1. MANAGEMENT OF
SCHIZOPHRENIA
11th POST GRADUATE COURSE
2005
Institute of Psychiatry
Rawalpindi General Hospital
PROF FAREED ASLAM MINHAS

2. SCHIZOPHRENIA
Characterized by fundamental and characteristic
disorder in thinking and perception, and by
inappropriate or blunted affect
Clear consciousness is usually maintained
Disorder of thinking, emotion, volition and perception
along with disintegration of personality

3. SCHIZOPHRENIA
The ICD-10 requires that a minimum of one
very clear symptom(two or more if less clear)
belonging to
• any one of the groups from (a)-(d) or
• from at least two of the groups (e)-(h)
• during a period of one month or more

4. ICD-10 Classification of
SCHIZOPHRENIA
(a) Thought echo/ insertion or withdrawal and
broadcasting
(b) Delusions of control,influence,passivity;
delusional perception
(c) Hallucinatory voices as a running commentary,
third-person or somatic hallucinations
(d) Persistent delusions that are inappropriate and
impossible

5. ICD-10 Classification of
SCHIZOPHRENIA
(e) Persistent hallucinations or over-valued ideas
(f) Breaks/interpolations in train of thought,
neologisms
(g) Catatonic behavior such as waxy
flexibility/negativism/stupor
(h) Negative symptoms e.g.. Marked apathy, paucity
of speech
(i) Significant consistent change in personal
behavior e.g. idleness

6. BIO-PSYCHO-SOCIAL
MODEL OF MANAGEMENT

7. BIOLOGICAL MANAGEMENT
ANTI-PSYCHOTIC DRUGS
(i)Conventional or Standard Antipsychotics
These drugs act through blocking the dopamine
receptors and bind strongly to dopamine D2
receptors.
These are phenothiazines, butyrophenones,
diphenylbutyl pipiredines, thioxanthenes and
substituted benzamides. These include:
chlorpromazine (Thorazine); fluphenazine (Prolixin);
haloperidol (Haldol); thiothixene (Navane);
trifluoperazine (Stelazine); perphenazine (Trilafon)
and thioridazine (Mellaril).

8. Anti-psychotic preparations available
•Oral drugs – Tablets and suspensions
•Injectables – Short acting( Haloperidol, zuclopenthixol acetate) or
depot preparations(zuclopenthixol decanoate, fluphenazine)

9. BIOLOGICAL MANAGEMENT
(ii)Atypical Antipsychotics
These are newer drugs with fewer side effects.They
are highly selective D2 receptor antagonists and some
drugs also possess 5-HT2 receptor antagonist
activity.
•
•
•
•
•
•
Amisulpiride
Clozapine
Olanzapine
Quetiapine
Risperidone
Zotepine

10. Atypical Antipsychotics
• Amisulpiride
highly selective D2 receptor antagonists
dose:400-800mg daily
Max 1.2gms daily
• Clozapine
weak D2 receptor antagonists
high affinity for 5HT2 receptors
Binds to H1,alpha 1 adrenergic
& muscarinic cholinergic receptors
• Olanzapine
weak D2 receptor antagonists
Anticholinergic and H1 receptor blocker

11. Atypical Antipsychotics
• Quetiapine
weak D2 receptor antagonists
modest 5Ht2 receptor antagonist
dose:25mg twice daily & increase
Range 300-450mg daily
• Risperidone
potent D2 & HT2 receptor antagonists
Alpha1 adreno receptor blocker
• Zotepine
low selectivity for 5Ht2 receptors
dose:25mg 3times daily
max 100mg 3times daily

12. NICE GUIDELINES
• The atypical antipsychotics (amisulpride, olanzapine quetiapine,
risperidone, and zotepine) should be considered when choosing
first-line treatment of newly diagnosed schizophrenia;
• An atypical antipsychotic is considered the treatment option of
choice for managing an acute schizophrenic episode when
discussion with the individual is not possible;
• An atypical antipsychotic should be considered for an individual
who is suffering unacceptable side-effects from a conventional
antipsychotic;

13. NICE GUIDELINES
• An atypical antipsychotic should be considered for an individual
in replase whose symptoms were previously inadequately
controlled;
• Changing to an atypical antipsychotic is not necessary if a
conventional antipsychotic controls symptoms adequately and the
individual does not suffer unacceptable side-effects;
• Clozapine should be introduced if schizophrenia is inadequately
controlled despite the sequential use of two or more
antipsychotics (one of which should be an atypical antipsychotic)
each for at least 6-8 weeks.

14. Side effects
Agitation
Typical
Clozapine
Risperidone
Olanzapine
Quetiapine
Sertindole
+ to ++
0
++
+
+
0
Agranulocytosis
Rare
+++
Rare
Rare
Rare
Rare
Anticholinergic
+ to +++
+++
+
++
+
0
AST/ALT levels
+
+
0
+
+
0
EPS
+ to +++
0
+
0
0
0
Nausea/Dyspepsia
+
0
+
+
0
+
Hypotension
+ to +++
+++
+
++
++
+
Prolactin levels
+ to ++
0
++
+
0
0
Sedation
++ to +++
+++
+
++
++
0
Seizures
+
+++
0
+
0
0
Dyskinesias
+++
0
+
?
?
?
Weight Gain
+ to ++
+++
+
++
+
++

15. BIOLOGICAL MANAGEMENT
ECTs
Traditional indications are catatonic stupor and severe
depressive symptoms in schizophrenia.
ANTI-DEPRESSANTS AND MOOD
STABILIZERS
Depression is a part of the syndrome of
schizophrenia. Value of use of anti-depressants is not
proven, may be helpful in chronic syndrome but
might worsen active psychosis.

16. PSYCHOLOGICAL MANAGEMENT
GENERAL PRINCIPLES:
• Individual Psychotherapy
• Family Education
• Self-help Groups
• Good Motivation and Productivity From Patients

17. PSYCHOLOGICAL MANAGEMENT
WORKING WITH RELATIVES with emotional
expressions within family is most beneficial
BEHAVIORAL TREATMENT include ‘token
economies’ and ‘cognitive behavior therapy’
(specially for positive symptoms as they are
amenable to structured reasoning)

18. SOCIAL MANAGEMENT
REHABILITATION include social and vocational
training and improvement of communication skills as
the onset of the illness is at a point where they are
training for skilled work.
CASE MANAGEMENT (followed in US)
Most consumers with severe or chronic
schizophrenia will have a case manager. The role of
the case manager is to assist in coordinating all the
services that the consumer may need. See figure
below as an example of how a case manager can
work with other professionals and agencies.

20. Thank you