Download SCHIZOPHRENIA

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- Psychosis is a break from reality involving delusions,
perceptual disturbances, disordered thinking (FTD),
and disorganized behavior.
- Schizophrenia and substance-induced psychosis
Are examples of commonly diagnosed psychotic
disorders.
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Schizophrenia Spectrum and Other
Psychotic Disorders
1.
2.
3.
4.
5.
6.
7.
Schizophrenia
Brief Psychotic Disorder
Schizophreniform Disorder
Schizoaffective Disorder
Delusional Disorder
Schizotypal (Personality) Disorder
Substance/Medication-Induced
Psychotic Disorder
8. Psychotic Disorder Due to Another
Medical Condition
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Scenario 1
19 year old male is brought to the ER by his
roommate after the patient stated the voices are
telling me to kill my teacher.
the patient has become withdrawn and isolated
over the last year. 6 weeks ago the patient
started talking to himself became paranoid and
started to be verbally and physically agressive.
Think
schiz-paranoid features
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Scenario 2
25 year old female is brought to the ER by her
family because they have been unable to get her to
eat or drink anything for the past 2 days. the
patient though awake is completely unresponsive
vocally and nonverbally. she actively resists any
attempt to be moved. her family reports over the
last 7 months she has become withdrawn, socially
isolated and bizarre, often speaking to people
nobody else could see.
Think
schiz-catatonic features
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Schizophrenia is a psychiatric disorder
characterized by a constellation of abnormalities
in thinking, emotion, perception and behavior.
There is no single symptom
that is pathognomonic, and the disease can
produce a wide spectrum of clinical
pictures. It is usually chronic and debilitating.
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In general, the symptoms of schizophrenia
are divided up into two categories:
Positive symptoms
Hallucinations,
2. Delusions,
3. Disorganized or
bizarre Behavior,
4. Formal Thought
disorder
1.
Negative symptoms:
1. Anhedonia (no interest)
2. Affect (flat)
3. Alogia (poverty of speech)
4. Avolition (apathy)
5. Attention (poor)
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Typical Course of the disease
Three Phases:
Symptoms of schizophrenia usually present in three phases:
1. Prodromal—decline in functioning that precedes the first
psychotic episode. The patient may become socially
withdrawn and irritable. He or she may have physical
complaints . bizarre ideas, development of an interest in
complex philosophical or religious ideas, strange perceptual
experiences and abnormal affect.
2. Psychotic—perceptual disturbances, delusions, and
disordered thought process/content, behavior.
3. Residual—occurs between episodes of psychosis. It is
marked by flat affect, social withdrawal, and odd thinking or
behavior (negative symptoms).
Patients can continue to have hallucinations even with
treatment.
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Note:
To make the diagnosis of
schizophrenia, a patient
must have symptoms of the
disease for at least 6
months.
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Diagnosis of Schizophrenia
DSM-V Criteria (2013)
 Two or more of the following must be present
for at least 1 month:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (such as flattened affect)
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 Must cause significant social or occupational
functional deterioration
 Duration of illness for at least 6 months (including
prodromal or residual periods in which above
criteria may not be met)
 Symptoms not due to medical, or substanceinduced disorder
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Specifiers of Schizophrenia
1. Paranoid features—highest functioning type, older age of
onset. Must meet the following criteria:
_ Preoccupation with one or more delusions or frequent
auditory hallucinations
_ No predominance of disorganized speech, disorganized or
catatonic behavior, or inappropriate affect
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2. Disorganized features—poor functioning
, early onset. Must meet the following criteria:
_ Disorganized speech
_ Disorganized behavior
_ Flat or inappropriate affect
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3. Catatonic features—rare. Must meet at least two of
the following criteria:
_ Motor immobility
_ Excessive purposeless motor activity
_ Extreme negativism or mutism
_ Peculiar voluntary movements or posturing
_ Echolalia or echopraxia
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4. Undifferentiated features—characteristic of more than
one subtype or none of the subtypes
5. Residual features—prominent negative symptoms
(such as flattened affect or social withdrawal) with only
minimal evidence of positive symptoms.
(such as hallucinations or delusions)
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Important Psychopathological Phenomena
Included in (ICD-10)
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•
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Thought Echo
Thought Insertion Or Withdrawal
Thought Broadcasting
Delusional Perception
Influence Or Passivity
Hallucinatory Voices Commenting Or Discussing The
Patient In The Third Person
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Psychiatric Exam of Schizophrenics
The typical findings in schizophrenic patients on exam
include:
_ Disheveled appearance
_ Flattened affect
_ Disorganized thought process
_ Auditory hallucinations
_ Paranoid delusions
_ Ideas of reference (feel references are being
made to them by the television or newspaper, etc.)
_ Concrete understanding of similarities/proverbs
_ Lack insight into their disease
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
Psychosis secondary to general medical condition

Substance-induced psychotic disorder

Delirium/Dementia

Bipolar disorder

Major depression with psychotic features

Brief psychotic disorder

Schizophreniform disorder

Schizoaffective disorder

Delusional disorder
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Medical causes of psychosis include:
1. CNS disease (cerebrovascular disease, multiple
sclerosis, neoplasm, Parkinson's disease, temporal
lobe epilepsy, encephalitis)
2. Endocrinopathies (Addison’s/Cushing’s disease,
hyper/hypothyroidism ,hyper /hypocalcemia ,
hypopituitarism)
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3. Nutritional/Vitamin deficiency states (B12,
folate, niacin)
4. Other (connective tissue disease [systemic lupus
erythematosus, porphyria)
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Note:
Always be sure to include the importance of
ruling out medical,
or substance-induced
conditions.
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
Schizophrenia affects approximately 1% of people
over their lifetime.
 Men
and women are equally affected but have
different presentations and outcomes:
 Men
tend to present around 20 years of age.

Women present closer to 30 years of age.

The course of the disease is generally more severe
in men, as men tend to have more negative
symptoms and are less able to function in society.
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

Schizophrenia rarely presents before age 15 or after age 45.
There is a strong genetic predisposition:

50% concordance rate among monozygotic twins

40% risk of inheritance if both parents have schizophrenia

12% risk if one first-degree relative is affected

There is a strong association with substance use which may
be a form of self medication and depression.

Postpsychotic depression occurs in 50% of patients.
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Note:
People born in winter and early spring have a
higher incidence of schizophrenia for unknown
reasons.
(One theory involves seasonal variation in viral
infections of mothers during pregnancy.)
Pathophysiology of schizophrenia
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The Dopamine Hypothesis
- Though the exact cause of schizophrenia is not known, it
appears to be partly related to increased dopamine activity
in certain neuronal tracts
- Evidence to support this hypothesis is that most
antipsychotics that are successful in treating schizophrenia are dopamine receptor antagonists.
In addition, cocaine and amphetamines increase dopamine
activity and can lead to schizophrenic-like symptoms.
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Note:
It is often impossible (clinically) to differentiate
an acute psychotic episode related to
schizophrenia from one related to cocaine or
amphetamine abuse, as these drugs excite
dopaminergic pathways.
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Theorized Dopamine Pathways
Affected in Schizophrenia

Prefrontal cortical—responsible for
negative symptoms
 Mesolimbic —responsible for
positive symptoms
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Other Important Dopamine Pathways
Affected by Neuroleptics
 Tuberoinfundibular—blocked
by neuroleptics,
causing hyperprolactinemia

Nigrostriatal—blocked by neuroleptics,
causing extrapyramidal side effects
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Other Neurotransmiter Abnormalities
Implicated in Schizophrenia
Elevated serotonin

some of the atypical antipsychotics (such as
risperidone and clozapine) antagonize serotonin
(in addition to their effects on dopamine).
Elevated norepinephrine
 long-term
use of antipsychotics has been shown
to decrease activity of noradrenergic neurons.
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Decreased gamma-aminobutyric
acid (GABA)—
recent data support the hypothesis that
schizophrenic patients have a loss of GABAergic
neurons in the hippocampus; this loss might
indirectly activate dopaminergic and noradrenergic
pathways.
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Glutamate and N-methyl-d-Aspartate

Glutamate is a major brain excitatory amino acid
neurotransmitter and is critically involved in
learning, memory and brain
development. Interest in glutamate and the NMDA
receptor In schizophrenia arose because of the
similarity between phencyclidine (PCP) psychosis
and the psychosis of schizophrenia.
PCP is a noncompetitive antagonist of the NMDA
receptor and produces a psychotic state that
includes auditory hallucinations, delusions and
negative symptoms.
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Note:
CT scans of patients with schizophrenia often
show enlargement of the ventricles and diffuse
cortical atrophy which are non-specific.
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PROGNOSTIC FACTORS
Schizophrenia is usually chronic and
debilitating. 40 to 50% of patients remain
significantly impaired after their diagnosis,
while only 20 to 30% function fairly well in
society with medication. Several factors are
associated with a better or worse prognosis
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*Associated with Better
Prognosis

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

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

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Later onset
Good social support
Positive symptoms
Mood symptoms
Acute onset
Female sex
Few relapses
Good premorbid functioning
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*Associated with Worse
Prognosis
Early onset
 Poor social support
 Negative symptoms
 Family history
 Gradual onset
 Male sex
 Many relapses
 Poor premorbid functioning
(social isolation, etc.)

TREATMENT

Hospitalization

Pharmacotherapy
 Acute
 Stabilization and maintenance

Psychosocial therapy

Others
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 A multimodality approach is the most
effective, and therapy must be tailored to
the needs of the specific patient.
 Delay in Rx --  worse prognosis
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Hospitalization
 Establish an effective association bet pt and
support systems in community
 Short stay (4-6 ws) is as effective as long stay
 Active behavioral approach is better
 Selfcare
 QOL (quality of life)
 Employment
 Social relationship
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 Pt linked to social agencies
 Day care centres
 Home visits
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pharmacotherapy
 Pharmacologic treatment consists primarily
of antipsychotic medications
 Antipsychotics are the mainstay treatment
(biological)
 Other psychosocial th augment improvement
 Both should be integrated, --  best resuls
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TREATMENT
pharmacotherapy
 Chlorpromazine 1952
 Dec syx and relapse rate
 70 % remission rate
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Typical Antipsychotics (neuroleptics), DRA
1st generaion

Chlorpromazine, trifluoperazine ,
haloperidol.
 These
are dopamine (mostly D2) antagonists.
 They
classically treat positive symptoms
 They
have important side effects and sequelae
such as extra pyramidal symptoms.
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 Risperidone,,
olanzapine, quetiapine,
aripiprazole,, Illiperidone (Invega). clozapine
 These
antagonize serotonin receptors (5-HT2) as
well as dopamine receptors.
 Atypical
neuroleptics are classically better at
treating negative symptoms than traditional
neuroleptics. They have a much lower incidence of
extrapyramidal side effects, but have other SE
(metabolic syndrome)
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_
Medications should be taken for at least 4
weeks before efficacy is determined.
 If
the medication fails, it is appropriate to
switch to another medication in a different
class.
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phases of Rx:
Acute
phase:

4-8 Ws +ve psych syx + excitement

Ddx Akathesia (anticholinergic)

IM Aps +/- Benzo

Haloperidol (EPS).

Olanzapine im/po (rapidly dissolving)

Chlorpromazine (hypotension)
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
Im Lorazepam 2mg (best absorption), short

Less amount of AP needed so less AP SE
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Continuaton/maintenance phase

on Rx  20% relapse in a year

without Rx  60 % relapse in a year

In general 80% relapse within 5 yrs
For
how long continue Rx?

1st episode -- > 1yr (1-2y) , no consensus

multi episodes (>2 in 5yrs) – at least 5 yrs
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if


Haldpl 50 mg /4w

Flufenazine 25 mg /2-3w

Fluanxol 20 mg 2-4w

Risperidone consta 25mg/2w
but check reasons for non-compliance
*

poor compliance  use long acting AP
psychoeducation is mandatory
Use minimum effective dose
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
60 % initially responds (complete, mild sys)

ensure adequate trial (4-6 w) with adequate dose

Even if mild improvement continue for 3-6
months (mostly will continue improvement)

Check compliance:

? plasma monitoring
if low levels:

non or poor compliance
Rapid
Poor
metabolizers*
absorption
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so increase the dose
-? SE
-Shift to another class DRA - SDA
- clozapine, esp if severe syxs, clear evidence
--
Management of SE:
-Usually start before improvement
DRA:
- low-potency  sedation, Hypotention,
anticholinergic
- high-potency EPS
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Behavioral therapy (social skills training)
 Attempts to improve patients’ ability to function in
society.
 Patients are helped through a variety of methods to
improve their social skills, become self-sufficient,
and act appropriately in public.
 Poor eye contact, delay in response, odd behavior,
asociability,
 Token economy (ward)
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Family therapy
 Family
oriented therapy
 Psychoeducation
 Stress
is vital
reducing and coping strategies
 Gradual
integration into society
 Decrease
high expressed emotions (imp)
group therapy
 Effective
in reducing social isolation
 Supportive
–oriented is most helpful
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Vocational therapy
 Regain
old skills or develop new ones
 Through
workshops and job assignment
Cognitive therapy
 Some
reports of ameliorating delusions and
hallucinations in some patents
 Improve
cognitive distortions and poor judgment
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ECT
 Supplementary
to AP
 For
catatonic pts.
 For
pregnant pts.
 Severe

non –drug responder
if drugs contraindication
Psychosurgery
 Limited
for severe, intractable cases
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Note:
Significant improvement is noted in 70% of
schizophrenic patients who take antipsychotic
medication
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An 18 - year-old woman diagnosed with schizophrenia
presents to the psychiatric emergency department after a
suicide attempt by carbon monoxide poisoning. Medical
evaluation was noncontributory and a urine toxicology
screen was negative.
The patient's mother reports that she has been refusing
to take haloperidol (Haldol) for the past 3 weeks.
The lifetime risk of death by suicide in patients with
schizophrenia is closest to which of the following?
(A) 1% (B) 5% (C) 10% (D) 30% (E) 50%