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Schizophrenia
 

Schizophrenia

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    Schizophrenia Schizophrenia Presentation Transcript

    • Chapter 13
    • Schizophrenia- Readings
      • Chapter 13
      • Chapter 36
        • Sections
          • 36.18 pages 1043 to 1062
          • 36.30, pages 1091 to 1098
    • What is Schizophrenia?
      • Clinical syndrome of variable but profoundly disruptive psychopathology
      • It involves:
        • Cognition, emotion, perception and other aspects of behavior
      • Normally begins before age 25
      • Persists throughout life
      • Affects persons of all social classes
    • Epidemiology
      • Gender and Age
        • Equal prevalence in men and women
        • 1 in 100 persons will develop the condition during their lifetime, with peak ages 10 to 25 in men and 25 to 35 in women
        • Women can display bimodal age distribution with a second peak occurring in middle age
        • 3% to 10% of women with schizophrenia present with disease onset after age 40
        • About 90% of patients in treatment for schizophrenia are between 15 and 55 years of age
    • Reproductive Factors
      • Marriage among schizophrenics has led to an increased number of children born to both schizophrenic parents.
    • Medical Illness
      • Patients with Schizophrenia have higher incidence of death from accidents and natural causes than the general population.
      • Studies have shown that up to 80% of patients with schizophrenia have significant concurrent medical illnesses, and up to 50% are undiagnosed.
    • Other Factors Related to the Development of Schizophrenia
      • Patients with schizophrenia are more likely to have been born in winter and early spring and less likely to have been born in late spring and summer
      • Season specific risk-factors may influence the development of the condition
        • Expossure to pathogens
      • Prenatal malnutrition may play a role in schizophrenia
    • Substance Abuse
      • Common in Schizophrenia
      • Lifetime prevalence often greater than 50% for any drug (other than tobacco)
      • Lifetime prevalence for alcohol abuse, 40%
      • Patients that reported high levels of cannabis use (more than 50 ocassions) were at sixfold increase risk of schizophrenia compared to non-users
      • Up to 90% of schizophrenic patients may be dependent on nicotine
    • Biochemical Basis: Dopamine Hypothesis
      • Dopamine hyperactivity hypothesis
        • Initially supported by neuroscientists and clinitians
        • Supported by observing drugs that enhance dopamine activity
          • Amphetamines- in chronic amounts can induce symptoms virtually identical to those in paranoid psychosis
          • This hypothesis failed at explaining many other aspects of schizophrenia such as negative symptoms, cognitive deficits and other neurochemical and pathological findings
    • Biochemical Basis: Dopamine Hypothesis
      • Antipsychotics neither cure or completely prevent relapse of symptoms
        • 30% of patients are refractory to treatment with antipsychotics
        • Conventional antipsychotics have a tendency to cause
          • Extrapyramidal symptoms
          • Poor efficacy against negative symptoms
          • Inability to reverse or prevent cognitive impairment
          • Inability to permit a normal level of psychosexual and work function
          • Atypical antipsychotics which are less specific blockers of dopamine may be superior to Haldol and result in less extrapyramidal symptoms.
          • Pharmacotherapy of Schizophrenia; The Past, Presnt and Future. Current Drug Therapy, 2006, Vol1, No. 13
    • Biochemical Basis:Serotonin Hypothesis
      • Hyper-Serotonin hypothesis
        • First observed in the 1950s when researchers noticed its similarity to LSD, which competes for 5-HT receptors resulting in psychosis-like symptoms
        • Evidence for action of 5HT lies in observations of brain behavior, neurotransmitter systems, drug mechanisms and postmortem studies.
        • Some studies found elevated levels of 5-HT in blood platelets
        • By far the strongest evidence of the role of 5-HT is the mechanism of atypical antipsychotic drugs like clozapine
    • Pharmacotherapy
      • Modern treatment primarily relies on somatic drug therapy
      • Most drugs used to treat schizophrenia antagonize post synaptic dopamine receptors
      • Antipsychotics are (Atypical)the mainstay of pharmacotherapy of schizophrenia
      • First-generation antipsychotics
        • Dopamine receptor antagonists
      • Second-generation antipsychotics
        • Serotonin dopamine antagonists (SDAs)
    • Families of Antipsychotics
      • Phenothiazines
        • Aliphatic
          • Chlorpromazine
          • Promazine
          • Triflupromazine
        • Piperazine
          • Acetophenazine
          • Fluphenazine
          • Perphenazine
          • Proclorphenazine
          • Trifluroperazine
          • Mesoridazine
          • Thioridazine
    • Families of Antipsychotics
      • Thioxantines
        • Dibenzoxapine
          • Chlorproxitene
          • Thiothixene
        • Dihydroindole
          • Molindone
        • Butyrophenones
          • Droperidol
          • Haloperidol
    • Families of Antipsychotics
      • Thioxantenes cont.
        • Dyphenylbutylpiperidine
          • Primozide
        • Benzamide
          • Sulpiride (not available in the U.S.)
        • Rauwolfia Alkaloid
          • Reserpine
    • DRAs
      • Therapeutic indications
        • Indicated for many types of psychiatric and neurologic disorders.
            • See table 36.18-2 pg 1045
    • Pharmacotherapy
      • Chlorpromazine (Thorazine)
        • Introduced in 1952
        • Most important single contribution to the treatment of a psychiatric illness
        • Effective at reducing hallucinations and delusions as well as excitement
        • Antipsychotics reduce relapse rates
        • Apprx. 70% of patients treated with antipsychotics achieve remission
    • Pharmacotherapy
      • Acute Psychosis
        • Lasts 4-8 weeks
        • Severe agitation as a result of:
          • Frightening delusions
          • Hallucinations
          • Suspiciousness
          • Other causes:
            • Stimulant abuse
    • Pharmacotherapy
      • Therapeutic options
        • Acute psychosis
        • Antipsychotics (DRAs)
          • Highly agitated patients: IM antipsychotics offer relatively fast relief
          • High Potency
            • Haloperidol (Haldol)
            • Acetophenazine (Tindal)
            • Fluphenazine (Prolixin, Permitil)
            • Perphenacin (Trilafon)
            • Thiotixene (Navane)
    • Pharmacotherapy
        • Antipsychotics (DRAs) cont.
        • Low Potency
          • Chlorpromazine (Thorazine)
          • Loxapine (Loxitane)
          • Mesoridazine (Serentil)
          • Molindone (Moban)
          • Pimozide (Orap)
          • Thioridazine (Mellaril)
    • Possible Adverse Effects of DRAs
      • Seizures
        • May lower seizure threshold
      • Sedation
      • Central and peripheral anticholinergic effects
      • Cardiac effects
      • Sudden death
      • Orthostatic (postural) hypotension
      • Hematologic effects
      • Endocrine effects
      • Skin and eye
      • Jaundice
      • Overdoses
        • Exagerated DRAs effects
      • Pregnacy and lactation
        • Related to malformations
      • Interactions
        • See table 36.18-5
    •  
    •  
    • Pharmacotherapy
      • Atypical Antipsychotics
        • Serotonin Dopamine antagonists (SDAs)
          • Effective in patients that present aggressive or violent behavior (10% of patients)
          • Treatment with SDAs decreases suicide risks and water intoxication in patients with schizophrenia
        • Adverse effects
          • SDAs share similar spectrum of adverse reactions, but differ in frequency and severity
          • See table 36.30-1 pg 1093, Kapplan & Sadock
    • Pharmacotherapy
      • Olanzapine
        • Effective in psychosis, and in the tratment of agitation in patients with schizophrenia
      • Clozapine
        • Effective in controlling psychosis but due to life- threatening adverse effects, appropriate only to non-responsive patients
        • Also effective in patients that present severe tardive dyskinesia.
        • Benzisoxazoles
          • Risperidone (Risperdal)
    •  
    • Pharmacotherapy
        • Benzodiazeoines- Effective for agitation during acute psychosis
          • Lorazepam (Ativan) – may reduce the amount of antipsychotic needed