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. 

Ans:B-Clozapine

Common side effects of clozapine include:

1. Sedation
2. Hypersalivation
3. Tachycardia
4. Hypotension
5. Hypertension
6. Weight gain
7. Constipation 
8. Hepatic effects
9. Urinary incontinence
10. Fever

Serious side effects include:

1. Agranulocytosis
2. Cardiovascular/respiratory arrest
3. Seizures

Ans:B-Cannabis

• A number of drugs used illicitly for recreational purposes do cause symptoms similar to those experienced in psychosis.
• For instance cocaine and methamphetamine can both cause paranoia and amphetamine and LSD can cause visual hallucinations.
• Cannabis can cause both auditory hallucinations (hearing voices) and paranoia. It is thought that this is caused by the primary active constituent of cannabis; a chemical called delta-9-tetrahydrocannabinol.
• It has been suggested that cannabis use in early life (young teen age) increases the likelihood of the person going on to develop schizophrenia later.
• It has also been suggested that with the newer forms of stronger cannabis that have become available in recent years this risk has increased.

Ans:D-All-A -Chlorpromazine; B – Haloperidol; C -Olanzepine

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

Antipsychotics include:

• Chlorpromazine
• Fluphenazine
• Haloperidol
• Perphenazine

Second generation antipsychotics and long injectable antipsychotics are also used

Ans:D-Fluphenazine 

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.

 Antipsychotics include:

• Chlorpromazine
• Fluphenazine
• Haloperidol
• Perphenazine

Second generation antipsychotics and long-acting injectable antipsychotics are also used in the treatment.

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

Paranoid schizophrenia used to be the most common form of schizophrenia.

In 2013, the American Psychiatric Association determined that paranoia was a positive symptom of the disorder, so paranoid schizophrenia wasn’t a separate condition. Hence, it was then just changed to schizophrenia.

Ans.D-pfropfschizophrenia

• The Kraepelinian concept of pfropfschizophrenia refers to the intertwined coexistence of mental retardation and schizophrenia.
• Patients with this syndrome are relatively treatment resistant and are often harmed by diverging policies and cost cuts within the framework of mental health care services.
• Thus, a better understanding of this syndrome has important practical implications

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 the 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 disorder.
• Exclusion of substance abuse/general medical condition.

Ans:C-Negative symptoms

Ans: C. Promethazine

• This case suggestive of acute muscular dystonia in a schizophrenia patient.
• Due to rigidity & inability 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-grimacing, torticollis, locked jaw.
• Occurs within a few hours of a single dose or at most in the first week of therapy.
• More common in children below 10 years & in girls, particularly after parenteral administration.

Treatment:

Central anticholinergic, promethazine or hydroxyzine.

Ans. C-Acute onset

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