Schizophrenia

Schizophrenia

1. SCHIZOPHRENIA NG BOON KEAT MOHD HANAFI RAMLEE

2. 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

3. Stories of Schizophrenia

4. 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

5. 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

6. Epidemiology

7. Epidemiology: Sex

8. Epidemiology: Race BUT IT CAN ALSO AFFECT ANYONE WITHOUT PREDISPOSITIONS !

9. Aetiology Uncertain; however there is evidence for several risk factors. Several models which can be grouped into….

10. Aetiology – Bio Genetics Consideration 1 st degree & 2 nd degree relative Environmental Abnormalities of pregnancy and delivery [2%] Maternal Influenza – 2 nd trimester [2%] Fetal Malnutrition [2%] Winter & Low Social Class birth [1.1%]

11. 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%]

12. 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

13. 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).

14. 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 ]

15. THREE PHASES OF SCHIZOPHRENIA

16. Clinical Features

17. DIAGNOSIS CRITERIA OF SCHIZOPHRENIA The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination.

18. 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

19. ICD diagnostic criteria – 2 of the following e. Persistent hallucinations in any modality occurring everyday for weeks or months f. 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 A significant and consistent change in behavior > aimless, idle, self-absorbed att

20. DSM-IV diagnostic criteria A. 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

21. Difference between DSMIV and ICD 10

22. Kurt Schneider (German psychiatrist) ’s symptoms of first rank Auditory hallucinations: audible thought or thought echo ; referring third person ; running commentary. Alienation of thought: thought insertion or withdrawal Diffusion of thought ( thought broadcasting ) Sensation of feelings, impulses or acts being controlled by external forces Somatic passivity < external agency (e.g. X-rays, hypnosis) Delusional perception

23. 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

24. DIFFERENTIALS & MANAGEMENTS

25. Differential diagnosis Organic syndrome Drug Temporal lobe epilepsy Delirium Dementia Diffuse brain disease Psychotic mood disorder Personality disorder Schizoaffective disorder

26. Course

27. Prognosis Recover completely/long term minimal symptoms- 30%(The percentage on the rise) Recurrent illness -poorer prognosis Young patient -high risk of suicide

28. Predictors for poor outcome Features of the illness Insidious onset Long 1 st 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

29. 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

30. Component of Evaluation Evaluation of of psychosis Medical evaluation Mental status and siucidality

31. Evaluation of of psychosis

32. Medical evaluation

33. Mental status and siucidality

34. Management Treatment of Schizophrenia Acute phase Relapse prevention phase Stable phase Psychosocial care and rehabilitation

35. 36 Need rapid tranquilisation 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

36. 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

37. Physical restrain Family education and counselling Emergency medication Antipsychotic Combination: antipsychotic + benzodiazepine Administered parenterally If cooperative, oral administration allowed.

38. 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)

39. ACT? Combined medication and psychosocial treatments with aggressive delivery and follow-up. Activities: Daily home visit “eyes-on” medication administration Transportation to clinician appointment

40. Stable phase Follow 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

41. Psychosocial and rehabilitation care Social skill training Employment training Cognitive remediation therapy Psychoeducation Family therapy Don’t forget medical illness too…

42. 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)

43. Benzodiazepine - Lorazepam Atypical antipsychotic for treatment resistant schizophrenia - Clozapine

44. THANK YOU NG BOON KEAT MOHD HANAFI RAMLEE

45. yes no no no yes yes

46. yes no