SCHIZOPHRENIANG BOON KEAT

MOHD 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

rie

s o

f Sc

hiz

op

hre

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 Chinese

Indian Others

BUT IT CAN ALSO

AFFECT ANYONE

WITHOUT

PREDISPOSITIONS !

AetiologyUncertain; however there is

evidence for several risk

factors.

Several models which can be

grouped into….

Biological Social

Psychological

Aetiology – Bio

Genetics Consideration

1st degree & 2nd degree relative

Environmental

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

• Disorganisedspeech/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 following

At least one of the symptoms a-d or two of the symptoms e- i

a. Thought echo, insertion, or withdrawal and thought broadcasting

b. Delusions of control, influence, or passivity; delusional perception

c. Hallucinatory voices-running commentary or other < part of body

d. 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. delusionsb. hallucinationsc. disorganized speechd. grossly disorganized or catatonic behavior

e. negativesymptoms, 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-10

The classification of

schizophrenia

Course and

functional

impairment

Schneider’s first

rank sign

The duration of illness 6 months 1 month

Prodromal and residual

period

included Not included

Occupational and social

functional deficiency

Expected since the

onset of the

disorder

Expected in the

course of the

disorder

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 Evaluation

Evaluation of of

psychosis

Medical evaluation

Mental 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

tranquilisationUrgent

No

Yes Combination of

parenteral treatmentYes

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 restrain

Family education and

counselling

Emergency medication

Antipsychotic

Combination: antipsychotic

+ benzodiazepine

Administered 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 medication

Remission 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…

Medications

Traditional 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 YOUNG BOON KEAT

MOHD 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

DiagnosisSpecifiersChronic Primary

Psychosis

Criterion A Sxand 6 mo

dysfunction?

Simultaneously meet criteria for mood disordes?

SchzioaffectiveDisorder

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