dementia praecox

Early in the 20th century, a physician named Bleuler described a group of mental disorders that he labelled dementia praecox. The DSM uses the more modern term, schizophrenia. The literal translation of the word is "split mind". Schizophrenia is an abnormal perception or expression of reality. The forms of schizophrenia are characterized by delusions, hallucinations (auditory and visual), disorganized speech and often grossly disorganized behavior. Speech, emotional response and motivation are diminished or absent.

The DSM IV lists paranoid, disorganized, catatonic, undifferentiated and other forms of schizophrenia. We are all familiar with the "Law and Order" episodes of paranoid schizophrenics who commit murder because of their delusions. This is a gross exaggeration of the actual danger to the public posed by paranoid schizophrenics. Their paranoid delusions are far more likely to lead to their own suffering. Catatonics are recognized by the absence of speech and behavior. They are so disconnected from reality, that they can be "posed" and maintain a rigid posture to exhaustion.

The biological basis of schizophrenia is increased dopamine activity in the mesolimbic pathways of the brain. The only reason I mention this is that all antipsychotic medication act primarily by supressing dopamine activity. The two classes of medication used to treat schizophrenia are typical and atypical. Being a physician for more than thirty years, I think of the meds as old and new. Stelazine, thorazine, mellaril, and haldol were the med available to me early in my career. They varied in their side effect profile. Movements disorders, dystonic and dyskinetic, are disturbing and may become permanent with prolonged use. Alterations in autonomic functions such as blood pressure may cause unexpected loss of consciousness.

Dystonic reactions are prolonged and often painful contractions of muscles. The muscles of the face, tongue, and neck are especially vulnerable. Antihistamines such as Benadryl and Cogentin can be administered as an antidote or given simultaneously to try and prevent the dystonic reaction. Dyskinesias are repetitive movements such as lip smacking, tongue motions, "pill rolling" of the hands and generalized twitching. Dyskinesias are similar to the symptoms of Parkinson's disease because the dopamine suppressing effect of antipsychotics mimic the loss of dopamine producing neurons seen in Parkinson's disease.

The atypical antipsychotics have additional and dangerous side effects. They can lead to significant weight gain with the onset of diabetes and elevated cholesterol levels. Clozapine has an addition side effect, it can cause loss of bone marrow function. Agranulocytosis is the loss of formation of red and white blood cells and platelets. Anemia, infections, and bleeding problems then occur.

All antipsychotics can cause neuroleptic malignant syndrome. Life threatening fevers, muscle rigidity with break down of muscle tissue and ultimately kidney failure and shock can be fatal if not recognized and treated promptly.

Be afraid, be very afraid. The behavioral issues of schizophrenic patients may be disruptive in the ER, but are realtively easy to manage with medications and occasionally physical restraints. A calm demeanor, a soft and consistent voice and adequate "space" go far in the ER management of psychotic patients. A paranoid schizophrenic patient whom I have known since his initial "breakdown" is illustrative of this approach. He is notorious for not being medication compliant and therefore is a frequent visitor to the ER. When caught smoking in the bathroom, the ER security staff gathered to get control of the situation. I intervened. I offered a nictine patch, food, a beverage, and medication. He gave me his cigarettes and his lighter without any physical confrontation.

My primary concern is for the safety of the patients and the staff. I will use physical and chemical restraints to accomplish these goals. It is often difficult to examine and treat medical and surgical problems that arise in psychotic patients. Their delusions, and altered perceptions make them poor historians and resistant to interventions. An added burden is that lifetime occurence of drug abuse in schizophrenics is 40%. The central nervous system effects of nicotine are beneficial to the schizophrenic. This makes the ban on smoking in hospitals another problem to be addressed.

I freely admit that I like caring for schizophrenics. Treating a patient who is suffering is the reason I became a physician. Although the options in the ER are limited, compassion, empathy and kindness are always appropriate. Chronic schizophrenics often present as a homeless "crazy" accompanied by the police. They smell, may be home to "critters", and resistant to any intervention. The family may have been exhausted in the effort to care for this disabling disease. Society would rather not acknowledge the pscyhotics in their communities. The ER is the one place that is obligated legally, morally and ethically to care.