Schizophrenia and Other Psychoses


Medical Management Considerations

Oral Health Consideration


Resources for Families

Advisory Committee

Publication Information


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Description and Cause

Psychosis is a general term and symptoms of psychosis may occur in a variety of medical as well as psychiatric illnesses. Psychotic symptoms are the result of an impairment in the process of thinking in which a person has difficulty perceiving thoughts and things as they really are. The most important psychiatric disorder in which psychotic symptoms predominate is schizophrenia. This chronic condition often begins in late adolescence and early adulthood and is often accompanied by a significant decline in overall functioning. Great progress has been made in controlling the symptoms of schizophrenia but no cure is known. The onset of schizophrenia may be acute, but more typically develops insidiously over many months. The exact cause of schizophrenia is unknown but it is clearly a neurobiological disorder with a strong genetic basis. Positive symptoms of psychosis may include hallucinations (hearing, seeing, or feeling things that are not there), delusions (false or often bizarre beliefs), and disorders in the flow of thought (vague, loose, and difficult to follow thinking). Negative symptoms of psychosis, including depression, social withdrawal, lack of initiative, and absence of normal personality features, may also be important characteristics of other psychiatric disorders. The differential diagnosis of schizophrenia includes mood disorders and may be difficult, particularly during the first episode of psychosis. In all cases where a diagnosis of schizophrenia is being considered, referral to a psychiatrist for assessment and recommendations is indicated.


Schizophrenia occurs in approximately 1% of the world’s population and may be even more common in individuals with developmental disabilities. It is difficult to determine the exact prevalence in persons with mental retardation because much of the diagnostic criteria for schizophrenia requires verbal reports from the individual. In persons with moderate or more severe mental retardation a diagnosis of Psychosis, Not Otherwise Specified may be more appropriate. The peak ages of onset are in the early 20s for males and late 20s early 30s for females. Fortunately, onset in young children is rare.

Characteristic Features

DSM-IV criteria for schizophrenia require a 1-month period characterized by two or more of the following symptoms:

  1. delusions
  2. hallucinations
  3. disorganized speech (e.g. frequent derailment or incoherence)
  4. grossly disorganized or catatonic behavior
  5. negative symptoms, i.e. affective flattening, alogia, avolition

Only one of the five may be required if the delusions are bizarre or if voices carry on a running commentary or include two or more voices talking to each other. These symptoms must be accompanied by social/occupational dysfunction, and be associated with a period of disturbance of at least six months. Mood disorders with psychotic features must be ruled out as well as psychosis caused by medications or drugs of abuse or a medical condition. Episodes of psychosis of a shorter duration (less than six months) may meet criteria for a Brief Psychotic Disorder or a Schizophreniform Disorder.

Diagnostic Considerations

Symptoms of psychosis in persons with developmental disabilities are similar in all age groups and similar to those seen in the general population. Diagnostic difficulties increase with the degree of mental retardation and it may be particularly difficult to assess disordered thinking in individuals with limited verbal abilities.  [Return to the index for a full document on Mental Retardation.]  Particular care must be made to distinguish true hallucinations from imaginary companions and delusions from child-like wishes or misperceptions based on poor cognitive understanding of the environment. In the former, a useful rule of thumb is whether the person is frightened, bothered, or confused by the “imaginary friends.”  If so, one must be more concerned that they may represent true symptoms. Similarly, night terrors and other sleep related phenomena must not be confused with true psychosis. A diagnosis of psychosis in individuals with mental retardation should never be made quickly. Medical and neurological illnesses must be carefully ruled out (see below). Typically, multiple informants over an extended period of time are required to firmly establish the diagnosis. This is particularly true if one is attempting to distinguish schizophrenia from a mood disorder with psychotic features, e.g., bipolar disorder. Another important consideration is that people with developmental disabilities including autism are particularly vulnerable to stress and may transiently develop psychotic features that quickly resolve as the stress is removed. Similarly, individuals with developmentally disabilities are more likely to be the victims of trauma and abuse. They may develop symptoms of Post Traumatic Stress Disorder with dissociative features that may be confused with psychosis.  [Return to the index for a full document on Post Traumatic Stress Disorder and Abuse.]


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Initial Assessment

In any individual presenting with an acute psychosis, after the initial history is obtained, the next step is a comprehensive medical and physical assessment. A neurological and physical examination should be performed. A variety of conditions need to be considered. These include:

  • acute intoxication (medication or substance of abuse)
  • delirium
  • seizure disorder
  • brain lesion or head trauma
  • infectious disease (encephalitis, meningitis, HIV etc.)
  • metabolic disorders (e.g. endocrinopathies)

Laboratory evaluation will depend on history and exam but generally would include:

  • complete blood count
  • chemistry panels
  • thyroid functions
  • urinalysis
  • toxicology screen

If neurological findings suggesting a structural lesion are present, an MRI and EEG should be performed. Some experts recommend these studies for all first episodes of psychosis even if the neurological examination is unremarkable and particularly when psychosis appears in adolescents, a slightly younger age group than the peak age of 20.

A comprehensive mental health consultation and/or referral must be obtained.

Safety Considerations

Individuals with or without developmental disabilities with an acute psychosis or exacerbation of a chronic disorder may present with symptoms of agitation, confusion and/or aggression. Hospitalization may be required for safe management. Suicidal and homicidal thinking must be carefully assessed. Command hallucinations to harm oneself or others represent a major emergency and hospitalization is mandatory.

Medication Management

Treatment with anti-psychotic medications is central to the management of schizophrenia. There is some evidence that delay in treatment, once the diagnosis has been established, may worsen outcome. Medication treatment of an initial episode of schizophrenia should be under the care of an experienced psychiatrist. Long-term care may involve coordinated care with a primary care physician and a psychiatric consultant.

Anti-psychotic drugs used to treat schizophrenia and related psychoses are described (somewhat inaccurately) as “typical” or “atypical”. The “typical” anti-psychotics are traditional drugs primarily interacting with the dopamine system. The newer “atypical” anti-psychotics have a broader range of action, affecting other receptor systems including serotonin.

Examples of traditional anti-psychotic medications include:

  • haloperidol (Haldol)
  • chlorpromazine (Thorazine)
  • thiothixene (Navane)

Examples of newer “atypical” anti-psychotics include:

  • risperidone (Risperdal)
  • olanzapine (Zyprexa)
  • clozapine (Clozaril)
  • quetiapine (Seroquel)
  • ziprasidone (Geodon)
  • aripiprazole (Abilify)

Choice of an anti-psychotic medication depends primarily on somewhat different side-effect profiles. Although it is still imperative to check for tardive diskinesia, in general, the “atypicals” are now first choices and are somewhat better tolerated by most patients. Clozapine is a special case in that it has demonstrated effectiveness in treatment resistant schizophrenia but also has a significant side-effect profile including agranulocytosis, requiring special monitoring. Clozapine is therefore utilized only when other medications have proven ineffective.

The prescribing physician must be well informed about the side effects of the anti-psychotics and important drug interactions and is referred to a number of sources (e.g., Shiloh, et al.). Particular considerations when treating individuals with developmental disabilities include the following:

  • many anti-psychotics lower the seizure threshold
  • individuals with MR may be more prone to extra-pyramidal and motor side-effects
  • many result in weight gain that can be problematic
  • several interact with anti-convulsants to alter blood levels
  • several have significant effects on cardiac conduction and require EKG monitoring (e.g. clozapine, ziprasidone, and thioridazine)

All of these considerations require careful client and caregiver consent and education.

Other Treatment Considerations 

Schizophrenia is a chronic and lifelong illness and when it occurs in an individual with a lifelong disability the challenges are indeed daunting. Other critical aspects of treatment include:

  • client education and supportive counseling geared to his/her level of disability
  • family and care-giver education and support (see resources)
  • specialized educational and vocational services
  • supportive living and/or day treatment programs
  • careful coordination between mental health and developmental service systems


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A thorough knowledge of the dental implications of schizophrenia and other psychoses will aid a primary care provider and dental practitioner in preventing dental problems and providing the most appropriate treatment. In particular, care should be taken to prevent adverse drug interactions between the medications addressing the psychosis and the medications used during dental treatment. Treatment options and limitations, as well as daily measures to take to prevent dental problems and maintain oral health, should be clearly explained to persons with developmental disabilities and their families/caregivers. Dental caries is an infectious and transmissible disease. Every person should be referred to an oral health professional for evaluation and have an oral health care plan by age 1 to prevent early childhood caries and later periodontal disease.

Dental Conditions Associated with Schizophrenia

  • Poor oral hygiene
  • Poor nutrition, poor diet
  • Decreased salivary flow
    • Xerostomia (mouth dryness), associated with some antipsychotic medications
  • Increased risk of dental decay and periodontal disease due to
    • Poor oral hygiene, poor diet, and xerostomia
    • Neglecting dental care (because of depression, confusion, or anxiousness)
  • Occasional parotitis (inflammation of the parotid gland)
  • Mucositis (inflammation of mucous membranes)
  • Attrition associated with tardive dyskinesia, a possible side effect of long-term use of neuroleptic drugs

Dental Management

Managing the preventive, restorative, and surgical aspects of dental treatment involve an early (by age 1) and regular oral health evaluation and caries risk assessment, as well as the establishment of a customized oral health care plan.

The patient may or may not be able to provide consent for the dental treatment. Practitioners should approach patients with paranoid schizophrenia in a nonthreatening manner, avoid sudden movements, and prepare patients on what to expect during the treatment.

Clinical Considerations

  • Since patients may be receiving medications to treat the disorder, consider drug interactions prior to using additional medications, sedatives, or anesthetics.
  • Consider prescribing artificial saliva substitutes for patients with xerostomia.

At-Home Care

  • Establish good daily oral hygiene procedures including plaque removal by brushing and flossing.
  • Encourage regular brushing/flossing.
  • Promote diet that does not increase the risk of dental decay.
  • Consider diet counseling for a patient with significant tooth decay.
  • Use fluoridated water and toothpaste.
  • Use gum, mints, or foods containing Xylitol as the primary sugar to reduce caries.
  • Use antimicrobial (Chlorhexidine) mouthwash or spray as an adjunct for some individuals with rampant caries and gingivitis.

[Return to the index for a full document on Dental Care]


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American Academy of Child and Adolescent Psychiatry (1999),  Your Adolescent:  Emotional, Behavioral, and Cognitive Development from Early Adolescence through the Teen Years; Pruitt DB, ed.  New York: Harper Collins

American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington DC: American Psychiatric Association

American Psychiatric Association (1997) Practice Guidelines for the Treatment of Patients with Schizophrenia, American Journal of Psychiatry 154(S4): 1-63

Borus N, ed (1999)  Psychiatric and Behavioural Disorders in Developmental Disabilities and Mental Retardation.  Cambridge:  Cambridge University Press

Campbell M, Rapoport JL, Simpson GM (1999),  Antipsychotics in children and adolescents.  Journal of the American Academy of Child and Adolescent Psychiatry 38(5): 537-545

Cherry KE, Peen, D, Matson, JL, Bamburg, JW (2000),  Characteristics of schizophrenia among persons with severe or profound mental retardation.  Brief Reports 51(7):  922-924

Clark DJ (2001), Treatment of schizophrenia. In: Treating Mental Illness and Behavior Disorders in Children and Adults with Mental Retardation; Dosen A, Day K, Eds, Washington DC: American Psychiatric Press,  pp 183-200

Dosen A, Day Kenneth, eds (2001)  Treating Mental Illness and Behavior Disorders in Children and Adults with Mental Retardation. Washington:  American Psychiatric Press

Duggan L, Brylewski J (1999),  Effectiveness of antipsychotic medication in people with intellectual disability and schizophrenia:  a systematic review.  Journal of Intellectual Disability 43 (Part 2):  94-104

Dykens EM (2000),  Psychopathology in children with intellectual disabilities.  Journal of Child Psychology and Psychiatry 41:  407-417

Madrid AL, State MW (2000), Pharmacologic management of psychiatric and behavioral symptoms in mental retardation. Child and Adolescent Psychiatric Clinics of North America  9: 225-243

McClellan J, Werry J (2001), Practice parameters for the assessment and treatment of children and adolescents with Schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry 40(S7): 4S-23S.

Reiss S, Aman MG, eds (1998),  Psychotropic Medications and Developmental Disabilities:  The International Consensus Handbook.  Columbus: Ohio State University Press

Rush J, Frances A, eds (2000) Expert Consensus Guideline Series: Treatment of psychiatric and behavioral problems in mental retardation. American Journal of Mental Retardation: 105(3):159-226.

Southern Association of Institutional Dentists (2001), “Module 9: Clinical Concerns in Dental Care for Persons with Mental Illness.” Modules. Accessed April 22, 2003 at

Szymanski L, King BH (1999), Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders. Journal of the American Academy of Child and Adolescent Psychiatry 38(S12): 5S-31S.

Szymanski L, King BH, Goldberg B, et al., (1998),  Diagnosis of mental disorders in people with mental retardation.  In:  Psychotropic Medications and Developmental Disabilities: The International Consensus Handbook; Reiss S, Aman MG, eds. Columbus: Ohio State University Press, pp. 3-17.

University of Florida, College of Dentistry, Department of Pediatric Dentistry (2001), “Schizophrenia.” Oral Health Care for Persons with Disabilities. Accessed April 22, 2003 at

Van Bellinghen M, De Troch C (2001),  Risperidone in the treatment of behavioral disturbances in children and adolescent with borderline intellectual functioning:  a double-blind, placebo-controlled pilot trial. Journal of Child and Adolescent Psychopharmacology 11(1): 5-13

Volkmar FR, Dykens E (2002), Mental Retardation. In: Child and Adolescent Psychiatry:  A Comprehensive Textbook, 3rd Ed.; Lewis M, ed., Philadelphia: Lippincott Williams & Wilkins,  pp. 603-611


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American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue, N.W.

Washington, D.C.  20016-3007


American Dental Association


Tips for People Who Have Special Needs

American Psychiatric Association

1400 K Street N.W.

Washington, DC  20005


The Arc (formally Association for Retarded Citizens)

500 East Border Street, Suite 300

Arlington, Texas  76010




Association of University Centers on Disabilities

8630 Fenton Street, Suite 410

Silver Spring, MD  20910-3803


California Alliance for the Mentally Ill

1111 Howe Avenue, Suite 475

Sacramento, CA 95825-8541



Fax:  916-567-1757

[email protected]

California Mental Health and Developmental Disabilities Center

California Regional Centers


The National Association for the Dually Diagnosed

132 Fair Street

Kingston, NY 12401


National Mental Health Association Information Center

2001 North Beauregard Street, 12th floor

Alexandria, VA  22311



Fax:  703-684-5968

infocс[email protected]

National Oral Health Information Clearinghouse


TTY 301-656-7581

Oral Conditions in Children with Special Needs

A Guide for Health Care Providers

Project MED (Medical Education for Consumers)

Southern Association of Institutional Dentists

Special Care Dentistry


Special Olympics Special Smiles

A Guide to Good Oral Health for Persons with Special Needs

The Tarjan Center for Developmental Disabilities at UCLA

University of Florida

College of Dentistry

Department of Pediatric Dentistry
Oral Health Care for Persons with Disabilities

University of the Pacific

School of Dentistry

Center for Oral Health for People with Special Needs

or , Community Programs


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Theodore A. Kastner, M.D., M.S.

Paul Glassman, D.D.S., M.A., M.B.A.

Donald M. Hilty, M.D.

Leonard Magnani, M.D., Ph.D.

Christine Miller, R.D.H., M.H.S., M.A.

Mary B. Tierney, M.D.

Terrance D. Wardinsky, M.D.


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Primary authors: Andrew Russell, M.D. and Bhavik Shah, M.D.

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.