Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Schizophrenia
Schizophrenia - Key Features
1. In adolescents presenting with problem behaviours, consider schizophrenia in the differential diagnosis.
2. In “apparently” stable patients with schizophrenia (e.g., those who are not floridly psychotic), provide regular or periodic assessment in a structured fashion e.g., positive and negative symptoms, ther performance of activities of daily living, and the level of social functioning at each visit:
- seeking collateral information from family members and other caregivers to develope a more complete assessment of symptoms and functional status;
- competency to accept or refuse treatement, and document specifically;
- suicidal and homicidal ideation, as well as the risk for violence;
- medication compliance and side effects.
3. In all patients presenting with psychotic symptoms, inquire about substance use and abuse.
4. Consider the possibility of substance abuse and look for it in patients with schizophrenia, as this is a population at risk.
5. In patients with schizophrenia, assess and treat substance abuse appropriately.
6. In decompensating patients with schizophrenia, determine:
- if substance abuse is contributory.
- the role of medication compliance and side-effect problems.
- if psychosocial supports have changed.
7. Diagnose and treat serious complications/side effects of antipsychotic medications (e.g., neuroleptic malignant syndrome, tardive dyskinesia).
8. Include psychosocial supports (e.g., housing, family support, disability issues, vocational rehabilitation) as part of the treatment plan for patients with schizophrenia.
- • Schizophrenia is a chronic, severe disabling psychiatric disorder
- • Major psychiatric disorder with prodrome, active and residual disturbances in appearance, speech (loosened associations), behavior (grossly disorganized) , perception (hallucinations), or thinking (delusions) that last for equal or more than 6 months.
- • There are 5 types of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual.
- • Lifetime risk is 0.2-0.7%. Highest prevalence in lower socioeconomic classes
- • More prevalent in males than females. 1.4 to 1.
- • Age of onset is usually from late teens to mid thirties.
DSM-IV diagnostic criteria for schizophrenia
- A Characteristic symptoms: Two or more of the following, each present for a significant portion of time during a one-month period:
- • delusions
- • hallucinations
- • disorganized speech (eg, frequent derailment or incoherence)
- • grossly disorganized or catatonic behavior
- • Negative symptoms (i.e., affective flattening, alogia, or avolition).
Note Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
- B Social/occupational dysfunction: Since the onset of the disturbance, one or more major areas of functioning, such as work, interpersonal relations, or self-care, are markedly below the level previously achieved.
- C Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less if successfully treated) that meet Criterion A.
- D Exclusion of schizoaffective disorder and mood disorder with psychotic features.
- E Substance/general medical condition exclusion: the disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.
- F Relationship to a pervasive developmental disorder: If there is a history of autistic disorder or another pervasive development disorder, the diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).
- • 2 main groups of antipsychotics:
- Conventional: Chlorpromazine, fluphenazine, Trifluoperazine, Perohenazine, Thioridiazine, Haloperidol, and Thiothixene.
- Atypical: Risperidone, Clozapine, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole, Paliperidone, Iloperidone, Asenapine.
- • Medication choice is based on clinical and subjective response and side effects.
- For Sensitivity to EPS: Atypical.
- For tardive dyskinesia: clozapine.
- For poor compliance: Injectable long antipsychotics such as fluphenazine.
- For acute dystonic reaction/EPS give benztropine 1-4 mg Po/IM.