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  • JOHN FORBES NASH JR. Born on June 13, 1928, (age 78)Maths professor - Winner of the Nobel Prize in Economics (1994) - Known for –Nash equilibrium -Nash embedding theorem -Algebraic geometry SUFFERING FROM schizophrenia SINCE HE WAS 30 YEARS OLD
  • Severity – more wore in men sue to more negative symptoms and less able to function in society
  • Hebephrenic = Disorganised
    The DSM-IV-TR contains five sub-classifications of schizophrenia, although the developers of DSM-5 are recommending they be dropped from the new classification

    The ICD-10 defines two additional subtypes.
    Post-schizophrenic depression: A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present. (ICD code F20.4)
    Simple schizophrenia: Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes.
  • Schizophrenia

    2. 2. To Know Schizophrenia is to know Psychiatry  The most devastating illness that psychiatrist treat.  One of the most challenging disease in medicine  1% of population has schizo.  An enormous economic burden  ? A major health concern
    3. 3. StoriesofSchizophrenia
    4. 4. History  Emil Kraepelin- original term- dementia praecox-early age, chronic deteriorating course.  Eugen Bleuler- coined the term schizophrenia (split mind)  affective blunting, loosening of associations, autism (withdrawal) and ambivalence (coexisting conflicting ideas) - 4 As- earned acceptance in USA  Kurt Schneider  first rank symptom
    5. 5. Definition Psychotic mental disorder of unknown aetiology characterized by disturbances in  Thinking (e.g. distortion of reality, delusions and hallucinations)  Mood (e.g. ambivalence, inappropriate affect)  Behaviour (e.g. Apathetic withdrawal, bizarre activity) at least 6 months
    6. 6. Epidemiology •Lifetime prevalence 1-1.5% •There is 7351 cases had been reported from 2003-2005 •The incidence was noted higher in males, urban and migrant population Incidence and prevalence(In Malaysia) •60% of the schizophrenia cases are man Sex ratio •Prevalence > low socioeconomic groups Socioeconomic status •Common between 15 and 35, rare before 10 and after 40 years old. Earlier onset for ♂ Age of onset
    7. 7. Epidemiology: Sex
    8. 8. Epidemiology: Race 54 28 9 9 Malay Chinese Indian Others BUT IT CAN ALSO AFFECT ANYONE WITHOUT PREDISPOSITIONS !
    9. 9. Aetiology Uncertain; however there is evidence for several risk factors. Several models which can be grouped into…. Biological Social Psychological
    10. 10. Aetiology – Bio Genetics Consideration  1st degree & 2nd degree relative Environmental  Abnormalities of pregnancy and delivery [2%]  Maternal Influenza – 2nd trimester [2%]  Fetal Malnutrition [2%]  Winter & Low Social Class birth [1.1%]
    11. 11. Social  Studies have shown an excess of schizophrenic patients in lower socioeconomic groups and in urbanised areas. This used to be attributed to “social drift”  Cannabis abusers [2%]
    12. 12. Psychological  abnormalities in processing sensory information, in separating “signal from background noise”, or in manipulating abstract information  Excess life traumas against controls at first presentation
    13. 13. Pathophysiology  disorder of dopaminergic function:  related to increased dopamine activity in certain neuronal tracts.  Other neurotransmitter abnormalities implicated in schizophrenia:  elevated serotonin.  elevated norepinephrine.  decreased gamma- aminobutyric acid (GABA).
    14. 14. Schizophrenia Subtypes Classically divided into five subtypes  Paranoid [stable, often persecutory delusion/hallucinations only]  Hebephrenic [thought/affective changes + -ve symptoms]  Undifferentiated [psychosis w/out clear predominance]  Catatonic [prominent psychomotor disturbances]  Residual [low intensity +ve symtoms]
    15. 15. THREE PHASES OF SCHIZOPHRENIA Prodromal •Decline in functioning that precedes 1st psychotic episode •Socially withdrawn, irritable •Physical complaints •Newfound interest in religion / the occult Psychotic (acute phase) •Positive symptoms •Perceptual disturbances (e.g. auditory hallucinations) •Delusions (usually secondary, delusion of reference common) •Disordered thought process / content Residual (chronic phase) •Occurs between episodes of psychosis •Marked by negative symptoms (flat affect, social withdrawal) •odd thinking and behaviour
    16. 16. Clinical Features Acute syndrome (positive symptoms) • Hallucinations • Delusion • Disorganised speech/thinking/ behaviour • Catatonic behaviours • Delusion of reference Chronic syndrome (negative symptoms) • Affective Flattening • Alogia • Avolition • Anhedonia • Attention(poor)
    17. 17. DIAGNOSIS CRITERIA OF SCHIZOPHRENIA The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination. (ICD-10) (DSM- IV)
    18. 18. ICD diagnostic criteria – 1 of the following At least one of the symptoms a-d or two of the symptoms e- i a. Thought echo, insertion, or withdrawal and thought broadcasting b. Delusions of control, influence, or passivity; delusional perception c. Hallucinatory voices-running commentary or other < part of body d. Persistent delusions of other kinds
    19. 19. ICD diagnostic criteria – 2 of the following e. Persistent hallucinations in any modality occurring everyday for weeks or months f. Breaks or interpolation in the train of thought > incoherence or irrelevant speech, or neologism g. Catatonic behavior, such as excitement, posturing, or waxy flexibility, negativism, mutism, stupor h. ‘negative’ symptoms; apathy, paucity of speech, blunting of emotional response i. A significant and consistent change in behavior > aimless, idle, self-absorbed att
    20. 20. DSM-IV diagnostic criteria A. Characteristic symptoms. At least 2 of the following; each for 1- month period: a. delusions b. hallucinations c. disorganized speech d. grossly disorganized or catatonic behavior e. negative symptoms, i.e. avolition, flattening of affect, alogia (poverty of speech) F. Social/occupational dysfunction G. Continuous signs of the disturbance persists for at least six months H. Schizoaffective and mood disorder exclusion I. Substance/medical condition exclusion J. Relationship to pervasive developmental disorder autism+ schiz.<D/H-1 m
    21. 21. Difference between DSMIV and ICD 10 DSMIV ICD-10 The classification of schizophrenia Course and functional impairment Schneider’s first rank sign The duration of illness 6 months 1 month Prodromal and residual period included Not included Occupational and social functional deficiency Expected since the onset of the disorder Expected in the course of the disorder
    22. 22. Kurt Schneider (German psychiatrist) ’s symptoms of first rank 1. Auditory hallucinations: audible thought or thought echo ; referring third person; running commentary. 2. Alienation of thought: thought insertion or withdrawal 3. Diffusion of thought (thought broadcasting) 4. Sensation of feelings, impulses or acts being controlled by external forces 5. Somatic passivity < external agency (e.g. X-rays, hypnosis) 6. Delusional perception
    23. 23. Schneider first rank symptoms of schizophrenia  Individual symptoms that are highly specific for schizophrenia  Occur in about 80% of schizo pts, 40% in bipolar mood disorder ( only mania)& 20% in severe major depression
    25. 25. Differential diagnosis  Organic syndrome  Drug  Temporal lobe epilepsy  Delirium  Dementia  Diffuse brain disease  Psychotic mood disorder  Personality disorder  Schizoaffective disorder
    26. 26. Course • Complete recovery20% • Recurrent acute illness 20% • Chronic disease starting acutely20% • Chronic disease starting insidiously20% • Suicide10-15%
    27. 27. Prognosis  Recover completely/long term minimal symptoms- 30%(The percentage on the rise)  Recurrent illness -poorer prognosis  Young patient -high risk of suicide
    28. 28. Predictors for poor outcome Features of the illness Insidious onset Long 1st episode Previous psychiatric history Negative symptoms Younger age at onset Features of the patient Male Single, separated, widowed or divorced Poor psychosexual adjustment Poor employment Social isolation Poor compliance
    29. 29. Assessment  No confirmatory laboratory studies.  Diagnosis made based on psychotic symptoms and functional deterioration.  Diagnostic evaluation: aim  Establish the presense of psychosis  Eliminate other differential diagnosis
    30. 30. Component of Evaluation Evaluation of of psychosis Medical evaluation Mental status and siucidality
    31. 31. Evaluation of of psychosis
    32. 32. Medical evaluation
    33. 33. Mental status and siucidality
    34. 34. Management  Treatment of Schizophrenia  Acute phase  Relapse prevention phase  Stable phase  Psychosocial care and rehabilitation
    35. 35. 36 Need rapid tranquilisation Urgent No Yes Combination of parenteral treatment Yes Yes No Identify Phases of Illness No Adequate dose & duration  Oral medication is preferred  When parenteral needed, use a single agent •Provide comprehensive plan (pharmacological, psychosocial & service level interventions) •Offer conventional APs (300-1000mg CPZ equivalent) or AMS or OLZ •Monitor clinical response, side effects & treatment adherence Poor response Optimise APs usage •Exclude substance abuse, treatment non-adherence & concurrent other general medical conditions •Optimise psychosocial interventions •Refer to psychiatrist for trial of clozapine Yes No •Plan for recovery (ACT, family intervention, psychoeducation, social skills training & supported employment) •APs usage to continue with single oral agent from acute phase; use depot when non-adherent •Monitor for clinical response, side effects & treatment adherence Acute phase Relapse prevention ALGORITHM FOR MANAGEMENT OF SCHIZOPHRENIA Diagnosis of Schizophrenia Stable phase  Follow-up at primary care  Follow manual on Garispanduan Perkhidmatan Rawatan Susulan Pesakit Mental di Klinik Kesihatan Prevention & management of side effects of APs at all phases aonitor EPS/akathisia/weight gain/diabetes/heart disease/sexual dysfunction Follow schedule of physical care as per follow-up manual
    36. 36. Acute phase  From home to hospital  Restrain  Aid from policemen  Safety of care provider, family members and patient is crucial  In the hospital  Room of seclusion  Consider involuntary admission
    37. 37. Physical restrain Family education and counselling Emergency medication Antipsychotic Combination: antipsychotic + benzodiazepine Administered parenterally If cooperative, oral administration allowed.
    38. 38. Relapse prevention phase  Started on routine anripsychotic as early as possible.  Maintenance doses of medication established and side effect reviewed.  Patient education and reassurance.  Building a therapeutic alliance with patient and family  Treatment resistance – Clozapine  Assertive Community Therapy(ACT)
    39. 39. ACT?  Combined medication and psychosocial treatments with aggressive delivery and follow-up.  Activities:  Daily home visit  “eyes-on” medication administration  Transportation to clinician appointment
    40. 40. Stable phase Follow up at primary care clinic. Life long medication Remission for at least 1 year achieve in 70 – 80% of patient taking antipsychotic at full doses Psychosocial support
    41. 41. Psychosocial and rehabilitation care  Social skill training  Employment training  Cognitive remediation therapy  Psychoeducation  Family therapy  Don’t forget medical illness too…
    42. 42. Medications Traditional Atypical Haloperidol (2-30 mg) Risperidone (4-16mg) Chlorpromazine (100-600mg) Olanzapine (5-20mg) Trifuoperazine (5-30mg) Sertindole (12-20mg) Sulpiride (400-800 mg) Clozapine (100-900 mg)
    43. 43.  Benzodiazepine - Lorazepam  Atypical antipsychotic for treatment resistant schizophrenia - Clozapine
    45. 45. Differential Diagnosis Psychotic Symptom Time Course Ruled out secondary causes Primary Psychosis Chronic (>1 mo) Schizoaffective Disorder Schizophrenia Delusional Disorder Psychosis NOS Brief (<1 mo) Brief Psychotic Disorder Psychosis NOS
    46. 46. DiagnosisSpecifiers Chronic Primary Psychosis Criterion A Sx and 6 mo dysfunction? Simultaneously meet criteria for mood disordes? Schzioaffective Disorder Schizophrenia Prominent Delusions? Delusional Disorder Psychosis NOS yes no no no yes yes
    47. 47. Diagnosis Brief Primary Psychosis Between 1 day and 1 mo Sx with full recovery Brief Psychotic Disorder Psychosis NOS yes no