact with the healthcare system. 22 The provider must then TABLE 290-1 Common Medications and Drugs of Abuse Causing Psychosis Medications Drugs of Abuse Corticosteroids Ethanol* Fluoroquinolones Cocaine Atropine and other anticholinergics Amphetamines and other stimulants (including “bath salts”) Dextromethorphan LSD and other hallucinogens Benzodiazepines* Marijuana Phencyclidine (PCP) MDMA (ecstasy) *Psychosis is more commonly seen in benzodiazepine withdrawal but can occur with ethanol intoxication or withdrawal. Tintinalli_Sec24_p1933-1966.indd 1953 8/2/19 5:19 PM

d other stimulants (including “bath salts”) Dextromethorphan LSD and other hallucinogens Benzodiazepines* Marijuana Phencyclidine (PCP) MDMA (ecstasy) *Psychosis is more commonly seen in benzodiazepine withdrawal but can occur with ethanol intoxication or withdrawal. Tintinalli_Sec24_p1933-1966.indd 1953 8/2/19 5:19 PM 1954 SECTION 24: Psychosocial Disorders determine whether the patient’s psychosis is the by-product of an acute medical condition, a reaction to a medication or illicit substance, or truly the new onset of a primary psychiatric illness. Newly symptomatic patients often warrant a more extensive medical evaluation than those with known underlying psychotic disorders. DISPOSITION AND FOLLOW-UP Patients with a chronic psychotic illness may present anywhere along a spectrum ranging from high functioning to completely disabled. Guide disposition decisions by considerations of patient safety and optimization of treatment. Patients thought to be violent, at risk of self-harm, or unable to care for themselves typically require emergent psychiatric evaluation and possibly inpatient psychiatric care. Patients with newonset psychosis (not thought to be due to a medical cause) or those with worsening of underlying psychotic symptoms should have psychiatric consultation in the ED, if available, or be transferred to a psychiatric facility. Patients with known psychoses under apparent good control may be referred for outpatient management. Ideally, such referrals should be made in consultation with the patient’s treating psychiatric provider. Finally, patients with psychosis secondary to a medical condition or those with comorbid illness should be managed accordingly. Give spe cial consideration to a patient’s functional level and ability to manage the medical condition as an outpatient. For example, a schizophrenic patient with an infection that might otherwise be treated with oral antibiotics at home might benefit from hospitalization if there is doubt about the patient’s ability to comply with treatment and follow-up instructions. PHARMACOTHERAPY Antipsychotic (neuroleptic) medications are typically used in the treat ment of schizophrenia and the other psychoses. The exact mechanism of action of the antipsychotics is not known. The majority of antipsychotics block the D 2 dopamine receptors and 5-HT2A serotonin receptors in the brain to a varying degree. Antipsychotics are classified as first-generation (typical) or second-generation (atypical) antipsychotics. The typical antipsychotic medications are often categorized as being of low, medium, or high potency. The “potency” of these drugs does not refer to effectiveness, but rather to the degree of dopamine blockade. High-potency drugs have higher D 2 dopamine receptor blockade and lower serotonergic and muscarinic binding affinity. In general, lowpotency medications tend to be more sedating and are more often associated with hypotension, dizziness, and anticholinergic symptoms. High-potency medications are generally less sedating, but are more frequently associated with extrapyramidal effects such as tremors, rigidity, muscle spasms, and akathisia. 13 Table 290-2 reviews the common typical antipsychotics. The U.S. Food and Drug Administration (FDA) has placed black box warnings on a number of the typical antipsychotics, due to con cerns about possible cardiac dysrhythmias associated with their use. In particular, several of these medications have been associated with QT prolongation and the FDA recommends evaluation of the QT c interval prior to their use. In clinical situations in which rapid treatment of agitation is necessary, a priori determination of the QTc interval is impractical and usually impossible.

e. In particular, several of these medications have been associated with QT prolongation and the FDA recommends evaluation of the QT c interval prior to their use. In clinical situations in which rapid treatment of agitation is necessary, a priori determination of the QTc interval is impractical and usually impossible. If ECG data are available from the ED visit, these should be reviewed for evidence of QT c prolongation. Similarly, if prior ECG data are available, incorporate them into clinical decision making. Haloperidol remains a popular and effective agent for rapid tranquilization, although newer agents such as olanzapine may be safer and equally effective. 23,24 Unfortunately, QTc prolongation does not directly correlate with the clinical risk of dysrhythmias or the development of the malig nant arrhythmia torsades de pointes. The black box warnings have led to apprehension in the use of highly effective medications. The atypical antipsychotics (Table 290-3) are generally newer medications that more specifically target the dopamine receptors or inhibit the reuptake of serotonin. Early studies showed that they had increased efficacy in the treatment of the negative symptoms of psychosis, although more recent data have found this effect to be comparable to that of the typical antipsychotics. 25 Based on this improved receptor specificity, adverse effects such as sedation, extrapyramidal effects, QT c prolongation, and tardive dyskinesia are generally reduced but are not completely eliminated. The incidence of hypotension does not appear to have been significantly altered. The FDA has placed a black box warning on both typical and atypical psychotics for their off-label use in manag ing agitation and psychosis in elderly patients with dementia, due to increased rates of cerebrovascular accidents, cardiovascular events, and mortality associated with chronic use. 26,27  ADVERSE EFFECTS The following side effects are more commonly associated with the typi cal antipsychotics, but may also occur with medications in the atypical class: acute dystonia, akathisia, parkinsonism, anticholinergic effects, cardiovascular effects, and neuroleptic malignant syndrome. Acute Dystonia Acute dystonias are probably the most common side effect of antipsychotic medications seen in the ED and are more com mon in younger patients and those who have never taken antipsychotic drugs before. 13 Muscle spasms of the neck, face, and back are the most common dystonias, but oculogyric crisis and even laryngospasm may also occur. Treatment with either benztropine, 1 to 2 milligrams IV or IM, or diphenhydramine, 25 to 50 milligrams IV , rapidly corrects the dystonia. For persistent reactions, both medications may be used, and benzodiazepines may be added for treatment failures or given prophy lactically. Dystonias often recur despite dosage reduction or discontinuation of the offending antipsychotic. Akathisia (Motor Restlessness) Akathisia, a sensation of motor restlessness with a subjective desire to move, can begin several days to several weeks after initiation of antipsychotic treatment. Management can be difficult. If possible, decrease the dosage of the antipsychotic after psychiatric consultation. The best treatment is probably administration of benzodiazepines or β-blockers such as propranolol. Antiparkinsonian or anticholinergic drugs such as benztropine, 1 milligram PO twice daily, may also afford some relief, although these may lead to anticholinergic side effects if not subsequently tapered off. In refractory cases, the antipsychotic may need to be changed to an atypical agent. Antipsychotic-Induced Parkinson’s Syndrome A complete Par kinson’s syndrome, including bradykinesia, resting tremor, cogwheel rigidity, shuffling gait, masked facies, and drooling, can occur.

ide effects if not subsequently tapered off. In refractory cases, the antipsychotic may need to be changed to an atypical agent. Antipsychotic-Induced Parkinson’s Syndrome A complete Par kinson’s syndrome, including bradykinesia, resting tremor, cogwheel rigidity, shuffling gait, masked facies, and drooling, can occur. The elderly are at greatest risk, with development in the first month after initiation of the antipsychotic agent. 13 Often only one or two features TABLE 290-2 Typical Antipsychotics Generic Name Brand Name Relative Potency U.S. Food and Drug Administration Warnings Phenothiazines Chlorpromazine Thorazine  Low Mesoridazine Serentil Intermediate QTc prolongation Thioridazine Mellaril Intermediate QTc prolongation Perphenazine Trilafon Intermediate Trifluoperazine Stelazine High Fluphenazine Prolixin High Thioxanthenes Loxapine Loxitane  Intermediate Thiothixene Navane High Dihydroindolones Molindone Moban  Intermediate Butyrophenones Haloperidol Haldol  High QTc prolongation and torsades de pointes Droperidol Inapsine High QTc prolongation and torsades de pointes Tintinalli_Sec24_p1933-1966.indd 1954 8/2/19 5:19 PM

hioxanthenes Loxapine Loxitane  Intermediate Thiothixene Navane High Dihydroindolones Molindone Moban  Intermediate Butyrophenones Haloperidol Haldol  High QTc prolongation and torsades de pointes Droperidol Inapsine High QTc prolongation and torsades de pointes Tintinalli_Sec24_p1933-1966.indd 1954 8/2/19 5:19 PM CHAPTER 290: Psychoses 1955 of the syndrome are obvious. Antipsychotic dosage reduction and/or anticholinergic medication is usually effective. Anticholinergic Effects Anticholinergic effects range from mild sedation to delirium. Peripheral manifestations may include dry mouth and skin, blurred vision, urinary retention, constipation, paralytic ileus, cardiac dysrhythmias, and exacerbation of angle-closure glaucoma. The central anticholinergic syndrome is characterized by dilated pupils, dysarthria, and an agitated delirium. Treatment is discontinuation of the antipsychotic and supportive measures. Cardiovascular Effects Cardiovascular side effects, such as orthostatic hypotension and tachycardia, are commonly encountered. These effects are likely related to anticholinergic and adrenergic blockade and occur at therapeutic dosages. Typically, hypotension can be managed with IV fluids. In severe cases, vasopressor support may be required. Additional effects caused by blockade of sodium, calcium, and potassium channels in the central nervous and cardiac systems are less well delineated. However, effects on specific potassium channels in the myocardium have been linked to the drug-induced prolongation of the QT c interval associated with several of the antipsychotics.28,29 It is this mechanism of action by which the antipsychotics are believed to induce torsades de pointes. Neuroleptic Malignant Syndrome Neuroleptic malignant syndrome is an uncommon idiosyncratic reaction to neuroleptic drugs manifested by rigidity, fever, autonomic instability (tachycardia, diaphoresis, and blood pressure abnormalities), and a confusional state. Although highpotency antipsychotics may be more likely to cause the disorder, all antipsychotics are potential offenders. Neuroleptic malignant syndrome is a medical emergency and has a mortality rate as high as 20%. Management includes immediate discontinuation of the antipsychotic medica tion, hydration, and supportive treatment in an intensive care setting. Anticholinergic medications are not helpful and may worsen the condition by further impairing centrally mediated temperature regulation. Medications such as dantrolene sodium or bromocriptine are sometimes used to relieve the rigidity. SCHIZOPHRENIA SPECTRUM OF DISORDERS The schizophrenia spectrum of disorders is listed in Table 290-4. Some of the more commonly encountered conditions are discussed in detail below. Schizophrenia is the most common form of psychosis. It typically involves a wide range of impairments in functioning and may affect all areas of a patient’s life, including occupational and social aspects. It usually begins to manifest between the late teens and the mid-30s. Its course is characterized by acute episodes and periods of partial or full remission. It is diagnosed more in men than in women, and the inci dence varies significantly based on age, gender, socioeconomic, racial, and geographic factors, with a higher incidence among migrants, urban populations, and ethnic minorities. 30-32 Patients with schizophrenia have high rates of medical comorbidity and concomitant substance abuse.33,34 Signs of the disturbance must be present for at least 6 months for a formal diagnosis, and symptoms cannot be attributable to another medical condition or the effects of a substance. Diagnostic criteria are listed in Table 290-5.

schizophrenia have high rates of medical comorbidity and concomitant substance abuse.33,34 Signs of the disturbance must be present for at least 6 months for a formal diagnosis, and symptoms cannot be attributable to another medical condition or the effects of a substance. Diagnostic criteria are listed in Table 290-5. Delusional disorder is diagnosed in the absence of schizophrenia and involves the presence of one or more delusions for at least 1 month. TABLE 290-3 Atypical Antipsychotics Drug U.S. Food and Drug Administration–Approved Indications Warnings and Common Side Effects (BLACK BOX WARNINGS IN CAPS) Clozapine (Clozaril ) Treatment-resistant schizophrenia Reduction in the risk of recurrent suicidal behavior in schizophrenic or schizoaffective disorders Sedation, dizziness, hypotension, tachycardia, salivation, weight gain, hyperthermia. AGRANULOCYTOSIS, SEIZURES, MYOCARDITIS, OTHER ADVERSE CARDIOVASCULAR AND RESPIRATORY EFFECTS Olanzapine (Zyprexa ) Schizophrenia Bipolar disorder Agitation associated with schizophrenia and bipolar I mania CVAE, sedation, postural hypotension, hyperglycemia, weight gain, dizziness Quetiapine (Seroquel ) Bipolar mania Schizophrenia NMS, hyperglycemia, sedation, hypotension, headache, weight gain CATARACT FORMATION Risperidone (Risperdal ) Schizophrenia Bipolar mania Extrapyramidal effects, hyperglycemia, hypotension, hyperprolactinemia, weight gain Ziprasidone (Geodon ) Schizophrenia Bipolar mania Acute agitation in schizophrenic patients Sedation, rash, dizziness, hypotension, hyperglycemia, extrapyramidal effects QT PROLONGATION AND RISK OF SUDDEN DEATH Aripiprazole (Abilify ) Schizophrenia Bipolar disorder NMS, CVAE, hyperglycemia, seizure, hypotension, headache, akathisia Asenapine (Saphris, Sycrest ) Schizophrenia Bipolar mania Blood dyscrasias, cerebrovascular effects, dyslipidemia, extrapyramidal symptoms, NMS, hyperglycemia, QTc prolongation, orthostatic hypotension, increased mortality with chronic use in dementia patients Iloperidone (Fanapt ) Schizophrenia Paliperidone (Invega, Sustenna ) Schizophrenia Schizoaffective disorder Abbreviations: CVAE = cerebrovascular adverse event; NMS = neuroleptic malignant syndrome. TABLE 290-4 The Schizophrenia Spectrum of Disorders • Schizophrenia • Brief psychotic disorder • Substance/medication-induced psychotic disorder • Schizotypal personality disorder • Unspecified catatonia • Unspecified schizophrenia spectrum and other psychotic disorder • Catatonia associated with another mental disorder • Delusional disorder • Schizoaffective disorder • Schizophreniform disorder • Psychotic disorder due to another medical condition • Catatonic disorder due to another medical condition • Other specified schizophrenia spectrum and other psychotic disorder TABLE 290-5 Diagnostic Criteria for Schizophrenia2 Criterion A* Other Selected Criteria Hallucinations Disturbance present for at least 6 months Disorganized speech Significant deficiencies in major areas of function (work, self-care, interpersonal relations) Delusions Depression, bipolar disorder, schizoaffective disorder ruled out Negative symptoms Not attributable to another medical condition or substance Grossly disorganized or catatonic behavior *Must have two or more criteria and at least one must be delusions or disorganized speech. Tintinalli_Sec24_p1933-1966.indd 1955 8/2/19 5:19 PM