SCHIZOPHRENIA – TREATMENT & PROGNOSIS

Paranoid

Valproic acid is an anticonvulsant used as a mood stabilizer. It is found useful in the treatment of mania in a bipolar disorder.

It has also been valuable in the treatment of rapid cycling bipolar patients.

Paroxetine is an example of a selective serotonin reuptake inhibitor (SSRI), which is a newer form of antidepressant.

The SSRis are being found to be as effective as the tricyclic antidepressants.

Haloperidol is an example of a neuroleptic or antipsychotic medication useful in the management of acute psychosis, as well as long-term care. Clozapine is a newer atypical antipsychotic medication.

It is not associated with tardive dyskinesia as are the older neuroleptics.

This makes it a drug of choice for individuals who have developed signs of tardive dyskinesia after using other neuroleptics.

Problems with agranulocytosis prevent clozapine from being used as a “first line” neuroleptic.  

Ref: Meltzer H.Y., Bobo W.V., Heckers S.H., Fatemi H.S. (2008). Chapter 16. Schizophrenia. In M.H. Ebert, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds),CURRENT Diagnosis & Treatment: Psychiatry, 2e. 

B i.e. Clozapine

D i.e. Amphetamine

A i.e. Chlorpromazine; B i.e. Haloperidol; C i.e. Olanzepine

D i.e. Fluphenazine 

Ans. is ‘a’ i.e., Pemoline

Antipsychotics (Neuroleptics)

o Antipsychotics are a group of psychoactive drugs commonly used to treat psychosis, e.g. Schizophrenia.

o Antipsychotic drugs are divided into:

A) Typical antipsychotics (first generation antipsychotics)

1. Phenothkanes – Chlorpromazine, Thioridazine, Trifluperazine, Fluphenazine.
2. Thioxanthenes – Thiothixene, Flupenthixol.
3. Butyrophenones – Haloperidol, Trifluperidol, Penfluridol.
4. Other heterocyclics – Pimozide, Loxapine, Sulpiride

B) Atypical antipsychotics (second generation antipsychotics)

1. Clozopine                  3. Olanzopine                       5. Aripiprazole
2. Risperidon                 4. Quetiapine                        6. Ziprasidone

Ans. is ‘b’ i.e., Anti psychotics

Ans. is ‘d’ i.e., Clozapine

o Clozapine (but not the newer atypicals) is more effective than classical agents for resistant schizophrenia.

Ans. A: Paranoid

The different types of schizophrenia are based on the specific symptoms a person is experiencing.

Since the symptoms of schizophrenia can change over time, it is possible for a person to have more than one type during his or her lifetime.

Schizophrenia types include:

• Paranoid schizophrenia
• Disorganized (hebephrenic) schizophrenia
• Catatonic schizophrenia
• Residual and latent schizophrenia
• Undifferentiated disorder-This is a very common type of schizophrenia.
• Simple schizophrenia
• Post-schizophrenic depression
• Others.

Ans. Pfropf schizophrenia

Ans. is ‘d’ i.e., Social withdrawal

Diagnostic criteria for schizophrenia

• Characteristic symptoms :- Two (or more) of the following for a 1 months duration (or less if successfully treated) :‑

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, i.e., affective flattening, alogia.

Note :- Only one of the above is required if delusions are bizarre or there are third person hallucinations (running commentary or two voices arguing or conversing).

• Social/occupational dysfunction
• Duration :- Continuous signs of disturbance persist for at least 6 months. This 6 months period must include at least 1 month of symptoms that meet criteria A.
• Exclusion of mood disorder and schizoaffective diorder.
• Exclusion of substance abuse/general medical condition.

Ans. is ‘c’ i.e., Negative symptoms

Ans: C. Promethazine

(Ref: Harrison I9/e p2624, 18/e p3544; Katzung I 3/e p500-501, I2/e p495).

• This case suggestive of acate muscular dystonia in schizophrenia patient.
• Due to rigidity & inabilily to move eyes after haloperidol use.

Treatment:

• IM anticholinergic (benztropine).
• IV/IM antihistaminic (diphenhydramine hydrochloride) – Relieves symptoms.
• Promethazine (25-50 mg IV or IM) – used less frequently but readily available.

Acute Muscular Dystonia:

Features:

• Bizarre muscle spasms, mostly involving linguo-facial muscles-grinacing, torticollis, locked jaw.
• Occurs within few hours of single dose or at most in first week of therapy.
• More common in children below 10 years & in girls, particularly after parenteral administration.

Treatment:

• Central anticholinergic, promethazineo or hydroryzine.

Ans. C. Acute onset

[Ref Neeraj Ahuja 7th/62; Kaplan & Sadock Synopsis of psychiatry 1|th/ 318]

Good Prognosis in Schizophrenia:

• Late onset (Onset >35 yr)
• Short duration (<6months)
• Obvious precipitating factors
• Acute onset/ Abrupt onset
• Good premorbid social, sexuaI and work histories
• Mood disorder symptoms
• (especially depressive disorders)
• Married
• Family history of mood disorders
• Good social support systems

Positive symptoms:

• Presence of precipitating stressor
• Catatonic subtype(paranoid- intermediate prognosis)
• First episode
• Pyknic (fat) body
• Female sex
• Presence of confusion, perplexity or disorientation in the acute phase
• Normal cranial CT
• Outpatient treatment – Proper treatment & good response to treatment