Paranoid Schizophrenia 2

7/29/2019 Paranoid Schizophrenia 2

http://slidepdf.com/reader/full/paranoid-schizophrenia-2 1/49

SchizophreniaDisease Review

And Treatment Update

Edward Moldenhauer, MS, RPh

LCDR, MSC, USN



Schizophrenia

Goal:To familiarize the practitioner with

schizophrenia and current treatment

options for the disease



Schizophrenia

Objectives:- Describe how schizophrenia is diagnosed

- Describe the symptoms of schizophrenia

- Identify the common side effects of schizophrenia medications

- Describe adjunct medication treatment

options for schizophrenia

- Compare schizophrenia medications

relating to dosing, special patient

populations, side effects, interactions and

precautions



Schizophrenia

True stories:“I thought that I had been shot in the head to remove a

blood clot. Then, I actually felt my brain crack open,

masses of blood came out of one of my ears and a small

trickle from the other.

Later that night, I thought that the devil was after me, I

saw him come through one of the speakers of my stereo

system. I was also probably hearing voices, but they were

mixed in with the radio music and DJs.”



Schizophrenia

True stories:“I had one particular friend. I called him the „Controller‟,

only I could see him and hear him, but no one else could.

He would punish me if I did something he didn't like.

He spent a lot of time yelling at me and making me feel

wicked. I didn't know how to stop him from screaming at

me and ruling my existence. It got to the point where I

couldn't decipher reality from what the „Controller‟ was

screaming.”



Schizophrenia

True stories:“Louis Wain, a prominent British

artist of the early 1900's, was

diagnosed with schizophrenia. He

was under psychiatric care but

lived at home surrounded by his

cats. Over a period of years he

painted their portraits, which are

in a way self-portraits, revealing

the tragic odyssey of his feelings.”



Schizophrenia

True stories:“John Nash, noble prize winning

mathematician, was virtually

incapacitated by paranoid

schizophrenia during the prime of his genius. Referred to as

Princeton‟s "Phantom of Fine Hall“,

he was a ghostly, silent figure

shuffling around wearing purple

sneakers and occasionally writingtreatises on blackboards. He was

immortalized in 2002 Academy

Award winning film, A Beautiful

Mind.”



Schizophrenia

Description: - a psychotic disorder characterized by a

loss of contact with the environment, by

noticeable deterioration in the level of

functioning in everyday life, and by thedisintegration of personality expressed as

disorder of feeling, thought, and conduct

Merriam-Webster Dictionary



Schizophrenia

Description: - chronic, severe, disabling

-- one of the most disabling and

emotionally devastating illnesses - first identified in 1911

- NOT split personality

- linked to anatomical abnormalities- a neurodevelopmental disorder of

excessive dopamine levels



Schizophrenia

Demographics: - risk factors;

-- genetic

-- perinatal- gender/age distribution

-- men & women equally prone

-- males; late teens/early 20s

-- women; late 20s to early 30s- no known racial differentiation

- most patients are smokers



Schizophrenia

Childhood Schizophrenia: - rare in US (0.01% or 1 in 10,000)

- recently separated from autism

- occurrence rates increase as child

approaches adulthood

- suicide mortality rate: 5-11%

- child may exhibit a failure to meet

expected life milestones rather thandeterioration in functioning



Schizophrenia

DSM-IV Criteria: - at least 2 characteristic symptoms

present for most of a 1-month period

over a 6-month period: Delusions

Hallucinations

Disorganized speech Catatonia / disorganized behavior

Negative symptoms



Schizophrenia

Symptoms: - insidious onset in 50% of patients

- characterized by a group of

distinctive & predictable symptoms

- positive symptoms(grossly abnormal behavior)-- behavior that is there that shouldn‟t be

- deficit or negative symptoms (absence of normal behavior)-- behavior that is not there that should



Schizophrenia

Positive Symptoms: - thought disorder

-- diminished ability to think clearly

and logically-- manifested by disconnected and

nonsensical language

-- incapable of participating in

conversation



Schizophrenia

Positive Symptoms (cont): - delusions

-- false yet strongly held belief

resulting from an inability toseparate the real from unreal

-- “paranoid delusions”: belief that

they are being conspired against

-- “broadcasting”: belief thatthoughts can be heard by others



Schizophrenia

Positive Symptoms (cont): - hallucinations

-- heard, seen, or even felt

-- most often they take the formof voices heard only by the patient

-- may describe the person's actions,

warn of danger or direct actions

-- at times, several voices may becarrying on a conversation



Schizophrenia

Deficit or Negative Symptoms: - the absence of normal behavior

- flat or blunted affect

(i.e. lack of emotional expression)- apathy

- social withdrawal



Schizophrenia

Diagnostic Parameters: - Cross-sectional

-- current clinical status

- Longitudinal -- frequency

-- severity

-- treatments

-- consequences of past episodes



Schizophrenia

Diagnostic Tools: - Structured Clinical Interview for

DSM-IV (SCID)

-- gold standard

-- admin by psych professional

-- takes 1-2 hours to administer

- Teaching Interview for Psychiatric

Students (TIPS)-- shorter than the SCID

-- guide for routine, brief clinical evals



Schizophrenia

Diagnostic Tools: - Positive and Negative Syndrome

Scale (PANSS)

-- structured clinical interview tool

-- 30-40 minute formalized interview

-- 30 questions on a 7-point scale

-- separates out nine different clinical

dimensions- Brief Psychiatric Rating Scale (BPRS)

-- evaluates psychotic symptoms

-- numerically scales symptoms



Schizophrenia

Differential Diagnosis: - other psychological disorders

-- bipolar affective disorder

-- delusional disorder

-- schizotypal personality disorder

- other medical illnesses

-- brain tumor, intracranial bleeding

-- head trauma-- systemic lupus erythematosus

-- Huntington disease



Schizophrenia

Differential Diagnosis: - metabolic disorders

-- Wilson‟s disease

-- porphyria

-- hypoxemia

-- electrolyte / vitamin imbalances



Schizophrenia

Differential Diagnosis: - endocrine disorders

-- hypo- or hyperthyroid

-- hypo- or hyperadrenalism

-- hypo- or hyperparathyroidism



Schizophrenia

Differential Diagnosis: - infectious diseases

-- neurosyphilis

-- HIV-1

-- cerebral abscesses

-- Creutzfeldt-Jakob disease



Schizophrenia

Differential Diagnosis: - miscellaneous

-- multiple sclerosis

-- heavy metal poisoning

-- seizure disorder

-- substance abuse



Schizophrenia

Differential Diagnosis: - medications

• corticosteroids (psychosis/mania)

• levodopa (hallucinations/insomnia)

• antidepressants (mania)

• interferon-alpha (depression)

• beta-blockers (depression)



Schizophrenia

Disease Course: - initial signs may appear as weird

changes in normal behavior

- “acute”

-- onset of severe psychotic sx

- “psychosis”

-- state of mental impairment

marked by hallucinations and/or delusions



Schizophrenia

Disease Severity: - “single”

-- only one episode

- “mild/moderate”

-- many episodes over lifetime with

relatively normal during interims

- “chronic”

-- continuous or recurring-- often do not fully recover

-- typically require long-term tx



Schizophrenia

Chronic Disease Treatment: - some patients completely recover

- many must be institutionalized

- medication treatment

-- 70% of patients respond well

-- 15% moderately improve but

still require support

-- 15% have no response



Schizophrenia

Disease Treatment: - supportive therapy

-- social work, family counseling

-- vocational rehabilitation

- hospitalization

-- brief in-patient to stabilize

- out-patient care

-- alcohol and drug abuse-- depression

-- medication non-compliance



Schizophrenia

Disease Treatment Phases: - acute phase

-- alleviate/reduce acute symptoms

-- assessment

-- treatment setting

-- psychiatric management

-- initiate medication



Schizophrenia

Disease Treatment Phases: - stabilization phase

-- minimize stress and relapse

- stable/maintenance phase

-- assessment

-- psychiatric management and specific

psychosocial treatments

-- monitoring medications-- early intervention



Schizophrenia

Medication Adherence/Relapse: - up to 75% of patients don't take

their medication regularly or stop

treatment altogether

- ~80% relapse within one year if

medications are stopped

- only 20% relapse if continually treated



Schizophrenia

Medication Classes: - classic antipsychotics

-- haloperidol (Haldol)

-- droperidol (Inapsine)

-- fluphenazine (Prolixin)

-- thioridazine (Mellaril)

-- chlorpromazine (Thorazine)

- a.k.a.; "neuroleptics“, due to potential

for inducing neurological side effects



Schizophrenia

Medication Classes: - atypical antipsychotics

-- Clozapine (Clozaril)

-- Risperidone (Risperdal)

-- Olanzapine (Zyprexa)

-- Quetiapine (Seroquel)

-- Ziprasidone (Geodon)

-- Aripiprazole (Abilify)- a.k.a.; SDAs

-- serotonin-dopamine antagonists -- pleiotropic pharmacology



Schizophrenia

Medication Classes: - therapy adjuncts

-- pimozide (Orap)

-- divalproex (Depakote)

-- carbamazepine (Tegretol)

-- lithium

-- anticholinergics

-- benzodiazepines (BZDs)-- antidepressants

-- ECT

S



Schizophrenia

Classical Antipsychotic Side Effects:(a.k.a.; EPS: Extrapyramidal Side Effect) - akathisia (restless leg)

- dystonia

- hyperprolactinemia

- akinesia & Parkinsonism-like sx

- weight gain

- anticholinergic adverse effects

S hi h i



Schizophrenia

Classical Antipsychotic Side Effects:(a.k.a.; EPS: Extrapyramidal Side Effect) - Neuroleptic Malignant Syndrome (NMS)

-- hyperthermia

-- muscular rigidity

-- altered mental state

-- autonomic instability

S hi h i



Schizophrenia

Classical Antipsychotic Side Effects:(a.k.a.; EPS: Extrapyramidal Side Effect) - Tardive Dyskinesia (TD)

-- high incidence in elderly (~70%)

-- involuntary and repetitive (not

rhythmic) mvt of mouth and face

-- rocking back & forth or tap feet

-- diaphragmatic dyskinesia exists,-- risk factors:

age, female, lower IQ,

negative symptoms

S hi h i



Schizophrenia

haloperidol (Haldol): - DOC for acute psychosis(when no contraindications exist)

- dopamine (D2) antagonist

- high potential for EPS/dystonia- precautions

-- monitor development of TD

-- if IV/IM, monitor for hypotension-- caution in diagnosed CNS depression,

cardiac disease, history of seizures

-- significant in body temp may indicate

intolerance

S hi h i



Schizophrenia

clozapine (Clozaril): - adrenergic, cholinergic, histaminic and

serotonin receptor antagonist

- precautions-- do not D/C aburptly

-- requirement to perform WBC count

-- hypotension, myoclonic jerks, seizures

-- urinary incontinence, constipation- requires National Registry registration

S hi h i



Schizophrenia

clozapine (Clozaril):

www. clozapineregistry.com

S hi h i



Schizophrenia

risperidone (Risperdal):- dopamine & serotonin receptor

antagonist

- precautions-- EPS, NMS, hyperprolactinemia,

hypotension, tachycardia, arrhythmias

-- cerebrovascular warning of stroke in

elderly patients with dementia-- can lengthen QT interval

- availability-- oral tablets, soln, &

distinegrating tabs

S hi h i



Schizophrenia

olanzapine (Zyprexa): - dopamine, serotonin and

muscarinic receptor antagonist

- precautions-- glaucoma, vascular disease, BPH,

seizures, hypovolemia, dehydration

-- may lead to weight gain

- availability-- oral tablets, disintegrating tablets

S hi h i



Schizophrenia

quetiapine (Seroquel):- dopamine and serotonin receptor

antagonist

- precautions-- may induce orthostatic hypotension

associated with dizziness, tachycardia,

and syncope

-- NMS

- availability-- oral tablets

S hi h i



Schizophrenia

ziprasidone (Geodon): - dopamine and serotonin receptor

antagonist

- injectable used for acutely agitated pt

- precautions-- prolongs QT/QTc (caution in patients

with known risk factors)

-- caution in seizure disorders-- may cause hypotension, EPS,

somnolence

- availability

-- oral capsules and injection

S hi h i

http://www.gifart.com/cgi-bin/affiliate/clickthru.cgi/school



Schizophrenia

aripiprazole (Abilify): - MOA is unknown, hypothesized to

work differently meds

- antagonizes serotonin (5HT2A)

- partial dopamine (D2) and

serotonin (5HT1A) agonist

- precautions:

-- headache, anxiety, somnolence, andinsomnia

- availability-- oral tablets



Schizophrenia- Debilitating to patient, family, society

- Severe personality changes

- Linked to neurochemical abnormalities- Positive and Negative Symptoms

- Differential diagnosis

- Treatment options- classic and atypical antipsychotics

- side effects and precautions






Schizophrenia

Date post:	03-Apr-2018
Category:	Documents
Upload:	gopscharan
View:	221 times
Download:	0 times

Paranoid Schizophrenia 2

Documents