Schizophrenia

Schizophrenia is a metal disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interaction. Here the etiology, epidemiology, types, signs and symptoms, pathophysiology, complications, diagnosis as well as management of schizophrenia is explained.

1. SCHIZOPHRENIA

2. Schizophrenia is  a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions . Although the course of schizophrenia varies among individuals, schizophrenia is typically persistent and can be both severe and disabling.

3. A disorder that affects a person's ability to think, feel and behave clearly . Schizophrenia literally means “Fragmented Mind” It is one of the most complex, chronic and challenging psychiatric disorders that affects how a person thinks, feels, behaves. It represents a hetero- geneous syndrome of disorganized thoughts, delusions, hallucinations, and impaired psychosocial functioning.

4. ETIOLOGY

5. There's no one cause for schizophrenia . Although  stress can trigger or worsen symptoms, stress does not cause schizophrenia. Schizophrenia is a disorder of the brain. It most likely develops from a mix of factors that may include: A defect in certain chemicals in the brain that control thinking and understanding. The person's genetic make-up (A likelihood for getting schizophrenia may be passed on to children by parents.) A defect in how the brain forms a person's personality.

6. EPIDEMIOLOGY Schizophrenia affects around 0.3–0.7% of people at some point in their life ,  or 21 million people worldwide as of 2011 Schizophrenia is diagnosed 1.4 times more frequently in males than females, and typically appears earlier in men. T he peak ages of onset are 20–28 years for males and 26–32 years for females In 2000, the World Health Organization found the prevalence and incidence of schizophrenia to be roughly similar around the world, with age-standardized prevalence per 100,000 ranging from 343 in Africa to 544 in Japan and Oceania for men and from 378 in Africa to 527 in Southeastern Europe for women

7. TYPES OF SCHIZOPHRENIA The classification of schizophrenia types  changed trusted s ource  with the 2013 update of the manual that mental health professionals use to diagnose mental health conditions. This is called the  Diagnostic and Statistical Manual of Mental Disorders  ( DSM ). The previous version, the  DSM-IV , described the following five types of schizophrenia: paranoid type disorganized type catatonic type undifferentiated type residual type

8. The current version,  DSM-V , no longer uses these categories. The features of these types — including paranoia, disorganized speech and behavior, and catatonia — are all still features of a schizophrenia diagnosis, but experts no longer consider them distinct subtypes .

9. Paranoid type Paranoid schizophrenia was characterized by being preoccupied with one or more delusions or having frequent auditory hallucinations. It did not involve disorganized speech, catatonic behavior, or a lack of emotion. Delusions and hallucinations are still elements of a schizophrenia diagnosis, but experts no longer consider it as a distinct subtype Disorganized type Disorganized schizophrenia was characterized by disorganized behavior and nonsensical speech. Another prominent feature was flat or inappropriate affect. Disorganized speech and thought are still elements of a schizophrenia diagnosis, but experts no longer consider this as a distinct subtype.

10. Catatonic type Catatonic schizophrenia was characterized by catatonia. This causes a person to experience either excessive movement, called catatonic excitement, or decreased movement, known as a catatonic stupor. For example, they may be unable to speak ( mutism ), may repeat another person’s words (echolalia), or may mimic actions ( echopraxis ). Catatonia can occur with schizophrenia and a range of other conditions, including bipolar disorder. For this reason, mental health professionals now consider it to be a specifier for schizophrenia and other mood disorders, rather than a type of schizophrenia.

11. Undifferentiated type Undifferentiated schizophrenia involved symptoms that did not fit into the paranoid, disorganized, or catatonic types of schizophrenia. Residual type In residual schizophrenia, a person would have had several symptoms of schizophrenia but would not exhibit prominent delusions, hallucinations, disorganization, or catatonic behavior. They might have had mild symptoms, such as odd beliefs or unusual perceptions

12. SIGNS AND SYMPTOMS The symptoms of Schizophrenia may vary depending on the individual and they usually include: Delusion Hallucinations and illusions Disordered thinking Disordered behavior Flat affect- lack of emotional expression Agitation Inappropriate reactions Phobia Lack of pleasure or interest in activities Lack of motivation to do anything Decreased speech output

13. PATHOPHYSIOLOGY

14. Schizophrenia is an extremely dangerous disease, especially when left untreated. Schizophrenia can bring upon the following issues: Suicide Poverty Homelessness Social isolation Aggressive behaviour Self harm COMPLICATIONS

15. DIAGNOSIS Diagnosis of schizophrenia involves ruling out other mental health disorders and determining that symptoms are not due to substance abuse, medication or a medical condition. Determining a diagnosis of schizophrenia may include: Physical exam.   This may be done to help rule out other problems that could be causing symptoms and to check for any related complications. Tests and screenings.   These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.

16. Psychiatric evaluation .  A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for violence or suicide. This also includes a discussion of family and personal history . Diagnostic criteria for schizophrenia.   A doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association Medical history A thorough medical history is the first step in the diagnosis of schizophrenia. This may be done to find other problems that could be causing symptoms and to check for any related complicatons .

17. Blood tests and imaging A Complete Blood Count (CBC) test is helpful to monitor general health and rule out other conditions that may have been responsible for the symptoms. A blood test can provide accurate information about the involvement of recreational drugs. In some cases, certain imaging techniques such as MRI or CT scan may aid in the diagnosis.

18. PROGNOSIS There is no known cure for Schizophrenia. Fortunately, there are effective treatments that can reduce symptoms, decrease the likelihood that new episodes of psychosis will occur, shorten the duration of psychotic episodes, and in general, offer the majority of people the possibility of living more productive and satisfying lives . With the proper medications and supportive counseling, the ability of schizophrenic persons to live and function relatively well in society is excellent

19. MANAGEMENT HOSPITALIZATION During crisis periods or times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition, adequate sleep and basic hygiene . PSYCHOSOCIAL INTERVENTIONS Individual therapy : Psychotherapy may help to normalize thought patterns. Also, learning to cope with stress and identify early warning signs of relapse can help people to manage their illness. Social skills training : This focuses on improving communication, social interactions and improving the ability to participate in daily activities.

20. Family therapy : This provides support and education to patient families. Vocational rehabilitation and supported employment : This focuses on helping people with schizophrenia prepare for, find and keep jobs. ELECTROCONVULSIVE THERAPY For adults with schizophrenia who do not respond to drug therapy, electroconvulsive therapy (ECT) may be considered. ECT may be helpful for someone who also has depression. The indications for ECT in schizophrenia are : • Catatonic stupor & uncontrolled catatonic excitement • Acute exacerbations not controlled with drugs • Risk of suicide, homicide or danger of physical assault 

21.   COGNITIVE BEHAVIOURAL THERAPY CBT aims to help to identify the thinking patterns that are causing to have unwanted feelings & behavior and learn to replace this thinking with more realistic and useful thoughts . Most people require between 8 and 20 sessions of CBT over the space of 6 to 12 months. CBT sessions usually last for about an hour.

22. CLINICAL MANAGEMENT  The APA guidelines treatment recommendations for patient with schizophrenia divide the treatment into 3 phases : 1. Acute Phase (Initial Presentation) 4 to 8 weeks : Defined by acute psychotic episode 2 . Stabilization Phase (Early symptom remission) as long as 3 months : Constitutes a time – limited transition to continuing treatment 3 . Stable Phase (Maintenance treatment) : Involves stable treatment APA guideline refers to the American Psychiatric Association.

23. ANTIPSYCHOTIC / NEUROLEPTIC / ATARACTIC/ MAJOR TRANQUILLIZER Typical or Classical or 1st generation antipsychotics : A. Phenoziazins : 1 . With aliphatic amine side chain : Chlorpromazine, Triflupromazine 2 . With Piperidine side chain : Thioridazine 3 . With Piperazine side chain : Trifluoperazine , Fluphenazine B . Butyrophenones : Haloperidol, Trifluperidol , Penfluridol C. Thiohaxanes : Flupenthixol , Thiothixene D . Other heterocyclics : Pimozide , Loxapine 28

24. Atypical or Novel or 2nd generation antipschycotics : • Clozapine • Olanzapine • Quetiapine • Aripiprazole • Risperidone • Amisulpride • Ziprasidone

25.  • FGA – First Generation Antipsychotic SGA – Second Generation Antipsychotic ECT – Electro Convulsive Therapy • Stage 1 of the treatment algorithm applies only to those patients experiencing their first episode of schizophrenia . • Stage 2 recommends either FGAs or SGAs, with the exception of clozapine. Because of safety concerns and the need for white blood cell (WBC) monitoring, it is recommended that patients be tried on one newer SGA and one other SGA or FGA as monotherapy before proceeding to a trial of clozapine. • Clozapine has superior efficacy in decreasing suicidal behavior, and it should also be considered as a higher treatment option in the suicidal patient (Stage 3). Clozapine can also be considered earlier in treatment in patients with a history of violence or comorbid substance abuse.

26.  • Stage 4 of the treatment algorithm includes clozapine and augmentation with either a FGA, SGA, or electroconvulsive therapy (ECT). Combination treatment at this stage is supported by limited controlled and equivocal evidence . • In general, patients who experience poor improvement with clozapine do not respond well with other antipsychotic monotherapies (Stage 5 ). • Stage 6 combination pharmacotherapy interventions should be implemented with time limited, careful evaluation of a patient’s symptom response and discontinuation of the combination if improvement does not occur . • If partial or poor adherence contributes to inadequate clinical improvement, then long-acting or depot injectable antipsychotics should be considered . • Risperidone microspheres is the only available long-acting injectable SGA, and long-acting FGAs include fluphenazine decanoate and haloperidol decanoate .

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