| ID | 123 |
|---|---|
| Name | SCHIZOPHRENIA |
| Cause | Diagnosis: Following steps should be carried out for a diagnosis of schizophrenia- 1. History from the patient and attendants. 2. Mental state examination of the patients. a. Overall functioning- the patient’s level of functioning declines or fails to achieve the expected level, b. Xhounht content- abnormal (e.g delusions, ideas of reference, poverty of content), c. Form of thought- illogical (e.g derailment, loosening of associations, incoherence, neologisms, blocking, echolalia). d. Perception- distorted (e.g hallucinations- visual, olfactory, tactile and most frequently auditory). e. Affect/Mood- abnormal (e.g flat, blunted, labile, inappropriate), f. Sense of self- impaired (e.g loss of ego boundaries, inability to distinguish internal from external reality), g. Insght- impaired or absent. 3. Physical examination to exclude organic cause that can produce schizophrenia like feature e.g temporal lobe epilepsy, abnormality of diencephalons, drug withdrawal syndrome etc. 4. Laboratory investigations to exclude relevant organic pathology |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | |
| Management | |
| Introduction | Schizophrenia is a major mental disorder (psychotic disorder) of unknown etiology and divergent presentation. It is characterized by positive and negative (deficit) symptoms. The symptoms of schizophrenia adversely affect thinking, feeling, behavior, and social and occupational functioning. A Swiss psychiatrist Eugen Bleuler introduced the term ‘schizophrenia’ (rending or splitting of mind or psychic function) in 1911. So, when normal integration of an emotional and cognitive function is ruptured is called schizophrenia. Schizophrenia is the most serious of all psychiatric illnesses. It affects about 1% of the adult population at some time in their lives. |
| History | |
| Etiology | Etiology: Schizophrenia is a disorder of multifactorial etioloy, no single factor is considered responsible. Genetic, biological and psychosocial or environmental factors are involved. 1. Genetic transmission- both single gene or polygenic transmission. 2. Psychosocial or environmental factors- abnormal family relationship, psychological stress etc. 3. Biological factors, such as overactivity of dopaminergic neuronal system-schizophrenic symptoms may result from increased limbic dopamine activity (positive symptoms) and decreased frontal dopamine activity (negative symptoms). 4. Neurodevelopmental and neurodegenerative theories- evidence for abnormal neuronal migration during the second trimester of fetal development. Glutamate receptor mediated cell loss may occur. |
| Clinical Features | Clinical features: Clinical features of schizophrenia are grouped into two basic concepts. A. Acute schizophrenia- positive symptoms. B. Chronic schizophrenia- negative symptoms. Clinical features of acute schizophrenia: Positive symptoms 1. Lack of insight (failure to feel and understand the disease process). 2. Auditory hallucinations. 3. Delusional mood. 4. Delusion of persecution. 5. Delusions of control. 6. Ideas of reference. 7. Suspiciousness. 8. Interference in thinking- thought insertion, thought broadcasting, thought withdrawal, thoughts spoken aloud. Clinical features of chronic schizophrenia: Negative symptoms 1. Social withdrawal. 2. Lack of drive and initiative. 3. Under activity. 4. Lack of conversation, 5. Thought disorders. 6. Deterioration of personal, social, educational & occupational functioning. 7. Depression 8. Odd behaviors. 9. Threats or violence. Schneider’s first-rank symptoms: It is a convenient tool for the diagnosis of schizophrenia. (It is important to remember that the first rank symptoms do not always have to be present for a diagnosis to be made). 1. Auditory hallucination (3rd person type, running commentary type, commanding type, discussing about the patient). 2. Primary delusion, i. Delusional mood, ii. Delusional perception, iii. Sudden delusional idea. 3. Thought insertion. 4. Thought withdrawal. 5. Thought broadcasting. 6. Delusion of control- action, feelings are experienced as controlld by external force or agency. 7. Hearing of one’s own thought (thought echo). |
| Preventions | |
| Treatment | Treatment: Clinical management of acute schizophrenia includes: 1. Hospitalization. 2. Psychosocial assessment & treatment- such as behavioral, family, group, individual, social skills and rehabilitation therapies. 3. Antipsychotic medication. Indications for hospitalization: i. Posing a danger to others; ii. Suicidal intention; iii. Severe symptomatalogy leading to poor self care or risk for injury secondary to disorganization; iv. Diagnostic evaluation; v. Failure to respond to treatment in less restrictive settings; vi. Complicating comorbidities & the need to other drug treatment regimens. Drug treatment: Mainly two groups of drugs are used in the treatment of schizophrenia, viz-Dopamine receptor antagonists (Typical antipsychotics) and Serotonin dopamine antagonists (Atypical antipsychotics). Some newer antipsychotic drugs are also in use now a days. The most common drugs used in acute schizophrenia are chlorpromazine and haloperidol. The starting dose of antipsychotic drugs depend on the degree of disturbances and body build of the persons. Oral dosages of some common antipsychotic drugs are given below with its usual side-effects. Selected antipsychotic drugs with dosages and route of administration: Drug Usual daily Sedative Autonomic Extra- pyramidal oral dose (mg) effect Side-effect adverse effect Dopamine receptor antagonists (Typical antipsychotics): Chlorpromazine 200-400 +++ +++ ++ Trifluoperazine 5-30 ++ + +++ Thioridazine 200-400 +++ +++ ++ Fluphenazine 2-20 + + +++ Haloperidol 5-20 + + +++ Serotonin dopamine antagonists (Atypical antipsychotics): Aripiprazole 5-15 + ++ 0? Olanzapine 5-10 + ++ 0? Quetiapine 150-300 ++ ++ 0? Risperidone 2-16 + ++ + Ziprasidone 40-60 + ++ 0? When long-term medication is required and there is history of poor drug compliance, use long-acting antipsychotic drug e.g. Fluphenazine decanoate (25mg) deep intramuscluar injection. It can be used fortnightly or monthly depending on the patient’s condition. Oral antipsychotic medication may or may not be required along with this drug. Patients refusing oral medication: In acutely excited patient chlorpromazine 50mg i.m can be given preferably in the gluteal area. If not controlled, it can be repeated every 4 or 6 hours or 8 hours to a maximum dose of 100-200mg. Injection haloperidol is effective in the management of acute schizophrenia and the dose is 5mg i.m stat and repeat every 6 to 8 hours to a maximum dose of 20mg. Antiparkinsonism drug: Extra pyramidal side-effects develop in 40% of patients receiving antipsychotic drugs. However, when the patients usually live at long distance from doctors, generally an antiparkinsonism drug is given in all patients to avoid side effects. The drug mostly used for this purpose is procyclidine, 5-I 5mg/day is effective in divided doses. Maintenance: Schizophrenia is usually a chronic illness and long treatment with antipsychotic medication is usually required to decrease the risk of relapse. If a patient has been stable for approximately 1 year, then the mdication can be gradually decreased to the minimum effective dosage, possibly at the rate of 10-20% per month. During dose reduction, patients and their families must be educatd to recognize and report warning signs of relapse, including insomnia, anxiety, withdrawal and odd behavior. Strategies for dose reduction must be individualized based on the severity of past episodes, stability of symptoms and tolerability of medication. A prescription for Schizophrenic patient:221 A. Hospitalisation. B. Psychiatric assessment and psychotherapy, (occupational therapy, emotional support and social rehabilitation is essential). C. Anti-psychotic drug treatment. 1. In acute schizophrenia: Chlorpromazine- initially 25mg 3 times daily, increasing if necessary by 25mg daily; maintenance, usually 75-300mg daily. Incase of aggressive or agitated patient: Chlorpromazine 150mg oraly or i.m 6-hourly may be given. Or, Haloperidol- initially 0.5-5mg orally 2 or 3 times daily, increasing gradually as required, maximum 20mg daily, when control is achieved reduce to maintenance dose 5-10mg daily. By injection initially 2-30mg i.m stat, then 5mg 1 to 8 hourly as required. In acute uncontrollable case: Electroconvulsive therapy (E.C.T)- volts for 0.2 second & repeated for about 6-12 such courses if required. 2. Maintenance therapy: Inj. Fluphenazine- initially 12.5mg (6.25mg elderly) as test dose (for extrapyramidal reactions), by deep i.m injection into gluteal region. Usual dosage range, 12.5-100mg every 2-5 weeks, starting 4 to 7 days after test. Or, Inj. Flupenthixol decanoate- initially 20mg as test dose (for extrapyramidal reactions), by deep i.m injection into gluteal region. Usual dosage range for maintainance for tretment of Pchizophernia is likely 20-40mg every 02 weeks. 3. Anti-parkinsonism drug- to control the side effect of the antipsychotic drug (extrapyramidal reactions) anti-parkinsonism drug, e.g procyclidine 5mg 3 times daily may be given. |
| Complications | |
| Prognosis | |
| Types | Types: 1. Simple 2. Hebephrenic 3. Catatonic. 4. Paranoid type. 5.Residual 6.Paranoid Type |
| Classification | |
| Observation | |
| Pathology |
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