Schizoaffective disorder

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.
• 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
• Depression

Organic Causes

• Meningitis
• Encephalitis
• Thyroid (Main)
• Toxin ingestion
• Medication effect
• See altered mental status

Evaluation

• Rule out other organic causes including substance abuse, medication effect or other medical conditions.
• Consider emergency psychiatric evaluation (e.g. safety assessment) 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
  • 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)

Disposition

• Home with outpatient psychiatric services if stable, versus inpatient psychiatric admission if unstable

See Also

• Schizophrenia
• Meningitis
• Encephalitis