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  • Echolalia: immediate and involuntary repetition of words
  • Simple schizophrenia (CD10)1- There is slow but progressive development, over a period of at least 1 year, of all three of the following: A-a significant and consistent change in the overall quality of some aspects of personal behavior, manifest as loss of drive and interests, aimlessness, idleness, a selfabsorbed attitude, and social withdrawal;B- gradual appearance and deepening of “negative” symptoms such as marked apathy, paucity of speech, underactivity, blunting of affect, passivity and lack of initiative, and poor nonverbal communication (by facial expression, eye contact, voice modulation, and posture);C- marked decline in social, scholastic, or occupational performance.2-At no time are there any of the symptoms referred to in criterion G1 for general schizophrenia, nor are there hallucinations or well-formed delusions of any kind; i.e., the individual must never have met the criteria for any other type of schizophrenia or for any other psychotic disorder.3-There is no evidence of dementia or any other organic mental disorder.
  • B-Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement)C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal (symptomatic of the onset) or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated)

schizophrenia schizophrenia Presentation Transcript

  • original term-dementia praecox-early age, chronic deteriorating course. coined the term schizophrenia (split mind)  affective blunting, loosening of associations, autism (withdrawal) and ambivalence (coexisting conflicting ideas) - 4 As- earned acceptance in USA first rank symptom
  • Psychotic mental disorder of unknown etiology characterized by disturbances in: (e.g. distortion of reality, delusions and hallucinations) (e.g. ambivalence, inappropriate affect) (e.g. Apathetic withdrawal, bizarre activity)
  • Age-related demographics • According to DSM5, the onset of schizophrenia usually occurs between the late teens and the mid 30s Sex-related demographics • The prevalence of schizophrenia is about the same in men & women • The onset is later in women than un men • The clinical course is less severe in women than in men Race-related demographics • No racial differences in the prevalence of schizophrenia have been positively identified View slide
  • •Dopaminergic system hypothesis •Increased Ventricular size •Glutaminergic dysfunction •Decreased brain volume in medial temporal areas •Serotonin abnormalities •Changes in the hippocampus •Overactivation of immune system Alteration in brain structure & function •Metabolic disturbance (Insulin resistance) View slide
  • DSM (Diagnostic & Statistical Manual) of Mental Disorders Published by APA ( American Psychiatry Association) DSM I 1952 DSM II 1968 DSM III 1980 DSM IV 1994 Classified Schizophrenia to 5 Subtypes DSM V 2013 Proposed the deletion of subtypes ICD ( International Classification of diseases) Published by WHO ICD 10 Classified Schizophrenia to 7 Subtypes
  • i Paranoid Vii Simple Schizophrenia ii Catatonic Vi PostSchizophrenic iii Disorganized V Residual IV Undifferentiated
  • A-preoccupation with 1 or more delusions or frequently auditory hallucinations B-Non of the following is prominent: -Disorganized speech -Disorganized or catatonic behavior - Flat affect -At least 2 of the following: i-Motoric immobility evidenced by catalepsy or stupor ii-excessive motor activity (purposeless& without stimulus) iii-Echolalia iv-Excessive negatism A- All of the following are prominent : - Disorganized speech -Disorganized behavior - Flat affect B- the criteria are not met for catatonic type
  • - Psychotic symptoms are present but criteria for paranoid, catat onic or disorganized have not been met - - Depressive episodes arising in the aftermath of schizophrenic illness where some low-level symptoms may still be present -The general criteria for schizophrenia have been met at sometime in the past but are not met in the present time - Insidious & progressive development of negative symptoms with no history of psychotic episodes
  • •Family history of Schizophrenia •Any potential cause of fetal hypoxic brain damage •History of brain complications •Advanced age of mother during pregnancy •Birth during winter months !!  •Substance abuse •Single marital status •Low socioeconomic class •Urban environment •Environmental stress
  • Hallucination Delusions Illusions Disorganized speech Behavioral disturbances Absence of normal cognition Allogia Avolition Anhedonia Social isolation  Impaired - attention - Working memory - Executive functions  Seems cheerful or sad without obvious reasons
  • • Gradual development of symptoms • Precedes 1st psychotic episode • Includes: - Isolation -Deterioration of hygiene - loss of interest in work • • • • • • • • • • Out of reality Hallucination Delusion Ambivalence Autism Disturbed sleep &appetite Impaired self care skills Flat affect Disconnected thoughts Aggression • Occurs between episodes of psychosis • Includes: - Anxiety - Avolition - poor insight - social withdrawal - lack of motivation - impaired judgment
  • Diagnostic criteria of schizophrenia DSM-IV ICD-10
  • 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) B. Social/occupational dysfunction C. Continuous signs of the disturbance persists for at least six months D. Schizoaffective and mood disorder exclusion E. Substance/medical condition exclusion F. Relationship to pervasive developmental disorder : the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month
  • ICD-10 Diagnostic Criteria At least one of the symptoms : OR At least one of the symptoms : 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 a. Persistent hallucinations in any modality occurring everyday for weeks or months b. Breaks or interpolation in the train of thought > incoherence or irrelevant speech, or neologism c. Catatonic behavior, such as excitement, posturing, or waxy flexibility, negativism, mutism, st upor d. Negative symptoms: apathy, paucity of speech, blunting of emotional response
  • Persistent dysfunction lasting longer than 6 months 2 or more symptoms for at least 1 month ( at least 1 of i, ii or iii) i- Hallucination ii- Delusions iii- Disorganized speech iv- Grossly disorganized or catatonic behavior v- Negative symptoms Significantly impaired functioning ( work, self care , interpersonal )
  • Differential Diagnosis • Alcohol-related psychosis • Bipolar affective disorder • Brief psychotic disorder • Cocaine-related psychiatric disorders • Delusional disorder • Depression • Mental disorders secondary to general medical conditions • Schizoaffective disorder • Schizophreniform disorder
  • 25% • Complete recovery 35% • Much improved 15% • Improved but require extensive therapy 10% • Hospitalized (unimproved ) 15% • Dead ( mostly Suicide )
  • 1. Alleviation of target symptoms 2. Avoidance of side effects 3. Importance of Psychosocial functioning and proactively 4. Compliance with the prescribed regimen 5. Involvement of the patient in the treatment plan 6. Not to be hospitalized
  • 1. Mental status examination 2. Physical & neurological examination 3. Complete family & social history (take in consideration family history of response to drugs) 4. Psychiatric diagnostic interview 5. Laboratory work up ( CBC, electrolytes, hepatic & renal functions, ECG, FBG, lipid profile, thyroid functions and urine drug screening )
  • Typical APs. Atypical APs. first generation Second generation
  • Typical APs. Atypical APs. traditional, conventional, first generation antipsychotics, classical neuroleptics, major tranquilizers Second generation Low potency Chlorobromazine: Neurazine ® Thioridazine: Mellcril ® Medium potency Molindone: Thiothixene: Navane® Pimozide: Orape forte ® Moban ® High potency Trifluperazine: Stellazine ® Haloperidol: Haldol ® Fluphenazine: Modecate ® Zuclopenthixol: Clopexol ® Aripiprazole: Apilify ® Clozapine: leponex ® Olanzapine: Zyprexa ® Quetiapine: Seroquil ® Resperidone: Resperidal ® Sulpiride: Dogmatil ® Ziprasidone: Zeldox ®
  • Typical APs. Atypical APs. first generation Second generation : - DA receptor blocker -Have activity on histamine, muscarinic & α-receptors ( not responsible for the therapeutic activity ) -DA antagonist and 5-HT2A – receptor blocker EXCEPT Aripiprazole Partial DA & 5-HT1Aagonist 5-HT2A- antagonist - Have activity on histamine, muscarinic & α-receptors ( not responsible for the therapeutic activity )
  • Typical APs. Atypical APs. first generation Second generation : - DA receptor blocker -Have activity on histamine, muscarinic & α-receptors ( not responsible for the therapeutic activity ) -DA antagonist and 5-HT2A – receptor blocker EXCEPT Aripiprazole Partial DA & 5-HT1Aagonist 5-HT2A- antagonist - Have activity on histamine, muscarinic & α-receptors ( not responsible for the therapeutic activity )
  • Typical APs. Atypical APs. first generation Second generation Sed. EPS A.Ch O.HoTN CPZ +++ ++ ++ +++ Thioridazine +++ + +++ +++ Molindone ++ ++ + + Sed. EPS A.Ch O.HoTN Wt.G clozapine +++ 0 +++ +++ +++ Resperidone + + 0 + ++ Olanzapine ++ + ++ + +++ Quetiapine ++ + 0 ++ ++ Thiothixene + +++ + ++ Trifluperazine + +++ + + Haloperidol + +++ + + Ziprasidone 0 + 0 0 0 Fluphenazine + +++ + + Aripeprazole + + 0 0 0 Sed : sedation, EXP: extrapyramidal side effects , A.Ch anticholinergic side effects , O.HoTN: orthostatic hypotension wt.G : weight gain
  • -Dry mouth ( ttt: fluid intake, oral lubricant, sugarless gum) -Constipation (ttt: Exercise , fluid and dietary fibers intake) -Blurred vision -Tachycardia - Inhibition of Ejaculation -Urinary retention -Impaired memory
  • i- Dystonia : Definition : Prolonged tonic muscle contraction, Risk : life threatening (pharyngeal –laryngeal dystonia Risk factors : young patient , male gender, high potency agent, high doses Treatment : IV or IM anticholenergic or BDZ Prophylaxis : Anticholinergic in : high potent 1st generation APs, young men or history of dystonia ii- Akathesia : Definition : Subjective complain : feeling of inner restlesness Objective symptoms: pacing, shuffling or tapping feet Treatment : decrease the dose of FGAPs or switch to SGAPs
  • iii-Pseudoparkinsonism: Symptoms : -Akinesia, brdykinesia or decreased motor activity including micrographia, slowed speech, decreased arm swing - Tremors -Cogwheel rigidity -Postural abnormalities Risk factors : - FGAPs specially in high dose -High doses -Old age Onset : 1-2 weeks after initiation or increment of APs dose Treatment : - Anti cholinergic s: - Benzotropine, Diphene hydramine, Biperidine) - Amantadine
  • Iv-Tardive dyskinesia: Definition : abnormal involuntary movement with chronic use of APs e.g: Oro facial movement , Risk : life threatening (pharyngeal –laryngeal dystonia Risk factors : Old age , long duration of ttt, high doses , diagnosis of organic mental disorder , DM or mood disorder Treatment : Decrease dose or switch to SGAPs Prophylaxis : Use SGAPs as first line -Highest risk of drug including seizures are chloropromazine& clozapine -Likely in initiation of ttt, high doses or rapid dose increment Treatment : - Decrease the FGAPs dose & switch to SGAPs - Anticonvulsant not recommended
  • -0.5% - 1 % of patients taking FGAPs Risk factors : - High potency FGAPs, - Injectable or depot FGAPs - Dehydrated patient - Organic mental disorder Symptoms : - Temp. 38 C -Altered level of consciousness -Rigidity -Autonomic dysfunction ( tachycardia, tachypnea , urinary & fecal incontinence ) Lab. Findings : -Leukocytosis -High CK, AST, ALT, LDH, -Myoglobin uria Treatment : -Discontinue AP drug -Supportive care -Bromocriptin ( reduce DA blockade, rigidity, fever & CK level) -Amantadine -Dabtrolone ( skeletal muscle relaxant with favourable effect on Temp.& respiratory rate ) -Lowest effective dose of SGAPs after 2 ws without AP & monitor closely
  • : -APs stimulate prolactin production which is associated with galactorhea & menstrual irregularities -Dose related -Frequently with FGAPs & risperidone -Management : switch to SGAPs aripiprazole or ziprasidone -Frequently with SGAPs Olanazapine , clozapine , risperidone & quetiapine more than ziprasidone & aripiprazole ) - New onset of diabetes reported with SGAPs
  • - 20 mmHG drop in systolic pressure upon standing - Frequently with : • low potency APs • APs combination • DM • Cardio vascular disease • Elderly patient -Tolerance occurs within 2-3ms -If not tolerated ; change AP drug or decease the dose
  • - Some SGAPs & phenothiazines cause elevation in serum TGs & cholesterol Risk decreases with ; risperidone,ziprasidone & aripiprazole -Impaired visual accommodation -Photophobia -Narrow angle glaucoma exacerbation -Opaque deposit in cornea & lens (frequently with chronic use of phenothiazines specially chloropromazine ) -Cataract : with quetiapine ( periodic slit lamp examination is recommended ) -Retinitis pigmentosa : with thioridazine 800 mg daily - Mainly to Control APs side effects e.g : anticholinergic agents and amantadine are often used in conjunction with the conventional APs to treat extrapyramidal symptoms.
  • Diagnosis of Schizophrenia Identify Phases of Illness Yes Acute phase Need rapid tranquilization Combination of parenteral treatment Urgent No No Oral medication is preferred When parenteral needed use 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 Yes Poor response Yes Adequate dose & duration No No Relapse prevention Stable phase •Exclude substance abuse, treatment non-adherence & concurrent other general medical conditions •Optimize psychosocial interventions •Refer to psychiatrist for trial of clozapine Optimize 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 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 Monitor EPS/akathisia/weight gain/diabetes/heart disease/sexual dysfunction Follow schedule of physical care as per follow-up manual 41
  • Cognitive remediation is a treatment modality derived from principles of neuropsychological rehabilitation. It is based, in part, on the ideas that the brain has some plasticity and that brain exercises can encourage neurons to grow and can develop the neurocircuitry underlying many mental activities. Most patients with schizophrenia would like to work; employment can improve income, self-esteem, and social status. However, few people with the disorder are able to maintain competitive employment. Supported employment programs currently thought to be most effective are those that offer individualized, supported, and rapid job assignments and that are integrated with other services
  • Schizophrenia affects the person’s whole family, and the family’s responses can affect the trajectory of the person’s illness. Familial “high expressed emotion” (hostile overinvolvement and intrusiveness) leads to more frequent relapses. Some studies have found that family therapy or family interventions may prevent relapse, reduce hospital admission, and improve medication compliance Most patients with schizophrenia smoke this may be a result of previous conventional antipsychotic treatment . Smoking may also be related to the boredom associated with hospitalizations, the peer pressure from other patients to smoke, or the anomie associated with unemployment. Whatever the cause of the high incidence of smoking, the health risks from smoking are well known, and all schizophrenic patients should be encouraged to stop smoking.
  • Many psychotropic medications can cause weight gain and changes in glucose or lipid metabolism. Occasionally, a person with schizophrenia develops odd food preferences. Finally, many persons with schizophrenia have limited funds, do not cook for themselves, and live in areas where fast food outlets are abundant. Therefore, nutritional counseling is difficult but important. Because many psychotropic medications are associated with weight gain, persons with schizophrenia should be encouraged to be as physically active as possible.
  • Medscape website Pharmacotherapy Comprehensive pharmacy review APA website
  • Thank you