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It is a chronic heterogeneous syndrome of disorganized and bizarre thoughts, delusions, hallucinations, inappropriate affect, cognitive deficits, and impaired psychosocial functioning.

It is the most severe and debilitating mental illness in psychiatry.

Typically begins in adolescence or early adulthood.

Schizophrenia occurs with regular frequency nearly everywhere in the world in 1 % of population.

• The “cancer of mental illness”.

• Even with treatment prognosis is poor.

• Prevalence same for men and women; onset age 16-25.In men begins earlier

and may be more severe; women more favorable outcomes.

paranoid schizophrenia

disorganized schizophrenia

catatonic schizophrenia

Paranoid schizophrenia is the most common type of

schizophrenia

Paranoid schizophrenia is a subtype of schizophrenia in

which the patient has delusions (false beliefs) and

auditory hallucination that a person or some individuals

are plotting against them or members of their family

› lCD-10 (International Classification of Disease, WHO)

› DSM-IV (Diagnostic and Statistical Manual, APA)

For the diagnosis of schizophrenia is necessary

presence of one very clear symptom - from point a) to d)

or the presence of the symptoms from at least two groups - from point e) to h)

for one month or more:

a) hearing of own thoughts, the feelings of thought withdrawal, thought insertion, or thought

broadcasting.

b) the delusions of control, outside manipulation and influence, or the feelings of passivity, which

are connected with the movements of the body or extremities, specific thoughts, acting or

feelings, delusional perception.

c) hallucinated voices, which are commenting permanently the behavior of the patient or they talk

about him between themselves, or the other types of hallucinatory voices, coming from different

parts of body

d) permanent delusions of different kind, which are inappropriate and unacceptable in given culture

e) blocks or intrusion of thoughts into the flow of thinking and resulting incoherence and irrelevance of

speach, or neologisms

f) catatonic behavior

g) the negative symptoms, for instance the expressed apathy, poor speech, blunting and inappropriateness

of emotional reactions

h) expressed and conspicuous qualitative changes in patient’s behavior, the loss of interests, hobbies,

aimlessness, inactivity, the loss of relations to others and social withdrawal

A. Characteristic symptoms: Two or more of the following, each persisting for a significant

portion of at least a 1-month period:

(1) Delusions

(2) Hallucinations

(3) Disorganized speech

(4) Grossly disorganized or catatonic behavior

(5) Negative symptoms

Note: Only one criterion A symptom is required if delusions are bizarre or if hallucinations

consist of a voice keeping a running commentary on the person’s behavior or two or more

voices conversing with each other.

B. Social/occupational dysfunction: For a significant portion of the time since onset of the disorder, one

or more major areas of functioning such as work,interpersonal relations, or self-care are

significantly below the level prior to onset.

C. Duration: Continuous signs of the disorder for at least 6 months. This must include at least 1 month

of symptoms fulfilling criterion A (unless successfully treated). This 6 months may include

prodromal or residual symptoms.

D. Schizoaffective or mood disorder has been excluded.

E. Disorder is not due to a medical disorder or substance use.

F. If a history of a pervasive developmental disorder is present, there must be symptoms of

hallucinations or delusions present for at least 1 month.

Age : 22 years Sex : Female

Wt. : 44kg Unit : Psychiatry

Reason for admission:

Excessive talking and praying since 2 months

Decreased sleep and aggressive behaviour since 3 days

Increased suspiciousness over family members

A 22 year old female patient was stable, while on

regular medication until 2 months back, and was on

T.Risperidone 2mg and Quetiapine 100mg.

One day she was watching some TV serial in which

there was a demon. After which, the patient started

saying that she could feel the demon doing some thing

to her in her stomach, a vague uncomfortable

sensation and that the demon was trying to harm them.

Patient condition has aggravated since past 1 year and she used to tell scary story but her family never knew about these. She thinks that there are evil spirits in the daily things that she uses like spoons, towels etc., she forbids the entire family from using this things or even touching them , she never responded to the question that were asked but she still believes in evil spirit and thinks that they will kill her family.

The patient was reported to have a history of praying and chanting loudly since 1 month. She would have vivid dreams in the night and as soon as she wakes up, she would insist the family to go to temple.

The patient was also reported to have a history of hitting her father under the false assumption that he is a evil spirit and she also says that some one has replaced her father. Upon examination the patient revealed that she is scared of her father and because of which she ran away as soon as she saw him. Due to this condition she never allows visitors inside the house and the family members to leave the house. She often has hallucinations that the evil spirit is growing like a baby inside her. Also she often tore her clothes and pulled her hair in frustration and this episode is for 1-2 hrs on most of the days.

No history of low mood/ smiling to herself/ fever/ head injury/ repeated words.

Since past 2 years patient is ill. The symptoms started 2 years back, the first incident was when she used have thoughts that people are spying on her while she’s bathing and she often thought that people could see her naked body through her clothes while she’s outside.

Patient also had suicidal thoughts and frequent crying spells which were immediately followed by laughter without any reason.

She has a history of talking to herself and she used to think that people are trying to harm her by taking photographs. After these episodes, she was treated at Spanadana in Banglore and diagnosed as Schizophrenia with Depressive symptoms .

She was treated accordingly for 4-5 months after

which she was normal.

PMHx:

2010: 1st episode : Medications:

Drug Dose Freq Route

T.Risperidone+Trihexphenydyl 3+2mg 1-0-1 PO

T.Alprazolam SR 0.5mg 0-0-1 PO

2011: 2nd episode : Medications:

Drug Dose Freq Route

T.Risperidone +

Trihexphenydyl

3+2 mg 0-0-1 PO

T.Risperidone +

Trihexphenydyl

2+2mg 1-0-0 PO

Liv 52 DS 1 tsp 1-0-1 PO

2012: 3rd episode : Same medications were contd and 1

more drug was added:

On 26/4/12:

T.Risperidone+Trihexphenydyl 3+2mg 1-0-1

Clozapine 50 mg 0-0-1 ,for 1 month

On 28/6/12:

Clozapine 25mg 0-0-1

T.Aripiprazole 15 mg 0-0-1, for 2 months

Clozapine + 50mg PO 0-0-1

-M

-F

GF GM

FA MO

PT

BRO

The patient is 2nd child and has an old brother, who has MD{muscular dystrophy}, mother had committed suicide 12 years ago with a history of depression, ? BPAD, when the patient was 10 years old.

Patient was diagnosed as schizophrenic at the age of 10 years and has been on medication and doing well and has no history of any substance abuse. Patient lives with her father and brother.

Patient has studied up to SSLC and she had no interest in studies, and moderately passed.

GA&B: ill kempt and not groomed, in touch with surroundings,

alert, not conscious and cooperative, eye contact is not maintain

PMA: decreased

Speech : Occasionally not responding to verbal commands,

Rarely speaks when spoken, volume & output- Decreased

Insight -1

BP: 120/90mmHg

O/e:

Pallor (+)

Icterus, Cyanosis, clubbing, edema(-)

CVS

RS NAD

PA

Drug Dose Freq Route

Inj.Haloperidol+Promethazi

ne

50mg/ml(2 amp)

+ 25mg(1 amp)

Stat and then sos IV

T.Quetiapine 200mg 0-0-1 PO

T.Risperidone +

Trihexphenydyl

4+2mg 0-0-1/2 PO

T.Clonazepam 0.5mg 0-0-1 PO

BP: 120/90mmHg

Sleep – disturbed

appetite - decreased

Adv: CST.

Stop T.Clonazepam 0.5mg

Start Inj.Lorazepam 4mg slow IV sos

BP: 110/90mmHg

Drowsiness was present, father c/o patient hitting him.

Sleep was adequate

Adv :

Start T.Quetiapine 300mg 1-0-2 PO

BP: 100/70mmHg

O/e:

Ill kept, not groomed

Conscious, alert.

Mood: Sub: ill ; Obj: irritated

Decreased drowsiness

Adv: CST., ophthalmology opinion

Ophthalmology Report

Impression: normal fundus in both eyes

BP: 100/70mmHg

c/o itching on her back.

GA&B: ill kempt and groomed, in touch with surroundings, alert,conscious and cooperative, eye contact is not maintain

PMA: decreased

Speech : Occasionally not responding to verbal commands, speakswhen spoken, volume & output- normal

Insight -1

Adv: NBM for ECT tomorrow

Stop Inj.Lorazepam 4mg IV

Start T. Lithium Carbonate 450mg 0-0-1

BP:110/70mmHg

GA: same

Insight:1

Adv: CST. ECT.

Start Ointment Thrombophob (Heparin sodium).

1. Patient on NBM

2. Shifted to minor OT

3. Inj. Atropine 1 amp slow iv given

4. Mouth gag inserted

5. ECT given at 31joules for 2 sec

6. GTCS observed for 25sec

7. RS/CVS: NAD

8. Vital stable

9. Adv . Patient can be given oral feeds after ½ hrs

BP:120/80mmHg

GA: normal

Speech: output and volume was normal

Insight:3

Adv: CST. Plan for ECT tommorrow

1. Patient NBM

2. Shifted to minor OT

3. Inj. Atropine 1 amp slow iv given

4. Mouth gag inserted

5. ECT given at 28joules for 2 sec

6. GTCS observed for 25sec

7. RS/CVS: NAD

8. Vital stable

9. Adv . Patient can be given oral feeds after ½ hrs

BP:110/70mmHg

GA and PMA was normal

Speech : Volume and Output was normal

Insight :5

Adv: CST. Plan for ECT

1. Patient NBM

2. Shifted to minor OT

3. Inj. Atropine 1 amp slow iv given

4. Mouth gag inserted

5. ECT given at 28joules for 2 sec

6. GTCS observed for 25sec

7. RS/CVS: NAD

8. Vital stable

9. Adv . Patient can be given oral feeds after ½ hrs

BP:110/70mmHg

GA: adequetly kempt and groomed in touch with surroundings, alert, conscious and cooperative, eye contact maintained, patient is good touch with the surroundings

Patient symptomatically improved by 90%

PMA: decreased

Speech : output and volume normal

Mood: subjectively and objectively good

Insight : 5

Pharmaceutical Care Plan

› Delusions

› Hallucinations

Excessive talking and praying since 2 months

Decreased sleep and aggressive behaviour since 3 days

Based on the subjective evidence the patient was

diagnosed as Paranoid Schizophrenia.

Short term goals

To reduce symptoms and improve the QOL

Maximize adherence with therapy

Long term goals

Ensure remission

Minimizes the ADR

Minimizes the Complications

Prevent relapse

Pharmacological

Typical Antipsychotics

Haloperidol

Fluphenazine

Loxapine

Atypical Antipsychotic

Aripiprazole

Quetiapine

Risperidone

Non-Pharmacological

ECT

Psychotherapy: CBT

Social & Vocational skills

training

Drug related ADR was reported

LFT not done.

Patient was improved by 90%

Insight -5

Disease based

Patient’s Mental Status-

Symptoms

Drug’s based

Body Wt

BP

CBC

LFT

RBS

ADRs: dry mouth, tremors,

pseudoparkinsonism,

akathisia, etc.

About Disease

Psychosocial Counseling

About Medications

About Lifestyle Modifications

Manage stress : Stress can trigger psychosis and make the symptoms of schizophrenia worse, so keeping it under control is extremely important. Don’t take on more than you can handle and take time to yourself if you’re feeling overwhelmed.

Try to get plenty of sleep: When you’re on medication, you most likely need even more sleep than the standard 8 hours. Many people with schizophrenia have trouble with sleep, but lifestyle changes (such as getting regular exercise and avoiding caffeine) can help.

Avoid alcohol and drugs : Some evidence indicates a link between drug use and schizophrenia. And it’s indisputable that substance abuse complicates schizophrenia treatment and worsens symptoms. If you have a substance abuse problem, seek help.

Get regular exercise: Studies show that regular exercise may help reduce the symptoms of schizophrenia. That’s on top of all the emotional and physical health benefits! Aim for 30 minutes of activity on most days.

Do things that make you feel good about yourself: If you can’t get a job, find other activities that give you a sense of purpose and accomplishment. Cultivate a passion or a hobby. Helping others is particularly fulfilling.

Reduce sugar, carbohydrate and caffeine intake. This will help your blood sugar stay balanced. Many drugs prescribed to treat schizophrenia can mess with your blood sugar, so avoiding excess stimulants can help keep it at a desired level.

Add foods containing essential fatty acids. People with schizophrenia have reduced amounts of these fatty acids in their brains, so adding foods that contain them can help treat the illness. Good sources include fish, nuts and olive oil


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