Download - Schizophrenia
SCHIZOPHRENIANG BOON KEATMOHD HANAFI RAMLEE
To Know Schizophrenia is to know Psychiatry The most devastating illness
that psychiatrist treat. One of the most challenging
disease in medicine 1% of population has schizo. An enormous economic
burden ? A major health concern
Sto
ries o
f S
ch
izop
hre
nia
History Emil Kraepelin- original term-
dementia praecox-early age, chronic deteriorating course.
Eugen Bleuler- coined the term schizophrenia (split mind) affective blunting, loosening of associations, autism (withdrawal) and ambivalence (coexisting conflicting ideas) - 4 As- earned acceptance in USA
Kurt Schneider first rank symptom
Definition
Psychotic mental disorder of unknown aetiology characterized by disturbances in Thinking (e.g. distortion of
reality, delusions and hallucinations)
Mood (e.g. ambivalence, inappropriate affect)
Behaviour (e.g. Apathetic withdrawal, bizarre activity)
at least 6 months
Epidemiology
• Lifetime prevalence 1-1.5%• There is 7351 cases had been reported from 2003-2005
• The incidence was noted higher in males, urban and migrant population
Incidence and prevalence(In Malaysia)
• 60% of the schizophrenia cases are man
Sex ratio
• Prevalence > low socioeconomic groups
Socioeconomic status
• Common between 15 and 35, rare before 10 and after 40 years old. Earlier onset for ♂
Age of onset
Epidemiology: Sex
Epidemiology: Race
54
28
9
9
Malay ChineseIndian Others
BUT IT CAN ALSO AFFECT ANYONE
WITHOUT PREDISPOSITION
S !
AetiologyUncertain; however there is evidence for several risk factors.
Several models which can be grouped into….
Biological Social
Psychological
Aetiology – BioGenetics Consideration
1st degree & 2nd degree relativeEnvironmental
Abnormalities of pregnancy and delivery [2%]
Maternal Influenza – 2nd trimester [2%] Fetal Malnutrition [2%] Winter & Low Social Class birth [1.1%]
Social Studies have shown an excess of
schizophrenic patients in lower socioeconomic groups and in urbanised areas. This used to be attributed to “social drift”
Cannabis abusers [2%]
Psychological abnormalities in
processing sensory information, in separating “signal from background noise”, or in manipulating abstract information
Excess life traumas against controls at first presentation
Pathophysiology disorder of dopaminergic
function: related to increased dopamine
activity in certain neuronal tracts.
Other neurotransmitter abnormalities implicated in schizophrenia: elevated serotonin. elevated norepinephrine. decreased gamma-
aminobutyric acid (GABA).
Schizophrenia Subtypes
Classically divided into five subtypes Paranoid [stable, often persecutory
delusion/hallucinations only]
Hebephrenic [thought/affective changes + -ve symptoms]
Undifferentiated [psychosis w/out clear predominance]
Catatonic [prominent psychomotor disturbances]
Residual [low intensity +ve symtoms]
THREE PHASES OF SCHIZOPHRENIA
Prodromal
• Decline in functioning that precedes 1st psychotic episode
• Socially withdrawn, irritable
• Physical complaints
• Newfound interest in religion / the occult
Psychotic (acute
phase)• Positive
symptoms• Perceptual
disturbances (e.g. auditory hallucinations)
• Delusions (usually secondary, delusion of reference common)
• Disordered thought process / content
Residual (chronic
phase)• Occurs between
episodes of psychosis
• Marked by negative symptoms (flat affect, social withdrawal)
• odd thinking and behaviour
Clinical Features
Acute syndrome (positive symptoms)
• Hallucinations• Delusion• Disorganised
speech/thinking/ behaviour
• Catatonic behaviours• Delusion of reference
Chronic syndrome (negative symptoms)
• Affective Flattening• Alogia• Avolition• Anhedonia• Attention(poor)
DIAGNOSIS CRITERIA OF SCHIZOPHRENIA
The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination.
(ICD-10)
(DSM-IV)
ICD diagnostic criteria – 1 of the followingAt least one of the symptoms a-d or two
of the symptoms e- ia. Thought echo, insertion, or
withdrawal and thought broadcastingb. Delusions of control, influence, or
passivity; delusional perceptionc. Hallucinatory voices-running
commentary or other < part of bodyd. Persistent delusions of other kinds
ICD diagnostic criteria – 2 of the followinge. Persistent hallucinations in any modality
occurring everyday for weeks or monthsf. Breaks or interpolation in the train of
thought > incoherence or irrelevant speech, or neologism
g. Catatonic behavior, such as excitement, posturing, or waxy flexibility, negativism, mutism, stupor
h. ‘negative’ symptoms; apathy, paucity of speech, blunting of emotional response
i. A significant and consistent change in behavior > aimless, idle, self-absorbed att
DSM-IV diagnostic criteriaA. Characteristic
symptoms. At least 2 of the following; each for 1- month period:
a. delusions b. hallucinations c. disorganized speech d. grossly disorganized or
catatonic behavior e. negative symptoms,
i.e. avolition, flattening of affect, alogia (poverty of speech)
F. Social/occupational dysfunction
G. Continuous signs of the disturbance persists for at least six months
H. Schizoaffective and mood disorder exclusion
I. Substance/medical condition exclusion
J. Relationship to pervasive developmental disorder
autism+ schiz.<D/H-1 m
Difference between DSMIV and ICD 10
DSMIV ICD-10The classification ofschizophrenia
Course andfunctionalimpairment
Schneider’s firstrank sign
The duration of illness 6 months 1 month
Prodromal and residualperiod
included Not included
Occupational and socialfunctional deficiency
Expected since theonset of thedisorder
Expected in thecourse of thedisorder
Kurt Schneider (German psychiatrist) ’s symptoms of first rank
1. Auditory hallucinations: audible thought or thought echo ; referring third person; running commentary.
2. Alienation of thought: thought insertion or withdrawal
3. Diffusion of thought (thought broadcasting)
4. Sensation of feelings, impulses or acts being controlled by external forces
5. Somatic passivity < external agency (e.g. X-rays, hypnosis)
6. Delusional perception
Schneider first rank symptoms of schizophrenia
Individual symptoms that are highly specific for schizophrenia
Occur in about 80% of schizo pts, 40% in bipolar mood disorder ( only mania)& 20% in severe major depression
DIFFERENTIALS & MANAGEMENTS
Differential diagnosis Organic syndrome
Drug Temporal lobe epilepsy Delirium Dementia Diffuse brain disease
Psychotic mood disorder Personality disorder Schizoaffective disorder
Course• Complete recovery 20%
• Recurrent acute illness20%
• Chronic disease starting acutely20%
• Chronic disease starting insidiously20%
• Suicide10-15%
Prognosis Recover completely/long
term minimal symptoms- 30%(The percentage on the rise)
Recurrent illness -poorer prognosis
Young patient -high risk of suicide
Predictors for poor outcome
Features of the illness
Insidious onset
Long 1st episode
Previous psychiatric history
Negative symptoms
Younger age at onset
Features of the patient
Male
Single, separated, widowed or divorced
Poor psychosexual adjustment
Poor employment
Social isolation
Poor compliance
Assessment
No confirmatory laboratory studies.
Diagnosis made based on psychotic symptoms and functional deterioration.
Diagnostic evaluation: aim Establish the presense of
psychosis Eliminate other differential
diagnosis
Component of EvaluationEvaluation of of
psychosisMedical evaluationMental status and
siucidality
Evaluation of of psychosis
Medical evaluation
Mental status and siucidality
Management
Treatment of Schizophrenia Acute phase Relapse prevention phase Stable phase Psychosocial care and
rehabilitation
36
Need rapid tranquilisati
on
Urgent
No
Yes Combination of parenteral treatment
Yes
Yes
No
Identify Phases of Illness
No
Adequate dose &
duration
Oral medication is preferred When parenteral needed, use a single agent
•Provide comprehensive plan (pharmacological, psychosocial & service level interventions)•Offer conventional APs (300-1000mg CPZ equivalent) or AMS or OLZ•Monitor clinical response, side effects & treatment adherence
Poor response
Optimise APs usage
•Exclude substance abuse, treatment non-adherence & concurrent other general medical conditions•Optimise psychosocial interventions•Refer to psychiatrist for trial of clozapine
Yes
No
•Plan for recovery (ACT, family intervention, psychoeducation, social skills training & supported employment)•APs usage to continue with single oral agent from acute phase; use depot when non-adherent•Monitor for clinical response, side effects & treatment adherence
Acute phase
Relapse prevention
ALGORITHM FOR MANAGEMENT OF SCHIZOPHRENIA
Diagnosis of Schizophrenia
Stable phase
· Follow-up at primary care· Follow manual on Garispanduan
Perkhidmatan Rawatan Susulan Pesakit Mental di Klinik Kesihatan
Prevention & management of side effects of APs at all phases·aonitor EPS/akathisia/weight gain/diabetes/heart disease/sexual dysfunction·Follow schedule of physical care as per follow-up manual
Acute phase From home to hospital
Restrain Aid from policemen Safety of care provider, family members
and patient is crucial In the hospital
Room of seclusion Consider involuntary admission
Physical restrainFamily education and
counsellingEmergency medication
AntipsychoticCombination: antipsychotic
+ benzodiazepineAdministered parenterally If cooperative, oral
administration allowed.
Relapse prevention phase Started on routine anripsychotic as early
as possible. Maintenance doses of medication
established and side effect reviewed. Patient education and reassurance. Building a therapeutic alliance with
patient and family Treatment resistance – Clozapine Assertive Community Therapy(ACT)
ACT? Combined medication and
psychosocial treatments with aggressive delivery and follow-up.
Activities: Daily home visit “eyes-on” medication
administration Transportation to clinician
appointment
Stable phaseFollow up at primary care
clinic.Life long medicationRemission for at least 1
year achieve in 70 – 80% of patient taking antipsychotic at full doses
Psychosocial support
Psychosocial and rehabilitation care Social skill training Employment training Cognitive remediation therapy Psychoeducation Family therapy
Don’t forget medical illness too…
MedicationsTraditional Atypical
Haloperidol (2-30 mg) Risperidone (4-16mg)
Chlorpromazine (100-600mg) Olanzapine (5-20mg)
Trifuoperazine (5-30mg) Sertindole (12-20mg)
Sulpiride (400-800 mg) Clozapine (100-900 mg)
Benzodiazepine - Lorazepam Atypical antipsychotic for treatment
resistant schizophrenia-
Clozapine
THANK YOU
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NG BOON KEATMOHD HANAFI RAMLEE
Differential
Diagnosis
Psychotic Symptom
Time Course
Ruled out secondary
causes
Primary Psychosis
Chronic (>1 mo)
Schizoaffective Disorder
Schizophrenia
Delusional Disorder
Psychosis NOS
Brief(<1 mo)
Brief Psychotic Disorder
Psychosis NOS
Diagnosis
Specifiers
Chronic Primary Psychosi
s
Criterion A Sx and 6 mo
dysfunction?
Simultaneously meet criteria
for mood disordes?
Schzioaffective Disorder
Schizophrenia
Prominent Delusions?
Delusional Disorder
Psychosis NOS
yes
no
no
no
yes
yes
DiagnosisBrief Primary Psychosis
Between 1 day and 1 mo Sx
with full recovery
Brief Psychotic Disorder
Psychosis NOS
yes
no