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Schizophrenia
PSYCHOTIC DISORDER
This includes:
(1) Schizophrenia,
(2) Affective disorders (Manic-depressive
psychosis).
(3) Delusional psychosis (Paranoid reaction)
Schizophrenia
SCHIZOPHRENIA
Definition Schizophrenia is a disorder of unknown etiology, which is characterized by psychotic symptoms that significantly impair mental function and that involve disturbances in feeling~ thinking and behavior. The disorder occur in the adolesent stage, tends to be chronic and generally has a prodromal phase, active phase with delusions,
Schizophrenia
Epidemiology Schizophrenia occurs in all cultures. Incidence is about 2-4 cases for 10000 population per year. Life time risk is about 1%. In industrialized countries, there are more schizophrenic patients in the lower socioeconomic classes. The peak incidence of onset is 15-26 in men and 25-35 years in women.
Schizophrenia
Etiology
1. Genetic factor Genetic factors play a significant role but are not sufficient alone to account for the development of schizophrenia. Compelling data have come from family studies. In the general population, the lifetime risk of developing schiztophrema is approximately 1%. A child born with one schizophrenic parent has about a 14% chance of developing schizophrenia. This risk rises to approximately 50% if both parents are schizophrenic.
Schizophrenia
Another approach has looked at siblings with varying degrees of genetic similarity. Nontwin siblings of a schizophrenic patient have about an 8% chance of developing schizophrenia. For nonindentical (dizygotic) twins, if one twin is schizophrenic, approximately 10% of the other twins develop schizophrenia. Concordance rate, rises to 40-50/o in identical (monozygotic) twins. Although such data support a strong role for genetics in the etiology of schizophrenia, they also clearly show that other factors play a significant role determining who does not develop schizophrenia.
Schizophrenia
Schizophrenia
3. Neurochemical Changes:
Multiple neurochemical changes also have been
schizophrenic
the advent of
symptoms.
clozapine,
Compelling
the
data
also
antipsychotic,
it
has
been
hypothesized
that
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4. Neurophysiological Changes:
Neurophysiological changes have been shown through
various neuropsychologic and physiologic measures. Schizophrenic patients have shown abnormal
informational processing on such measures as the Continuous Performance Test. They also have shown abnormal sensory processing on such measures as skin conductance habituation, backward masking, smooth pursuit eye movements, prepulse inhibition of acoustic
Schizophrenia
5. Endocrine factors:
Endocrine factors have long been suspected. Females tend to develop schizophrenia later and often have less severe symptoms than males. In males, the onset of schizophrenia is often during puberty. Changes in prolactin, melatonin, and thyroid functions have been found in schizophrenia.
Schizophrenia
6. Viral and immune factors: Have also been implicated. Although the search for a causative virus in schizophrenia has thus far been unfruitful, various factors points to this possibility, for example, a number of immune changes have been found, including IgA, IgG and 1gM. Furthermore, a larger
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7. Psychosocial factors:
Are no longer left to be causative in schizophrenia but clearly play a role in
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Clinical picture:
The clinical presentation of schizophrenia
Schizophrenia
1. Perceptual disturbance
Hallucinations are sensory perceptions in the absence of external stimuli. Auditory hallucinations (especially voices) are by far the most common in schizophernia. Their content varies, being sometimes threatening, insulting, commanding or helpful. According to their form they are classified as:
Schizophrenia
Second person: Voices adress the patient directly. Third person: Voices discuss the patient in the third person. Running commentary: Voices comment on the patients actions, referring to him in the third person. Visual, tactile, oflactory and gustatory hallucinations may occur, but are less common. Ocasionally, schizophrenic patients report bizarre sensations in body organs such as burning in the brain or bursting of blood through the vessels.
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2.Thought disturbance
a. Disorders of thought process (formal thought disorders)
Schizophrenia
b. Passivity phenomena:
These can take the form of:
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3. Cognitive defects:
Schizophrenic patients are usually oriented in time, place and person. However attention and concentration are often impaired, and memory and learning may be poor. For many years these cognitive deficits were
Schizophrenia
4. Abnormal affect: The most characteristic affective abnormalities in schizophrenia are: Reduced motional expression (shallow emotion). Blunt of affect that is a quantitative abnormality with reduction in emotional intensity and variation. Inappropriate or incongruous affect: that is a quantitative abnormality where affective response is incompatible with the ideas or thoughts expressed.
Schizophrenia
Anhedonia: Patients can not experience any pleasurable feeling. Ambivlance: Presence of contradictory emotion or idea towards the same stimulus at the same time. At the onset of the illness or during acute exacerbations patients may experience intence emotions such as terror, anxiety or exhilaration in response to the content of their delusions. Apathy: That is absence of emotional experience and expression.
Schizophrenia
5. Motor abnormalities: Disturbances in motor behaviour were an essential part of the early descriptions of schizophrenia. Either quantitative or qualitative changes may occur: Posturing: Voluntary adoption of bizarre or inappropriate positions for prolonged periods, may have some symbolic meaning. Waxy flexibility: Sustaing imposed position for prolonged time. Negativism: Automatic resistance to instructions or attempts at movement. Ecopraxia: Pathological, automatic imitation of another persons movements.
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purposeless
pattern
of
disorganized activity.
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Schizophrenia
Clinical Phases:
I. Premorbid and Prodramal Phases: Social and cognitive deficits in schizophrenic patients can be traced back to childhood. The preschizophrenics showed increased deviance with age. The cognitive slippage become progressively more marked in early adolescence, prodromal phase starts by actual functional decline, accompanied by eccentric ideas and interests, changes in affect; unusual speech and bizarre perceptual experiences. The onset of the prodromal phase is often gradual, and as the symptoms are non specific, it is often difficult to draw a line between premorbid personality and prodromal phase.
Schizophrenia
2. Acute Phase:
The most frequent symptoms in acute phase are
unreality state specially depersonalization,
suspiciousness delusional mood, lack of drive, thought alienation and lack of insight Patients may develop overwhelmed anxiety and depression and may commit suicide secondary to these changes.
Schizophrenia
3. Chronic Phase:
That is the frank schizophrenic psychotic symptoms persist more than two years with either exacerbation of the symptoms or show no response to treatment.
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Paranoid
Preoccupation with one or more delusions or frequent auditory hallucinations. None of the following should be prominent: Disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
Disorganized
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Catatonic
At least two of the following: motor immobility as evidenced by catalepsy or stupor; excessive motor activity apparently purposeless and not influenced by external stimuli; peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms or prominent grimacing; echolalia or echopraxia. Does not fulfil the criteria for any of the above types. Absence of prominent delusions, hallucination, disorganized speech and grossly disorganized or catatonic behaviour; continuing evidence of the disturbance indicated by the presence of negative symptoms or two or more of the above symptoms in an attenuated form.
Undifferentiated Residual
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Course:
The course of schizophrenia was considered to
be one of continuous deterioration. Today, most clinicians would agree that this extremely pessimistic view is not justified and that there is a great degree of variability in the course:
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22%
35%
8%
35%
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Differential diagnosis From psychiatric conditions Mania: Though the symptoms often overlap, mania is characterized by prominent affective component (elation, grandiosity, disinhibition, ovberactivity, irriability and lability of mood), while acute schizophrenia is characterized most often by suspicion, paranoia or perplexity. Depression: Chronic schizophrenia may mimic or coexist with depression, patricularly in young people and those who retain insight into the nature of their illness.
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From organic conditions Includes very rare chorea, conditions Wilsons such as
Huntingtons
disease,
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Management:
1. Hospitalization It is essential to hospitalize those with acute schizophrenic symptoms for investigation and treatment. Patients with chronic schizophrenia
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2 Pharmacotherapy:
Antipsychotic drugs (major tranquilizers) ameliorate and reduce the signs and symptoms of schizophrenia. Consider
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4. Rehabilitation: Rehabilitation aims to allow the patient to lead as near normal life as possible and
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Psychopharmacology
Psychopharmacology deals with the drugs used in the
3. Anxiolytic drugs.
4. Mood stabilizing drugs. 5. Cerebral stimulants.
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Antipsychotic Medications
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Conventional (typical) antipsychotics Phenothiazine derivatives 1. Aliphatic: Chlorpromazine (largctil). 100-1000 mg/day. 2. Piperidine: Thioridazine (melleril) 300 600 mg/day. 3. Piperazine: Trifluoperazine (stelezine) 5-30 mg/day. Non phenothazine: 1. Bytrophenones: Haloperidol (Safinase)
Oral tablets
Watery injection
5-30
5-20
mg/day
mg/day
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Mechanism of action: The typical antipsychotic drugs are believed to act via
effect.
2. In the basal ganglia leads to the unwanted extrapyramidal side effect.
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Indications:
Acute and maintenance treatment of schizophrenia Psychosis associated with acute mania and major depression. Psychosis secondary to organic brain syndrome (delirium and dementia). Tics due to neurologic conditions e.g. tourettes syndrome and huntington chorea. In rheumatic chorea to get benefit from the extrapyramidal side effect so as to increase the muscle tone in a hypotonic patient, thus reach to the euotonia normal tone and disappearance of choriec movement. In flash back reaction, nightmares and agitation due to post-traumatic stress disorder. For medical uses (nausea and vomiting).
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Side effects:
1. Dopaminergic side effect:
observable restlessness, the patient can not maintain set in one place.
Schizophrenia
TARDIVE DYSKINESIA
It is a syndrome of abnormal involuntary movements such as buccoliingual masticatory movements, choreoathetoid movements of the limbs or even trunk and neck, and facial grimacing or tics. Its secondary to long administrations of antipsychotic drugs.
coma.
Oculogyric crisis that is upward movement of the eye globe inside the orbital cavity.
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Orthostatic hypotensmon.
4. Antihistaminergic side effects. Sedation.
Pigmentary retinopathy.
Skin rashes. Agrnulocytosis.
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Preparation:
1. Clozapine (Leponex) given single dose at bed time, dose range between 100-300 mg/day, side effect: a. Agranulocytosis that is why patient should be monitored weekly for WBC. For 6 months then once/month for another 6 months. b. Less commonly are sialorrhia, excessive sleep and in rare cases nocturnal enuresis. 2. Rispridone (Risperdal) given in a dose of 4-6 mg/day. 3. Olanzapine zyprexa 4. Ziprazidene (zeldox) 5. Quitaban (Seoquel) 6. Sertendol (serdluct)