SCHIZOPHRENIA<br />NG BOON KEAT<br />MOHD HANAFI RAMLEE<br />
To Know Schizophrenia is to know Psychiatry<br />The most devastating illness that psychiatrist treat.<br />One of the mos...
Stories of Schizophrenia<br />
History<br />Emil Kraepelin- original term-dementia praecox-early age, chronic  deteriorating course.<br />EugenBleuler- c...
Psychotic mental disorder of unknown aetiology characterized by disturbances in<br />Thinking (e.g. distortion of reality,...
Epidemiology<br />
Epidemiology: Sex<br />
Epidemiology: Race<br />BUT IT CAN ALSO AFFECT ANYONE WITHOUT PREDISPOSITIONS !<br />
Aetiology<br />Uncertain; however there is evidence for several risk factors.<br />Several models which can be grouped int...
Aetiology – Bio<br />Genetics Consideration<br />1st degree & 2nd degree relative<br />Environmental<br />Abnormalities of...
Social<br />Studies have shown  an excess of schizophrenic patients in lower socioeconomic groups and in urbanised areas. ...
Psychological<br />abnormalities in processing sensory information, in separating “signal from background noise”, or in ma...
Pathophysiology<br />disorder of dopaminergic function:<br />related to increased dopamine activity in certain neuronal tr...
Schizophrenia Subtypes<br />Classically divided into five subtypes<br />Paranoid[stable, often persecutory delusion/halluc...
THREE PHASES OF SCHIZOPHRENIA<br />
Clinical Features<br />
DIAGNOSIS CRITERIA OF SCHIZOPHRENIA<br />The diagnosis of schizophrenia is based entirely on the clinical presentation – h...
ICD diagnostic criteria – 1 of the following<br />At least one of the symptoms a-d or two of the symptoms e- i<br />a.Thou...
ICD diagnostic criteria – 2of the following<br />e. Persistent hallucinations in any modality occurring everyday for weeks...
DSM-IV diagnostic criteria<br />A. Characteristic symptoms. At least 2 of the following; each for 1- month period:<br />  ...
Difference between DSMIV and ICD 10<br />
Kurt Schneider (German psychiatrist) ’s symptoms of first rank<br />Auditory hallucinations: audible thought or thought ec...
Schneider first rank symptoms of schizophrenia<br />Individual symptoms that are highly specific for schizophrenia<br />Oc...
DIFFERENTIALS & MANAGEMENTS<br />
Differential diagnosis<br />Organic syndrome<br />Drug<br />Temporal lobe epilepsy<br />Delirium<br />Dementia<br />Diffus...
Course<br />
Prognosis<br />Recover completely/long term minimal symptoms- 30%(The percentage on the rise)<br />Recurrent illness	 -poo...
Predictors for poor outcome<br />
Assessment<br />No confirmatory laboratory studies. <br />Diagnosis made based on psychotic symptoms and functional deteri...
Component of Evaluation<br />Evaluation of of psychosis<br />Medical evaluation<br />Mental status and siucidality<br />
Evaluation of of psychosis<br />
Medical evaluation<br />
Mental status and siucidality<br />
Management<br />Treatment of Schizophrenia<br />Acute phase<br />Relapse prevention phase<br />Stable phase<br />Psychosoc...
Identify Phases of Illness<br />Need rapid tranquilisation<br />Urgent<br />Yes<br />Combination of <br />parenteral treat...
When parenteral needed, use a single agent</li></ul>No<br /><ul><li>Provide comprehensive plan (pharmacological, psychosoc...
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 </li></ul>Adequate dose & duration<br />Poor response<br />Yes<br />Yes<br />...
APs usage to continue with single oral agent from acute phase; use depot when non-adherent
Monitor for clinical response, side effects & treatment adherence</li></ul>Relapse prevention<br />ALGORITHM FOR MANAGEMEN...
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</li></ul>Stable phase<br />36...
Acute phase<br />From home to hospital<br />Restrain<br />Aid from policemen<br />Safety of care provider, family members ...
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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 final

    1. 1. SCHIZOPHRENIA<br />NG BOON KEAT<br />MOHD HANAFI RAMLEE<br />
    2. 2. To Know Schizophrenia is to know Psychiatry<br />The most devastating illness that psychiatrist treat.<br />One of the most challenging disease in medicine<br />1% of population has schizo.<br />An enormous economic burden<br />? A major health concern<br />
    3. 3. Stories of Schizophrenia<br />
    4. 4. History<br />Emil Kraepelin- original term-dementia praecox-early age, chronic deteriorating course.<br />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<br />Kurt Schneider  first rank symptom<br />
    5. 5. Psychotic mental disorder of unknown aetiology characterized by disturbances in<br />Thinking (e.g. distortion of reality, delusions and hallucinations)<br />Mood (e.g. ambivalence, inappropriate affect)<br />Behaviour(e.g. Apathetic withdrawal, bizarre activity)<br />at least 6 months<br />Definition <br />
    6. 6. Epidemiology<br />
    7. 7. Epidemiology: Sex<br />
    8. 8. Epidemiology: Race<br />BUT IT CAN ALSO AFFECT ANYONE WITHOUT PREDISPOSITIONS !<br />
    9. 9. Aetiology<br />Uncertain; however there is evidence for several risk factors.<br />Several models which can be grouped into….<br />
    10. 10. Aetiology – Bio<br />Genetics Consideration<br />1st degree & 2nd degree relative<br />Environmental<br />Abnormalities of pregnancy and delivery [2%]<br />Maternal Influenza – 2nd trimester [2%]<br />Fetal Malnutrition [2%]<br />Winter & Low Social Class birth [1.1%]<br />
    11. 11.
    12. 12. Social<br />Studies have shown an excess of schizophrenic patients in lower socioeconomic groups and in urbanised areas. This used to be attributed to “social drift”<br />Cannabis abusers [2%]<br />
    13. 13. Psychological<br />abnormalities in processing sensory information, in separating “signal from background noise”, or in manipulating abstract information<br />Excess life traumas against controls at first presentation<br />
    14. 14. Pathophysiology<br />disorder of dopaminergic function:<br />related to increased dopamine activity in certain neuronal tracts.<br />Other neurotransmitter abnormalities implicated in schizophrenia:<br />elevated serotonin.<br />elevated norepinephrine.<br />decreased gamma- aminobutyric acid (GABA).<br />
    15. 15. Schizophrenia Subtypes<br />Classically divided into five subtypes<br />Paranoid[stable, often persecutory delusion/hallucinations only]<br />Hebephrenic[thought/affective changes + -ve symptoms]<br />Undifferentiated [psychosis w/out clear predominance]<br />Catatonic[prominent psychomotor disturbances]<br />Residual [low intensity +vesymtoms]<br />
    16. 16. THREE PHASES OF SCHIZOPHRENIA<br />
    17. 17. Clinical Features<br />
    18. 18. DIAGNOSIS CRITERIA OF SCHIZOPHRENIA<br />The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination.<br />
    19. 19. ICD diagnostic criteria – 1 of the following<br />At least one of the symptoms a-d or two of the symptoms e- i<br />a.Thought echo, insertion, or withdrawal and thought broadcasting<br />b. Delusions of control, influence, or passivity; delusional perception<br />c. Hallucinatory voices-running commentary or other < part of body<br />d. Persistent delusions of other kinds<br />
    20. 20. ICD diagnostic criteria – 2of the following<br />e. Persistent hallucinations in any modality occurring everyday for weeks or months<br />f. Breaks or interpolation in the train of thought > incoherenceor irrelevant speech, or neologism<br />g.Catatonicbehavior, such as excitement, posturing, or waxy flexibility, negativism, mutism, stupor <br />h. ‘negative’ symptoms; apathy, paucity of speech, blunting of emotional response<br />A significant and consistent change in behavior > aimless, idle, self-absorbed att<br />
    21. 21. DSM-IV diagnostic criteria<br />A. Characteristic symptoms. At least 2 of the following; each for 1- month period:<br /> a. delusions<br /> b. hallucinations<br /> c. disorganized speech<br /> d. grossly disorganized or catatonic behavior<br /> e. negative symptoms, i.e. avolition, flattening of affect, alogia (poverty of speech)<br />F. Social/occupational dysfunction<br />G. Continuous signs of the disturbance persists for at least six months<br />H. Schizoaffective and mood disorder exclusion<br />I. Substance/medical condition exclusion<br />J. Relationship to pervasive developmental disorder<br /> autism+ schiz.<D/H-1 m<br />
    22. 22. Difference between DSMIV and ICD 10<br />
    23. 23. Kurt Schneider (German psychiatrist) ’s symptoms of first rank<br />Auditory hallucinations: audible thought or thought echo ; referring third person; running commentary.<br />Alienation of thought: thought insertion or withdrawal<br />Diffusion of thought (thought broadcasting)<br />Sensation of feelings, impulses or acts being controlled by external forces<br />Somatic passivity < external agency (e.g. X-rays, hypnosis)<br />Delusional perception<br />
    24. 24. Schneider first rank symptoms of schizophrenia<br />Individual symptoms that are highly specific for schizophrenia<br />Occur in about 80% of schizopts, 40% in bipolar mood disorder ( only mania)& 20% in severe major depression<br />
    25. 25. DIFFERENTIALS & MANAGEMENTS<br />
    26. 26. Differential diagnosis<br />Organic syndrome<br />Drug<br />Temporal lobe epilepsy<br />Delirium<br />Dementia<br />Diffuse brain disease<br />Psychotic mood disorder<br />Personality disorder<br />Schizoaffective disorder<br />
    27. 27. Course<br />
    28. 28. Prognosis<br />Recover completely/long term minimal symptoms- 30%(The percentage on the rise)<br />Recurrent illness -poorer prognosis<br />Young patient -high risk of suicide<br />
    29. 29. Predictors for poor outcome<br />
    30. 30. Assessment<br />No confirmatory laboratory studies. <br />Diagnosis made based on psychotic symptoms and functional deterioration. <br />Diagnostic evaluation: aim<br />Establish the presense of psychosis<br />Eliminate other differential diagnosis<br />
    31. 31. Component of Evaluation<br />Evaluation of of psychosis<br />Medical evaluation<br />Mental status and siucidality<br />
    32. 32. Evaluation of of psychosis<br />
    33. 33. Medical evaluation<br />
    34. 34. Mental status and siucidality<br />
    35. 35. Management<br />Treatment of Schizophrenia<br />Acute phase<br />Relapse prevention phase<br />Stable phase<br />Psychosocial care and rehabilitation<br />
    36. 36. Identify Phases of Illness<br />Need rapid tranquilisation<br />Urgent<br />Yes<br />Combination of <br />parenteral treatment<br />Acute phase<br />Yes<br />No<br /><ul><li>Oral medication is preferred
    37. 37. When parenteral needed, use a single agent</li></ul>No<br /><ul><li>Provide comprehensive plan (pharmacological, psychosocial & service level interventions)
    38. 38. Offer conventional APs (300-1000mg CPZ equivalent) or AMS or OLZ
    39. 39. Monitor clinical response, side effects & treatment adherence
    40. 40. Exclude substance abuse, treatment non-adherence & concurrent other general medical conditions
    41. 41. Optimise psychosocial interventions
    42. 42. Refer to psychiatrist for trial of clozapine </li></ul>Adequate dose & duration<br />Poor response<br />Yes<br />Yes<br />No<br />No<br />Optimise APs usage<br /><ul><li>Plan for recovery (ACT, family intervention, psychoeducation, social skills training & supported employment)
    43. 43. APs usage to continue with single oral agent from acute phase; use depot when non-adherent
    44. 44. Monitor for clinical response, side effects & treatment adherence</li></ul>Relapse prevention<br />ALGORITHM FOR MANAGEMENT OF SCHIZOPHRENIA<br />Diagnosis of Schizophrenia<br />Prevention & management of side effects of APs at all phases<br /><ul><li>aonitor EPS/akathisia/weight gain/diabetes/heart disease/sexual dysfunction
    45. 45. Follow schedule of physical care as per follow-up manual
    46. 46. Follow-up at primary care
    47. 47. Follow manual on Garispanduan Perkhidmatan Rawatan Susulan PesakitMental di Klinik Kesihatan</li></ul>Stable phase<br />36<br />
    48. 48. Acute phase<br />From home to hospital<br />Restrain<br />Aid from policemen<br />Safety of care provider, family members and patient is crucial<br />In the hospital<br />Room of seclusion<br />Consider involuntary admission<br />
    49. 49. Physical restrain<br />Family education and counselling<br />Emergency medication<br />Antipsychotic<br />Combination: antipsychotic + benzodiazepine<br />Administered parenterally<br />If cooperative, oral administration allowed. <br />
    50. 50. Relapse prevention phase<br />Started on routine anripsychotic as early as possible.<br />Maintenance doses of medication established and side effect reviewed. <br />Patient education and reassurance. <br />Building a therapeutic alliance with patient and family<br />Treatment resistance – Clozapine<br />Assertive Community Therapy(ACT)<br />
    51. 51. ACT?<br />Combined medication and psychosocial treatments with aggressive delivery and follow-up.<br />Activities:<br />Daily home visit<br />“eyes-on” medication administration<br />Transportation to clinician appointment <br />
    52. 52. Stable phase<br />Follow up at primary care clinic.<br />Life long medication<br />Remission for at least 1 year achieve in 70 – 80% of patient taking antipsychotic at full doses<br />Psychosocial support<br />
    53. 53. Psychosocial and rehabilitation care<br />Social skill training<br />Employment training<br />Cognitive remediation therapy<br />Psychoeducation<br />Family therapy<br />Don’t forget medical illness too…<br />
    54. 54. Medications<br />
    55. 55. Benzodiazepine - Lorazepam<br />Atypical antipsychotic for treatment resistant schizophrenia - Clozapine<br />
    56. 56. THANK YOU<br />NG BOON KEAT<br />MOHD HANAFI RAMLEE<br />
    57. 57.
    58. 58. yes<br />yes<br />no<br />yes<br />no<br />no<br />
    59. 59. yes<br />no<br />
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