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Seminar on approach to schizophrenia.pptx
- 1. Seminar on approachto schizophrenia Moderator –Dr ABDI B.(MD,Assistant Prof.of Psychiatry) Presenter –Dr FIRAOL G.(MD,IMR-I)
- 2. OUTLINE • Introduction • Definition •Clinical diagnosis • Management principles
- 3. Introduction • Schizophrenia isamong the most disabling and economically catastrophic medical disorders. • It is ranked by the World Health Organization as one of the top 10 illnesses contributing to the global burden of disease
- 4. Cont… • The prevalenceof schizophrenia approaches 1 percent internationally. • The incidence is about 1.5 per 10,000 people . • Age of onset is typically during adolescence • childhood and late-life onset (over 45 years) are less common. • Slightly more men are diagnosed with schizophrenia than women (1.4:1) and women tend to be diagnosed later in life than men
- 5. Definition • Chronic, sever,debilitating mental illness. • It is characterized by symptoms of thought, behaviour, and functional problems
- 6. Clinical manifestations • Schizophreniais a syndrome. • Individuals with schizophrenia generally present with several symptoms -Positive symptoms -Negative symptoms - Cognitive impairment -Mood and anxiety symptoms
- 7. • Positive symptoms— -This group of symptoms includes the reality distortion symptoms of hallucinations and delusions, as well as disorganized thoughts and behavior Hallucinations — Hallucinations are defined as the perception of a sensory process in the absence of an external source. -They can be auditory, visual, somatic, olfactory, or gustatory -Auditory hallucinations are the most common form of hallucination, with prevalence estimates between 40 and 80 percent in people with schizophrenia
- 8. • Delusions —Delusions are defined as a fixed, false belief and are present in approximately 80 percent of people with schizophrenia • Delusions are broadly categorized as bizarre or nonbizarre -Bizarre delusions are clearly implausible (ie, they have no possibility of being true - A nonbizarre delusion is one that while not true is understandable and has the possibility of being true.
- 9. • Disorganization —People with schizophrenia typically display some disorganization in behavior or thinking • The symptoms of disorganization are - -Tangential speech – The person gets increasingly further off the topic without appropriately answering a question. -Circumstantial speech – The person will eventually answer a question, but in a markedly round about manner. -Derailment – The person suddenly switches topic without any logic -Neologisms – The creation of new, idiosyncratic words. -Word salad – Words are thrown together without any sensible meaning.
- 10. • Negative symptoms— Negative symptoms are usually one of the first manifestations of schizophrenia. • up to 70 percent of patients experience negative symptoms prior to their first positive symptom
- 12. Abnormal motor activity Extrememotor agitation or retardation Stereotyped behaviors Waxy flexibility Stupor Negativism Ecopraxia
- 13. Cognitive symptoms • Inattention,easily distracted • Impaired memory • Poor problem-solving skills • Poor decision-making skills • Illogical thinking • Impaired judgment • Impaired learning
- 14. Mood and anxietysymptoms • Depressed mood • Anxious mood • Guilty feeling • Irritability • Worry and tension 25-30% of schizophrenics develop depression in any phase of the illness.
- 15. Functional impairment • Decreasedability to work • Problem in interpersonal relationships • Poor self care • Social functioning
- 18. Outcome of schizophrenia Devastatingillness >50% of patients- long-term incapacity >10% of patients commit suicide Bad prognostic signs Insidious onset Long duration of episode Childhood behavioral problems Family history of schizophrenia Unmarried, male Low social class
- 19. Etiology • Multifactorial causation •Biologic, • Non-biologic • 1. BIOLOGIC • Genetic • Biochemical Factors • Structural changes • Physiological changes • Psychoneuroendocrinology/immunology
- 20. Genetic -Twin studies-Adoptionstudies - Family studies Prevalence of Schizophrenia in Specific Populations Population Prevalence (%) General population 1 Non-twin sibling of a schizophrenia patient 8 Child with one parent with schizophrenia 12 Dizygotic twin of a schizophrenia patient 12 Child of two parents with schizophrenia 40 Monozygotic twin of a schizophrenia patient 47
- 21. Biochemical Factors Dopamine Hypothesis Schizophreniaresults from too much dopaminergic activity Revised Dopamine hypothesis – increased dopamine at mesolimbic, and decreased dopamine at mesocortical pathway Other neurtransmitters- Glutamate, GABA, Serotonine, norepinephrine, neuropeptides
- 22. Structural changes Neuropathological basisfor schizophrenia, • Lateral and third ventricular enlargement • Some reduction in cortical volume • Reduced symmetry in schizophrenia • the temporal, frontal, and occipital lobes
- 23. Physiological changes • EEG •Evoked Potentials • Magnetic resonance spectroscopy- decreased brain metabolism Psychoneuroimmunology - Immunological abnormalities Psychoneuroendocrinology Hormonal abnormality- hypothalamic-pitutary axis
- 24. Non biologic causes PsychoanalyticTheories Schizophrenia resulted from developmental fixations that occurred earlier odefects in ego development Affects Interpretation of reality and the control of inner drives(sex and aggression) oA disturbance in interpersonal relatedness Learning Theories poor models for learning during childhood learn irrational reactions and ways of thinking by imitating parents
- 25. Family Dynamics Apoor mother-child relationship - increase in the risk of developing schizophrenia A specific family pattern plays a causative role in the development of schizophrenia Pathological family behavior that can significantly increase the emotional stress Psychosocial Low social class Immigration Social isolation
- 26. DIAGNOSIS Psychosis is firstand foremost a diagnosis of exclusion • Relevant and known causes of psychosis should be ruled out before diagnosing primary psychiatric disorders • A comprehensive history • Physical examination • Neurological examination
- 27. Excluding medical illnesses Bloodtests • TSH -exclude hypo or hyperthyroidism, • Basic electrolytes and serum calcium to rule out a metabolic disturbance • OFT • CBC including ESR to rule out a systemic infection or chronic disease • Blood film; titers of thyphoid/typhus • Serology to exclude syphilis or HIV infection Other investigations include: • EEG to exclude epilepsy • MRI or CT scan of the head to exclude brain lesions Substance/ medication screening – urinalysis, serum toxicology- as indicated
- 28. MANAGEMENT The treatment ofpsychosis depends on the specific diagnosis 1. Treating primary condition- medical illness/ substance use disorder/primary psychiatric disorder 2. Antipsychotic medications • The first line psychiatric treatment for many psychotic disorders is antipsychotic medications • Can reduce the positive symptoms of psychosis 3. Adjunctive drugs 4. ECT
- 29. Hospitalization- is indicatedfor • diagnostic purposes • for stabilization of medications • for patients' safety because of suicidal or humicidal ideation • for grossly disorganized or inappropriate behaviour • Short stays of 4 to 6 weeks are just as effective as long-term hospitalizations
- 30. ACUTE TREATMENT The goalis immediate control of psychosis. Treatment principles for to treat someone with first episode of schizophrenia - start treatment as soon as possible -decrease stress and other risk factors -start with low dose and titrate to initial dose range. -best use Second generation antipsychotics, if possible
- 31. Pharmacological treatment beinitiated promptly Antipsychotic medications- selection guided by • the patient’s previous experience with antipsychotics Adjunctive medications • Benzodiazepines may be used to treat catatonia, anxiety and agitation • Antidepressants -for treating co-morbid major depression • Mood stabilizers and beta-blockers may be used for reducing the severity of recurrent hostility and aggression Psychosocial interventions - Reducing over stimulating or stressful relationships, environments
- 32. –The dose maybe titrated as quickly as tolerated to the target therapeutic dose of the antipsychotic medication • Monitoring of the patient’s clinical status for 2–4 weeks • Avoid the temptation to prematurely escalate the dose for patients who are responding slowly
- 33. II-Stabilization phase • Goals- to enhance the patient’s adaptation to life • Premature lowering of dose or discontinuation of medication during this phase may lead to a recurrence of symptoms and possible relapse III-Stable Phase • Goal- ensure that symptom remission or control is sustained • Regular monitoring for adverse effects
- 34. During the stablephase of treatment - routinely monitor • Extrapyramidal side effects • Weight, waist circumference, and BMI • Blood pressure • Symptoms of diabetes- Fasting glucose • Evaluate whether residual negative symptoms are present or prominent • Hematology • Blood chemistries, lipid abnormalities
- 35. Drug discontinuation • Noreliable indicator to differentiate the minority from the majority who will relapse with drug discontinuation. • Warn early signs of relapse; • attend outpatient visits on a regular basis • Indefinite maintenance antipsychotic medication - patients who have had multiple prior episodes or two episodes within 5 years
- 36. Psychotherapy in Psychosis Psychosocialtreatments during the stable phase. • Family intervention • Supported employment • Assertive community treatment, • skills training, and • cognitive behaviorally oriented psychotherapy
- 37. REFERENCES • Kaplan andSadock’s, Synopsis of Psychiatry 11th edition • ONLINE UPTODATE
- 38.
Editor's Notes
- #33 Monotherapy –”start low-go slow”