This document provides information on the management plan for schizophrenia. It discusses the typical professionals involved in treatment which includes psychiatrists, psychologists, nurses, and social workers. It describes treatment settings as either inpatient or outpatient. It outlines the main modalities used which are pharmacotherapy, psychotherapy, and electroconvulsive therapy. Both short-term and long-term goals are discussed. Short-term goals focus on safety, control of symptoms, and functional recovery. The document also provides details on antipsychotic medications, their side effects and treatment algorithms.

1. Antipsychotics
Management of

2. 1%

3. treatment
management

4. treatment
management
Diagnosis

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management plan of schizophrenia
who
 Psychiatrist
 Psychologist
 Nurse
 social worker.
where
 Inpateint
 Outpaient
what
Pharmacotherapy
Psychotherapy
ECT
goals
 Short terms
 Long terms

6. management plan; goals
Short term goals “Acute Phase”
Short term goals Acute Phase
• Prevent harm.
• Control disturbed behavior.
• Reduce the severity of psychosis and associated
symptoms (e.g., agitation, aggression, negative
symptoms, affective symptoms).
• Determine and address the factors that led to the
occurrence of the acute episode.
• Effect a rapid return to the best level of
functioning.
• Develop an alliance with the patient and family. •
Connect the patient with appropriate aftercare in
the community.
Minimize stress on the patient and provide support
to minimize the likelihood of relapse.
• Enhance the patient’s adaptation to life in the
community.
• Facilitate continued reduction in symptoms and
consolidation of remission, and promote the process
of recovery.

7. management plan; where to treat
Outpatient Inpatient

8. ECT
management plan; modalities
pharmacotherapy
Non-
pharmacologi
cal
management

9. Treatment
algorithms
for
schizophrenia
Either:
Agree the choice of antipsychotic medication
with patient1 and/or carerOr, if not possible:
Start second-generation antipsychotic medication
Titrate, as necessary, to minimum effective dose
Adjust dosage regimen according to therapeutic
response and tolerability/safety
Assess over 2–3 weeks
Continue at dose
established as effective
Consider
switching to
depot/long-acting injection
before discharge
Change drug and
follow above process
 If poor adherence related to
poor tolerability, discuss with
patient and change to drug with
more favourable adverse-effect
 If poor adherence related to
other factors, consider early
use of depot/long-acting
injection
Not
Effective
Not
Effective
Clozapine
First‐episode
schizophrenia

10. Relapse
or acute
exacerbation
of
schizophrenia
Investigate oscial or psychological precipitants
Provide appropriate support and/or therapy
Continue usual drug treatment
Add short-term sedative
or
Switch to a different, more acceptable antipsychotic
medication if appropriate
Discuss medication choice with patient and/or carer
Assess over 6 weeks
Switch to clozapine
Treatment
ineffective
full
adherence
confirmed
Acute drug
treatment
required

11. Relapse
or acute
exacerbation
of
schizophrenia
Investigate reasons for
poor adherence
Discuss with patient
Consider depot/LAI
antipsychotic
medication
Simplify drug regimen
Reduce any anticholinergic load
Consider ‘compliance aids’*
Consider depot/LAI
Poorly
tolerated
treatment
Discuss with patient
Switch to
antipsychotic
medication with
a more favourable
adverse-effect prole
adherence
in doubt

12. classification of antipsychotics
Atypical
Typical
Second
generation
First
generation
novel
conventional
High
potency
Low
potency

14. 1860
Morel
démence précoce
1892
Kraepelin
Dementia praecox
Manic-depressive
psychosis
Kraepelinian
dichotomy
1908
Bleuler
schizophrenia
Schneider
1959
Schneiderian first-
rank symptoms

15. 1860
Morel
démence précoce
Henri Laborit
French surgeon
1952
chlorpromazine
Institutionalization
Insulin coma
ECT
Leucotomy

17. 1958
Haloperidol
Paul Janssen

22. Dopamine
Hyperactivity
at mesobimic pathway
Dopamine
Theory

23. Dopamine
Dopamine Receptor Blockade:
Antipsychotic Drugs
First generation

24. Dopamine Receptor

25. Dopamine Receptor Blockade:
Antipsychotic Drugs

26. Dopamine Pathways

27. Dopamine Pathways

28. Dopamine Pathways

32. 1. Mesolimbic pathway
Midbrain (mesencephalon)
ventral tegmental area (VTA)
Limbic system
nucleus accumbens
MOTIVATION, EMOTION,
REWARD,
Positive Symptoms
Reduce Positive Symptoms

33. Dopamine Pathways

34. 2. Mesocotical pathway
Midbrain (mesencephalon)
ventral tegmental area (VTA)
prefrontal cortex
cognitive control,
excutive function (DLPFC)
Affect (VMPFC)
Hypofuction related to
cognitive & Negative
symptoms

35. Dopamine Pathways

36. 3. nigrostriatal pathway
substantia nigra
dorsal striatum
(caudate nucleus & putamen)
production of movement,
system called the basal
ganglia motor loop
D2 antagonism induce
Extrapyramidal Symptoms
(EPS)

37. Dopamine Pathways

38. 4. Tuberoinfundibular pathway
Tuberal region of the
hypothalamus
(arcuate nucleus)
median eminence
(pituitary gland)
 dopamine is released in portal
circulation connecting the median
eminence with the anterior pituitary
 dopamine tonically inhibit prolactin
release
D2 anatagonism increases
prolactin levels
~0–530 mIU/L
0–25 ng/mL
Women
Normal
~0–424 mIU/L
0–20 ng/mL
Men

39. Dopamine
Hyperactivity
Dopamine Theory

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dopamine
MOTIVATION,
EMOTION,
Positive Symptoms
cognitive control,
excutive function (DLPFC)
Affect (VMPFC)
production of movement,
inhibit prolactin release
Mesolimbic
Tubero
infundibular
nigrostriatal
Mesocotical
dopamine
blockade
Reduce Positive Symptoms
Hypofuction related to cognitive
& Negative symptoms
EPS
increases prolactin levels
(impotence,
gactorreha, amenorrhea

41. Modified Dopamine Theory
mesolimbic pathway
Dopamine
Hyperactivity
Mesocotical pathway
Dopamine
Hypoactivity

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Lorem Ipsum
Lorem ipsum dolor sit amet, nibh est. A magna
Serotonin Dopamine
Serotonin Dopamine
Dopamine Serotonin

43. Dopamine - serotonin Receptor Blockade:
second generation Antipsychotic Drugs

44. Modified Dopamine
Theory

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dopamine
MOTIVATION,
EMOTION,
Positive Symptoms
cognitive control,
excutive function (DLPFC)
Affect (VMPFC)
Normal movement,
inhibit prolactin release
Mesolimbic
Tubero
infundibular
nigrostriatal
Mesocotical
Dopamine
serotonin
blockade
Reduce Positive Symptoms
Improve cognitive
& Negative symptoms
Normal movement,
inhibit prolactin release

46. Clozapine
agranulocytosis
treatment-resistant
schizophrenia
risk of suicide in schizophrenic
or schizoaffective patients

47. Developments in medical treatments
for psychotic disorders
’30s ’40s ’50s ’60s ’70s ’80s ’90s ’00 ’02 ʼ05 ʼ10
ECT
Insulin coma
Leucotomy
Chlorpromazine
Haloperidol
Fluphenazine
Thioridazine
Loxapine
Perphenazine
First-generation
antipsychotics
Second-generation
antipsychotics
Risperidone
Olanzapine
Sertindole
Quetiapine
Ziprasidone
Amisulpride
Aripiprazole
Clozapine
Sertindole
Paliperidone

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antipsychotic side effects
EPS
Weight
gain NMS
Dys
lipidemia
Hyper-
prolactinemia
QT
prolongation
sedation

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antipsychotic side effects
Weight
gain
Antipsychotic‐induced weight gain
Clozapine
Olanzapine
High
Chlorpromazine
Iloperidone
Sertindole
Quetiapine
Risperidone
Paliperidone
Moderate
Amisulpride
Asenapine
Brexpiprazole
Aripiprazole
Cariprazine
Haloperidol
Lurasidone
Sulpiride
Trifluoperazine
Ziprasidone
Low

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antipsychotic side effects
QT
prolongation
(440 ms for men,
470 ms for women)
Unknown effect
High effect
Moderate effect
Low effect
No effect
Pipotiazine
Trifluoperazine
Zuclopenthixol
Any intravenous
antipsychotic
Pimozide
Sertindole
Thioridazine
Any drug or
combination of
drugs used in
doses exceeding
recommended
maximum
Amisulpride
Chlorpromazine
Haloperidol
Iloperidone
Levomepromazine
Melperone
Quetiapine
Ziprasidone
Aripiprazole
Asenapine
Clozapine
Flupentixol
Fluphenazine
Loxapine
Perphenazine
Prochlorperazine
Olanzapine
Paliperidone
Risperidone
Sulpiride
Brexpiprazole
Cariprazine
Lurasidone

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Extrapyramidal Symptoms (EPS)
Psuedo
parkinsonism
 Tremors
 Rigidity
 Bradykinesia
 Bradyphernia
 salivation
Dystonia
 Oculogyric crisis
 Torticollis
 Unable to swallow or speak
clearly
 Back may arch or jaw
dislocate
Akathisia
 Subjectively unpleasant
stste of inner
restlessness where there
is a strong desire or
compulsion to move .
Tardive
dyskinesia
lip smacking or chewing
tongue protrusion (fly
catching) choreiform hand
movements (pill rolling)
Psu-park DYSTONIA AKATHISIA TD
 reduce the antipsychotic dose
 change to an antipsychotic with
lower propensity for
pseudoparkinsonism
 Anticholinergic drugs given
orally, IM or IV
 Switching to an antipsychotic
with a low propensity for EPS
 reduce the antipsychotic dose
 Switching to an antipsychotic
with a low propensity for EPS
 propranolol 30–80 mg/day,
 reduce the antipsychotic dose
 Switching to an antipsychotic
with a low propensity for EPS
 clozapine

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Step 3
Step 2
Step 1 Step 4
before you prescribe
. Lab inv
Develop a
therapeutic
alliance and
promote
treatment
adherence
ECG
BMI

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antipsychotic forms
tablet
. All antipsychotics
solution
Risperidone
aripiprazole.
Ampule
short acting
Haloperidol
aripiprazole.
zuclopenthixol acetate
olanzapine
.
ampoule
depot form
haloperidol
Risperidone
paliperidone
.

54. Treatment
CBT
Pimozide
Haloperidol
Trifluoperazine
Chlorpromazine
(largactil)
(neurozine)
 starting dose : 25
 Max dose : 800 mg
 in divided doses
 Hypotension
 induced liver injury
tic
(Stelazine) (Stelazill)
 starting dose : 5 mg
 Max dose : 20mg
 in divided doses
(Haldol) (Safinase)
(Halonase)
 starting dose : 1.5–5mg
2–3 times daily in
divided doses
 Max daily dose : 30mg
 Ampule ever 4 – 8
hours
(Orap)
 starting dose : 2 mg
Max dose : 20 mg
FGA
 ECG, QT
 May be sedating

55. Treatment
CBT
Quetiapine
Paliperidone
Olanzapine
Risperidone
(Risperdal) (Riscure)
(Apexidone) (Rispadex)
(Pschycodal)
 starting dose : 2
 Max dose : 8 mg
 in 1 / 2 doses
 Low EPS, but
 can raise prolaction
(Zyprexa) (Bioprex)
 starting dose : 5mg
 Max dose : 20mg
 Now EPS, No
Prolactin
 sedation, weight
gain, dizziness,
glucose
dysregulation.
(Invega)
 starting dose : 6mg
 Max daily dose : 12 mg
 Low EPS
 active metabolite of
risperidone.
(Seroquel) (Quetiapine)
(Quetiazic) (Quetiapex)
 starting dose : 300 mg
Max dose : 800 mg
SGA,
 Low EPS
 May be sedating
 sedation, dizziness
 weight gain

56. Treatment
CBT
Clozapine
Sertindole
Aripiprazole
Amisulpride
(Solian) (Amipride)
 starting dose : 50
 Max dose 1200 mg
 in 2 doses
 Low EPS, but
 can raise prolaction
(Abilify) (Aripiprazole)
(Aripiprex)
 starting dose : 10 mg
 Max dose : 30mg
 once daily
 No weight gain
 low EPS, butakathisia
(Serdolect)
 starting dose : 12 mg
 Max daily dose : 20 mg
 single daily dose
 no EPS
 Increase in QTc—
needs ECGmonitoring
(Leponex) (Clozapine)
(Clozapex)
 starting dose : 12.5
mg Max dose : 900 mg
SGA,2
 Postural
hypotention
 Sedation, weight
gain
 Agranulocytosis

57. Long Acting
Antipsychotics

58. Sustenna

59. Dose and dosing frequency of long-acting injectable antipsychotic
Sustenna

60. medication
Would it help?

61. Long term outcome
WITHOUT
TREATMENT
05
02
WITH
TREATMENT
05
02
60 – 80 % will
relapse within 2 years
100 % will
relapse within 5 years
20 – 40 % will
relapse within 2 years
50 % will
relapse within 5 years

62. • First episode patients: at least 1-2 years.
• Multiple episode patients: at least 5 years.
• Despite the currently limited evidence, we believe
that depot medication has obvious advantages
such as assured medication and the awareness of
when a patient stopped treatment.
Duration
Patel et al, 2009
Kane et al, 2003

63. 2
What is OCD
Epidemiology
Nosology
Symptoms
Diagnosis
OCPD Vs. OCD
Investigations
Etiology
Treatment
Questions
Terms
‫يحبذ‬ ‫حسين‬

64. Further reading

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