Schizophrenia and other psychotic and case

(urine test) = test for amphetamine, cannabinol (THC)

temporal lobe epilepsy - eeg, auditory cortex

admission volutory or involuntary, deescalation, restraint, tranquillisation.

EMS SE vs metabolic SE

DD treated with antipsychotic and psychotherapy

Some stuff about "expressed emotions"

dont be too involved or under involved. both postive and negative EE increased relapse.

https://www.therecoveryvillage.com/mental-health/psychosis/

perception normal, no delusions. nut experince is peculiarly not shared by others

educate the relatives dont be too evolved and under evolved…(expressed emotions)

WBC count and differential (not fbc necessary)

Schizo

Epidemiology

Cause

Risk factors

Types

Type description in icd

Catatonic 7

Negative 5

Positive 5

Cognitive

Icd 1p diagnosis

Exlcusion in icd

Coruse description in Icd

Dsm 5 Criteria and other criteria

Words used to describe

Associated features

Clinical staging and importance

Severity in Dsm

Other 2 and classification of course

Comorbidies and cognitive deficits

Complications

Diagnosis basis

Methods

3 phases of treatment

Hospitalisation?

Stable phase mx 7

And acute phase

Psychiatric mx 7

Plan of management in acute +5

Factors affecting choice of treatment setting

Providing a supportive environment 5

Minimising harm (ass and mx)

Educating the pt and family

Discharge plan

Follow up

ECT

Psychosocial interventions

Antipsychotic medications

Flowchart?

At each visit?

Acute psychotic pt

Issue with antipsychotic 2

Side effects of antipsychotics?

Min effective dose vs starting dose

Combination?

Treatment resistance?

Approach to tx resistance?

Clozapine problems?

Sri Lankan long acting injectable?

Cessation of Tx?

Guidelines for duration?

-------------------

Diagnostic Criteria

Specify it

The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.

First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.

First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.

First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.

Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).

Multiple episodes, currently in partial remission

Multiple episodes, currently in full remission

Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course

Unspecified

With catatonia?

Specify current severity

Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

Diagnostic features

The characteristic symptoms of schizophrenia involve a range of cognitive, behavioral, and emotional dysfunctions, but no single symptom is pathognomonic of the disorder. The diagnosis involves the recognition of a constellation of signs and symptoms associated with impaired occupational or social functioning. Individuals with the disorder will vary substantially on most features, as schizophrenia is a heterogeneous clinical syndrome.

At least two Criterion A symptoms must be present for a significant portion of time during a 1-month period or longer. At least one of these symptoms must be the clear presence of delusions (Criterion Al), hallucinations (Criterion A2), or disorganized speech (Criterion A3). Grossly disorganized or catatonic behavior (Criterion A4) and negative symptoms (Criterion A5) may also be present. In those situations in which the activephase symptoms remit within a month in response to treatment. Criterion A is still met if the clinician estimates that they would have persisted in the absence of treatment.

Schizophrenia involves impairment in one or more major areas of functioning (Criterion B). If the disturbance begins in childhood or adolescence, the expected level of function is not attained. Comparing the individual with unaffected siblings may be helpful. The dysfunction persists for a substantial period during the course of the disorder and does not appear to be a direct result of any single feature. Avolition (i.e., reduced drive to pursue goal-directed behavior; Criterion A5) is linked to the social dysfunction described under Criterion B. There is also strong evidence for a relationship between cognitive impairment (see the section "Associated Features Supporting Diagnosis" for this disorder) and functional impairment in individuals with schizophrenia.

Some signs of the disturbance must persist for a continuous period of at least 6 months (Criterion C). Pi;odromal symptoms often precede the active phase, and residual symptoms may follow it, characterized by mild or subthreshold forms of hallucinations or delusions. Individuals may express a variety of unusual or odd beliefs that are not of delusional proportions (e.g., ideas of reference or magical thinking); they may have unusual perceptual experiences (e.g., sensing the presence of an unseen person); their speech may be generally understandable but vague; and their behavior may be unusual but not grossly disorganized (e.g., mumbling in public). Negative symptoms are common in the prodromal and residual phases and can be severe. Individuals who had been socially active may become withdrawn from previous routines. Such behaviors are often the first sign of a disorder

Mood symptoms and full mood episodes are common in schizophrenia and may be concurrent with active-phase symptomatology. However, as distinct from a psychotic mood disorder, a schizophrenia diagnosis requires the presence of delusions or hallucinations in the absence of mood episodes. In addition, mood episodes, taken in total, should be present for only a minority of the total duration of the active and residual periods of the illness.

In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom domains is vital for making critically important distinctions between the various schizophrenia spectrum and other psychotic disorders

Associated features supporting diagnosis

Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the absence of an appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety, or anger; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in eating or food refusal. Depersonalization, derealization, and somatic concerns may occur and sometimes reach delusional proportions. Anxiety and phobias are common. Cognitive deficits in schizophrenia are conrmion and are strongly linked to vocational and functional impairments. These deficits can include decrements in declarative memory, working memory, language function, and other executive functions, as well as slower processing speed. Abnormalities in sensory processing and inhibitory capacity, as well as reductions in attention, are also found.

Some individuals with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind), and may attend to and then inteφret irrelevant events or stimuli as meaningful, perhaps leading to the generation of explanatory delusions. These impairments frequently persist during symptomatic remission. Some individuals with psychosis may lack insight or awareness of their disorder (i.e., anosognosia). This lack of "'insight" includes unawareness of symptoms of schizophrenia and may be present throughout the entire course of the illness. Unawareness of illness is typically a symptom of schizophrenia itself rather than a coping strategy. It is comparable to the lack of awareness of neurological deficits following brain damage, termed anosognosia. This symptom is the most common predictor of non-adherence to treatment, and it predicts higher relapse rates, increased number of involuntary treatments, poorer psychosocial functioning, aggression, and a poorer course of illness.

Hostility and aggression can be associated with schizophrenia, although spontaneous or random assault is uncommon. Aggression is more frequent for younger males and for individuals with a past history of violence, non-adherence with treatment, substance abuse, and impulsivity. It should be noted that the vast majority of persons with schizophrenia are not aggressive and are more frequently victimized than are individuals in the general population.

Currently, there are no radiological, laboratory, or psychometric tests for the disorder. Differences are evident in multiple brain regions between groups of healthy individualsand persons with schizophrenia, including evidence from neuroimaging, neuropathological, and neurophysiological studies. Differences are also evident in cellular architecture, white matter connectivity, and gray matter volume in a variety of regions such as the prefrontal and temporal cortices. Reduced overall brain volume has been observed, as well as increased brain volume reduction with age. Brain volume reductions with age are more pronounced in individuals with schizophrenia than in healthy individuals. Finally, individuals with schizophrenia appear to differ from individuals without the disorder in eyetracking and electrophysiological indices. Neurological soft signs common in individuals with schizophrenia include impairments in motor coordination, sensory integration, and motor sequencing of complex movements; left-right confusion; and disinhibition of associated movements. In addition, minor physical anomalies of the face and limbs may occur

Prevalance

The lifetime prevalence of schizophrenia appears to be approximately 0.3%-0.7%, although there is reported variation by race/ethnicity, across countries, and by geographic origin for immigrants and children of immigrants. The sex ratio differs across samples and populations: for example, an emphasis on negative symptoms and longer duration of disorder (associated with poorer outcome) shows higher incidence rates for males, whereas definitions allowing for the inclusion of more mood symptoms and brief presentations (associated with better outcome) show equivalent risks for both sexes.

Development and Course

The psychotic features of schizophrenia typically emerge between the late teens and the mid-30s; onset prior to adolescence is rare. The peak age at onset for the first psychotic episode is in the early- to mid-20s for males and in the late-20s for females. The onset may be abrupt or insidious, but the majority of individuals manifest a slow and gradual development of a variety of clinically significant signs and symptoms. Half of these individuals complain of depressive symptoms. Earlier age at onset has traditionally been seen as a predictor of worse prognosis. However, the effect of age at onset is likely related to gender, with males having worse premorbid adjustment, lower educational achievement, more prominent negative symptoms and cognitive impairment, and in general a worse outcome. Impaired cognition is common, and alterations in cognition are present during development and precede the emergence of psychosis, taking the form of stable cognitive impairments during adulthood. Cognitive impairments may persist when other symptoms are in remission and contribute to the disability of the disease.

The predictors of course and outcome are largely unexplained, and course and outcome may not be reliably predicted. The course appears to be favorable in about 20% of those with schizophrenia, and a small number of individuals are reported to recover completely. However, most individuals with schizophrenia still require formal or informal daily living supports, and many remain chronically ill, with exacerbations and remissions of active symptoms, while others have a course of progressive deterioration. Psychotic symptoms tend to diminish over the life course, perhaps in association with normal age-related declines in dopamine activity. Negative symptoms are more closely related to prognosis than are positive symptoms and tend to be the most persistent. Furthermore, cognitive deficits associated with the illness may not improve over the course of the illness. The essential features of schizophrenia are the same in childhood, but it is more difficult to make the diagnosis. In children, delusions and hallucinations may be less elaborate than in adults, and visual hallucinations are more common and should be distinguished from normal fantasy play. Disorganized speech occurs in many disorders with childhood onset (e.g., autism spectrum disorder), as does disorganized behavior (e.g., attention-deficit/ hyperactivity disorder). These symptoms should not be attributed to schizophrenia without due consideration of the more common disorders of childhood. Childhood-onset cases tend to resemble poor-outcome adult cases, with gradual onset and prominent negative symptoms. Children who later receive the diagnosis of schizophrenia are more likely to have experienced nonspecific emotional-behavioral disturbances and psychopathology, intellectual and language alterations, and subtle motor delays. Late-onset cases (i.e., onset after age 40 years) are overrepresented by females, who may have married. Often, the course is characterized by a predominance of psychotic symptoms with preservation of affect and social functioning. Such late-onset cases can still meet the diagnostic criteria for schizophrenia, but it is not yet clear whether this is the same condition as schizophrenia diagnosed prior to mid-life (e.g., prior to age 55 years).

Risk and Prognostic Factors

Environmental. Season of birth has been linked to the incidence of schizophrenia, including late winter/early spring in some locations and summer for the deficit form of the disease. The incidence of schizophrenia and related disorders is higher for children growing up in an urban environment and for some minority ethnic groups.

Genetic and physiological. There is a strong contribution for genetic factors in determining risk for schizophrenia, although most individuals who have been diagnosed with schizophrenia have no family history of psychosis. Liability is conferred by a spectrum of risk alleles, common and rare, with each allele contributing only a small fraction to the total population variance. The risk alleles identified to date are also associated with other mental disorders, including bipolar disorder, depression, and autism spectrum disorder. Pregnancy and birth complications with hypoxia and greater paternal age are associated with a higher risk of schizophrenia for the developing fetus. In addition, other prenatal and perinatal adversities, including stress, infection, malnutrition, maternal diabetes, and other medical conditions, have been linked with schizophrenia. However, the vast majority of offspring with these risk factors do not develop schizophrenia.

Culture-Related Diagnostic

Issues Cultural and socioeconomic factors must be considered, particularly when the individual and the clinician do not share the same cultural and socioeconomic background. Ideas that appear to be delusional in one culture (e.g., witchcraft) may be commonly held in another. In some cultures, visual or auditory hallucinations with a religious content (e.g., hearing God's voice) are a normal part of religious experience. In addition, the assessment of disorganized speech may be made difficult by linguistic variation in narrative styles across cultures. The assessment of affect requires sensitivity to differences in styles of emotional expression, eye contact, and body language, which vary across cultures. If the assessment is conducted in a language that is different from the individual's primary language, care must be taken to ensure that alogia is not related to linguistic barriers. In certain cultures, distress may take the form of hallucinations or pseudo-hallucinations and overvalued ideas that may present clinically similar to true psychosis but are normative to the patient's subgroup.

Gender-Related Diagnostic Issues

A number of features distinguish the clinical expression of schizophrenia in females and males. The general incidence of schizophrenia tends to be slightly lower in females, particularly among treated cases. The age at onset is later in females, with a second mid-life peak as described earlier (see the section "Development and Course" for this disorder). Symptoms tend to be more affect-laden among females, and there are more psychotic symptoms, as well as a greater propensity for psychotic symptoms to worsen in later life. Other symptom differences include less frequent negative symptoms and disorganization. Finally, social functioning tends to remain better preserved in females. There are, however, frequent exceptions to these general caveats.

Suicide Risk

Approximately 5%-6% of individuals with schizophrenia die by suicide, about 20% attempt suicide on one or more occasions, and many more have significant suicidal ideation. Suicidal behavior is sometimes in response to command hallucinations to harm oneself or others. Suicide risk remains high over the whole lifespan for males and females, although it may be especially high for younger males with comorbid substance use. Other risk factors include having depressive symptoms or feelings of hopelessness and being unemployed, and the risk is higher, also, in the period after a psychotic episode or hospital discharge.

Functional Consequences of Schizoplirenia

Schizophrenia is associated with significant social and occupational dysfunction. Making educational progress and maintaining employment are frequently impaired by avolition or other disorder manifestations, even when the cognitive skills are sufficient for the tasks at hand. Most individuals are employed at a lower level than their parents, and most, particularly men, do not marry or have limited social contacts outside of their family.

Differential Diagnosis

Major depressive or bipolar disorder with psychotic or catatonic features. The distinction between schizophrenia and major depressive or bipolar disorder with psychotic features or with catatonia depends on the temporal relationship between the mood disturbance and the psychosis, and on the severity of the depressive or manic symptoms. If delusions or hallucinations occur exclusively during a major depressive or manic episode, the diagnosis is depressive or bipolar disorder with psychotic features.

Schizoaffective disorder. A diagnosis of schizoaffective disorder requires that a major depressive or manic episode occur concurrently with the active-phase symptoms and that the mood symptoms be present for a majority of the total duration of the active periods.

Schizophreniform disorder and brief psychotic disorder. These disorders are of shorter duration than schizophrenia as specified in Criterion C, which requires 6 months of symptoms. In schizophreniform disorder, the disturbance is present less than 6 months, and in brief psychotic disorder, symptoms are present at least 1 day but less than 1 month.

Delusional disorder. Delusional disorder can be distinguished from schizophrenia by the absence of the other symptoms characteristic of schizophrenia (e.g., delusions, prominent auditory or visual hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms).

Schizotypal personality disorder. Schizotypal personality disorder may be distinguished from schizophrenia by subthreshold symptoms that are associated with persistent personality features.

Obsessive-compulsive disorder and body dysmorphic disorder. Individuals with obsessive-compulsive disorder and body dysmorphic disorder may present with poor or absent insight, and the preoccupations may reach delusional proportions. But these disorders are distinguished from schizophrenia by their prominent obsessions, compulsions, preoccupations with appearance or body odor, hoarding, or body-focused repetitive behaviors.

Posttraumatic stress disorder. Posttraumatic stress disorder may include flashbacks that have a hallucinatory quality, and hypervigilance may reach paranoid proportions. But a trau- matic event and characteristic symptom features relating to reliving or reacting to the event are required to make the diagnosis.

Autism spectrum disorder or communication disorders. These disorders may also have symptoms resembling a psychotic episode but are distinguished by their respective deficits in social interaction with repetitive and restricted behaviors and other cognitive and communication deficits. An individual v^ith autism spectrum disorder or communication disorder must have symptoms that meet full criteria for schizophrenia, w^ith prominent hallucinations or delusions for at least 1 month, in order to be diagnosed with schizophrenia as a comorbid condition.

Other mental disorders associated with a psychotic episode. The diagnosis of schizophrenia is made only when the psychotic episode is persistent and not attributable to the physiological effects of a substance or another medical condition. Individuals with a delirium or major or minor neurocognitive disorder may present with psychotic symptoms, but these would have a temporal relationship to the onset of cognitive changes consistent with those disorders. Individuals with substance/medication-induced psychotic disorder may present with symptoms characteristic of Criterion A for schizophrenia, but the substance/medication-induced psychotic disorder can usually be distinguished by the chronological relationship of substance use to the onset and remission of the psychosis in the absence of substance use.

Comorbidity

Rates of comorbidity with substance-related disorders are high in schizophrenia. Over half of individuals with schizophrenia have tobacco use disorder and smoke cigarettes regularly. Comorbidity with anxiety disorders is increasingly recognized in schizophrenia. Rates of obsessive-compulsive disorder and panic disorder are elevated in individuals with schizophrenia compared with the general population. Schizotypal or paranoid personality disorder may sometimes precede the onset of schizophrenia. Life expectancy is reduced in individuals with schizophrenia because of associated medical conditions. Weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary disease are more common in schizophrenia than in the general population. Poor engagement in health maintenance behaviors (e.g., cancer screening, exercise) increases the risk of chronic disease, but other disorder factors, including medications, lifestyle, cigarette smoking, and diet, may also play a role. A shared vulnerability for psychosis and medical disorders may explain some of the medical comorbidity of schizophrenia.

What is schizophrenia (means fragmented mind)?

Schizophrenia is a complex disorder of brain function with wide variation in symptoms and signs, and in the course of the illness.

‘disturbance involving the most basic functions that give the normal person a feeling of individuality, uniqueness and self-direction’ (World Health Organization [WHO], 1992).

The deficits in neurological, psychological and social function that manifest in the various syndromes of schizophrenia appear to have a number of genetic and environmental causes.

Epidemiology

The prevalence of 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 rare.

Slightly more men are diagnosed with schizophrenia than women (on the order of 1.4:1)

Modal age of onset is between 18 and 25 for men and between 25 and 35 for women, with a second peak occurring around menopause.

There is also some indication that the prognosis is worse in men.

Progression of shizophrenia

Pathophysiology (3)

1. Dopamine hypothesis

2. Glutamate hypothesis

3. Serotonin hypothesis

Model of neurobiology of schizophrenia

Genetics of Schizophrenia

Heritability is high and genetic factors contribute about 80% of the liability for the illness.

There is no ‘major’ gene locus that could explain a substantial portion of the heritability and a large number of candidate susceptibility genes may contribute to the liability for the illness.

No gene appears to be either sufficient or necessary for the development of schizophrenia.

Although there are many “findings” of genetic variations being linked to differential risk for developing the illness, inconsistent replication prevents the consideration of any single allelic variant as a gene for schizophrenia with absolute certainty at this time.

Rajiv Tandon et al. Schizophrenia Research, 2008

Types of schizophrena

Paranoid schizophrenia

- hearing voices

- paranoid delusions

Catatonic schizophrenia

- features of catatonia

Hebephrenic schizophrenia or disorganized

- shallow and inappropriate emotional responses

- bizarre behavior

- delusions (+ or -)

- hallucinations (+ or -)

Simple schizophrenia

- negative symptoms ( avolition ,apathy, anhedonia, lack of motivation,

lack of initiative, low activity)

- no delusions ,no hallucinations

DIagnosis

The diagnosis is commonly made from history and the mental status examination

Should be differentiated from other psychiatric illnesses with similar presentation and medical disorders

Neuroimaging and cognitive testing may help to rule out alternatives such as schizophrenia-like manifestations of other disorders affecting brain function

Schizophrenia is essentially a clinical diagnosis.

ICD-10 diagnostic criteria or DSM-IV criteria can use for diagnosis.

ICD-10 diagnostic criteria

The ICD -10 diagnostic criteria require minimum of one clear symptom belonging to groups listed as a to d or symptoms from at least two of the groups listed from e to i and also requires the symptoms to be present for one month or more.

a)thought echo, thought insertion or withdrawal, and thought broadcasting;

b)delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;

c)hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;

d)persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world)

e)persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;

f)breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;

g)catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;

h)“negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;

i)a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

Staging the disease

Importance of clinical staging

Treatments offered earlier in the course of an illness have the potential to be safer, more acceptable , more effective and more affordable than those offered later.

Interventions can be evaluated in terms of their ability to prevent or delay progression from earlier to later stages of illness

Can be selected by the individual with schizophrenia and their clinicians on the basis of defined risk/benefit criteria.

At all stages, the therapeutic relationship is the foundation of clinical care.

Classification

Complications of schizophrenia

Suicide

Any type of self-injury

Anxiety and phobias

Depression, anxiety

Abuse of alcohol, drugs or prescription medications

Poverty

Homelessness

Family conflicts

Inability to work or attend school

Social isolation

Co-morbidities of schizophrenia

substance abuse

cigarette smokinh

m-mood disorders/suicides

anxiety disorders, panic disorders, OCD

obesity, diabetes, dyslipidaemia, hypertension, hep B and C, HIV, COPD and CVS disease

Cognitive deficits need to be taken into account in planning psychosocial treatments for the individual.

Eight cognitive domains are commonly (but not uniformly) impaired in people living with schizophrenia

1.Speed of processing

2. Attention/vigilance

3.Working memory (non-verbal)

4. Working memory (verbal)

5.Verbal learning

6. Visual learning

7. Reasoning and problem solving

8. Social cognition

Impairment in these domains influences functional capacity and limits functional outcomes

It is important to do cognitive screening in patients with schizophrenia with using a screening tool

F20 SCHIZOPHRENIA (ICD10)

This overall category includes the common varieties of schizophrenia, together with some less common varieties and closely related disorders.

F20.0 - F20.3 General criteria for Paranoid, Hebephrenic, Catatonic and Undifferentiated type of Schizophrenia:

G1. Either at least one of the syndromes, symptoms and signs listed below under (1), or at least two of the symptoms and signs listed under (2), should be present for most of the time during an episode of psychotic illness lasting for at least one month (or at some time during most of the days).

(1) At least one of the following:

a) Thought echo, thought insertion or withdrawal, or thought broadcasting.

b) Delusions of control, influence or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception.

c) Hallucinatory voices giving a running commentary on the patient's behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body.

d) Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather, or being in communication with aliens from another world).

(2) or at least two of the following:

e) Persistent hallucinations in any modality, when occurring every day for at least one month, when accompanied by delusions (which may be fleeting or half-formed) without clear affective content, or when accompanied by persistent over-valued ideas.

f) Neologisms, breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech.

g) Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.

h) "Negative" symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication).

G2. Most commonly used exclusion criteria: If the patient also meets criteria for manic episode (F30) or depressive episode (F32), the criteria listed under G1.1 and G1.2 above must have been met before the disturbance of mood developed.

G3. The disorder is not attributable to organic brain disease (in the sense of F0), or to alcohol- or drug-related intoxication, dependence or withdrawa

Comments: In evaluating the presence of the these abnormal subjective experiences and behaviour, special care should be taken to avoid false-positive assessments, especially where culturally or sub-culturally influenced modes of expression and behaviour, or a subnormal level of intelligence, are involved. In view of the considerable variation of the course of schizophrenic disorders it may be desirable (especially for research) to specify the pattern of course by using a fifth character. Course should not usually be coded unless there has been a period of observation of at least one year (For remission, see note X in Introduction).

Pattern of course

F20.x0 Continuous (no remission of psychotic symptoms throughout the period of observation);

F20.x1 Episodic, with a progressive development of 'negative' symptoms in the intervals between psychotic episodes;

F20.x2 Episodic, with persistent but non-progressive 'negative' symptoms in the intervals between psychotic episodes;

F20.x3 Episodic (remittent) with complete or virtually complete remissions between psychotic episodes;

F20.x4 Incomplete remission;

F20.x5 Complete or virtually complete remission;

F20.x8 Other pattern of course.

F20.x9 Course uncertain, period of observation too short.

F20.0 Paranoid schizophrenia

A. The general criteria for Schizophrenia (F20.0 - F20.3 above) must be met.

B. Delusions or hallucinations must be prominent (such as delusions of persecution, reference, exalted birth, special mission, bodily change or jealousy; threatening or commanding voices, hallucinations of smell or taste, sexual or other bodily sensations).

C. Flattening or incongruity of affect, catatonic symptoms, or incoherent speech must not dominate the clinical picture, although they may be present to a mild degree.

F20.1 Hebephrenic schizophrenia

A. The general criteria for Schizophrenia (F20.0 - F20.3) above must be met.

B. Either (1) or (2): (1) Definite and sustained flattening or shallowness of affect; (2) Definite and sustained incongruity or inappropriateness of affect. C. Either (1) or (2): (1) Behaviour which is aimless and disjointed rather than goal-directed; (2) Definite thought disorder, manifesting as speech which is disjointed, rambling or incoherent. D. Hallucinations or delusions must not dominate the clinical picture, although they may be present to a mild degree.

F20.2 Catatonic schizophrenia

A. The general criteria for Schizophrenia (F20.0 - F20.3 above) must eventually be met, though this may not be possible initially if the patient is uncommunicative. B. For a period of at least two weeks one or more of the following catatonic behaviours must be prominent: (1) Stupor (marked decrease in reactivity to the environment and reduction of spontaneous movements and activity) or mutism; (2) Excitement (apparently purposeless motor activity, not influenced by external stimuli); (3) Posturing (voluntary assumption and maintenance of inappropriate or bizarre postures); (4) Negativism (an apparently motiveless resistance to all instructions or attempts to be moved, or movement in the opposite direction); (5) Rigidity (maintenance of a rigid posture against efforts to be moved); (6) Waxy flexibility (maintenance of limbs and body in externally imposed positions); (7) Command automatism (automatic compliance with instructions). C. Other possible precipitants of catatonic behaviour, including brain disease and metabolic disturbances, have been excluded.

F20.3 Undifferentiated schizophrenia A. The general criteria for Schizophrenia (F20.0 - F20.3) above must be met. B. Either (1) or (2): (1) There are insufficient symptoms to meet the criteria of any of the sub-types F20.0, .1, .4, or .5; (2) There are so many symptoms that the criteria for more than one of the subtypes listed in B(1) above are met.

F20.4 Post-schizophrenic depression

A. The general criteria for schizophrenia (F20.0 - F20.3 above) must have been met within the past twelve months, but are not met at the present time. B. One of F20 G1.2 e, f, g or h must still be present. C. The depressive symptoms must be sufficiently prolonged, severe and extensive to meet criteria for at least a mild depressive episode (F32.0).

F20.5 Residual schizophrenia A. The general criteria for Schizophrenia (F20.0 - F20.3 above) must have been met at some time in the past, but are not met at the present time. B. At least four of the following 'negative' symptoms have been present throughout the previous twelve months: (1) Psychomotor slowing or underactivity; (2) Definite blunting of affect; (3) Passivity and lack of initiative; (4) Poverty of either the quantity or the content of speech; (5) Poor non-verbal communication by facial expression, eye contact, voice modulation or posture; (6) Poor social performance or self-care.

F20.6 Simple schizophrenia

A. Slowly progressive development over a period of at least one year, of all three of the following: (1) A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of drive and interests, aimlessness, idleness, a self-absorbed attitude, and social withdrawal. (2) Gradual appearance and deepening of "negative" symptoms such as marked apathy, paucity of speech, underactivity, blunting of affect, passivity and lack of initiative, and poor non-verbal communication (by facial expression, eye contact, voice modulation and posture). (3) Marked decline in social, scholastic, or occupational performance. B. Absence, at any time, of any symptoms referred to in G1 in F20.0 - F20.3, and of hallucinations or wellformed delusions of any kind, i.e. the subject must never have met the criteria for any other type of schizophrenia, or any other psychotic disorder. C. Absence of evidence of dementia or any other organic mental disorder listed in section F0.

F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified

Management of schizophrenia

First some extra stuff

Stages of Schizophrenia and goals

Diagnosis

Diagnosis of schizophrenia involves ruling out other mental health disorders and determining that symptoms are not due to substance abuse, medication or a medical condition. Determining a diagnosis of schizophrenia may include:

Physical exam. This may be done to help rule out other problems that could be causing symptoms and to check for any related complications. A neurologiccal exam, MSE are included

Tests and screenings. These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. CBC, electrolytes. fasting glucode, lipid profile, renal, thyroid function, The doctor may also request imaging studies, such as an MRI or CT scan. Pregnancy test and HIV test too

Psychiatric evaluation. A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for violence or suicide. This also includes a discussion of family and personal history.

Diagnostic criteria for schizophrenia. A doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Plan of management

Treatment setting

Providing a supportive environment

Minimizing harm

Educating the patient and the family

Pharmacological and non pharmacological treatment(according to clinical staging)

Discharge plan

Follow up

Factors Affecting Choice of Treatment Setting

Availability of the setting or housing

The patient’s clinical condition

Patient’s and family’s preference

Requirements of the treatment plan (Need for a particular treatment or a particular intensity of treatment that may be available only in certain settings)

Characteristics of the setting(Degrees of support, structure, and restrictiveness)

Patient’s current environment or circumstances(Family functioning, Available social supports)

Providing a supportive environment

Patient need support from family and ward staff during the period of active illness

Seek support from extended circles, such as therapists, self-help groups and clergy.

A structured environment, which provides adequate rest and recreation is ideal for acute illness

Assist with teaching and reinforcing Activities of Daily Living such as bathing, dressing and grooming.

Socialization rather than isolation at their comfort level will enhance stability.

Minimising harm

Evaluate the risk to the patient and others in initial risk assessment

Risks should clearly documented in clinical records

All members of management team should aware of the risk

If there is Risks carried out Specific interventions to minimizing the risk

Management of high risk patients

§Ensuring safe environment

§Rapid tranquilization if needed

§Treating the illness

§Treating comorbid substance use

§Monitoring risks

Educating the patient and family

Working with patients to recognize early symptoms of relapse can result in preventing full-blown illness exacerbations .

Patient and family should be educated about the etiology, symptoms , treatment options and prognosis of the illness.

Family and patient education about the nature of the illness and coping strategies can markedly diminish relapses and improve quality of life for patients

Should correct misconceptions about illness.

Management modalities

Medications (see own card)

Medications are the cornerstone of schizophrenia treatment, and antipsychotic medications are the most commonly prescribed drugs. They're thought to control symptoms by affecting the brain neurotransmitter dopamine.

The goal of treatment with antipsychotic medications is to effectively manage signs and symptoms at the lowest possible dose. The psychiatrist may try different drugs, different doses or combinations over time to achieve the desired result. Other medications also may help, such as antidepressants or anti-anxiety drugs. It can take several weeks to notice an improvement in symptoms.

Because medications for schizophrenia can cause serious side effects, people with schizophrenia may be reluctant to take them. Willingness to cooperate with treatment may affect drug choice. For example, someone who is resistant to taking medication consistently may need to be given injections instead of taking a pill.

Ask your doctor about the benefits and side effects of any medication that's prescribed.

Second-generation antipsychotics

These newer, second-generation medications are generally preferred because they pose a lower risk of serious side effects than do first-generation antipsychotics. Second-generation antipsychotics include:

Aripiprazole (Abilify)

Asenapine (Saphris)

Brexpiprazole (Rexulti)

Cariprazine (Vraylar)

Clozapine (Clozaril, Versacloz)

Iloperidone (Fanapt)

Lurasidone (Latuda)

Olanzapine (Zyprexa)

Paliperidone (Invega)

Quetiapine (Seroquel)

Risperidone (Risperdal)

Ziprasidone (Geodon)

First-generation antipsychotics

These first-generation antipsychotics have frequent and potentially significant neurological side effects, including the possibility of developing a movement disorder (tardive dyskinesia) that may or may not be reversible. First-generation antipsychotics include:

Chlorpromazine

Fluphenazine

Haloperidol

Perphenazine

These antipsychotics are often cheaper than second-generation antipsychotics, especially the generic versions, which can be an important consideration when long-term treatment is necessary.

Long-acting injectable antipsychotics

Some antipsychotics may be given as an intramuscular or subcutaneous injection. They are usually given every two to four weeks, depending on the medication. Ask your doctor about more information on injectable medications. This may be an option if someone has a preference for fewer pills and may help with adherence.

Common medications that are available as an injection include:

Aripiprazole (Abilify Maintena, Aristada)

Fluphenazine decanoate

Haloperidol decanoate

Paliperidone (Invega Sustenna, Invega Trinza)

Risperidone (Risperdal Consta, Perseris)

Hospitalization

During crisis periods or times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition, adequate sleep and basic hygiene.

vTreatment in the hospital has the advantage of providing a safe, structured, and supervised environment and reducing stress in both patients and family members.

Indications of hospital admission

> for diagnositic purposes

> stabilising of mediciations

Patients who are serious threat of harm to themselves or others

Suicidal ideas or suicidal attempts

Poor social support

Severe disorganized or disturbed behavior

vIf patient prefer, Consider about possibility of community care

Psychosocial interventions

Psychological and psychosocial therapies

There is a growing evidence base to support the use of psychotherapy and psychosocial strategies for psychosis

These should be provided along with optimal antipsychotic medication.

The therapeutic relationship is the cornerstone of effective treatment. All clinicians working with people with schizophrenia need psychological skills.

CBT

Illness self-management training

Family support and psychoeducation

Cognitive remediation therapy and compensation

Emerging psychological and psychosocial therapies (Social cognition therapy, Acceptance and commitment therapy and mindfulness-based therapies for psychosis, Meta-cognitive training)

Vocational rehabilitation

Once psychosis recedes, in addition to continuing on medication, psychological and social (psychosocial) interventions are important. These may include:

Individual therapy. Psychotherapy may help to normalize thought patterns. Also, learning to cope with stress and identify early warning signs of relapse can help people with schizophrenia manage their illness.•CBT for people with psychosis (CBT) has emerged as an evidenced based treatment

•usually used as an adjunct to pharmacotherapy to reduce the distress and disability associated with residual or persistent psychotic symptoms.•CBT is more effective than other talking therapies such as supportive counselling for hallucinations

Social skills training. This focuses on improving communication and social interactions and improving the ability to participate in daily activities.

Family therapy. This provides support and education to families dealing with schizophrenia.

Vocational rehabilitation and supported employment. This focuses on helping people with schizophrenia prepare for, find and keep jobs. •The desire to work in the open labour market is often a priority for people with psychotic illness

•Vocational rehabilitation aims to improve economic and social participation•There are two main models1.Prevocational training – training is provided during a period of preparation before the person seeks competitive employment2.Supported employment – people are placed in competitive employment with on-the-job support.

Most individuals with schizophrenia require some form of daily living support. Many communities have programs to help people with schizophrenia with jobs, housing, self-help groups and crisis situations. A case manager or someone on the treatment team can help find resources. With appropriate treatment, most people with schizophrenia can manage their illness.

Electroconvulsive therapy

Electroconvulsive therapy is considered as first line treatment only in catatonic schizophrenia

In other types of schizophrenia ECT used, if there is poor response to medications

For adults with schizophrenia who do not respond to drug therapy, electroconvulsive therapy (ECT) may be considered. ECT may be helpful for someone who also has depression.

Discharge plan

Once acute symptoms resolve, patient can be discharged

Written discharged plan should be made

Plan should be include place of follow up, frequency of follow up, duration of treatment, and care worker who will act as the main contact.

If poor response to treatment should be reviewed by consultan

Follow up care

During the follow up visits assess

>Response to treatment

>Compliance

>Side effect and tolerability

>Level of functioning

>During the follow up visits can adjust the doses of medication

Pharcacological treatment of schizophrenia

General algorithm

Antipsychotic medication

Antipsychotic medicines treat the symptoms of schizophrenia but not its underlying causes.

All antipsychotic medicines derive their effect on positive symptoms of psychosis from the blocking of dopamine receptors.

These medications are described as First Generation Antipsychotic or Second Generation Antipsychotic.

Antipsychotic medicines for First Episode of Psychosis

Oral SGAs should be prescribed as first- and second-line treatment for people with FEP

choice of SGA depends on various factors such as side effects, tolerability/discontinuation rate and long-term outcomes

The initial dose should be low

If response is slow or incomplete, the dose should be increased slowly at suitable intervals.

Common second???????????????????????? generation antipsychotics

Aripiprazole

Clozapine

Olanzapine

Risperidone

Quetiapine

Ziprasidone

Common 1nd generation antipsychotics

Chlorpromazine

Haloperidol

Pimozide

Trifluoperazine

acute phase

he choice of antipsychotic medicine should take into consideration prior response to treatment, side effects and the person’s preference.

Oral SGAs are usually the treatment of choice

SGA’s are generally lower risk of extrapyramidal side effects, compared with FGAs.

Long-acting injectable antipsychotic agents, particularly SGAs, provide an important treatment option in all phases of the disease for people whose adherence to oral treatment is poor.

Parenteral administration of antipsychotics (along with benzodiazepines) may be required for the treatment of agitation in emergency situations.

Maintenance phase

In established illness, it is generally considered advisable to continue maintenance treatment with the prescribed antipsychotic to which the person responded in the acute episode

If dose reduction is indicated, it should be performed gradually to avoid withdrawal effects and rebound psychoses

When planning long-term treatment, antipsychotic agents with the best balance between efficacy, side effects and adherence for the individual should be selected.

Clozapine should be considered when there is a poor response or significant side effects.

Long-acting injectable antipsychotic agents provide an important option, particularly in the management of non-adherence, and can reduce relapse rates and rehospitalisation in people with schizophrenia.

Long-acting injectable antipsychotic agents can reduce the risk of accidental or deliberate overdose in high-risk individuals.

Treatment resistance

Treatment resistance is usually defined as continued positive symptoms after trials of at least two different antipsychotics at moderate doses (usually at least 300 mg chlorpromazine equivalents per day) for a reasonable period (usually at least 6 weeks).

It is important to differentiate non-response from lack of tolerability

Combination of antipsychotic agents

The concurrent use of two or more antipsychotics for people with treatment-resistant or refractory schizophrenia is common practice, despite limited evidence to support this practice.

Compared with antipsychotic monotherapy, combined antipsychotic treatment has been associated with an increased side effect burden, high-dose prescribing, increased hospitalization rates and length of stay, higher treatment costs and increased mortality

Clozapine

Clozapine can be a highly effective agent for those who fail to respond to other antipsychotic medications.

Ideally, treatment resistance should be identified early (within the first 6–12 months) and treatment with clozapine started without delay, to minimize the disability that develops with unremitting illness.

The high side-effect burden means clozapine is reserved for people who have not responded to other treatments.

Mandated blood monitoring (weekly for the first 18 weeks, every 4 weeks thereafter)

cardiomyopathy and myocarditis are also potentially dangerous side effects

It can take up to 12 months to see the full benefits of clozapine.

If clozapine is ineffective, the choice is whether to augment clozapine with another drug or electroconvulsive therapy(ECT), or switch to another agent.

Cessation of medicine

The decision to reduce, or possibly cease, medication requires careful discussion and evaluation of risks and benefits for each individual.

The person should have made a full recovery and been well for at least 12 months before cessation of medication is considered

Severity of illness, risk factors, individual circumstances and family history should be taken into account, and medical supervision during and after medication cessation is essential.

> shpould be gradual and closely monitored

Schizo QAR Epidemiology

Cause

Risk factors

Types

Type description in icd

Catatonic 7

Negative 5

Positive 5

Cognitive

Icd 1p diagnosis

Exlcusion in icd

Coruse description in Icd

Dsm 5 Criteria and other criteria Words used to describe

Associated features

DdClinical staging and importanceSeverity in Dsm

Other 2 and classification of course

Comorbidies and cognitive deficits

Complications

Diagnosis basis Methods

3 phases of treatment Hospitalisation?

Stable phase mx 7

And acute phase Psychiatric mx 7

Plan of management in acute +5

Factors affecting choice of treatment setting

Providing a supportive environment 5

Minimising harm (ass and mx)

Educating the pt and family

Discharge plan

Follow up

ECT

Psychosocial interventions

Antipsychotic medications Flowchart?

At each visit?

Acute psychotic pt Issue with antipsychotic 2Side effects of antipsychotics?

Min effective dose vs starting dose Combination?

Treatment resistance?

Approach to tx resistance?

Clozapine problems?

Sri Lankan long acting injectable?

Cessation of Tx?

Guidelines for duration? ------------------—

ECT

Used as last resort treatment for bipolar and depression And psyhosis and schizo But first line in catatonia Usually a short course of several sessions

Used for quick and emergency therapy also

Its about treating by inducing a convulsion Placed under GA (so fasting?) Given neuromuscular blockers and paralysed Then elextrodes put into brain to monitor activity And then another set to trugger electricty and convlsion Usually only sign of colvulsion is pt moving their leg And the activity in the elctrode paper monitorint EEG Usually for a few minutes And pt recovers like from surgery A/E are there...but mainly memory problems!!! Retrograde amnesia Good and beneficial most times

Marror

Casebook

2019

Add from ward classes done below

Write pc at the end and make it fit a diagnostic criteria

For example: if you think it's psizhophrenia then say presented with hearing voices of unseen people for 3 months with worsening of symptoms due to poor compliance after defaulting treatment.

The state ment of pc in psychiatry should be like the summary statement in medicine.. Having all relevant information. Pc according to a crteiria... Duratkom.. Defaulting... Why right now came...

Consequences and complications of the symptoms... To the patient can be distress.. Distress to himself is an important complication of disease

No need to repeat in mse - and can say as mentioned earlier in history and say about mse.

If lot of delusion then it's schizophrenia with mostly bizarre and stuff but in delusional disorder it's just one delusional system with all delusions just to fit this system. And it doesn't fit the icd 10 criteria for schizophrenia.... But have a delusional system.

Ask for sleep, apetite and libido. Pair these up.. When asking about functional impact.

Pshizo dds... Manic with psychotic symptoms... Organic cause.. Subyanve abuse... Encephalitis

In depression. Difficult to sleep and early a morning awakening. In mania can't sleep and don't want to sleep.

First episode is important. Describe first episode in detail as can identify triggering factors. Other episodes just in brief and then final episode in detail. Why trigger and why. Triggering factors are important.

Ask for admission to nimh which can indicate a severe episode.

Must also say why episode. What was trigger. Whether compliance and defaulting issue or some stressor.

Inter episodic functioning.. Can be in levels. In basic activities of living. Or instrumental. Then occupational functioning social functioning. Family duties. On dependants. Etc different levels of functioning to consider as different impact.

In hopc must categorise positive and negative and cognitive symptoms. Cognitive symptoms are important in accessing rehabilitation... And how from there.

In hopc don't use any special technical terms.. Don't say he has delusions of grandeur. It's like the patients account say he believes that he's bad but he doesn't have belief that other people are out to get him. Even negative stuff don't put in technical terms.

Shcozo can be mixed with mood disorders. For schizo affective it's both schizo and mood in the same intensity but seoerate by at max a few days. Same intensity and others manic with psychotic symptoms..

Sguzoaffective vs mania with psychotic features.. Main difference is whether mood congruent or not mood congruent. Mania is mood congruent.. Dhzio isn't.

risk assessment - risk to self (can be active or passive - neglect) , others (can be acrive or passive - neglect to dependants), reputtation to individual and family, property, stigma, defaulting, STDs,

Post schizophrenic depression... Shhizo criteria was met within 12 months and resolutions of psychotic features and now depressive criteria met,

....

ACUTE Verbal - Oral - BZDs (lorazepam, clonazepam, midazolam - doses??) , antipsychotics (clozapine rapid or haloperidol) IM - IM haloperidol (5mg - 10mg), IM clorpomazine (25mg), IM midazolam (5-7.5mg). IM aripriprazole and IM ckahchwhc - N/A in SL. Better to take ECG before haloperidol IV - need ICU setting so not done usually paralyse and ventilate -

Anti-psyhcotic regimen for schizophrenia Start with resperidone 2mg and then increase to 6-8mg - maximum 18mg but in SL max 10mg. If no response then change to olanzapine (5mg => 20mg).

ACtually no difference in antipsychotic efficacy except for clozapine which is reserved for resistant schizophrenia) but side effect profile varies so choice can vary First gen mostly EPS and second gen mainly metabolic side effects EPS - benzhezol In SL first choice is resperidone. second choice is olanzapine, aripriprazole, amisulphide, quietiapine. third choice is clozapine. if on clozapine send for clinic thing.

IM depot. first gen and second gen. first gen is flufsthdecanoath, flupenthizole, haloperiod, supropenthizole. second gen is IM resperidone, IM aripriprozole. first gen needs test dose to test allergy for oils/additives. second gen not avaiavle in SL.

other management is occupational therapy, CBT. cognitive SCALES - RBAN, VCAT - assess copetency for CBT. Community psychiatric nurse and communication psychiatirc social worker can arrange family counseeling, home visits and all arranging social benefits, relapse prevention plans