In Two Minds? EMS Care of the Schizophrenic Patient
EMS management and assessment of the schizophrenic patient
Schizophrenia is a common psychiatric condition encountered by EMS professionals that is characterized by disturbances in the patient's perceptions, thoughts, behaviors and affect that last for more than six months. Although in Greek the word schizophrenia means "split mind," it does not mean split personality. Because schizophrenia is commonly mistaken for various other psychiatric conditions, it is important for EMS providers to know what it is and how to assess and manage patients who have or display signs and symptoms associated with this condition.
EPIDEMIOLOGY
Schizophrenia is a debilitating brain disorder that affects 2.4 million American adults, or 1.1% of the population.1 Schizophrenia usually occurs in late adolescence or early adulthood, although it can occur at any age. Typically, the psychotic symptoms associated with this disorder appear earlier in males than in females, but the disorder usually affects both genders equally.2 Schizophrenia is more common than multiple sclerosis, insulin-dependent diabetes, muscular dystrophy and Huntington's disease.3 Life expectancy associated with this condition is reduced by 20% compared with the general population. The reasons for this include an increased risk of suicide, increased risk of coronary heart disease, cardiovascular disease, hypertension, obesity, cigarette smoking, and insulin resistance and diabetes.4
CAUSES
Unlike many medical conditions, there is no known cause for schizophrenia, although the majority of researchers believe it is caused by interaction of a number of biological and environmental factors. Some of the most commonly cited factors are listed below:5
• Genetic factors
Genetic factors are believed to play a significant role in the development of schizophrenia. Patients who have a family history of schizophrenia have an increased chance of developing this condition.
• Structural brain changes
Abnormalities within the frontal, temporal, limbic and basal ganglia areas of the brain have been identified via CT, MRI, PET scan and postmortem studies. Atrophy and reduced brain volume have also been attributed to this condition.
• Neurochemical and neurophysical changes
Changes in dopamine, norepinephrine, serotonin, cholinergic glutamatergic, neuropeptide and GABAergic have been implicated. Neuronal loss in the thalamus has also been cited.
• Endocrine factors
Changes in prolactin, melatonin and thyroid function have been cited.
• Viruses and immune factors
Although a specific virus has not been identified, it is suspected that perinatal viral infections may be a cause. Immune changes have also been found in schizophrenic patients.
• Environmental factors
Difficult birth or obstetrical trauma resulting in hypoxia can play a role. Some also link winter births as a predisposing factor.
• Psychosocial factors
Once believed to be the cause of schizophrenia, these factors are now believed to only have a role in the illness itself.
SIGNS AND SYMPTOMS
The signs and symptoms seen in patients with schizophrenia vary with each individual and can impair personal, social and occupational functioning.6 Most frequently, the signs and symptoms will continuously wax and wane throughout the patient's lifetime. During active periods, the signs and symptoms are classified as positive or negative.
POSITIVE SYMPTOMS
• Delusions
Delusions are false beliefs that are not shared by others within a culture. Many delusions are bizarre, religious, somatic or persecutory in nature and often involve loss of control over the mind or body.7
• Hallucinations
Hallucinations are any type of sensory experience (auditory, visual, olfactory, gustatory or tactile) that does not exist, but is very real to the patient. Auditory hallucinations are the most common symptom. Patients may hear unpleasant sounds, words, phrases or voices. Sometimes, the voices command or suggest that a patient do things that may be dangerous to himself or others.8
