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Dr.Balan Stephen

Clinical Presentation
Schizophrenia is a brain disorder affecting a person's

Clinical Features    
Hearing imaginary voices (auditory hallucinations)
Believing that these voices are controlling their thoughts and actions.
Believing that people are plotting to harm them (Delusions).
Over time, they become withdrawn and avoid company.
Their speech and behaviour become disorganized, if left untreated.
The onset is generally gradual, and rarely sudden or dramatic.
Certain symptoms can develop slowly, in an almost imperceptible fashion
While other symptoms develop more rapidly and are very easy to recognize.
All the symptoms described, may not appear in any one individual or at the same point of time.

The symptoms broadly classified as Positive and Negative.

Positive symptoms are easily noticeable, more disruptive to the family, more distressing to the patient and make the patient more responsive to medicines.

Positive symptoms
Delusions, hallucinations, thought disorders.

Negative symptoms are not easily noticeable and are not very disruptive socially, but can be more disabling than the positive symptoms. Patients with these symptoms are less responsive to medicines. .

Negative symptoms
Reduced motivation and drive
Difficulty in experiencing pleasure
Lack of emotions
Lack of energy
Alogia, Anhedonia,  Anergia,  Apathy, Amotivation.
Patients with negative symptoms are often mistaken to be deliberately lazy or are not making any effort and the family may turn hostile towards the patient on account of these symptoms. They are subjected to criticism.

Behavioural changes
Are common
More easily recognised by family members
Different forms of behavioural changes :
Social withdrawal
Persistent preoccupations
Antisocial behaviour.
Impairment of day to day functioning. a drop in school attendance and performance.
Increasing unproductivity, difficulties in maintaining interpersonal relationships, neglect of house hold activities and preoccupation in a personal world are the common clinical manifestations  .

    Delusions are patient's fixed beliefs in something that is obviously untrue. They may believe that they are being persecuted, that people are conspiring against them at work or at home. They may suspect their spouse of infidelity and may take to watching them constantly. They may believe that their thoughts are being controlled by some external force (e.g.) that a radio receiver is planted in their head. These beliefs will not be shaken by attempts to reason with them.

Hallucinations are imaginary voices which the patient hears responds to. These voices can be distressing and patients sometime feel controlled by them. The patients are seen apparently talking to themselves in a disjointed way, often laughing, gesticulating or smiling. Often, the patients see frightening figures and their fear may make it difficult for others to control them. They could even be driven to suicide.

Thought Disturbance
Schizophrenia is often characterised by disturbances in thinking. This may be reflected in incoherent and irrelevant speech. The patients may report that their thoughts are muddled, are withdrawn by somebody else or that other people get to know what they are thinking. The patients may also believe that thoughts are inserted into their minds.

Loss of Interest and Social Withdrawal
The persons start losing interest in their work, studies, family and friends. They are very irritable, look vacant when questioned, and stop going to work.Spend time wandering aimlessly or doing nothing, looking preoccupied or lost in thought. This is usually accompanied by sharp fall in academic or work performance, disturbed sleep patterns and loss of appetite. The individuals also begin withdrawing into themselves; shunning company and social interact of any sort.

Disinterst in Personal Hygiene
  Often, the patients refuse to bathe or keep themselves clean, and lose interest in their physical appearance and that of their surroundings.

Inability to Express Emotion
Patients become emotionally blunted. They are unable to express appropriate emotion and do not appear to be in touch with reality outside of themselves. Many complain that they neither feel sad nor happy.

Lack of Attention and Concentration
This is very often a symptom of schizophrenia and may be reported either by the parents or any of their family members. They could have difficulty in performing daily activities such as reading the newspaper or watching the television. Because of this, they leave the task half done. This is a frequent problem at work.

Lack of Insight
Very few persons with schizophrenia know or admit that they have a problem. They often deny any illness or difficulty, sometimes blame those who take them to doctors, or attribute everything to physical illness. This can delay or hinder the treatment process.

Prodromal Symptoms
The term prodrome generally signifies the prepsychotic period before the onset of the illness, or that preceding an episode of relapse. Veryoften, a patient has similar prodromal symptoms before each relapse. It is important for both the patient and their family members to be aware of this in order to facilitate early intervention.

Common Prodromal Features
Reduced concentration
Reduced drive and motivation
Depressed mood
Sleep disturbance
Social withdrawal
Deterioration in role functioning

Conditions other than Schzophrenia
Psychotic symptoms can be seen in conditions other than schizophrenia
Temporal lobe and frontal lobe epilepsy
Neuro- degenerative disorders like wilsons disease, dementias, mental retardation.
Abuse of drugs like cannabis, amphetamine, cocaine
Alcohol abuse leads to paranoia
During post-partum period
Transient psychotic symptoms are seen as part of dissociative states called as hysterical psychosis.

Course and Outcome of Schizophrenia
The common type of course is
1.   Ccontinuous illness
2.   A relapsing course with increasing disability
3.   A single episode followed by complete improvement

Factors indicating a better outcome in patients:
1.    Female gender
2.    Married status
3.    Early treatment
4.   Acute onset of the illness
5.   Rural background and cohesive family
6.   Absence of negative symptoms
7.   Predominance of florid positive symptoms
8.   Short duration of first episode
9.   Few episodes of similar illness in the past.
10. Good premorbid personality and adjustment.

Factors indicating a poor outcome in patients:
1. Male gender
2. Strong family history of psychotic disorders
3. Unmarried status
4. Earlier age onset or gradual onset of illness
5. Delayed or irregular treatment.
6. Substance abuse- alcohol, cannabis
7. Excessive criticism, hostility, or over-involvement in the home and family atmosphere.

Management of Schizophrenia
Not possible to prevent the development of schizophrenia.
It is possible to identify high-risk populations, such as children born to parents with the disorder.
No intervention to delay or prevent its manifestation
Identify the illness as early as possible, treat the symptoms, provide skills to the family, maintain improvement over a period of time, prevent relapses and reintegrate the ill person in the community to lead a normal life.

Early Diagnosis
Increase the level of awareness about the illness
Early symptom can be similar to those of several other conditions, such as depression.
Hence community awareness and education promoted on a large scale.

Treatment Phases & Goals
1.   Acute Phase
Reduction of symptoms and risk of harm,    improvement of functioning.

2. Post-acute phase
Consolidation of remission, continued reduction in symptoms & prevention of early relapses.

3. Stable phase
Maintaining/ improving level of functioning, prevention of recurrences.
Treatment of schizophrenia requires integration of medical, psychological and psycho social inputs.

Pharmacological Management
Main stay: antipsychotic medications
Anti-depressant and mood stabilizers may also have to be used at times.
Antipsychotic medications diminish the positive symptoms of schizophrenia and prevent relapses.
Approximately 80% of patients relapse within one year if antipsychotic medications are stopped
Only 20% relapse if treated.
These drugs must be used with caution in children, pregnant or breast-feeding women, and elderly patients.
Patients may require hospitalization for exacerbation of symptoms
Exacerbation is caused by noncompliance with pharmaco therapy, substance abuse, adverse effects or toxicity of medications, medical illness, psychosocial stress, or the waxing or waning of the illness itself.
Hospitalization is brief and oriented towards crisis management or symptom stabilization.

Optimal Dose of Commonly Used Antipsychotics
Single doses / day
haloperidol---------------------  1.5 to 20 mg
trifluperazine  ------------------ 5 to 15 mg.
chlorpromazine --------------  50 to 300 mg
risperidon ----------------------  2 to 8 mg
olanzapine ---------------------  5 to 20 mg
amisulpiride ------------------  50 to 400 mg
clozapine   --------------------  50 to 300 mg

Depot injection IM
inj haloperidol ------- 50 to 100 mg (4 weekly)
injfluphenazine ----  20 to 40 mg ( 2 to 4 weekly)
injfluphenthixol ------- 20 to 40 mg (2 to 4 weekly)

Side Effects of Antipsychotics
Anti-cholinergic side effects
Weight gain
Tardive dyskinesia
Galactorrhoea- amenorrhoea
First Generation antipsychotic drugs have Extra pyramidal adverse effects.
The second generation drugs are more likely to cause weight gain and metabolic side effects.

Choice of Antipsychotics
There is no clear antipsychotic drug of choice for schizophrenia.
The choice of the drug depends on availability and side effect profile.
Treatment should be started with one antipsychotic in optimal dosage.
If no response after a period of 4 weeks - switch to the second anti-psychotic.
When patient is violent, more than one drug may be necessary.

Adherence to Medication
Non-compliance with pharmacologic therapy is common,
Iintramuscular (IM) preparation of antipsychotics use of depot IM medications ,such as every 2-4 weeks
Non adherence can be partial or complete, but even partial adherence is associated with relapse.
Non adherence may be due to lack of insight of the patient or due to side effects.
The family or care taker must be advised to supervise regular intake of medicines.

Duration of Treatment
The duration of treatment depends on
Duration of untreated illness
Response to treatment
Course of the disorder.
For a single episode which remits fast, medicines can be stopped anywhere between 6 and 24 months.
1-2 relapses - a minimum of 5 year
In case of multiple relapses - lifelong treatment.
ECT or Electro Convulsive Therapy for acute phase, catatonic states and poor response to medications

Psycholosocial Treatment
Essential for people with schizophrenia and includes a number of approaches:
Social skills training
Cognitive behaviour therapy
Cognitive remediation
Social cognition training.
Cognitive impairment,  (eg. delusions, hallucinations), but interferes with work, social relationships, and independent living,  is not improved by medication and requires psychological interventions.

Cognitive Remediation
Cognitive remediation - brain exercises to encourage neurons to grow and develop the neuro circuitry underlying mental activities.
Drill based practising of isolated cognitive skills with aid of computers
Other forms of this therapy are known as cognitive rehabilitation, cognitive enhancement, or meta cognitive therapy.

Vocational Rehabilitation
Employment can improve income, self-esteem, and social status.
Supported employment programmes

Psycho Education
Imparting correct and scientific information to families

Assertive Community Treatment
Used for patients who have had multiple hospitalizations.
The treatment involves active outreach to patients.
Case managers or even community level workers in rural areas can be trained to identify persons requiring treatment, make referral to appropriate services, and promote engagements with interventions.

Family Interventions
Schizophrenia affects the person's whole family, and the family responses can affect the course of the person'sillness. high expressed emotions (hostile over involvement and intrusiveness) leads to more frequent relapses. Family interventions may prevent relapses, reduce hospital admission, and improve medication compliance.