all about schizophrenia

4. original term-dementia praecox-early age,
chronic deteriorating course.
coined the term schizophrenia (split mind) 
affective blunting, loosening of associations,
autism (withdrawal) and ambivalence
(coexisting conflicting ideas) - 4 As- earned
acceptance in USA
first rank symptom

5. Psychotic mental disorder of
unknown etiology
characterized by disturbances
in:
(e.g. distortion of
reality, delusions and
hallucinations)
(e.g.
ambivalence,
inappropriate affect)
(e.g.
Apathetic
withdrawal, bizarre activity)

6. Age-related demographics
• According to DSM5, the onset of schizophrenia
usually occurs between the late teens and the mid 30s
Sex-related demographics
• The prevalence of schizophrenia
is about the same in men & women
• The onset is later in women than un men
• The clinical course is less severe in women than in men
Race-related demographics
• No racial differences in the prevalence of
schizophrenia have been positively identified

9. •Dopaminergic system
hypothesis
•Increased
Ventricular size
•Glutaminergic
dysfunction
•Decreased brain
volume in medial
temporal areas
•Serotonin
abnormalities
•Changes in the
hippocampus
•Overactivation of
immune system
Alteration in brain
structure & function
•Metabolic
disturbance (Insulin
resistance)

10. DSM (Diagnostic & Statistical Manual) of Mental
Disorders Published by APA
( American Psychiatry Association)
DSM I
1952
DSM II 1968
DSM III 1980
DSM IV 1994 Classified Schizophrenia to 5 Subtypes
DSM V 2013 Proposed the deletion of subtypes
ICD ( International Classification of diseases)
Published by WHO
ICD 10 Classified Schizophrenia to 7 Subtypes

11. i
Paranoid
Vii
Simple
Schizophrenia
ii
Catatonic
Vi
PostSchizophrenic
iii
Disorganized
V
Residual
IV
Undifferentiated

12. A-preoccupation with
1 or more delusions or
frequently auditory
hallucinations
B-Non of the following
is prominent:
-Disorganized speech
-Disorganized or
catatonic behavior
- Flat affect
-At least 2 of the
following:
i-Motoric immobility
evidenced by
catalepsy or stupor
ii-excessive motor
activity (purposeless&
without stimulus)
iii-Echolalia
iv-Excessive negatism
A- All of the following are prominent :
- Disorganized speech
-Disorganized behavior
- Flat affect
B- the criteria are not met for catatonic
type

13. - Psychotic
symptoms are
present but
criteria for
paranoid, catat
onic or
disorganized
have not been
met
- - Depressive
episodes arising
in the aftermath
of schizophrenic
illness where
some low-level
symptoms may
still be present
-The general
criteria for
schizophrenia
have been met at
sometime in the
past but are not
met in the present
time
- Insidious &
progressive
development
of negative
symptoms
with no history of
psychotic
episodes

14. •Family history of Schizophrenia
•Any potential cause of fetal hypoxic brain
damage
•History of brain complications
•Advanced age of mother during pregnancy
•Birth during winter months !! 
•Substance abuse
•Single marital status
•Low socioeconomic class
•Urban environment
•Environmental stress

16. Hallucination
Delusions
Illusions
Disorganized speech
Behavioral disturbances
Absence of normal
cognition
Allogia
Avolition
Anhedonia
Social isolation
 Impaired
- attention
- Working memory
- Executive functions
 Seems cheerful or sad
without obvious reasons

17. • Gradual
development
of symptoms
• Precedes 1st
psychotic
episode
• Includes:
- Isolation
-Deterioration
of hygiene
- loss of
interest
in work
•
•
•
•
•
•
•
•
•
•
Out of reality
Hallucination
Delusion
Ambivalence
Autism
Disturbed
sleep
&appetite
Impaired self
care skills
Flat affect
Disconnected
thoughts
Aggression
• Occurs
between
episodes of
psychosis
• Includes:
- Anxiety
- Avolition
- poor insight
- social
withdrawal
- lack of
motivation
- impaired
judgment

19. Diagnostic
criteria of
schizophrenia
DSM-IV
ICD-10

20. DSM-IV Diagnostic Criteria
A. 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)
B. Social/occupational dysfunction
C. Continuous signs of the
disturbance persists for at least
six months
D. Schizoaffective and mood
disorder exclusion
E. Substance/medical condition
exclusion
F. Relationship to pervasive
developmental disorder :
the additional diagnosis of
Schizophrenia is made only if
prominent delusions or
hallucinations are also present
for at least a month

21. ICD-10 Diagnostic Criteria
At least one of the symptoms : OR At least one of the symptoms :
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
a. Persistent hallucinations in any
modality occurring everyday for
weeks or months
b. Breaks or interpolation in the
train of thought > incoherence or
irrelevant speech, or neologism
c. Catatonic behavior, such as
excitement, posturing, or waxy
flexibility, negativism, mutism, st
upor
d. Negative symptoms:
apathy, paucity of
speech, blunting of emotional
response

22. Persistent dysfunction lasting longer
than 6 months
2 or more symptoms for at least 1
month ( at least 1 of i, ii or iii)
i- Hallucination
ii- Delusions
iii- Disorganized speech
iv- Grossly disorganized or catatonic
behavior
v- Negative symptoms
Significantly impaired functioning
( work, self care , interpersonal )

23. Differential Diagnosis
•
Alcohol-related psychosis
•
Bipolar affective disorder
•
Brief psychotic disorder
•
Cocaine-related psychiatric
disorders
•
Delusional disorder
•
Depression
•
Mental disorders secondary to
general medical conditions
•
Schizoaffective disorder
•
Schizophreniform disorder

24. 25%
• Complete recovery
35%
• Much improved
15%
• Improved but require
extensive therapy
10%
• Hospitalized (unimproved )
15%
• Dead ( mostly Suicide )

25. 1. Alleviation of target symptoms
2. Avoidance of side effects
3. Importance of Psychosocial functioning
and proactively
4. Compliance with the prescribed regimen
5. Involvement of the patient in
the treatment plan
6. Not to be hospitalized

26. 1. Mental status examination
2. Physical & neurological examination
3. Complete family & social history (take in consideration family history
of response to drugs)
4. Psychiatric diagnostic interview
5. Laboratory work up ( CBC, electrolytes, hepatic & renal
functions, ECG, FBG, lipid profile, thyroid functions and
urine drug screening )

28. Typical APs.
Atypical APs.
first generation
Second generation

29. Typical APs.
Atypical APs.
traditional, conventional, first generation
antipsychotics, classical neuroleptics, major
tranquilizers
Second generation
Low potency
Chlorobromazine: Neurazine ®
Thioridazine: Mellcril ®
Medium potency
Molindone:
Thiothixene: Navane®
Pimozide: Orape forte ®
Moban ®
High potency
Trifluperazine: Stellazine ®
Haloperidol: Haldol ®
Fluphenazine: Modecate ®
Zuclopenthixol: Clopexol ®
Aripiprazole: Apilify ®
Clozapine: leponex ®
Olanzapine: Zyprexa ®
Quetiapine: Seroquil ®
Resperidone: Resperidal ®
Sulpiride: Dogmatil ®
Ziprasidone: Zeldox ®

30. Typical APs.
Atypical APs.
first generation
Second generation
:
- DA receptor blocker
-Have activity on histamine,
muscarinic & α-receptors ( not
responsible for the therapeutic
activity )
-DA antagonist and 5-HT2A –
receptor blocker
EXCEPT
Aripiprazole Partial DA & 5-HT1Aagonist 5-HT2A- antagonist
- Have activity on histamine,
muscarinic & α-receptors ( not
responsible for the therapeutic
activity )

31. Typical APs.
Atypical APs.
first generation
Second generation
:
- DA receptor blocker
-Have activity on histamine,
muscarinic & α-receptors ( not
responsible for the therapeutic
activity )
-DA antagonist and 5-HT2A –
receptor blocker
EXCEPT
Aripiprazole Partial DA & 5-HT1Aagonist 5-HT2A- antagonist
- Have activity on histamine,
muscarinic & α-receptors ( not
responsible for the therapeutic
activity )

32. Typical APs.
Atypical APs.
first generation
Second generation
Sed.
EPS
A.Ch
O.HoTN
CPZ
+++
++
++
+++
Thioridazine
+++
+
+++
+++
Molindone
++
++
+
+
Sed.
EPS
A.Ch
O.HoTN
Wt.G
clozapine
+++
0
+++
+++
+++
Resperidone
+
+
0
+
++
Olanzapine
++
+
++
+
+++
Quetiapine
++
+
0
++
++
Thiothixene
+
+++
+
++
Trifluperazine
+
+++
+
+
Haloperidol
+
+++
+
+
Ziprasidone
0
+
0
0
0
Fluphenazine
+
+++
+
+
Aripeprazole
+
+
0
0
0
Sed : sedation, EXP: extrapyramidal side effects , A.Ch anticholinergic side effects , O.HoTN: orthostatic hypotension wt.G : weight gain

33. -Dry mouth ( ttt: fluid intake, oral lubricant, sugarless gum)
-Constipation (ttt: Exercise , fluid and dietary fibers intake)
-Blurred vision
-Tachycardia
- Inhibition of Ejaculation
-Urinary retention
-Impaired memory

34. i- Dystonia :
Definition : Prolonged tonic muscle contraction,
Risk : life threatening (pharyngeal –laryngeal dystonia
Risk factors : young patient , male gender, high potency agent,
high doses
Treatment : IV or IM anticholenergic or BDZ
Prophylaxis : Anticholinergic in : high potent 1st generation APs,
young men or history of dystonia
ii- Akathesia :
Definition :
Subjective complain : feeling of inner restlesness
Objective symptoms: pacing, shuffling or tapping feet
Treatment : decrease the dose of FGAPs or switch to SGAPs

35. iii-Pseudoparkinsonism:
Symptoms :
-Akinesia, brdykinesia or decreased motor activity including micrographia, slowed speech,
decreased arm swing
- Tremors
-Cogwheel rigidity
-Postural abnormalities
Risk factors :
- FGAPs specially in high dose
-High doses
-Old age
Onset :
1-2 weeks after initiation or increment of APs dose
Treatment :
- Anti cholinergic s: - Benzotropine, Diphene hydramine, Biperidine)
- Amantadine

36. Iv-Tardive dyskinesia:
Definition : abnormal involuntary movement
with chronic use of APs
e.g: Oro facial movement ,
Risk : life threatening (pharyngeal –laryngeal dystonia
Risk factors : Old age , long duration of ttt, high doses ,
diagnosis of organic mental
disorder , DM or mood disorder
Treatment : Decrease dose or switch to SGAPs
Prophylaxis : Use SGAPs as first line
-Highest risk of drug including seizures
are chloropromazine& clozapine
-Likely in initiation of ttt, high doses
or rapid dose increment
Treatment :
- Decrease the FGAPs dose & switch to SGAPs
- Anticonvulsant not recommended

37. -0.5% - 1 % of patients taking FGAPs
Risk factors :
- High potency FGAPs,
- Injectable or depot FGAPs
- Dehydrated patient
- Organic mental disorder
Symptoms :
- Temp. 38 C
-Altered level of consciousness
-Rigidity
-Autonomic dysfunction ( tachycardia,
tachypnea , urinary & fecal incontinence )
Lab. Findings :
-Leukocytosis
-High CK, AST, ALT, LDH,
-Myoglobin uria
Treatment :
-Discontinue AP drug
-Supportive care
-Bromocriptin ( reduce DA blockade,
rigidity, fever & CK level)
-Amantadine
-Dabtrolone ( skeletal muscle relaxant with
favourable effect on Temp.& respiratory
rate )
-Lowest effective dose of SGAPs after 2 ws
without AP & monitor closely

38. :
-APs stimulate prolactin production which is associated with
galactorhea & menstrual irregularities
-Dose related
-Frequently with FGAPs & risperidone
-Management : switch to SGAPs aripiprazole or ziprasidone
-Frequently with SGAPs
Olanazapine , clozapine , risperidone
& quetiapine more than
ziprasidone & aripiprazole )
- New
onset of diabetes reported with SGAPs

39. - 20 mmHG drop in systolic pressure upon standing
- Frequently with :
• low potency APs
• APs combination
• DM
• Cardio vascular disease
• Elderly patient
-Tolerance occurs within 2-3ms
-If not tolerated ; change AP drug or decease the dose

40. - Some SGAPs & phenothiazines cause elevation in serum TGs & cholesterol
Risk decreases with ; risperidone,ziprasidone & aripiprazole
-Impaired visual accommodation
-Photophobia
-Narrow angle glaucoma exacerbation
-Opaque deposit in cornea & lens (frequently with chronic use of phenothiazines
specially chloropromazine )
-Cataract : with quetiapine ( periodic slit lamp examination is recommended )
-Retinitis pigmentosa : with thioridazine 800 mg daily
- Mainly to Control APs side effects
e.g : anticholinergic agents and amantadine are often used in conjunction
with the conventional APs to treat extrapyramidal symptoms.

41. Diagnosis of
Schizophrenia
Identify Phases of Illness
Yes
Acute
phase
Need rapid
tranquilization
Combination of
parenteral treatment
Urgent
No
No
Oral medication is preferred
When parenteral needed use 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
Yes
Poor
response
Yes
Adequate dose
& duration
No
No
Relapse
prevention
Stable
phase
•Exclude substance abuse, treatment
non-adherence & concurrent other
general medical conditions
•Optimize psychosocial interventions
•Refer to psychiatrist for trial of
clozapine
Optimize APs usage
•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
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
Monitor EPS/akathisia/weight gain/diabetes/heart
disease/sexual dysfunction
Follow schedule of physical care as per follow-up manual 41

42. Cognitive remediation is a treatment modality derived
from principles of neuropsychological rehabilitation. It is
based, in part, on the ideas that the brain has some
plasticity and that brain exercises can encourage neurons
to grow and can develop the neurocircuitry underlying
many mental activities.
Most patients with schizophrenia would like to work;
employment can improve income, self-esteem, and social
status. However, few people with the disorder are able to
maintain competitive employment. Supported
employment programs currently thought to be most
effective are those that offer individualized, supported,
and rapid job assignments and that are integrated with
other services

43. Schizophrenia affects the person’s whole family, and
the family’s responses can affect the trajectory of
the person’s illness. Familial “high expressed
emotion” (hostile overinvolvement and
intrusiveness) leads to more frequent relapses. Some
studies have found that family therapy or family
interventions may prevent relapse, reduce hospital
admission, and improve medication compliance
Most patients with schizophrenia smoke
this may be a result of previous conventional antipsychotic
treatment . Smoking may also be related to the boredom
associated with hospitalizations, the peer pressure from
other patients to smoke, or the anomie associated with
unemployment.
Whatever the cause of the high incidence of smoking, the
health risks from smoking are well known, and all
schizophrenic patients should be encouraged to stop
smoking.

44. Many psychotropic medications can cause
weight gain and changes in glucose or lipid
metabolism. Occasionally, a person with
schizophrenia develops odd food
preferences. Finally, many persons with
schizophrenia have limited funds, do not
cook for themselves, and live in areas where
fast food outlets are abundant. Therefore,
nutritional counseling is difficult but
important.
Because many psychotropic medications
are associated with weight gain, persons
with schizophrenia should be encouraged to
be as physically active as possible.

45. Medscape website
Pharmacotherapy
Comprehensive pharmacy review
APA website

46. Thank
you