schizophrenia clinical features .pdfhahahahahhahah

SCHIZOPHRENIA

1. Presenter: DrKaushikNandi
Clinical Features
and
Management
of

2. OVERVIEW
•Introduction
•Clinical features
•DSM 5 vsICD 10
•Assessment and evaluation
•Treatment modalities
•Adherence to treatment
•Phases of illness
•Side-effects of medication
•Special Populations
•References

3. INTRODUCTION
•BenedictAugustinMorelin1850susedDemenceprecoceto
describeayoungboywhosuddenlyhadsymptomsofmental
deterioration
•EmilKraepelindescribedDementiaprecoxascharacterised
byearlyonsetofsymptomsfollowedbyprogressivecourse
culminatingindementia
•“Schizophrenia”wasfirstusedbyEugeneBleulerin1911

4. •Bleulerlaidemphasisonsymptompresentationanddescribed
fundamentalorprimarysymptomsnowcalledasBleuler’s4
As
1.Ambivalence:Markedinabilitytodecidefororagainst
2.Autisticbehavior:Withdrawalintoself
3.Affectdisturbances:suchasinappropriateaffect,blunted
affect.
4.Associationdisturbances:Looseningofassociations;
thoughtdisorder

5. •Bleulerconsideredthelossofassociationbetweenthought
processes,emotion,andbehaviortobethehallmarkofthe
illness.
•Healsoconsideredhallucinations,delusions,social
withdrawal,anddiminisheddriveassecondary
manifestationsoftheillnessthatdependedontheadaptive
capacityoftheindividualandenvironmentalcircumstances.

6. •KurtSchneiderinhisclassificationofthoughtdisorders
attemptedtomakethediagnosisofschizophreniamore
reliablebyidentifyingagroupofsymptoms(knownasFirst
ranksymptoms)ofschizophreniathatwerethemost
characteristicoftheillness.
•Thepresenceofoneofthesesymptoms,intheabsenceof
intoxication,braininjury,orclearaffectiveillness,wastaken
assufficientformakingthediagnosisofschizophrenia.

7. First-Rank Symptoms of Kurt Schneider:
1.Audiblethoughts:Auditoryhallucinationsofaperson’svoice
beingspokenaloud
2.Voicesarguingordiscussing:Auditoryhallucinationsoftwo
ormorevoicesarguingordiscussing,usuallyaboutthe
personexperiencingthehallucination
3.Voicescommentingonpatient’sactions:Auditory
hallucinationscommentingonaperson’sbehaviors

8. 4.Thoughtwithdrawal:Sensationofthoughtsbeingactively
removedfromaperson’smind
5.Thoughtinsertion:Thoughtsinsertedintoaperson’smindby
someexternalagent
6.Thoughtbroadcasting:Thesensethataperson’sthoughtsare
experiencedasrealphenomenabyothers—thethoughtsare
madeaudible,ormaybeexperiencedbyothersthrough
telepathy

9. 7.Madefeelings:Feelingsthatarenotaperson’sownare
imposedonthatpersonbyanexternalagent
8.Madeimpulsesordrives:Animpulseoractionisimposedon
apersonbysomeexternalagent
9.Madevolitionalacts:Aperson’sactionsarefromandare
controlledbyanexternalagent;thepersonisapassive
participantintheaction

10. 10.Somaticpassivity:Passiverecipientofbodilysensations
imposedfromoutsideforces.
11.Delusionalperception:Aperceptionthathasauniqueand
idiosyncraticmeaningforaperson,whichleadstoan
immediatedelusionalinterpretation

11. •Someschizophrenicpatientsneverexhibitfirst-ranksymptoms
oronlyexperiencetheminsomepsychoticepisodes.
•Theymayalsobepresentinotherconditionslike:
1.Mania
2.Delusionaldisorder
3.Personalitydisorders
4.Substanceusedisorders
5.Organicbraindisorder

12. •AsperSchneider,therewerelessimportantcriteriaforthe
diagnosisofschizophreniaotherthanFRSandhetermedthem
assecondranksymptoms.
•Thoseare:
1.Otherhallucinations
2.Delusionalnotions
3.Perplexity
4.Depressedorelatedmood,
5.Experiencesofflattenedfeelings.

13. •Otherabnormalmodesofexpressioneg.,disorderofspeech
andothermotormanifestationswereknownasthirdrank
symptoms.

15. CLINICAL FEATURES
•DiagnosisofSchizophreniacanbemadebyfollowingthe
diagnosticcriteriaofanyofthetwomanuals:
1.ICD-10(InternationalClassificationofDisease,WHO)
2.DSM-5(DiagnosticandStatisticalManual,APA)

16. ICD-10
•Schizophrenia(F20):Theschizophrenicdisordersare
characterizedingeneralbyfundamentalandcharacteristic
distortionsofthinkingandperception,andbyinappropriateor
bluntedaffect.
•Forpracticalpurposesitisusefultodividethesymptomsinto
groupsthathavespecialimportanceforthediagnosisandoften
occurtogether.

17. a)Thoughtecho,thoughtinsertionorwithdrawal,andthought
broadcasting;
b)Delusionsofcontrol,influence,orpassivity,clearlyreferred
tobodyorlimbmovementsorspecificthoughts,actions,or
sensations;delusionalperception;
c)Hallucinatoryvoicesgivingarunningcommentaryonthe
patient'sbehaviour,ordiscussingthepatientamong
themselves,orothertypesofhallucinatoryvoicescoming
fromsomepartofthebody;

18. d)Persistentdelusionsofotherkindsthatareculturally
inappropriateandcompletelyimpossible,suchasreligiousor
politicalidentity,orsuperhumanpowersandabilities(e.g.
beingabletocontroltheweather,orbeingincommunication
withaliensfromanotherworld);
e)Persistenthallucinationsinanymodality,whenaccompanied
eitherbyfleetingorhalf-formeddelusionswithoutclear
affectivecontent,orbypersistentover-valuedideas,orwhen
occurringeverydayforweeksormonthsonend;

19. f)breaksorinterpolationsinthetrainofthought,resultingin
incoherenceorirrelevantspeech,orneologisms;
g)catatonicbehaviour,suchasexcitement,posturing,orwaxy
flexibility,negativism,mutism,andstupor;
h)"negative"symptomssuchasmarkedapathy,paucityof
speech,andbluntingorincongruityofemotionalresponses,
usuallyresultinginsocialwithdrawalandloweringofsocial
performance;itmustbeclearthatthesearenotdueto
depressionortoneurolepticmedication;

20. i)asignificantandconsistentchangeintheoverallqualityof
someaspectsofpersonalbehaviour,manifestaslossof
interest,aimlessness,idleness,aself-absorbedattitude,and
socialwithdrawal.

21. Diagnostic guidelines
A minimum of one very clear symptom (and usually two
or more if less clear-cut) belonging to any one of the groups listed
as (a) to (d) above,
or
Symptoms from at least two of the groups referred to as
(e) to (h), should have been clearly present
formostofthetimeduringaperiodof1monthormore.

22. •Viewedretrospectively,itmaybeclearthataprodromalphase
inwhichsymptomsandbehaviour,suchaslossofinterestin
work,socialactivities,andpersonalappearanceandhygiene,
togetherwithgeneralizedanxietyandmilddegreesof
depressionandpreoccupation,precededtheonsetofpsychotic
symptomsbyweeksorevenmonths.
•Becauseofthedifficultyintimingonset,the1-monthduration
criterionappliesonlytothespecificsymptomslistedabove
andnottoanyprodromalnonpsychoticphase.

23. Pattern of course
•F20.x0 Continuous
•F20.x1 Episodic with progressive deficit
•F20.x2 Episodic with stable deficit
•F20.x3 Episodic remittent
•F20.x4 Incomplete remission
•F20.x5 Complete remission
•F20.x8 Other
•F20.x9 Course uncertain, period of observation too short

24. DSM-5
DiagnosticCriteria:(295.90)
A.Two(ormore)ofthefollowing,eachpresentforasignificant
portionoftimeduring1-monthperiod(orlessifsuccessfully
treated).Atleastoneofthesemustbe(1),(2),or(3):
1.Delusions.
2.Hallucinations.
3.Disorganizedspeech(e.g.,frequentderailmentorincoherence).
4.Grosslydisorganizedorcatatonicbehavior.
5.Negativesymptoms(i.e.,diminishedemotionalexpressionor
avolition).

25. B.Forasignificantportionofthetimesincetheonsetofthe
disturbance,leveloffunctioninginoneormoremajorareas,
suchaswork,interpersonalrelations,orself-care,ismarkedly
belowthelevelachievedpriortotheonset.
C.Continuoussignsofthedisturbancepersistforatleast6
months.This6-monthperiodmustincludeatleast1monthof
symptoms(orlessifsuccessfullytreated)thatmeetCriterionA
(i.e.,active-phasesymptoms)andmayincludeperiodsof
prodromalorresidualsymptoms.

26. D.Schizoaffectivedisorderanddepressiveorbipolardisorder
withpsychoticfeatureshavebeenruledout
E.Thedisturbanceisnotattributabletothephysiologicaleffects
ofasubstance(e.g.,adrugofabuse,amedication)oranother
medicalcondition.

27. Course specifiers:
Onlytobeusedaftera1-yeardurationofthedisorder
•Firstepisode,currentlyinacuteepisode
•Firstepisode,currentlyinpartialremission
•Firstepisode,currentlyinfullremission
•Multipleepisodes,currentlyinacuteepisode
•Multipleepisodes,currentlyinpartialremission
•Multipleepisodes,currentlyinfullremission
•Continuous
•Unspecified

28. Differences between DSM 5 and ICD10

29. •Schizophrenia spectrum and
other psychotic disorders
•Schizophrenia, schizotypal
and delusional disorders
ICD 10DSM 5

30. •Schizotypal disorder
•Brief psychotic disorder
•Delusional disorder
•Schizophreniform disorder
•Schizophrenia
•Schizoaffective disorder
•Psychotic disorders induced by another
condition (Substance induced/ medical
condition)
•Catatonia
•Other specified and unspecified
schizophrenia spectrum and other
psychotic disorders
•Schizophrenia F20
•Schizotypal disorder F21
•Persistent delusional disorder F22
•Acute and transient psychotic disorder
F23
•Induced delusional disorder F24
•Schizoaffective disorder F25
•Other non-organic psychotic disorder
F28
•Unspecified non-organic psychotic
disorder F29
ICD 10DSM 5

31. Differences –Schizophrenia
•First rank symptoms
excluded
•IncludesFirstRankSymptoms
•Thoughtecho,insertionor
withdrawal, broadcasting,
delusionsofcontrol,influenceor
passivity,delusionalperception,
hallucinatoryvoices(commenting
ordiscussingthepatientwith
eachother),persistentdelusions.
ICD 10DSM 5

32. Differences –Schizophrenia
•Duration of illness is 6
months
•Impairment in level of
functioning is one of the
criteria
•Duration of illness is 1
month or more
•No mention of functioning
ICD 10DSM 5

33. Differences –Schizophrenia
•Subtypes excluded
•Subtype present
•F20.0: paranoid schizophrenia
•F20.1: hebephrenic schizophrenia
•F20.2: catatonic schizophrenia
•F20.3: undifferentiated schizophrenia
•F20.4: post-schizophrenia depression
•F20.5: residual schizophrenia
•F20.6: simple schizophrenia
•F20.8: other schizophrenia
•F20.9: schizophrenia, unspecified
ICD 10DSM 5

34. Differences –Schizophrenia
–Course specifier
•Catatonia
•Severity
•Catatonic schizophrenia is
a subtype
•No course specifier for
severity
ICD 10DSM 5

35. Assessment and Evaluation

36. Patient with Psychotic features
Consider differential diagnoses like
• Organic Mental Conditions
• Acute and transient psychotic disorder
• Persistent Delusional disorder
• Schizoaffective disorder
• Severe depression with psychotic symptoms
• Mania with psychotic symptoms
• Drug induced psychosis
Establish the
diagnosis of
Schizophrenia

37. Assessment
•Severityofillness
•Riskofharmtoselfandothers
•Comorbidsubstanceuse/dependence
•Leveloffunctioning
•DetailedPhysicalexamination
•Record-bloodpressure,weightandwhereverindicatedbody
massindexandwaistcircumference
•MentalStatusExamination

38. •Investigations-haemogram,liverfunctiontest,renalfunction
test,fastingbloodglucoselevel,electrocardiogram(focuson
QTc)
•Treatmenthistory-responsetopreviousmedicationtrials,
compliance,sideeffects,etc.
•Patient’sandcaregiversbeliefsaboutthecauseofillnessand
beliefsaboutthetreatment
•Assessmentforsocialsupport,stigma,copingskills
•Assessmentofcaregiverburden,copinganddistress

39. Decide about treatment setting
Indicationsforinpatientcare:
•Presenceofsuicidalbehaviourwhichputsthelifeofthe
patientatrisk
•Presenceofsevereagitationorviolencewhichputsthelifeof
othersatrisk
•Refusaltoeatwhichputsthelifeofpatientatrisk
•Severemalnutrition

40. Liaison with other specialists depending on the need of
the patient
•Patientunabletocareforselftotheextentthatshe/herequires
constantsupervisionorsupport
•Catatonia
•Presenceofgeneralmedicalorcomorbidpsychiatric
conditionswhichmakemanagementunsafeandineffectivein
theoutpatientsetting

42. Options for management
Pharmacological Non-Pharmacological
•Antipsychotic medications
•Adjunctive medications
•Somatic treatments
•Psychosocial interventions
•Lifestyle and dietary
modifications

43. Options for management
•Antipsychotic medications
–First-generation antipsychotic medications
(Oral/parenteral/depot or long acting-preparations)
–Second-generation antipsychotic medications
(Oral/parenteral/depot or long acting-preparations)
•Somatic treatments
–Electroconvulsive therapy (ECT)

44. •Adjunctivemedications
–Anticholinergics,antidepressants,benzodiazepines,
hypnotic-sedatives,anticonvulsants,lithiumcarbonate
•Psychosocialinterventions
–Familyintervention,cognitivebehaviouraltherapy,social
skillstraining,individual&grouptherapy,vocational
rehabilitation,early-interventionprogrammes,community
mental-healthteams
•Othermeasures
–Lifestyleanddietarymodifications

45. Factors that influence selection of
antipsychotics
•Past treatment response
•Cost of treatment,
affordability
•Psychiatric comorbidity
•Medical comorbidity
•Side effects
•Patient or family preference
•Preferred route of
administration
•Concomitant medications
•Non-adherence
•Treatment resistance

46. Recommended therapeutic dose ranges for
various antipsychotics
First Generation
Antipsychotics (FGAs)
Usual daily dose
(in mg/day)
Maximum
daily dose
Chlorpromazine 300-800 800
Haloperidol 5-20 20
Penfluridol 20-60 mg/week 250 mg/week
Perphenazine 12-64 64
Trifluoperazine 15-30 30
Grover, et al.: CPG for Schizophrenia

47. Second Generation
Antipsychotics (SGAs)
Usual daily dose
(in mg/day)
Maximum
daily dose
Amisulpride 50-800 1200
Aripiprazole 10-30 30
Clozapine 150-600 900
Olanzapine 10-30 30
Paliperidone 3-12 12
Quetiapine 300-800 800
Risperidone 2-8 16
Grover, et al.: CPG for Schizophrenia

48. Antipsychotic depot preparations available in India
Name of antipsychotic Usual 2-4 weekly dose in mg
Zuclopenthixoldecanoate 200
Paliperidonepalmitate 234 initially, followed by 117 monthly
Fluphenazinedecanoate 12.5-50
Haloperidol decanoate 50
Risperidonedepot 25-50
Olanzapine pamoate 210-405
Grover, et al.: CPG for Schizophrenia

49. Treatment Response
•RESPONSE:
Ascoreof2or1intheCGI-change(ClinicalGlobal
ImpressionScale)or>20pointsonFACTSCZ(functional
assessmentforcomprehensivetreatmentforschizophrenia)
or
> 20 % decrease in BPRS or PANSS
[Suzkiet al,2012]

50. •PARTIALRESPONSE:
Ascoreof3intheCGI-changeor10-20points
increaseonFACTSCZ(functionalassessmentfor
comprehensivetreatmentforschizophrenia)
or
GAF or >10% decrease in BPRS or PANSS
[Suzkiet al,2012]

51. Defining Remission
•REMISSION:
Reductionofsymptomstoalevelthatdoesnot
interferewithpatient’spsychosocialfunctions,quantifiedby
using8symptomsofPANSSwhichmayreachupto
maximumlevelof3(mild).
[Suzkietal,2012]

52. Evaluation of patient with non-response to
antipsychotic medications
Patient given an adequate
antipsychotic trial (adequate
dose for atleast6 weeks
duration)
Adequate Response:
Continue with the same dose
of antipsychotic medication
and keep on monitoring the
side effects
Non-response to treatment
Evaluation
•Re-evaluate the diagnosis
•Medication compliance

53. True Non-response
• Change the antipsychotic
medication
Pseudo Non-response due to poor
compliance
•Evaluate the causes, address the same
and ensure compliance
•In case of poor compliance due to
intolerable side effects –consider
change of antipsychotic (oral/depot)
Failure of 2 adequate
trials of antipsychotic,
one of which is SGA
• Consider clozapine
Adequate Response
• Continue with the same dose of
antipsychotic medication and keep
on monitoring the side effects

54. Inadequate Response to clozapine
•Consider combining clozapine with ECT or another
antipsychotic medication
•More intensive psychosocial intervention
Failure of 2 adequate trials
of antipsychotic, one of
which is SGA
• Consider clozapine
Grover, et al.: CPG for Schizophrenia

55. ADJUNCTIVE MEDICATIONS
•Althoughantipsychoticagentsarethemainstayoftreatmentof
schizophrenia,managementmayinvolveuseofadjunctive
treatmentslikewithantidepressants,moodstabilizersor
benzodiazepines.
•However,thesecanbeusedwithproperrationaleandfor
shortestpossibleduration.
•Lithiumandothermoodstabilizerscanbeprescribedin
agitated,overactivepatientsorthosewithaffectivesymptoms

56. •Benzodiazepinescanbeusefulinmanagingagitationand
sleepdisturbance.
•Antidepressantsmaybeofuseinpost-psychoticdepression
andmaybeavoidedwhenthepatienthasfloridpsychotic
symptoms.
•Ingeneralprophylacticuseofanticholinergicsisnot
recommended.Itisbettertostartthesedrugswhenthepatient
actuallydevelopsextrapyramidalsideeffects.

57. ECT in Schizophrenia
Possibleindications:
•Catatonicsymptoms
•Needforrapidcontrolofsymptoms
•Presenceofsuicidalbehaviourwhichputsthelifeofthe
patientatrisk
•Presenceofsevereagitationorviolencewhichputsthelifeof
othersatrisk
•Affectivesymptoms

58. Possibleindications(contd.):
•Refusaltoeatwhichputsthelifeofpatientatrisk
•Historyofgoodresponseinthepast
•Patientsnotrespondingtoadequatetrialofanantipsychotic
medication
•Augmentationofpartialresponsetoantipsychoticmedication
•Clozapineresistantschizophrenia
•Notabletotolerateantipsychoticmedications
•Pregnantpatients

59. Basic components of Psychoeducation
•Assessingtheknowledgeofthepatientandcaregiversabout
aetiology,treatmentandprognosis
•Introducingthediagnosisofschizophreniaintodiscussion
•Discussingaboutvarioussymptomdimensions
•Providinginformationaboutaetiology
•Providinginformationabouttreatmentintermsofavailable
options,theirefficacy/effectiveness,sideeffects,durationof
use

60. •Discussingaboutimportanceofmedicationandtreatment
compliance
•Providinginformationaboutpossiblecourseandlongterm
outcome
•Discussingaboutproblemsofsubstanceabuse,marriageand
otherissues
•DiscussingaboutCommunicationpatterns,problemsolving,
disabilitybenefits

61. •Discussingaboutrelapseandhowtoidentifytheearlysignsof
relapse
•Dealingwithday-to-daystress
•Handlingexpressedemotionsandimprovingcommunication
•Enhancingadaptivecopingtodealwithpersistent/residual
symptoms

62. Life style and Dietary modifications
•Allthepatientsaretobeadvisedforachangeinthelifestyle
anddiettoreducetheriskofmetabolicsideeffectsand
cardiovascularmorbidityandmortality.
•Theseincludephysicalexercises,dietarymodificationsand
abstinencefromsmokingetc.

63. TREATMENT ADHERENCE
•Adherenceisdefinedas“theextenttowhichthepatients’
behaviour,intermsofregularclinicvisit,takingmedications,
followingdiets,executinglifestylechanges,coincidewiththe
clinicalprescription”.
•Non-adherenceinthiscontextthusdenotesfailuretoentera
treatmentprogramme,prematureterminationoftreatment,or
incompleteimplementationofinstructions,includingthose
thatpertaintomedicationadministration.

64. •Evidencesuggeststhatabouthalfofthepatientswith
schizophreniadonotcomplywiththetreatment
recommendations,aboutone-thirdmisstheirappointments
withthecliniciansand20-60%ofpatientsdropoutfrom
treatment.

65. Factors associated with poor medication
compliance
•Demographicriskfactors:Youngerage,malegender,
unemployment,lowersocioeconomicstatus
•Patientrelatedfactors:Knowledgeaboutillnessand
treatment,perceivedneedfortreatment(insight),motivation,
beliefsabouttreatmentrisksandbenefits,past
experiences/“transference”,pasthistoryofadherence,
self-stigma

66. •Socialriskfactors:Livingindependently,poorsocialsupport,
poorfinancialsupport
•Clinicalriskfactors:Poorerpremorbidfunctioning,earlier
ageofonset,priorhistoryofnon-adherence
•Symptom-relatedriskfactors:Lackofinsight,paranoia,
grandiosedelusions,conceptualdisorganization,impaired
cognition,substanceabuse,comorbidities,depression,
refractoriness,spontaneousremissions

67. •Treatment-relatedriskfactors:Medicationsideeffects,poor
treatmentalliance,complexdosing,negativeexperienceof
medication,routeofadministration,lengthoftreatment,cost
oftreatment,numberofmedications
•Service-relatedriskfactors:Highcostofmedication,poor
accessibilityoftreatmentservices

68. •Family/caregivers-relatedriskfactors:Lackofsupervision,
negativeattitudestowardstreatment,lackofknowledgeabout
medicines,natureofrelationshipwithpatient,perceivedneed
fortreatment,involvementintreatment,stigma,financial
constraints
•Clinician/providerrelatedfactors:Therapeuticalliance,
frequencyandnatureofcontactwithclinicians,accessibilityto
cliniciansandservices,reimbursement,psychoeducationand
psychosocialtreatment,complexityofadministration

69. •Someofthecommonclinicianrelatedfactorswhichmaybe
relevantinIndiancontextincludepoorcommunication
betweentheclinicianandthepatient/caregiver,poor
therapeuticallianceandnon-collaborativedecision-making.
•Hence,cliniciansneedtofocusonbettercommunicationand
improvetherapeuticalliancewithpatientandthefamilyto
improveoveralloutcome.
•Medicationcompliancecanbeimprovedbyusingdepot
preparationsanduseofmouthdissolvingformulationsunder
supervision.

70. Phases of Illness
•Managementofschizophreniacanbebroadlydividedinto
threephases:
1.acutephase,
2.continuationorstabilizationphase,
3.maintenanceorstablephase.
•Somepatientsmaypresentveryearlyinaprodromalphase
andappropriatestrategiesfordetectionandmanagementfor
thisphasemightberequired.

71. Prodromal stage
•Itisnowwellknownthatonsetoffrankpsychosisisoften
precededbypsychologicalandbehavioralabnormalities
involvingcognition,emotion,perception,communication,
motivationandsleep.
•Thesesymptomsmayprecedethepsychosisbyweeksto
years.
•Evidencealsosuggeststhatmanypatientswithprodrome,
havehigherchanceofconversiontofrankschizophrenia.

72. •Therefore,nowmoreandmoreemphasisislaidonearly
detectionandintervention.
•Intermsofmanagementofprodromeitissuggestedthat
treatmentoughttobebasedontheneedsofthepatient.
•Thereissomeevidencetosuggestthatuseofantipsychoticsin
prodromalphasecandelaytheconversiontopsychosisand
antidepressantsmaybeusefulinsymptomaticimprovementin
asub-groupofpatients.

73. •However,atpresentevidenceforuseofantipsychoticsin
prodromalphaseisnotconvincingtorecommenditsuseinall
patients.
•Useofpharmacotherapyneedtobeweighedagainsttheside
effectsofantipsychoticsandsensitizationofdopamine
receptorsinbrain,whichcanpossiblyleadtosuper-sensitivity
psychosisorrapid-onsetpsychosisfollowingstoppageof
antipsychoticmedication.

74. Management in the Acute phase
•Comprehensiveassessment(psychiatric/medical/psychosocial)
•Decidingongoalsoftreatment
•Choiceoftreatmentsetting
•Antipsychotictreatment
•Useofadjunctivemedicationswhenindicated
•UseofECTwhenindicated
•Planningforfurthertreatment

75. Management in the Continuation and
Maintenance phase
•Determining goals
•Further assessment
•Antipsychotic treatment
•Psychosocial interventions
•Monitoring for response, side effects and treatment adherence
•Early intervention for relapses

76. Duration of treatment
•Durationoftreatmentdependsonanumberoffactorsandwill
needtobeindividualized.
•Thesuggestedguidelinesareasfollows:
–First-episodepatientsoughttoreceive1-2yearsof
maintenancetreatment
–Patientswithseveralepisodesorexacerbationsareto
receivemaintenancetreatmentfor5yearsorlongerafter
thelastepisode
–Patientswithhistoryofaggressionorsuicideattempts
shouldreceivetreatmentforlongerperiodorlifelong.

77. Indications for life long/long term use of
antipsychotic medications
•History of multiple relapses while on treatment
•History of relapses when the medications are tapered off
•History of suicidal attempts
•Presence of residual psychotic symptoms
•Family history of psychosis with poor outcome
•Comorbid substance dependence

79. SIDE EFFECTS AND THIER
MANAGEMENT
•Antipsychoticsareassociatedwithmanysideeffects,which
requireintervention.
•Someofthecommonsideeffectsthatcanbeverydistressing
tothepatientsincludeextrapyramidalsideeffects,
cardiovascularsideeffects,sexualdysfunctionandmetabolic
sideeffects.
•Thecardiovascularsideeffectscanbelifethreateningtoo.

80. Extrapyramidal side effects:
•Extrapyramidalsideeffects(EPS)areoftennotedinpatients
receivingFGAs,especiallyhighpotencyantipsychotic
medications.However,EPSisalsoseenwithSGAs.
•TheacuteEPSincludeAcutedystonia,Pseudo-
parkinsonismandAkathisia.
•AcuteEPSisusuallyseenduringthefirstfewdaysorweeks
ofstartingtreatment,isdosedependentandsubsideswith
stoppageofoffendingagent.

81. •ChronicEPSisusuallyseenafterprolongeduse(monthsto
years)ofantipsychotics.
•ItisimportanttonotethatchronicEPSisnotdependentonthe
doseofantipsychoticsandpersistsevenafterstoppingthe
offendingagent.
•IncaseapatientisexperiencingParkinsonismduringthe
initialphaseoftreatment,thefirststepofmanagement
involvesloweringthedoseoftheantipsychoticmedication.

82. •Ifreductionindoseisassociatedwithunacceptableefficacy
thanchangeofantipsychoticmedicationmaybeconsidered.
•Whenchangeofantipsychoticmedicationisconsidered,a
medicationwithlowerEPSpotentialneedtobeopted.
•Inpatientswhorespondtoanantipsychoticandcontinueto
experienceParkinsonism,ashortcourseofanticholinergic
medicationsmaybeconsidered.

83. •Acutedystoniaisalsoseenduringtheinitialphaseof
treatment,i.e.,afterreceivingfirstfewdosesofantipsychotics.
Acutedystoniasresponddramaticallytoadministrationof
parenteralanticholinergicmedications.
•Firststepinmanagementofacuteakathisiainvolves
reductionindoseorchangingtheantipsychotictoa
medicationwithlowerEPSpotential.Somepatientsmay
requiretheuseofmedicationslikebeta-blockersand
benzodiazepineslikeclonazepamorlorazepamfor
managementofakathisia.

84. Neuroleptic Malignant Syndrome (NMS):
•Itisanacutepsychiatricemergency,whichhasbeenreported
tooccurmoreoftenwithFGAs.
•However,dataintheformofcasereportsandcaseseriesalso
suggestassociationofalmostallSGAswithdevelopmentof
NMS.
•Variousfactorslikeyoungage,malegender,useofhigh
potencyantipsychotic,dehydration,etc.increasetheriskof
NMS

85. •Managementinvolvesstoppingtheantipsychoticmedication,
supportivemeasuresanduseofBromocriptine,Amantadineor
Dantrolene.
•UseofLorazepammayalsobehelpfulandthosepatientswith
NMS,whodonotrespondtothesetreatments,maybenefit
withECT.

86. Sedation:
•Many antipsychotics are known to cause sedation by virtue of
their anti-histaminergic, anti-adrenergic, and anti-
dopaminergic action.
•The risk of sedation is high with Chlorpromazine, Clozapine
andQuetiapine.
•Initial strategy should be to wait and watch and if this is not
beneficial, if possible dose reduction must be considered.

87. Anticholinergic and antiadrenergic side
effects:
•Thesesideeffectsmanifestasdrymouth,blurredvision,
constipation,urinaryretention,thermoregulatoryeffects,
impairedlearningandmemoryandslowedcognition.
•Somepatientmaydevelopconfusion,delirium,somnolence
andhallucinationsduetosevereanticholinergicsideeffects.
•Anticholinergicsideeffectsaremorecommonlyseenwith
ClozapineandChlorpromazine.

88. •Itisreportedthattheanticholinergicsideeffectsareusually
dose-dependentandreducewithreductioninthedoseof
antipsychoticorconcomitantlyusedanticholinergicagent.

89. Cardiovascular side effects:
•ThecommonlyencounteredsideeffectsincludeQTc
prolongation,orthostatichypotensionandtachycardia.
•QTcintervalofmorethan500millisecondsisassociatedwith
elevatedriskofventriculararrhythmias,knownas“torsades
depointes”,whichmayleadtoventricularfibrillationand
suddencardiacdeath.
•Amongtheolderantipsychotics,thioridazine,pimozideand
highdoseofintravenoushaloperidolarereportedtobe
associatedwithincreasedriskofQTcprolongation.

90. •AmongtheSGAs,ziprasidoneisreportedtohavehigherrisk
ofQTcprolongation;however,thishasnotbeenshowntobe
associatedwithsuddencardiacdeaths.
•Incase,thereisQTcprolongation,changeofantipsychoticis
tobeconsidered.

91. •Hypotensionassociatedwithvariousantipsychoticsis
attributedtoantiadrenergicactivity.
•ItiscommonlyseenwithClozapine,Risperidone,
Quetiapine.
•AmongtheFGAs,hypotensionisoftenseenwith
chlorpromazine.
•Hypotensioncanbepreventedbystartingwithlowerdoses
andslowupwardtitrationofmedication.

92. Hyperprolactinemiaand Sexual dysfunction:
•Ingeneral,ratesofsexualdysfunctionarereportedtobe
higherwithFGAsandrisperidone.
•OneofthecommoncausesforsexualdysfunctionwithFGAs
andrisperidoneisincreaseinprolactinlevels,whichleadsto
disruptionofhypothalamo-pituitary-gonadalaxis.
•Femaleshavebeenreportedtobemoresensitiveto
hyperprolactinemiarelatedsexualdysfunction.

93. Monitoring for metabolic side effects:
•Higherprevalenceofmetabolicsyndromesuggeststhat
cliniciansneedtomonitorthepatientsforemergenceof
metabolicsideeffectsandmanagethesametoreducethe
cardiovascularmorbidityandmortality.
•Antipsychoticshavealsobeenshowntoincreasetheriskof
developmentofdiabetesmellitus.
•Clozapineandolanzapinehavebeenreportedtobeassociated
withhighestriskfordevelopmentofweightgain,lipid
abnormalitiesandelevationinbloodglucoselevels

94. •Ingeneralitissuggestedthatpatientsneedtobemonitoredfor
metabolicdisturbancesatbaseline,at4-6weeksand12weeks
afterstartingantipsychoticandthenafterevery3monthsorat
leastannually.
•Ingeneralifapatientgainsmorethan7%ofthebaseline
weightordevelopshyperglycemia,hyperlipidemia,
hypertensionoranyothersignificantcardiovascularor
metabolicsideeffect,thenachangeinantipsychoticistobe
considered.

95. •Ifswitchingofantipsychoticisnotpossiblethenmedications
likemetforminortopiramatemaybeconsidered,alongwith
moreintensivedietaryandlifestylemodifications.
•Acloseliaisonneedtobemaintainedwithendocrinologistand
cardiologisttoprovidebestqualitycaretopatients.

96. SPECIAL POPULATIONS

97. Pregnancy
•Noclearevidencethatanyantipsychoticisamajorteratogen
•Considerusing/continuingdrugmotherhaspreviously
respondedtoratherthanswitchingpriorto/duringpregnancy
•Avoiddepotpreparationsandanticholinergicmedications.
•MostexperiencewithChlorpromazine,Trifluoperazine,
Haloperidol,Olanzapine

98. •ExperiencegrowingwithRisperidone,Quetiapineand
Aripiprazole
•Screenforadversemetaboliceffects
•Arrangeforthewomantogivebirthinaunitwithaccessto
neonatalintensivecarefacilities.
•Antipsychoticdiscontinuationsymptomscanoccurinthe
neonate(e.g.crying,agitation,increasedsuckling).

99. Breastfeeding
•Allpsychotropicsareexcretedinbreastmilk,tovarying
degrees.
•Neonatesandinfantsdonothavethesamecapacityfordrug
clearanceasadults.
•Whereverpossible:
–usethelowesteffectivedose
–avoidpolypharmacy
–timedosingtoavoidfeedingatpeakplasma/milklevelsorexpressmilk
togivelater

100. •RecommendedAntipsychotic:Olanzapine
•OthersmaybeusedlikeRisperidone,Quetiapineand
Aripiprazole

101. Renal impairment
No agent clearly preferred to another, however:
•Avoid Sulpirideand Amisulpride
•Avoid highly anticholinergic agents because they may cause
urinary retention
•First-generation antipsychotic –suggest Haloperidol 2–6 mg
a day
•Second-generation antipsychotic –suggest Olanzapine 5 mg a
day

102. Hepatic impairment
•UselowerstartingdosesandAvoidmedicineswithalong-
halflifeorthosethatneedtobemetabolisedtorenderthem
active(pro-drugs).
•Avoiddrugsthatareverysedativebecauseoftheriskof
precipitatinghepaticencephalopathy.
•MonitorLFTsweekly,atleastinitially.

103. •Haloperidol:lowdose
or
•Sulpiride/amisulpride:nodosagereductionrequiredifrenal
functionisnormal
•Paliperidone:ifdepotrequired

104. Elderly
•Usedrugsonlywhenabsolutelynecessary.
•Startwithalowdoseandincreaseslowlybutdonot
undertreat.Somedrugsstillrequirethefulladultdose.
•Trynottotreattheside-effectsofonedrugwithanotherdrug.
•Dailydoses:Aripiprazole:5–15mg,Olanzapine:5–10mg,
Quetiapine:75–125mg,Risperidone:1.0–2.5mg,
Haloperidol:1.0–3.5mg

105. References
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•World Health Organization. ICD-10 : International statistical classification
of diseases and related health problems : tenth revision, 2nd ed.World
Health Organization; 2004.

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