schizophrenia final
TRANSCRIPT
SCHIZOPHRENIANG BOON KEAT
MOHD 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
rie
s o
f Sc
hiz
op
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 Chinese
Indian Others
BUT IT CAN ALSO
AFFECT ANYONE
WITHOUT
PREDISPOSITIONS !
AetiologyUncertain; however there is
evidence for several risk
factors.
Several models which can be
grouped into….
Biological Social
Psychological
Aetiology – Bio
Genetics Consideration
1st degree & 2nd degree relative
Environmental
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
• Disorganisedspeech/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 following
At least one of the symptoms a-d or two of the symptoms e- i
a. Thought echo, insertion, or withdrawal and thought broadcasting
b. Delusions of control, influence, or passivity; delusional perception
c. Hallucinatory voices-running commentary or other < part of body
d. 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. delusionsb. hallucinationsc. disorganized speechd. grossly disorganized or catatonic behavior
e. negativesymptoms, 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-10
The classification of
schizophrenia
Course and
functional
impairment
Schneider’s first
rank sign
The duration of illness 6 months 1 month
Prodromal and residual
period
included Not included
Occupational and social
functional deficiency
Expected since the
onset of the
disorder
Expected in the
course of the
disorder
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 Evaluation
Evaluation of of
psychosis
Medical evaluation
Mental 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
tranquilisationUrgent
No
Yes Combination of
parenteral treatmentYes
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 restrain
Family education and
counselling
Emergency medication
Antipsychotic
Combination: antipsychotic
+ benzodiazepine
Administered 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 medication
Remission 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…
Medications
Traditional 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 YOUNG BOON KEAT
MOHD 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
DiagnosisSpecifiersChronic Primary
Psychosis
Criterion A Sxand 6 mo
dysfunction?
Simultaneously meet criteria for mood disordes?
SchzioaffectiveDisorder
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