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  1. 1. Schizophrenia Part – II :Clinical Manifestations and Phenomenology, Differential Diagnosis, Course, Prognosis Management & Rehabilitation<br />13th November’2009<br />::Moderator ::Dr. Kamala DekaAssociate Professor <br />:: Speaker ::Dr. Santanu GhoshPostgraduate Student<br />Department of Psychiatry, Assam Medical College<br />
  2. 2. Layout of presentation:<br />Introduction<br />Clinical Manifestation<br />Phenomenology<br />Differential Diagnosis<br />Course<br />Prognosis<br />Management <br />Rehabilitation<br />Conclusion<br />Take home message<br />Bibliography<br />
  3. 3. Introduction<br /> Schizophrenia is a stress-related, neurobiological disorder characterized by disturbances in the form and content of an individual's thought and perceptual processes, affect and social and instrumental role behavior. The pervasive impact of schizophrenia across perceptual, cognitive, emotional and behavioral domains, as well as the heterogeneity within those domains require a multimodal and comprehensive approach to treatment and rehabilitation which involves the individual and his or her environment. A multidimensional and interactive model that includes stress, vulnerability, and protective factors best guides the types of interventions for treating and rehabilitating persons with schizophrenia.<br />
  4. 4. Clinical Manifestation<br />
  5. 5. Clinical Features of Schizophrenia<br />Negative symptomsAutism<br />Affective flatteningAvolitionSocial withdrawan<br />Alogia<br />Functional ImpairmentsWork/school performanceInterpersonal relationships &Self-care deterioration<br />Positive symptomsDelusionsHallucinations<br />Mood symptomsDepression/AnxietyAggression/Hostility<br />Suicidality<br />Disorganization<br />Inappropriate affect<br />Disorganized behavior<br />Thought disorder<br />Cognitive deficitsAttentionMemory<br />Verbal fluencyExecutive function<br />
  6. 6. Prodromal Symptoms<br /> Severe anxiety<br /> Severe distractibility<br /> Person feels “strange”<br /> Symbolization, mysterious thinking<br /> Profound withdrawal, isolation,<br /> Rejection, paranoid thinking<br /> Preoccupation with religion<br /> Altered sexuality, preoccupation with homosexual themes<br />Speech and language disturbance<br />
  7. 7. Phenomenology<br />
  8. 8. Concept of Phenomenology:<br /><ul><li>Phenomenology can be defined as the study of events or phenomena, either psychological or physical, by means of empathy & immaculate clinical observation, but without embellishing those events or phenomena with explanation of cause or function.
  9. 9. In psychiatry, phenomenology is the way of understanding & describing the psychological phenomena, involved in various psychopathological states.</li></li></ul><li>Phenomenology of Schizophrenia:(Historical Overview)<br /><ul><li>Emil Kraepelintranslated Morel’s “demenceprecoce” into “dementia praecox”, to emphasize the distinct cognitive decline (dementia) & early onset (praecox) of the disorder.
  10. 10. EugenBleulercoined the term “schizophrenia”to mean “splitting” of the psychic functions. Bleuler made a distinction between the fundamental & accessory symptoms of schizophrenia. </li></ul>The fundamentalsymptoms of Bleuler, which were also designated as the four “A”sare-<br />Disturbance of Association (e.g, looseness),<br />Affective disturbance(eg, flattening),<br />Autism (i.e. withdrawn from reality into an inner fantasy world) &<br />Ambivalence.<br />
  11. 11. Phenomenology of Schizophrenia:(Historical Overview)<br /><ul><li>Bleulerviewed some of the most frequent & striking symptoms were accessory (or secondary). These include- hallucinations, delusions, catatonia & abnormal behavior.
  12. 12. Adolf Meyersaw schizophrenia & other mental disorders as reactions to life stress & he called these “schizophreniform reaction”.
  13. 13. Harry Stack Sullivanemphasized social isolation as a cause & a symptom of schizophrenia.
  14. 14. Wolfgang Blankenburg– ‘loss of common sense’</li></li></ul><li>Phenomenology of Schizophrenia:(Historical Overview)<br /><ul><li>Ernst Kretschmercompiled data to support the idea that schizophrenia occurs more in persons with asthenicbody built.
  15. 15. Gabriel Langfeldtproposed a distinction between “true schizophrenia” having insidious onset, derealization, depersonalization, autism, emotional blunting and poor outcome; from “schizophreniform states”
  16. 16. Eugene Minkowski</li></ul> – ‘Loss of vital contact with reality’<br /> – Compensatory ‘morbid rationalism’/‘hypertrophy of intellect’<br /> – ‘Pragmatic dementia’<br /><ul><li>Kurt Schneidertried to make the diagnosis more reliable by identifying a group of symptoms characteristic of schizophrenia, but rare in other disorders</li></li></ul><li>Phenomenology of Schizophrenia:(Historical Overview)<br /><ul><li>The first rank symptoms of Schneider
  17. 17. Audible thoughts,
  18. 18. Voices arguing, discussing or both,
  19. 19. Voices commenting,
  20. 20. Somatic passivity experiences,
  21. 21. Thought withdrawal, insertion & other experiences of influenced thought,
  22. 22. Thought broadcasting.
  23. 23. Delusional perceptions,
  24. 24. All other experiences involving made volition, made affects, & made impulses.
  25. 25. Second rank symptoms
  26. 26. Other disorders of perception,
  27. 27. Sudden delusional ideas,
  28. 28. Perplexity,
  29. 29. Depressive & euphoric mood changes,
  30. 30. Feeling of emotional impoverishment,
  31. 31. Several other abnormal experiences </li></li></ul><li>Phenomenology of Schizophrenia:(Historical Overview)<br /><ul><li>Karl Kleist, looked for association between brain pathology & different subtypes of psychotic illness.
  32. 32. Leonhard, distinguished schizophrenia from “cycloid psychosis”. He divided schizophrenia into 2 groups-
  33. 33. Systematic schizophrenia, which included catatonias, hebephrenias & paraphrenias.
  34. 34. Non- systematic schizophrenia, which included affect- laden paraphrenia, schizophasia & periodic catatonia.</li></li></ul><li>Phenomenology of Schizophrenia:(Historical Overview)<br /><ul><li>T. J. Crowproposed a classification of schizophrenic patients into type- I & type- II, on the basis of the presence or absence of positive (or productive) & negative (or deficit) symptoms.
  35. 35. Carpentercoined the term ‘ deficit schizophrenia’ for specifically to those negative symptoms that are present as enduring traits. Deficit symptoms may be present during & in between episodes of exacerbation of positive symptoms regardless of patient’s medication status.
  36. 36. Presently, schizophrenia is diagnosed by using classification systems of DSM- IV & ICD- 10. These have the advantage of international comparability, but many have criticized them for trading of validity for the sack of reliability & were conceived as “gatekeepers”- i.e. the minimum numbers of checklist symptoms needed to make a diagnosis.</li></li></ul><li>Thought disorders found in schizophrenia<br />1. Disorders of the Form of Thinking: (Formal Thought Disorders)<br /><ul><li>Predominantly a disturbance ofconceptual or abstract thinking & association between consecutive thoughts.
  37. 37. Camerongrouped thought disorganization symptoms into 4 groups-
  38. 38. In- coordination
  39. 39. Interpenetration (of themes)
  40. 40. Fragmentation &
  41. 41. Over- inclusion
  42. 42. He introduced 2 terms-
  43. 43. Asyndesis(loss of adequate connection between subsequent thoughts)
  44. 44. Metonyms (imprecise approximation & substitution of words or phrases)</li></li></ul><li>Thought disorders found in schizophrenia contd…<br /><ul><li>Bleuler regarded schizophrenia as a disorder of association. He believed these incompleteness or disorganization of ideasto have resulted from-
  45. 45. condensation
  46. 46. displacement&
  47. 47. misuse of symbols.
  48. 48. Goldsteindifferentiated concrete thinking of patients with schizophrenia from those with coarse brain damage, as in the former patient’s fund of words remains intact.</li></li></ul><li>Thought disorders found in schizophrenia contd…<br /><ul><li>Schneiderisolated 5 types of FTDs-
  49. 49. Derailment(sliding of subsequent thoughts, without logical association)
  50. 50. Substitution(ofone major thought by a subsidiary one)
  51. 51. Omission(of a thought or part of it in a senseless way)
  52. 52. Fusion(of heterogeneous elements of thought)
  53. 53. Driveling(or intermixture of constituted partsof one complex thought)</li></li></ul><li>Thought disorders found in schizophrenia contd…<br />Some commonly encountered FTDs in schizophrenia are-<br /><ul><li>Irrelevancy
  54. 54. Incoherence-
  55. 55. Derailment
  56. 56. Loosening of Association
  57. 57. Word Salad
  58. 58. Neologism
  59. 59. Illogical Thinking
  60. 60. Tangentiality. </li></li></ul><li>Thought disorders found in schizophrenia contd…<br />2. Disorders of Flow or Stream of thought:<br /><ul><li>Disorders of Tempo:</li></ul>Flight of ideas<br />Inhibition or Retardation of Thinking<br />Circumstantiality<br /><ul><li>Disorders of Continuity of Thinking:</li></ul>Perseveration<br />Thought Blocking<br />
  61. 61. Thought disorders found in schizophrenia contd…<br />3. Disorders of Possession of Thought:<br /><ul><li>Obsessions & Compulsions
  62. 62. Thought Alienation Experiences</li></ul>Thoughtinsertion<br />Thought Broadcasting<br />Thought Withdrawal or Deprivation<br />
  63. 63. Thought disorders found in schizophrenia contd…<br />4. Disorders of the Content of Thinking:<br /><ul><li>Delusions, Ideas& Overvalued Ideasdepending upon the degree of conviction upon the falsely held beliefs.
  64. 64. Delusions are false, unshakablebelief held , which can not be correctedby any means of reasoning & are not keeping with the patient’s socio- cultural background.</li></li></ul><li>Thought disorders found in schizophrenia contd…<br />From phenomenological point of view, delusions are classified into- <br /><ul><li>Primary Delusions: Ultimately un- understandable. Occurs de- novo & does not allow empathy. Conrad termed “Apophany”.</li></ul>3 types were described by Schneider-<br /><ul><li>Delusional Mood or Atmosphere
  65. 65. Sudden Delusional Idea (Autochthonous Delusion)
  66. 66. Delusional Perception (Characteristic 2-memberedness)
  67. 67. Secondary Delusions:Understandablein context of other morbid experiences, physical or psychological. Some suggest “Projection” in its formation. Freud suggested “Latent Homosexuality”.</li></li></ul><li>Thought disorders found in schizophrenia contd…<br />Depending upon the content, delusions are-<br /><ul><li>Delusions of Persecution
  68. 68. Delusions of Jealousy
  69. 69. Delusions of Love
  70. 70. Delusions of Influence or Control
  71. 71. Delusions of infidelity
  72. 72. Somatic or HypochondriacalDelusions
  73. 73. Delusions of Grandeur (sometimes in paranoid schizophrenia)</li></li></ul><li>Misidentifications <br />Capgras syndrome (Capgras and Reboul-Lachaux, 1923)<br /> An uncommon syndrome in which the patient believes that a person to whom they are close, usually a family member, has been replaced by exact double. <br /> Associated with paranoid, suspicious beliefs<br />Intermetamorphosis(Courbon and Tusques, 1932)<br /> Characterized by Delusion that people have swapped identities while maintaining the same appearance . <br /> Involves a false recognition of both appearance and identity<br />
  74. 74. Misidentification contd…<br />Fregoli delusion or Fregoli syndrome<br />The is a rare disorder in which a person holds a delusional belief that different people are in fact a single person who changes appearance or is in disguise. <br />The syndrome may be related to a brain lesion, and is often of a paranoid nature with the delusional person believing themselves persecuted by the person they believe is in disguise.<br />The condition is named after the Italian actor Leopoldo Fregoli who was renowned for his ability to make quick changes of appearance during his stage act.<br />
  75. 75. Disorders of Speech:<br /><ul><li>Stammering & Stuttering-occasionally in acute schizophrenia (especially early onset).
  76. 76. Mutism- in catatonic stupor, guarded paranoid patients & also in drug induced akinesia.
  77. 77. Vorbeireden or talking past the point (in hebephrenic schizophrenia).
  78. 78. Neologism- in catatonic & hebephrenic schizophrenia.
  79. 79. Speech Confusion-in chronic schizophrenics (Bleuler termed “schizophasia”).
  80. 80. Echolalia- in catatonic patients.
  81. 81. Alogia- in negative or deficit schizophrenia.
  82. 82. Coprophrasia(involuntary use of obscene or vulgar language).
  83. 83. Pressure of Speech & Poverty of Speech.</li></li></ul><li>Disorders of perception:<br />I. Sensory Distortions: It includes- Changes in<br /><ul><li>Intensity (Hypoaesthesia or Hyperaesthesia)
  84. 84. Quality (Xanthopsia, Chloropsia, Erythopsia)
  85. 85. Spatial Form (Dysmegalopsia- micropsiaormacropsia)
  86. 86. These are rarely found in schizophrenia & are suggested to be involved in formation of neurotic symptoms like hypochonricalor dysmorphophobic symptoms seen in few schizophrenics.
  87. 87. Disorders of Experience of Time (sense of slowing or fastening of physical or personal events) are also considered as sensory distortions, are seen in some schizophrenics.</li></li></ul><li>Disorders of perception contd…<br />II. Sensory Deceptions:<br /><ul><li>Illusions: Rare in schizophrenia. Can occur in all sensory modalities, mostly visual.</li></ul>Type of illusion present in schizophrenia<br /><ul><li>Pareidolia- (vivid illusions without the patient making any effort)- due to excessive fantasy thinking & vivid visual imagery. Seen in schizophrenics with excessive autistic thinking.</li></li></ul><li>Disorders of perception contd…<br />III. Hallucinations: (“perception occurring without the presence of a corresponding object in sensory field”) <br /><ul><li>Jaspers distinguished between true hallucinations & pseudo- hallucinations, by the person’s experience of the hallucinatory object being located in the objective or subjective space respectively.
  88. 88. The term “pseudo- hallucination” was given by Hagen . Earlier it was also known as “pale hallucination” & “apperceptive hallucination”.
  89. 89. Hillers argued schizophrenic hallucinations to be mental images based on patient’s thought or affect, rather than true perceptions. E.g. a schizophrenic with persecutory delusions can report that his food tasted of arsenic, which in fact is tasteless & which he never tasted.</li></li></ul><li>Disorders of perception contd…<br />Hallucinationscan be the resultof intense emotions, suggestion, disorders of sense organ, sensory deprivation, CNS disorders & several other causes.<br />Schizophrenic hallucinations are-<br />Auditory: It can be elementary (noises), or partly organized (music), or completely organized (hallucinatory voices).<br />Classical schizophrenic hallucinations are persistent, prominent & organized. Hallucinatory voices are characteristic of schizophrenia. <br />
  90. 90. Disorders of perception contd…<br /><ul><li>Schizophrenic auditory hallucinations are
  91. 91. Hearing one’s own thought spoken aloud (Thought Echo).
  92. 92. Hallucinatory voices commenting or discussing (3rd person hallucination).
  93. 93. Hallucinatory voice giving running commentary.
  94. 94. Internal hallucination
  95. 95. Others are-
  96. 96. Extracampine hallucination.
  97. 97. Functional hallucination
  98. 98. Occasionally, hallucinatory voices may speak incomprehensible nonsenseor may useneologism.</li></li></ul><li>Disorders of perception contd…<br /><ul><li>Unlike normal people, many schizophrenic are quite undisturbed by their inability to describe the direction & the sex of the speaker of those voices. These have variable effects on the patient’s behavior (some quite unconcerned & others totally disturbed).
  99. 99. Visual hallucination- Rare in schizophrenia.
  100. 100. Tactile, Gustatory, Olfactory & Somatic hallucinations- Not common in schizophrenia (related to patient’s delusional theme).
  101. 101. Cenesthetic Hallucinations- can occur in schizophrenia (e.g. Burning in Brain, Pushing sensation in Blood Vessels, or Cutting sensation in Bone Marrow etc )</li></li></ul><li>Disorders of Mood & Affect:<br /><ul><li>Inadequacy & incongruity of emotional reactions are hallmarks of schizophrenia.
  102. 102. The emotional status of schizophrenic patient’s vary between 2 extremes groups-
  103. 103. One group shows reduced emotional responsiveness (Shallow, Blunt & Flat ), which when severe lead to “Anhedonia” or “Apathy”. These inadequacies or blunting of affect was termed as “Parathymia” by Bleuler.
  104. 104. Others are overtly active & show inappropriate emotional expression. Reactivity is present & range may be labile, called “Affective Incontinence” or “Compulsive Affect” & seen in hebephrenic schizophrenia (e.g. silly euphoria, querulous ill- humor, careless indifference & autistic depression).</li></li></ul><li>Disorders of Mood & Affect contd…<br /><ul><li> Schizophrenics include Perplexity, Overwhelming Ambivalence, a sense of isolation & depression.
  105. 105. These abnormal emotional expressions in schizophrenics does not allow empathy or rapport to establish. In addition, dissociation of affect, affectionless personality & effects of anxiety may also lead to diagnostic dilemma.</li></li></ul><li>Disorders of Motor Behavior:<br /><ul><li>General appearance of a schizophrenic can range from a completely disheveled, screaming & agitated patient to an obsessively groomed or completely silent & immobile patient
  106. 106. The motors disorders of schizophrenia are viewed by some as organic neurological signs. Karl Ludwig Kahlbaumfollowed this view while describing the features of catatonia.
  107. 107. Several others considered them to be the result of patient’s conscious or unconscious attitudes (e.g. stereotypy is explained as having some symbolic meaning).</li></li></ul><li>Disorders of Motor Behavior contd…<br />Some common motor abnormalities in schizophrenia are-<br /><ul><li>Decrease in Psychomotor activity
  108. 108. Increase in Psychomotor Activity
  109. 109. Various Catatonic Signs- It includes
  110. 110. Mutism,
  111. 111. Rigidity, Posturing,
  112. 112. Negativism (“Gagenhalten”),
  113. 113. Automatic Obedience (“Mitmachen” & “Mitgehen”),
  114. 114. Waxy Flexibility
  115. 115. Psychological Pillow,
  116. 116. Ambitendency,
  117. 117. Echopraxia & Echolalia,
  118. 118. Tics,
  119. 119. Mannerisms & Stereotypy,
  120. 120. Facial Grimacing (includes “Schauzkrampf”).</li></li></ul><li>Disorders of Sensorium & Cognition:<br /><ul><li> Usually schizophrenics are conscious & well oriented. Meyer- Grossdescribed “Oneiroid Schizophrenia”,characterized by clouding of consciousness, disorientation, perceptual disturbances & a dream- like state.
  121. 121. Depersonalization& Derealization.
  122. 122. Cognitive disturbance-
  123. 123. seen in chronic schizophrenics & is highly responsible for socio- occupational dysfunctions.
  124. 124. Involves higher mental functioning like- Attention & Concentration, Memory, Vocabulary & Arithmetic skills, General Intelligence, Conceptual or Abstract Thinking .
  125. 125. Lack of social & personal Judgment and impaired Insight.</li></li></ul><li>Other Signs & Symptoms:<br /><ul><li>Lack of proper personal hygiene
  126. 126. Decreased work functioning
  127. 127. Diminished social interaction
  128. 128. Decreased sleep & oral intake
  129. 129. Impulsivity & violent behavior including suicidal & homicidal tendencies
  130. 130. Multiple vague somatic complains
  131. 131. Several localizing (hard) or non- localizing (soft) neurological signs (e.g. dysdiadochokinesia, astereognosis, primitive reflexes, diminished dexterity, abnormalities of motor tones & movements). </li></li></ul><li>Suicide in schizophrenia<br />People with schizophrenia attempt suicide much more often than people in the general population.<br />About 10% (especially young adult males) succeed. <br />I t is hard to predict which people with schizophrenia are prone to suicide<br />so if someone talks about or tries to commit suicide, professional help should be sought right away<br />Source: NIMH site<br />
  132. 132. Differential Diagnosis<br />
  133. 133. <ul><li>Other Functional Psychotic Disorders:</li></ul>Schizoaffective Disorder, <br />Delusional Disorders. <br />Brief Reactive Psychosis<br />Postpartum Psychosis<br /><ul><li>Mood Disorders (especially with psychotic symptoms). </li></ul>Affective symptoms of schizophrenic episode, <br />post- psychotic depression & <br />Side- effects of anti- psychotics add to diagnostic dilemma.<br /><ul><li>Personality Disorders (Schizotypal, Schizoid PD). </li></li></ul><li>Course of Schizophrenia<br />
  134. 134. Course of Schizophrenia<br />Prodromal phase<br />Active phase<br />Residual phase<br />
  135. 135. Psychosis<br />Level of symptoms<br />REMISSION<br />Pre-psychotic<br />VULNERABILITY<br />Prodromal<br />phase<br />Premorbid<br />phase<br />1ST admission<br />Neurodevelopmental<br />anomalies<br />adolescence<br />4-5 years<br />Time<br />
  136. 136. Course of Schizophrenia: The ¼, ¼, ½ Rule<br />Enormous individual variability<br />About 1/4 of those who experience an episode of schizophrenia recover completely; another 1/4 experience recurrent episodes, but often with only minimal impairment of functioning<br />The other one-half, schizophrenia becomes a chronic mental illness, and the ability to function normally in society may be severely impaired. <br />
  137. 137. Course & outcome:<br />Luc Ciompi1980 report shows:<br /> Complete remission-27%<br /> Remission with minor residual deficit- 22%<br /> Intermediate outcome- 24%<br /> Unstable or uncertain outcome- 9%<br />ICMR report shows:<br /><ul><li> Very favorable outcome -27%
  138. 138. Favorable outcome- 40%
  139. 139. Intermediate outcome- 31%
  140. 140. Unfavorable outcome- 2%</li></ul>ICD-10 suggest s the course of schizophrenia -<br /><ul><li> Continuous
  141. 141. Episodic with progressive deficit
  142. 142. Episodic with stable deficit
  143. 143. Episodic remittent
  144. 144. Incomplete remission
  145. 145. Complete remission</li></li></ul><li>Course of Schizophrenia<br />Stages of Illness<br />residual/stable<br />prodromal<br />premorbid<br />onset/deterioration<br />Higher Function<br />More symptoms <br />10<br />20<br />40<br />50<br />30<br />Gestation/Birth<br />
  146. 146. Indian Study on course & outcome<br /> The International Pilot Study of Schizophrenia (IPSS; WHO, 1979)and the Determinants of Outcomeof Severe Mental Disorders (DOSMED) study (Sartorius et al,1986) have provided convincing evidence for a better outcomein India thanin the West. This finding of a good outcome of treatment alsoemerged in the Chandigarh studies (Kulhara & Wig, 1978;Kulhara, 1994). Kulharaet al (1989) showed that regardlessof diagnostic definition, the outcome in Indian patients wasfavourable. One spin-off of the IPSS in India was the multi-siteStudy of Factors Affecting the Course and Outcome of Schizophrenia(SOFACOS).This was a 5-year follow-up of 386 patients in three centers,aimed at identifying social and clinical factors affectingcourse and outcome. The 2-year follow-up revealed that amongthe 423 patients followed up, 64% were in remission, and only11% continued to be ill (Vergheseet al, 1989). Data fromthe Madras centre also revealed a better outcome for womenat the end of 5 years of follow-up (Thara & Rajkumar, 1992).<br />
  147. 147. Prognosticfactors:<br />Good Prognostic Factors Poor Prognostic Factors<br /> Acute or abrupt onset 1. Insidious onset<br /> Onset > 35 years of age 2. Onset < 20 years of age<br /> Presence of stressor 3. Absence of stressor<br /> Catatonic subtype 4. Disorganized, simple, undiff<br /> Good premorbid adjustment 5. Poor premorbid adjustment <br /> Short duration(<6 months) 6. Chronic course(>2 years)<br /> Presence of depression 7. Absence of depression<br /> Predominant positive symptoms 8. Predominant negative symp<br /> Family h/o mood disorder 9. Family h/o schizophrenia<br /> Female sex 10. Male sex<br /> Good social support 11. Poor social support <br /> Normal cranial CT scan 12. Ventricular enlargement on CT<br />
  148. 148. Treatment<br />
  149. 149. Challenges in the Treatment of Schizophrenia<br />Stigma<br />Impaired “insight”– no agreement on problem<br />Treatment “compliance”<br />Substance abuse very common<br />Violence risk<br />Suicide risk<br />Medical problems common, often unrecognized<br />
  150. 150. Important Consideration in Treatment<br /> Comprehensive & continuous treatment for prolonged periods for most.<br />Integrated, bio- psychosocial approach to care.<br /> Active collaboration with the family while planning & delivering treatment. <br /> Treatment sensitive to the patient’s needs & empirically titrated to the patient’s response & progress.<br />
  151. 151. Schizophrenia Treatment<br /><ul><li> Therapeutic Goals
  152. 152. Minimize symptoms
  153. 153. Minimize medication side effects
  154. 154. Prevent relapse
  155. 155. Maximize function
  156. 156. “Recovery”
  157. 157. Types of Treatment
  158. 158. Biological Treatment</li></ul> - Pharmacotherapy<br /> - ECT<br /> - Psychosurgery(anterior capsulotomy)<br /> - Deep brain stimulation<br /><ul><li>Psychosocial/psychotherapeutic Treatment</li></li></ul><li>Types of Drug Treatment<br />1. Antipsychotic medications<br /> -1stgeneration<br /> - 2nd generation<br /> - Oral/ parental/ depotpreparation<br />2. Adjunctive medications <br /> - Lithium carbonate<br /> - Antidepressant<br /> - Benzodiazepines<br /> - Anticonvulsants<br />3. Other medications<br /> - Antiparkinsonian medications<br /> - Beta blockers<br />
  159. 159. Atypical Antipsychotics:<br />Olanzapine<br />+ Less prolactin elevation<br />- Weight gain, diabetes mellitus, anticholinergic side-effects<br />Quetiapine<br />+ Less EPS<br /><ul><li>Somnolence, postural hypotension</li></ul>Aripiprazole<br />+ Lesshyperprolactinaemia, weight gain or cardiac disarrythmia, glucose or lipid profile changes.<br /> - Insomnia, akathesia, orthostatic hypotension, constipation.<br />Amisulpride<br />+ Effective in both positive & negative symptoms, low potency foe weight gain, glucose intolerance.<br />- EPS, Galactorrhoea, amenorrhea, Costly, <br />Clozapine<br /> + Less EPS, TD<br /> -Agranulocytosis, anticholinergic side- effects<br />Risperidone<br /> + Consistent positive efficacy data, no anticholinergic side-effects<br /> - Postural hypotension<br />Ziprasidone<br /> + Effective in both positive & negative symptoms, Anxiolytic & antidepressant property, low potency for weight gain, cognitive impairment, sedation & cardiovascular side effect.<br /> - EPS, Orthostatic hypotension, QT prolongation<br />
  160. 160. IPS Guidelines recommendations :<br /> Therapy includes 3 phases-<br /><ul><li>Acute Phase(Goal- symptom reduction, harm reduction, improvement of functioning)
  161. 161. Post- acute or Continuation Phase(Goal- consolidation of remission, relapse prevention). It usually lasts 6 months.
  162. 162. Stable or Maintenance Phase(Goal- maintaining or improving functioning, prevention of recurrence)</li></ul>Choice of Drugs depends upon-<br /><ul><li>Side effect profile
  163. 163. Prior Response pattern
  164. 164. Patient preferences & Cost
  165. 165. Preferred route of administration</li></li></ul><li>Treatment contd …<br />Adequate trial needs-<br /><ul><li>Minimum duration of 4-6 weeks for all drugs, except Clozapine (3-6 months)
  166. 166. Doses need to be individualized. Recommended dose is mostly in the range of 300- 1000 mg of Chlorpromazine equivalents per day.
  167. 167. Tapering of dose @ 20% of the initial dose in every 6 months, until a minimum effective dose is reached.</li></li></ul><li>Duration of treatment:<br />It should be individualized. The suggested guidelines are:<br /> 1st episode patients : 1-2 years of maintenance <br /> Patients with several episode or exacerbation : ≥5 years of maintenance<br /> Patient with h/o aggression, suicide attempts : Indefinite period even life long<br />
  168. 168. Algorithm for the Treatment of Schizophrenia<br />Trial of single SGA<br />(Resperidone, Olanzepine, Aripiprazole, Qutiapine, <br />Ziprasidone)<br />ne<br /> Stage 1<br />Partial or No response<br />Trial of a single SGA or FGA<br />(not SGA tried in Stage 1)<br /> Stage 2<br />Partial or No response<br />CLOZAPINE<br />Stage 3<br />Partial or No response<br />CLOZAPINE<br />+<br />(FGA, SGA or ECT<br />Stage 4<br />Nonresponse<br />Trial of a single agent<br />FGA or SGA<br />(not tried in Stages 1 or 2 )<br />Stage 5<br />Nonresponse<br />Combination Therapy<br />e.g. SGA + FGA,<br />combination of SGAs, + ECT, + other agent<br />(e.g. mood stabilizer)<br />Stage 6<br />Source: IPS clinical Guidelines<br />
  169. 169. Typical Antipsychotic limitation: <br />Extrapyramidal side effects (EPS)<br />Parkinsonism<br />Akathesia<br />Dystonia<br />Tardive Dyskinesia (TD)-- the worst form of EPS-- involuntary movements<br />
  170. 170. Typical Antipsychotic limitation: Other common side effects<br />Anticholinergic side effects: dry mouth, constipation, blurry vision, tachycardia<br />Orthostatic hypotension (adrenergic)<br />Sedation (antihistamine effect)<br />Weight gain<br />“Neurolepticdysphoria”<br />
  171. 171. Parkinsonian side effects<br />Rigidity, tremor, bradykinesia, mask like facies<br />Management: <br />Lower antipsychotic dose if feasible<br />Change to different drug (i.e., to an atypical antipsychotic)<br />Anticholinergic medicines:<br />Benztropine <br />Trihexylphenidile <br />Promethazine<br />Procylidine<br />
  172. 172. Akathesia<br />Restlessness, pacing, fidgeting; subjective jitteriness; associated with suicide<br />Resembles psychotic agitation, agitated depression<br />Management: <br />lower antipsychotic dose if feasible<br />Change to different drug (i.e., to an atypical antipsychotic)<br />Adjunctive medicines:<br />Propranolol (or another beta-blocker)<br />Benztropine <br />Benzodiazepines<br />
  173. 173. Acute dystonia<br />Muscle spasm: oculogyric crisis, torticollis, opisthotonus, tongue protrusion<br />Dramatic and painful<br />Treat with intramuscular (or IV) promethazine or benztropine<br />
  174. 174. Tardive Dyskinesia (TD)<br />Involuntary movements, often choreoathetoid<br />Often begins with tongue or digits, progresses to face, limbs, trunk<br />Etiologic mechanism unclear<br />Incidence about 3% per year with typical antipsychotics<br />Higher incidence in elderly<br />
  175. 175. Tardive Dyskinesia (TD)<br />Major risk factors: <br />high doses, long duration, increased age, women, history of Parkinsonian side effects, mood disorder<br />Prevention: <br />minimum effective dose, atypical meds, monitor with AIMS test<br />Treatment: <br />lower dose, switch to atypical, Vitamin E (?), tetrabenazine<br />
  176. 176. Tardive Dyskinesia- Video<br />
  177. 177. Neuroleptic Malignant Syndrome (NMS)<br />Fever, muscle rigidity, autonomic instability, delirium<br />Muscle breakdown indicated by increased CK<br />Rare, but life threatening<br />Risk factors include:<br />High doses, high potency drugs, parenteral administration <br />Management: <br />stop antipsychotic, supportive measures (IV fluids, cooling blankets, bromocriptine, dantrolene)<br />
  178. 178. Electroconvulsive Therapy (ECT):<br /> Schizophrenia itself is not a primary indication for ECT. The indications for ECT in schizophrenia are-<br /><ul><li>Catatonic stupor
  179. 179. Uncontrolled catatonic excitement
  180. 180. Acute exacerbations not controlled with drugs
  181. 181. Severe side effects with drugs in presence of untreated or resistant schizophrenia
  182. 182. Risk of suicide,homicide or danger of physical assault. </li></li></ul><li>Non Pharmacological Management<br />
  183. 183. Psychoeducation<br />It empowers the patient so they can take control of their own illness. <br />Start basic and acquire consent to discuss with patient’s family. <br />Be quite confident with your diagnosis because it’s pretty unfair to label a patient schizophrenic if they’re not. They have to wear the stigma for the rest of their lives!<br />
  184. 184. Family Psychoeducation contd…<br />Provides information about schizophrenia: course, symptoms, treatments, coping strategies<br />Supportive<br />One aim is to decrease expressed emotion (hostility, criticism, etc.)<br />Not blaming<br />
  185. 185. Relapse signature and relapse prevention plans<br />It is a set of individualised symptoms occurring in a specific order over a particular time that the patient can learn to identify and manage themselves.<br /> It helps to identify the earliest signs of impending psychotic relapse (Subtle changes in thought, affect and behaviour precede development of frank psychosis) <br /> It offers timely and effective intervention to arrest their progression towards frank psychosis. <br />
  186. 186. Psychotherapy (individual or group)<br /><ul><li>Supportive
  187. 187. Cognitive-behavioral
  188. 188. “Compliance” therapy
  189. 189. Psychoeducational
  190. 190. Not regressive / psychoanalytic</li></li></ul><li>Psychotherapies for psychosis:<br /><ul><li> Supportive therapy:</li></ul>Focused on the “here and now” of the patient's life <br /> Aims to help the patient define reality more clearly and solve practical problems.<br />Involves providing reassurance, offering explanations and clarification, and giving guidance and suggestions.<br />
  191. 191. Supportive therapy contd…<br />Regular and supportive interaction with a psychotherapist may help sustain a patient with schizophrenia and may reduce the patient's feelings of aloneness and despair. <br />A positive relationship with the prescribing psychiatrist may also enhance the patient's adherence to prescribed medication. <br />It may reduce suicidal ideas and behaviours.<br />
  192. 192. Cognitive behavioural strategies<br />Emotional distress is assumed to be associated with faulty thinking, which, if modified, can alter emotional responses. <br />Generally starts with several sessions assessing the patient's specific symptoms and the distress associated with the symptoms. <br />Coping strategies that the patient has used may also be reviewed. <br />The therapy aims to address issues systematically over a fixed number of sessions.<br />
  193. 193. Steps of CBT<br /> Concerned Topic<br />Determine the focus of <br />the subsequent sessions<br /> Specific therapeutic strategies Application<br /> Homework exercises, Activity schedule maintenance advised<br /> The therapist focuses on any coexisting anxiety and depression<br />Therapist turns to specific positive psychotic symptoms that the patient experiences<br />Negative symptoms is addressed, but only after work has been completed on positive <br /> symptoms.<br />
  194. 194. Families and expressed emotion (EE)<br />High levels of criticism, hostility, or over involvement, have more frequent relapses.<br />The three attitudes pertaining to expressed emotion are known as hostile, critical, and emotional over-involvement. <br />The relatives influence the outcome of the disorder through negative comments and nonverbal actions. <br />The stress from the family for the patient to recover and end certain behaviours causes the person a relapse in their illness.<br />
  195. 195. Common factors associated with psychotic relapse<br /><ul><li>Antipsychotics not completely effective
  196. 196. “Noncompliance”—inconsistent antipsychotic medication use
  197. 197. Poor family economical status
  198. 198. Stressful life events/home environment (Expressed Emotion—hostility, criticism, over involvement)
  199. 199. Alcohol use
  200. 200. Drug use</li></li></ul><li>Rehabilitation<br />
  201. 201. Steps<br />Participants are told what skill they will learn and why they should learn it.<br />Introduction to Skill<br />Video Tape Demonstration<br />videotaped demonstration of the skill that is stopped periodically .<br />Each participant roleplays the skill that was demonstrated.<br />Role Play<br />Participants apply the problem solving method to resolve difficulties that may occur when they try to get the resources – time, money, etc.<br />Resource Problem Solving<br />Participants apply the problem solving method to resolve difficulties that may occur when they implement the skill and the outcomes are not as expected.<br />Outcome Problem Solving<br />Participants generalize what they have learned by practicing the skill outside of the<br />learning environment.<br />In Vivo Assignment<br />Participants generalize what they have learned by either practicing or completing a related task on their own.<br />Home Work Assignment<br />
  202. 202. Take Home Message<br />Schizophrenia usually starts in late adolescence or early adulthood<br />The most common symptoms are lack of insight, auditory hallucinations, and delusions<br />Clinicians should suspect the disorder in a young adult presenting with unusual symptoms and altered behavior<br />Treatments can alleviate symptoms, reduce distress, and improve functioning<br />Delayed treatment worsens the prognosis<br />
  203. 203. Conclusion<br />To describe the differential diagnosis of psychosis – schizophrenia, Schizotypal, Schizoid PD and depression<br />Explore some of the phenomenology – has diagnostic utility and misidentifications are particularly interesting<br />Understand the main etiological factors – good evidence for biological supporting <br />Examine the evidence for most effective management – good evidence for drug treatment but other approaches are very important<br />5. Treatment of schizophrenia should be done as a team work with Psychiatrist, family & social support.<br />
  204. 204. Bibliography:<br /> CTP – Kaplan & Sadock, 8thed, P 1329-1558<br /> Synopsis of Psychiatry, Kaplan & Sadock, 10thed, P 467-97<br /> Symptoms in the mind, Andrew Sims,3rded, Saunders<br /> Fish’s clinical psychopathology, 3rd ed.<br /> IPS clinical practice guideline on schizophrenia<br /> Textbook of post graduate Psychiatry, Vyas & Ahuja 2nded, P 151-86<br /> A short Textbook of Psychiatry, Niraj Ahuja, 6thed, P 57-73<br /> Web:<br /> - http://www.<br />-<br /> -<br /> -<br /> -<br /> - http://<br />
  205. 205. Thank You<br />Happiness Delivered<br />