SCHIZOPHRENIANG BOON KEATMOHD HANAFI RAMLEE

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

Sto

ries o

f S

ch

izop

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nia

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

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

Epidemiology

• Lifetime prevalence 1-1.5%• There is 7351 cases had been reported from 2003-2005

• The incidence was noted higher in males, urban and migrant population

Incidence and prevalence(In Malaysia)

• 60% of the schizophrenia cases are man

Sex ratio

• Prevalence > low socioeconomic groups

Socioeconomic status

• Common between 15 and 35, rare before 10 and after 40 years old. Earlier onset for ♂

Age of onset

Epidemiology: Sex

Epidemiology: Race

54

28

9

9

Malay ChineseIndian Others

BUT IT CAN ALSO AFFECT ANYONE

WITHOUT PREDISPOSITION

S !

AetiologyUncertain; however there is evidence for several risk factors.

Several models which can be grouped into….

Biological Social

Psychological

Aetiology – BioGenetics Consideration

1st degree & 2nd degree relativeEnvironmental

Abnormalities of pregnancy and delivery [2%]

Maternal Influenza – 2nd trimester [2%] Fetal Malnutrition [2%] Winter & Low Social Class birth [1.1%]

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%]

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

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).

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]

THREE PHASES OF SCHIZOPHRENIA

Prodromal

• Decline in functioning that precedes 1st psychotic episode

• Socially withdrawn, irritable

• Physical complaints

• Newfound interest in religion / the occult

Psychotic (acute

phase)• Positive

symptoms• Perceptual

disturbances (e.g. auditory hallucinations)

• Delusions (usually secondary, delusion of reference common)

• Disordered thought process / content

Residual (chronic

phase)• Occurs between

episodes of psychosis

• Marked by negative symptoms (flat affect, social withdrawal)

• odd thinking and behaviour

Clinical Features

Acute syndrome (positive symptoms)

• Hallucinations• Delusion• Disorganised

speech/thinking/ behaviour

• Catatonic behaviours• Delusion of reference

Chronic syndrome (negative symptoms)

• Affective Flattening• Alogia• Avolition• Anhedonia• Attention(poor)

DIAGNOSIS CRITERIA OF SCHIZOPHRENIA

The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination.

(ICD-10)

(DSM-IV)

ICD diagnostic criteria – 1 of the followingAt least one of the symptoms a-d or two

of the symptoms e- ia. Thought echo, insertion, or

withdrawal and thought broadcastingb. Delusions of control, influence, or

passivity; delusional perceptionc. Hallucinatory voices-running

commentary or other < part of bodyd. Persistent delusions of other kinds

ICD diagnostic criteria – 2 of the followinge. Persistent hallucinations in any modality

occurring everyday for weeks or monthsf. 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

i. A significant and consistent change in behavior > aimless, idle, self-absorbed att

DSM-IV diagnostic criteriaA. 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

Difference between DSMIV and ICD 10

DSMIV ICD-10The classification ofschizophrenia

Course andfunctionalimpairment

Schneider’s firstrank sign

The duration of illness 6 months 1 month

Prodromal and residualperiod

included Not included

Occupational and socialfunctional deficiency

Expected since theonset of thedisorder

Expected in thecourse of thedisorder

Kurt Schneider (German psychiatrist) ’s symptoms of first rank

1. Auditory hallucinations: audible thought or thought echo ; referring third person; running commentary.

2. Alienation of thought: thought insertion or withdrawal

3. Diffusion of thought (thought broadcasting)

4. Sensation of feelings, impulses or acts being controlled by external forces

5. Somatic passivity < external agency (e.g. X-rays, hypnosis)

6. Delusional perception

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

DIFFERENTIALS & MANAGEMENTS

Differential diagnosis Organic syndrome

Drug Temporal lobe epilepsy Delirium Dementia Diffuse brain disease

Psychotic mood disorder Personality disorder Schizoaffective disorder

Course• Complete recovery 20%

• Recurrent acute illness20%

• Chronic disease starting acutely20%

• Chronic disease starting insidiously20%

• Suicide10-15%

Prognosis Recover completely/long

term minimal symptoms- 30%(The percentage on the rise)

Recurrent illness -poorer prognosis

Young patient -high risk of suicide

Predictors for poor outcome

Features of the illness

Insidious onset

Long 1st 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

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

Component of EvaluationEvaluation of of

psychosisMedical evaluationMental status and

siucidality

Evaluation of of psychosis

Medical evaluation

Mental status and siucidality

Management

Treatment of Schizophrenia Acute phase Relapse prevention phase Stable phase Psychosocial care and

rehabilitation

36

Need rapid tranquilisati

on

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

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

Physical restrainFamily education and

counsellingEmergency medication

AntipsychoticCombination: antipsychotic

+ benzodiazepineAdministered parenterally If cooperative, oral

administration allowed.

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)

ACT? Combined medication and

psychosocial treatments with aggressive delivery and follow-up.

Activities: Daily home visit “eyes-on” medication

administration Transportation to clinician

appointment

Stable phaseFollow up at primary care

clinic.Life long medicationRemission for at least 1

year achieve in 70 – 80% of patient taking antipsychotic at full doses

Psychosocial support

Psychosocial and rehabilitation care Social skill training Employment training Cognitive remediation therapy Psychoeducation Family therapy

Don’t forget medical illness too…

MedicationsTraditional 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)

Benzodiazepine - Lorazepam Atypical antipsychotic for treatment

resistant schizophrenia-

Clozapine

THANK YOU

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NG BOON KEATMOHD HANAFI RAMLEE

Differential

Diagnosis

Psychotic Symptom

Time Course

Ruled out secondary

causes

Primary Psychosis

Chronic (>1 mo)

Schizoaffective Disorder

Schizophrenia

Delusional Disorder

Psychosis NOS

Brief(<1 mo)

Brief Psychotic Disorder

Psychosis NOS

Diagnosis

Specifiers

Chronic Primary Psychosi

s

Criterion A Sx and 6 mo

dysfunction?

Simultaneously meet criteria

for mood disordes?

Schzioaffective Disorder

Schizophrenia

Prominent Delusions?

Delusional Disorder

Psychosis NOS

yes

no

no

no

yes

yes

DiagnosisBrief Primary Psychosis

Between 1 day and 1 mo Sx

with full recovery

Brief Psychotic Disorder

Psychosis NOS

yes

no