A patient had just arrived at the emergency department in police custody. He was upset and excited and had to be stopped by hospital security guards so he couldn’t run away. The nurse asked me to see him right away because she was worried he might need some medicine so we could evaluate him safely.
I felt the urgency in her voice, so I went straight to his room. I saw a very frightened young man and tried to talk to him. He looked past me and seemed to be talking to someone who was not in the room with us. I said his name repeatedly and tried to calm him down, but I couldn’t get his attention. I was worried that if we let him go he would get into traffic or otherwise injure himself.
I went back to my computer to see if he had ever been seen in our emergency department for similar behavior before. He had visited a few times over the years, for little things, but never for psychosis or excitement. I had the nurse give him medicine to calm him down so we could find out what was going on.
What I knew at the time was that the police had been called by the patient’s mother for acting strangely at home. He heard voices and thought there were people outside their house looking in through the windows. When his mother asked him questions, he left the house upset. Police found him in a nearby alley and he seemed to be having a heated conversation with someone who was not there. The police tried to persuade him in their cruiser to check out of the rescue service. He agreed, but became more and more restless while driving.
I went back to see him about 30 minutes later after he got some medication and he was calmer. He had changed into a hospital gown and lay under a thin sheet. At first he was hesitant to speak to me, but eventually he opened. He said he had been very stressed for the past few weeks because he had just finished school and was trying to get a job, but hadn’t worked out so far. He was anxious and did not sleep or eat. For the past week, he started hearing voices and seeing things that other people didn’t see. He said he tried to rest, but the voices kept getting louder and he had to get up and do something to silence them.
I was concerned that this episode was due to schizophrenia. A severe mental disorder, schizophrenia, is characterized by thoughts out of touch with reality (with visual or auditory hallucinations), disorganized speech and behavior, and difficulty participating in daily activities. Patients often lack emotion and have difficulty with memory and concentration. They may also neglect their personal hygiene and lose interest in everyday activities that they used to enjoy. The exact cause is not fully known, but genetics, environmental factors, brain chemistry and structure probably all play a role. Schizophrenia usually occurs in men in their early 20s and women in their late 20s.
Treatment is usually lifelong and requires a combination of medication and psychotherapy. Left untreated, schizophrenia can lead to serious problems such as suicidal thoughts and attempts, drug and alcohol abuse, financial problems and homelessness, social isolation, anxiety and depression.
The medications used to treat the condition are called antipsychotics. They affect neurotransmitters in the brain, which can help with symptoms. Many of these drugs have unpleasant side effects that make it less likely that people will take them as prescribed. The drugs can be taken daily as a pill or as longer-acting versions that can be given as an injection monthly, which can help ensure they are taken as needed.
Once schizophrenic patients have stabilized, they can undergo psychotherapy, where they can learn to cope with stress and recognize warning signs of a psychotic relapse. A case manager can make sure they get their medications and find resources to help with work, housing, and day-to-day life support.
My patient was evaluated by our psychiatric team. They met him and his mother to discuss his history and the psychotic episode that took him to the emergency room. They felt that his acute psychosis was consistent with a diagnosis of schizophrenia, and he was eventually hospitalized to start taking antipsychotics to help stabilize him. His mother could also take classes for family members. While the future will have challenges, he and his mother seemed very motivated to stay on track with his medications and counseling and be in close touch with his case manager to help him navigate his new diagnosis.
Dr. Erika Kube is an emergency physician working for Mid-Ohio Emergency Services and OhioHealth.