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Farhan is a young boy of 23 years of age, single ,unmarried, educated upto Fsc. He is resident of district Chakwal and was referred to me by one of my senior colleague from Rawalpindi , in OPD on 26.9.2006. This is his first admission in PIMH . Presenting Complains Aggressive abusive and irritable Suspicious to his family members, Self talking , self laughing along with odd behaviour. Disturbed sleep Family History No family history of any Psychiatric illness. Personal History Poor performance in school Asocial Down ward drift Premorbid Schizoid History Drug History During his stay with us Following drugs has been given SEP to NOV 2006 Risperidone upto 6mg /day but with poor response DEC to 15JAN 2007 olanzapine 20mg/day but with poor response 15JAN to MARCH 2007 Zeldox400mg/day but with poor response Currently he is on Clozapine 400mg/day and gradually increasing the dose (100mg/week) Mental State Examination Appearance and Behavior Young thin boy .wearing hospital uniform, sitting comfortably in chair ,cooperative , making and maintaining eye contact adequately showing self smiling during interview. MOOD Subjectively I am happy MOOD Objectively Euthymic Talk Verbatum of the Patient Verbatum is in urdu, It is translated in English for your convenience. I have been selected for president First of all iwas Major General but iwas not promoted to Brigadier I have the power of four knowledge's Religion Knowledge Black knowledge (Magic) Sky Knowledge Knowledge .which I developed myself. There are army control room They control my whole village.Also in my home and control me. Army people have taken out my brain. Now aday Iam General “Ghain” this name has been given to me by GHQ Rawalpindi In Navy Iam “QUTTAR KANDUCTOR”(invented word with no meaning) In air force Iam “DEAL LAKORA”(invented word with no meaning in urdu) Iam the GUL of whole world. Iam under women like magic they want to convert me in a girl. Ihave the knowledge of ideas that is very powerful.I come to know each and every thing through this This is not for only muslims but also people belonging to other religions. People living in my village also have this knowledge. Thatpush different thoughts into my mind,rather they push my thought into the mind other peoples While describing all this talk, there was no pressure of speech,no elation rather he was quite cold and devoid of any emotion Auditory Hallucination Not found Thoughts disorder Thought insertion Broadcasting Withdrawl Delusion of grandeur / paranoid Passivity - positive Orientation and Concentration He is well oriented in time and space. Insight According to patient, he is not suffering from any psychiatric illness and needs no medication. D/D In my opinion The most likely diagnosis is SCHIZOPHRENIA SCHIZOAFFECTIVE DISORDER BAD CHRONIC MANIA Points in favour of first diagnosis Continuous pattern of illness without seasonal variation . Premorbid personality Delusion of control and thoughts disorder . Absence of pressure of speech ,poor emotional response while talking Neologism Precipitating Factors The poor performance in Fsc result in the initiation of the illness. Maintaining Premorbid personality Poor drug compliance HEE Factors MANAGEMENT I would like to manage this case on following aspect Pharmacological Psychological Social Along with pharmacological treatment, psychosocial education of the family is being carried out. SCHIZOPHRENIA Schizophrenia is one of the group of psychiatric disorders traditionally called the functional psychoses. SCHIZOPHRENIA NEGATIVE SYMPTOMS POSITIVE SYMPTOMS DIAGNOSIS DSM-TR ICD-10 PARANOID PARANOID DIORGANISED HEBEPHERNIC CATATONIC CATATONIC UNDIFFERENTIATED UNDIFFERENTIATE RESIDUAL SIMPLE EPIDEMIOLOGY INCIDENCE .1% PREVALENCE Life time risk is 7-13% per 1000 population. MORTALITY Suicide is the most common cause of early death in schizophrenia (713%). AETIOLOGY BIOLOGICAL FACTORS BIRTH COMPLICATIONS NEURODEVELOPEMENTAL POST NATAL INFECTIONS (VIRAL) EXPOSURE TO DRUGS CONTINUE……. ENVIROMENTAL FACTORS HOME ATMOSPHERE ROLL OF CAREGIVERS MIGRATION EARLY DEATHS OF PARENTS UNUSUAL STRESS CONTINUE….. GENETIC FACTORS IDENTICAL TWINS NON IDENTICAL TWIN REAL SIBLINGS BOTH PARENTS ONE PARENT GENERAL POPULATION RISK 46% 12-15% 08% 40% 12-15% 1% JUEL K(1993) MORTALITY AND CAUSES OF DEATH IN FIRST ADMITTED SCHIZOPHERNIC PATIENTS BJP 163 NEUROPSYCHOLOGICAL FINDINGS NEUROIMAGINING CT-SCAN/MRI VENTRICULAR ENLARGEMENT AMYGDLA THICKENING CEREBELLAR ATROPHY CONTINUED….. PET SCAN REDUCED CEREBERAL BLOOD FLOW AN APPROACH TO TREATMENT RESISTANT SCEHIZOPHRENIA DEFINITION FAILURE TO RESPOND TO 2 OR MORE ANTIPSYCHOTIC MEDICATION GIVEN IN THERAPEUTIC DOSAGE FOR SIX WEEKS. PREVALENCE APPROX 30% . AETIOLOGY NEURODEVELOPEMENT FACTORS,COGNITIVE IMPAIRMENT,DRUG NON COMPLIANCE. CONTINUE… MANAGEMENT CLARIFY DIAGNOSIS,ADRESS COMORBIDITY AND NON COMPLIANCE PHARMACOLOGICAL INTERVENTION ONLY CLOZAPINE IS APPROVED FOR TRS. REHABILITATION SIDE EFFECTS OF CONVENTIONAL ANTIPSYCHOTICS ACUTE ANTICHOLINERGIC SIDE EFFECTS,NMS,EPS SUB ACUTE PIGMENTATION,WEIGHT GAIN,LFT, CHRONIC TARDIVE DYSKINESIA SIDE EFFECT PROFILE OF ATYPICAL ANTIPSYCHOTICS(RISPERIDONE,OLANZAPIN E, QUETIAPINE,ZYPRESSIDONE,CLOZAPINE) SEDATION CHOLINERGIC VS ANTICHOLENERGIC WEIGHT GAIN METABOLIC SYNDROME BLOOD DYSCRASIA ECG CHANGES SEIZURES EPS APPROVED INDICATIONS FOR CLOZARIL TREATMENT RESISTANT SCHIZOPHRENIA REDUCING THE RISK OF RECURRENT SUICIDAL BEHAVIOUR PSYCHOSIS DURING THE COURSE OF PARKINSONS DISEASE OTHER INDICATIONS OF CLOZAPINE SCHIZOAFFECTIVE DISORDERS? BIPOLAR DISORDERS? POST TRAUMATIC STRESS DISORDERS? THE END