In Two Minds? EMS Care of the Schizophrenic Patient

   • Disorganized speech

   Patients with disorganized speech may jump randomly from one subject to another. Their speech may lack content. Some may use neologisms, or meaningless made-up words, or may frequently repeat words or phrases. Some patients' speech may be totally incoherent and disorganized, referred to as word salad.⁷

   • Catatonic or disorganized behavior

   Patients with schizophrenia often display unorganized behavior. Some may display negativism, doing or saying things that are completely opposite of what is appropriate for the situation, while others may automatically obey anything they are told despite the consequences of their actions.

   Many patients with disorganized behavior may appear improperly dressed and walk about aimlessly talking to themselves. Their behavior is often bizarre, and they may appear agitated or aggressive. Others may be completely unaware of their surroundings and maintain a rigid posture, resisting any type of movement. This positioning is usually referred to as catatonia.⁷ These types of unusual behaviors often lead to 9-1-1 calls from bystanders or family members for medical and sometimes police assistance.

NEGATIVE SYMPTOMS

   • Flat affect or decreased emotional reactivity

   This is one of the most common symptoms associated with schizophrenia. While some patients with schizophrenia may be depressed, many just have a lifeless facial expression and speak in monotone.

   • Alogia or poverty of speech

   Patients talk, but there is no real content to their conversation.

   • Avolition or lack of purposeful action

   Patients lack purpose when performing any activity.

DIAGNOSIS OF SCHIZOPHRENIA

   Diagnosis of schizophrenia is based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria (see Figure 1 on page 66).⁷

   Various tests are performed, along with a thorough history, physical exam and neuropsychological assessment by physicians, to formulate the diagnosis. Part of this process includes ensuring that other medical conditions are not the cause of the patient's signs and symptoms. The following medical conditions can induce psychosis and may be mistaken for schizophrenia.⁵

• Huntington's or Parkinson's disease
• Head trauma
• Infections—encephalitis, abscess, neurosyphilis
• Endocrine disease—thyroid, Cushing's, Addison's, pituitary, parathyroid diseases
• Substance abuse and drug toxicity
• Central nervous system lesions, tumors, aneurysms
• Systemic lupus erythematosus and multiple sclerosis
• Cerebrovascular disease or stroke
• Withdrawal from alcohol and benzodiazepines
• Delirium or dementia
• Migraine headache and temporal arteritis
• Pellagra and pernicious anemia
• Porphyria
• Sensory deprivation or overstimulation states.

   Like physicians, it is imperative that the EMS provider thoroughly assess the patient to ensure that no underlying traumatic or medical condition is responsible for the presenting signs and symptoms in the field. When in doubt, it is best to err on the side of the patients and treat them as if they have an underlying medical or traumatic cause (if suspected) for their behavior.

TYPES OF SCHIZOPHRENIA

   According to the DSM-IV, there are four major types of schizophrenia: paranoid, disorganized, catatonic and undifferentiated.⁹ Knowing the types may help you understand the behaviors usually associated with the patient's condition.

   • Paranoid

   Patient is preoccupied with one or more delusions or auditory hallucinations.

   • Disorganized

   Patient displays all of the following: disorganized speech, disorganized behavior, flat or inappropriate affect.

   • Catatonic

   At least two of the following: motor immobility as evidenced by catalepsy or stupor, excessive motor ability, extreme negativism or mutism, peculiarities in voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms or grimacing, echolalia or echopraxia.

   • Undifferentiated