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Schizophrenia

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Schizophrenia

Schizophrenia

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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 = DisorganisedThe DSM-IV-TR contains five sub-classifications of schizophrenia, although the developers of DSM-5 are recommending they be dropped from the new classificationThe 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 Schizophrenia Presentation Transcript

  • SCHIZOPHRENIA
    NG BOON KEAT
    MOHD HANAFI RAMLEE
  • 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
  • Stories of Schizophrenia
  • History
    Emil Kraepelin- original term-dementia praecox-early age, chronic deteriorating course.
    EugenBleuler- 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
  • 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
    Definition
  • Epidemiology
  • Epidemiology: Sex
  • Epidemiology: Race
    BUT IT CAN ALSO AFFECT ANYONE WITHOUT PREDISPOSITIONS !
  • Aetiology
    Uncertain; however there is evidence for several risk factors.
    Several models which can be grouped into….
  • 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%]
  • 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%]
  • 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
  • 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).
  • 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 +vesymtoms]
  • THREE PHASES OF SCHIZOPHRENIA
  • Clinical Features
  • DIAGNOSIS CRITERIA OF SCHIZOPHRENIA
    The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination.
  • 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
  • ICD diagnostic criteria – 2of the following
    e. Persistent hallucinations in any modality occurring everyday for weeks or months
    f. Breaks or interpolation in the train of thought > incoherenceor irrelevant speech, or neologism
    g.Catatonicbehavior, such as excitement, posturing, or waxy flexibility, negativism, mutism, stupor
    h. ‘negative’ symptoms; apathy, paucity of speech, blunting of emotional response
    A significant and consistent change in behavior > aimless, idle, self-absorbed att
  • 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
  • Difference between DSMIV and ICD 10
  • Kurt Schneider (German psychiatrist) ’s symptoms of first rank
    Auditory hallucinations: audible thought or thought echo ; referring third person; running commentary.
    Alienation of thought: thought insertion or withdrawal
    Diffusion of thought (thought broadcasting)
    Sensation of feelings, impulses or acts being controlled by external forces
    Somatic passivity < external agency (e.g. X-rays, hypnosis)
    Delusional perception
  • Schneider first rank symptoms of schizophrenia
    Individual symptoms that are highly specific for schizophrenia
    Occur in about 80% of schizopts, 40% in bipolar mood disorder ( only mania)& 20% in severe major depression
  • DIFFERENTIALS & MANAGEMENTS
  • Differential diagnosis
    Organic syndrome
    Drug
    Temporal lobe epilepsy
    Delirium
    Dementia
    Diffuse brain disease
    Psychotic mood disorder
    Personality disorder
    Schizoaffective disorder
  • Course
  • Prognosis
    Recover completely/long term minimal symptoms- 30%(The percentage on the rise)
    Recurrent illness -poorer prognosis
    Young patient -high risk of suicide
  • Predictors for poor outcome
  • 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
  • Component of Evaluation
    Evaluation of of psychosis
    Medical evaluation
    Mental status and siucidality
  • Evaluation of of psychosis
  • Medical evaluation
  • Mental status and siucidality
  • Management
    Treatment of Schizophrenia
    Acute phase
    Relapse prevention phase
    Stable phase
    Psychosocial care and rehabilitation
  • Identify Phases of Illness
    Need rapid tranquilisation
    Urgent
    Yes
    Combination of
    parenteral treatment
    Acute phase
    Yes
    No
    • Oral medication is preferred
    • When parenteral needed, use a single agent
    No
    • 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
    • Exclude substance abuse, treatment non-adherence & concurrent other general medical conditions
    • Optimise psychosocial interventions
    • Refer to psychiatrist for trial of clozapine
    Adequate dose & duration
    Poor response
    Yes
    Yes
    No
    No
    Optimise APs usage
    • 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
    Relapse prevention
    ALGORITHM FOR MANAGEMENT OF SCHIZOPHRENIA
    Diagnosis of Schizophrenia
    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
    • Follow-up at primary care
    • Follow manual on Garispanduan Perkhidmatan Rawatan Susulan PesakitMental di Klinik Kesihatan
    Stable phase
    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
  • Physical restrain
    Family education and counselling
    Emergency medication
    Antipsychotic
    Combination: antipsychotic + benzodiazepine
    Administered parenterally
    If cooperative, oral administration allowed.
  • 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)
  • ACT?
    Combined medication and psychosocial treatments with aggressive delivery and follow-up.
    Activities:
    Daily home visit
    “eyes-on” medication administration
    Transportation to clinician appointment
  • 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
  • Psychosocial and rehabilitation care
    Social skill training
    Employment training
    Cognitive remediation therapy
    Psychoeducation
    Family therapy
    Don’t forget medical illness too…
  • Medications
  • Benzodiazepine - Lorazepam
    Atypical antipsychotic for treatment resistant schizophrenia - Clozapine
  • THANK YOU
    NG BOON KEAT
    MOHD HANAFI RAMLEE
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