Psychiatry 5th year, 2nd & 3rd lectures (Dr. Nazar M. Mohammad Amin)

Schizophrenia

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SchizophreniaHistory

It is a disease of thoughts, action and emotions. In the year 1860, Morel used the term demence precoce to describe a state of bizarre behavior and abnormal mental functions. Emil kraeplin 1899 used the term dementia precox and differentiated it from manic depressive illness. Bleuler 1911, coined the term schizophrenia and he thought that it resulted from splitting of psychic functions particularly affective and cognitive.

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SchizophreniaEtiology

There are a variety of etiological factors including:Biological Psychological Social “ Biopsychosocial”

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Biological factors:Genetics:The risk of developing schizophrenia in the general population is 1%. The risk becomes 10% if one parent or a sibling in the family is schizophrenic. The risk is 40% if both parents are schizophrenic. It is 10-15% for a dizygotic co twin of an affected individual and 40% for a monozygotic co twin.

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Biological factors:Genetics: The effect of the environment is controlled for by adoption studies because individuals of the same family have different environments.

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Biological factors:Neurochemistry: Dopamine based on the effect of amphetamine which releases dopamine causing psychosis and classical antipsychotic drugs which block dopamine receptors. Serotonin based on the atypical antipsychotics which block both dopamine and serotonin receptors. Glutamate based on the antagonism of glutamate receptors by phencyclidine leading to psychosis.

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Psychological factors:Cognitive factors including impairments of attention and memory.

Personality factors: adults with schizophrenia are much more likely to have a premorbid schizoid or schizotypal personality traits

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Psychological factors:Psychological stress-high expressed emotions:Families who have excessive critical comments and hostility as well as emotional overinvlovement with the patients are described as high expressed emotions families. The chance of relapse for schizophrenic patients living in those families is greater than in other families. Tim Crew and Mary Johnstone.

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Social Cannabis: the use of cannabis in adolescence increases the risk of schizophrenia in adulthood. Life events: schizophrenic patients may exposed to more life events than normals.

PSYCHIATRY 4:10 History9

Schizophreniaepidemiology and risk factors

Age of onset: 15-35 years and it is 3-4 years earlier for males than females. Sex: the incidence is the same for both sexes but recent metanalysis indicates more in men .Socia class: more in lower socioeconomic states ( drift hypothesis)

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Schizophreniaepidemiology and risk factors

Immigration it is more common in immigrants than native population but this could be a gene environment interaction.It is more common in urban than rural populations.PSYCHIATRY 4:10 Epid

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Schizophreniasymptoms

DSM IV and ICD described some types of schizophrenia as paranoid, hebephrenic and catatonic types and the symptoms are classified into positive, acute or type I symptoms and negative, chronic and type II symptoms.

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Positive symptoms include: delusions which could be bizarre, persecutory, control or somatic. Hallucinations which are mostly auditory of the second or third person, commanding and running commentary. Visual hallucination are less common. Other thought disorders include loosening of association and thought block

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Negative symptoms include: AlogiaAffective flatteningAvolition-apathyAnhedonia- asocialityInattentionThey are mostly a reflection of cognitive dysfunctions due to prefrontal cortex atrophy.Depression and extrapyramidal side effects of antipsychotics could be misdiagnosed as negative symptoms. PSYCHIATRY 4:10

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Schizophreniadiagnosis

There have been many descriptions of the condition and many criteria for the diagnosis including Bleuler’s 4 A s and Schneider’s first rank and second rank symptoms and more recently DSM and ICD.The main symptoms required for the diagnosis includes delusions, hallucinations, disorganised thoughts and behaviour.

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Schizophreniacognition

Cognitive disorders are now considered as the core symptoms of schizophrenia. They impair individuals in areas of vocation, social network and living independently.Typical antipsychotics cause cognitive impairments and atypicals have no such an effect.Am J Psychiatry 166:6, June 2009

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Schizophreniaoutcome and prognosis

Most of the studies done on the schizophrenic patients revealed that a proportion of the patients will remain ill from the first episode and will never recover. Another proportion will have only one episode with some residual effect and will be able to function normally in areas of social and occupational life.

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In the UK, a 5-year follow-up study of a first-admission cohort of 49 schizophrenic patients found that in most cases the illness followed one of four broad patterns: • one episode only and no impairment (22%) • several episodes with no or minimal impairment (35%) • repeated episodes with impairment after first episode with subsequent exacerbation and no return to normality (8%) • impairment increasing with each of several episodes, with increasingly severe residual symptoms and no return to normality (35%

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The outcome is generally better for females. The prognosis is better for both sexes in developing than industrialized countries. Factors indicating poor prognosis include male sex, family history of schizophrenia, structural brain abnormalities, absence of life events, early onset, cognitive deficit, substance abuse and poor premorbid functioning

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Good prognosis is predicted in good premorbid social functioning, later and sudden onset, presence of depressive symptoms, good initial response to medications and absence of tension in the family.PSYCHIATRY 4:10

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Schizophreniadifferential diagnosis

Mood disorders also called affective disorders. Delusional disorderOrganic psychosisSubstance induced psychosisDelerium Dementia 21

Schizophreniadifferential diagnosis

Schizoaffective disorderPersonality disordermalingering

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SchizophreniaManagement

The management of first episode schizophrenia should include diagnosis and differential diagnosis.Proper history, physical and neurological examination is mandatory. Investigations are needed to exclude other disorders and they include:Urine screening for drugsBlood tests including full blood count, liver function tests, thyroid function tests, urea and electrolytes and calcium.EEG and Neuroimaging including CT and MRI

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Antipsychotics: it is better to start with an atypical antipsychotic if the patient is not already on antipsychotics.Benzodiazepines may be needed as adjuvants for a short time to control agitation and insomnia. Control drug and alcohol intake. Family support in the form of psycho education and groups . Try to identify high expressed emotions to avoid future relapses.

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Encourage drug compliance. Minimise the duration of untreated psychosis DUP.Cognitive behaviour therapy to improve residual psychopathology. Try to avoid stigma of mental illness. Hospitalisation Risk assessment. Especially possibility of suicide and homicide.

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Pharmacological treatment of schizophrenia:Chlorpromazine was introduced in 1952. it is one of a group of antipsychotics called classical, typical, dopamine blocking or first generation antipsychotics. The other members include trifluperazine, fluphenazine, thioridazine, haloperidone etc..In the year 1990 another generation of antipsychotics was introduced called nonclassical, second generation, serotonin and dopamine blocking or atypical antipsychotics. They include resperidone, olanzepine, quetiapine, sertindole, zotepine, amisulpride, ziprasidone and colzapine

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Antipsychotics have parenteral preparations for patients who have low compliance. Antipsycotics are absorbed in the jejunum and metabolized in the liver. They also induce liver enzymes and are protein bound. The antipsychotic action of these drugs is thought to be postsynaptic blockade of dopamine (D2)receptors in the mesolimbic area of the brain. Modification of dopamine transmission in the frontal cortex may be relevant too.

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They act on other receptors too leading to some side effects and they include other dopamine receptor subtypes, serotonin, muscarinic, adrenergic and histaminergic receptors. It is recommecded by NICE that a first onset of schizophrenia be treated with oral atypical antipsychotic. Parentral antipsychotics are left for noncompliant patients. These drugs are used to treat the acute episode and mentainence treatment afterwards which could be for months or years.

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If the patient did not respond to atypical antipsychotics or could not tolerate them he will be switched to typical antipsychotics. Patients who did respond or could not tolerate those drugs too will be given clozapine under close monitering because of the serious side effects.

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Atypical antipsychotics are thought to have a wider antipsychotic effect because they on both serotonin and dopamine receptors. They produce less side effects therefore they are more tolerable by patients and there will be shorter DUP duration of untreated psychosis. However they much more expensive. However the new side effect profile of those drugs has changed a lot of those beliefs. It is always preferable to discus the choice of the treatment with the patients, family doctor and his carers .

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Contraindications for typical antipsychotics include bone marrow suppression and coma produced by CNS depressants. Caution should be taken when given to psychotic patients with cardiovascular, liver, renal and neurological disorders as well as glaucoma. Atypical drugs should be used with caution in pregnancy and breast feeding mothers. Clozapine is contraindicated in neutropenia, agranylocytosis and myeloproliferative disorders.

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Unwanted effects Typical antipsychotics Extrapyramidal side effects include acute dystonia, akathisia and parkinsinism. They could be controlled by reducing the dose, changing the drug or adding an anticholinergic drug like procyclidine or benzhexol either orally or parenterally. Akithisia is controlled by adding a beta blocker.Tardive dyskinesia after prolonged use of antipsychotics could be helped by changing to an atypical antipsychotic or if no response clozapine.

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Unwanted effects Anticholinergic side effects including constipation, urinary hesitancy or retention, blurred vision, precipitaton of glaucoma, failure of ejaculation and cutaneous flushling. Antiadrenergic effects as hypotension and inhibition of ejaculation too. Sedation due to D2, H1 and alpa receptor antagonism. Cardiovascular effects as tachycardia, prolonged QT interval, flat T wave, cardiac arrythmias and myocarditis.

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Unwanted effects Hyperprolactinemia due to hypothalamopituitary D2 receptor blockade in the form ammenorrhea, galactorrhea, and breast enlargement in females. Impotence and gynecomastia in males. Other side effects include photosensivity, skin pigmentation, allergic rash, corneal and lense deposits, cholestatic jaundice, leucopenia and agranulocytosis, and lowering seizure threshold.

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Unwanted effects Neuroleptic malignant syndrome it is fatal in 20% of the cases and is characterised by hyperthermia, autonomic instability, alteration of consciousness and elevated serum CPK.They might also produce weight gain, hypothermia, nausia and agitation and anxiety.

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Unwanted effects Atypical antipsychotics were thought to have a very safe profile of side effects, however they were found to cause somnolence with metabolic syndrome in the form of type 2 diabetes, obesity and dyslipidemia. Amisulpride: insomnia and agitation. Aripiprazole: nausia, vomiting, anxiety and restlessness.

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Clozapine: sedation, fatigue, hypersalivation, anticholinergic effects, weight gain, postural hypotension, tachycardia and nausia. Agranulocytosis, lowering seizure threshold and hyperglycemia. Olanzepine: obesity, somnolence, dizziness, anticholinergic effects and hyperglycemia.

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Quetiapine: postural hypotension, somnolence, dizziness, constipation and dry mouth and prolonged QT interval. Resperidone: extrapyramidal side effects, insomnia, anxiety, agitation, headache and weight gain.

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Schizophrenia related disorders

• Schizophreniform psychosis or acute schizophrenia like psychosisThis is a condition were the symptoms are similar to

schizophrenia but the duration of the symptoms is more than one month and less than six months.

Patients return to their baseline level of functioning once the disorder has resolved.

(60-80)% of patients progress to schizophrenia.

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• Schizophreniform psychosis or acute schizophrenia like psychosis

• It has a rapid onset without a prodrome. Hallucinations, delusions and negative symptoms of alogia and avolition may be present. Speech may be confused or disorganized and behaviour may be disorganized or catatonic.

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• Schizoaffective disorder• They are a heterogenous group of disorders. Some

may have a mood disorder with prominent schizophrenic symptoms, schizophrenia with prominent affective symptoms and others have a distinct clinical picture.

• Men with disorder are more likely to have antisocial behaviour with flat or inappropriate affect.

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• Delusional disorder• Occurs when a patient exhibit nonbizarre

delusions of at least one month’s duration that cannot be attributed to other psychotic disorders.

• Nonbizarre means that the delusions must be about situations that can occur in real life, such as being followed, infected, loved at a distance and so on

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Delusional disorder

• It is much rarer than schizophrenia. Slightly more common in females. Men are more likely to develop paranoid delusions than women, who are more likely to develop delusions of erotomania.

• There is some association with recent immigration and low socioeconomic status.

• Types:• persecutory type.• jealous type.• erotomanic type.• somatic type. MHP : Parasitosis, Foul body odour or

Halithosis, and dysmorphophobia.• grandiose type.

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Brief psychotic disorder

• Is an acute and transient psychotic syndrome. It lasts from one day to one month and the symptoms may resemble those of SZ. It may develop in response to a severe psychosocial stressor or group of stressors.

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Psychiatry 5th year, 2nd & 3rd lectures (Dr. Nazar M. Mohammad Amin)

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Transcript of Psychiatry 5th year, 2nd & 3rd lectures (Dr. Nazar M. Mohammad Amin)