Schizophrenia management-prof. fareed minhas

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Schizophrenia management-prof. fareed minhas

  1. 1. MANAGEMENT OF SCHIZOPHRENIA 11th POST GRADUATE COURSE 2005 Institute of Psychiatry Rawalpindi General Hospital PROF FAREED ASLAM MINHAS
  2. 2. SCHIZOPHRENIA Characterized by fundamental and characteristic disorder in thinking and perception, and by inappropriate or blunted affect Clear consciousness is usually maintained Disorder of thinking, emotion, volition and perception along with disintegration of personality
  3. 3. SCHIZOPHRENIA The ICD-10 requires that a minimum of one very clear symptom(two or more if less clear) belonging to • any one of the groups from (a)-(d) or • from at least two of the groups (e)-(h) • during a period of one month or more
  4. 4. ICD-10 Classification of SCHIZOPHRENIA (a) Thought echo/ insertion or withdrawal and broadcasting (b) Delusions of control,influence,passivity; delusional perception (c) Hallucinatory voices as a running commentary, third-person or somatic hallucinations (d) Persistent delusions that are inappropriate and impossible
  5. 5. ICD-10 Classification of SCHIZOPHRENIA (e) Persistent hallucinations or over-valued ideas (f) Breaks/interpolations in train of thought, neologisms (g) Catatonic behavior such as waxy flexibility/negativism/stupor (h) Negative symptoms e.g.. Marked apathy, paucity of speech (i) Significant consistent change in personal behavior e.g. idleness
  6. 6. BIO-PSYCHO-SOCIAL MODEL OF MANAGEMENT
  7. 7. BIOLOGICAL MANAGEMENT ANTI-PSYCHOTIC DRUGS (i)Conventional or Standard Antipsychotics These drugs act through blocking the dopamine receptors and bind strongly to dopamine D2 receptors. These are phenothiazines, butyrophenones, diphenylbutyl pipiredines, thioxanthenes and substituted benzamides. These include: chlorpromazine (Thorazine); fluphenazine (Prolixin); haloperidol (Haldol); thiothixene (Navane); trifluoperazine (Stelazine); perphenazine (Trilafon) and thioridazine (Mellaril).
  8. 8. Anti-psychotic preparations available •Oral drugs – Tablets and suspensions •Injectables – Short acting( Haloperidol, zuclopenthixol acetate) or depot preparations(zuclopenthixol decanoate, fluphenazine)
  9. 9. BIOLOGICAL MANAGEMENT (ii)Atypical Antipsychotics These are newer drugs with fewer side effects.They are highly selective D2 receptor antagonists and some drugs also possess 5-HT2 receptor antagonist activity. • • • • • • Amisulpiride Clozapine Olanzapine Quetiapine Risperidone Zotepine
  10. 10. Atypical Antipsychotics • Amisulpiride highly selective D2 receptor antagonists dose:400-800mg daily Max 1.2gms daily • Clozapine weak D2 receptor antagonists high affinity for 5HT2 receptors Binds to H1,alpha 1 adrenergic & muscarinic cholinergic receptors • Olanzapine weak D2 receptor antagonists Anticholinergic and H1 receptor blocker
  11. 11. Atypical Antipsychotics • Quetiapine weak D2 receptor antagonists modest 5Ht2 receptor antagonist dose:25mg twice daily & increase Range 300-450mg daily • Risperidone potent D2 & HT2 receptor antagonists Alpha1 adreno receptor blocker • Zotepine low selectivity for 5Ht2 receptors dose:25mg 3times daily max 100mg 3times daily
  12. 12. NICE GUIDELINES • The atypical antipsychotics (amisulpride, olanzapine quetiapine, risperidone, and zotepine) should be considered when choosing first-line treatment of newly diagnosed schizophrenia; • An atypical antipsychotic is considered the treatment option of choice for managing an acute schizophrenic episode when discussion with the individual is not possible; • An atypical antipsychotic should be considered for an individual who is suffering unacceptable side-effects from a conventional antipsychotic;
  13. 13. NICE GUIDELINES • An atypical antipsychotic should be considered for an individual in replase whose symptoms were previously inadequately controlled; • Changing to an atypical antipsychotic is not necessary if a conventional antipsychotic controls symptoms adequately and the individual does not suffer unacceptable side-effects; • Clozapine should be introduced if schizophrenia is inadequately controlled despite the sequential use of two or more antipsychotics (one of which should be an atypical antipsychotic) each for at least 6-8 weeks.
  14. 14. Side effects Agitation Typical Clozapine Risperidone   Olanzapine Quetiapine Sertindole + to ++ 0 ++ + + 0 Agranulocytosis Rare +++ Rare Rare Rare Rare Anticholinergic + to +++ +++ + ++ + 0 AST/ALT levels + + 0 + + 0 EPS + to +++ 0 + 0 0 0 Nausea/Dyspepsia + 0 + + 0 + Hypotension + to +++ +++ + ++ ++ + Prolactin levels + to ++ 0 ++ + 0 0 Sedation ++ to +++ +++ + ++ ++ 0 Seizures + +++ 0 + 0 0 Dyskinesias +++ 0 + ? ? ? Weight Gain + to ++ +++ + ++ + ++
  15. 15. BIOLOGICAL MANAGEMENT ECTs Traditional indications are catatonic stupor and severe depressive symptoms in schizophrenia. ANTI-DEPRESSANTS AND MOOD STABILIZERS Depression is a part of the syndrome of schizophrenia. Value of use of anti-depressants is not proven, may be helpful in chronic syndrome but might worsen active psychosis.
  16. 16. PSYCHOLOGICAL MANAGEMENT GENERAL PRINCIPLES: • Individual Psychotherapy • Family Education • Self-help Groups • Good Motivation and Productivity From Patients
  17. 17. PSYCHOLOGICAL MANAGEMENT WORKING WITH RELATIVES with emotional expressions within family is most beneficial BEHAVIORAL TREATMENT include ‘token economies’ and ‘cognitive behavior therapy’ (specially for positive symptoms as they are amenable to structured reasoning)
  18. 18. SOCIAL MANAGEMENT REHABILITATION include social and vocational training and improvement of communication skills as the onset of the illness is at a point where they are training for skilled work. CASE MANAGEMENT (followed in US) Most consumers with severe or chronic schizophrenia will have a case manager. The role of the case manager is to assist in coordinating all the services that the consumer may need. See figure below as an example of how a case manager can work with other professionals and agencies.
  19. 19. Thank you

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