Kembara Xtra - Medicine - Schizophrenia
A severe and ongoing mental condition marked by delusions, hallucinations, disordered thinking and behavior, cognitive dysfunction, and difficulty judging reality .Major psychiatric condition with a varied course, usually characterized by prodromal, active, and persistent psychotic symptoms as well as problems in cognition, speech, mood, behavior, and perception. Subcategories of schizophrenia such as paranoid, disorganized, catatonic, etc. were dropped from the DSM-5. Central nervous system (CNS) is/are the affected system(s). Incidence 7.7 to 43/100,000 cases per 100,000 Age of onset: typically 30 years, earlier in males (late teens to mid-20s) than in females (early 20s to early 30s), with a smaller peak that occurs in women >45 years. Predominant sex: male-to-female ratio = 1.4:1.0; age of onset: typically 30 years; more subtle changes in cognition and functioning can precede the diagnosis (prodromal period) by several years. Low socioeconomic levels and metropolitan areas have the highest prevalence over the course of a lifetime (1%) (2-fold higher risk). 1.1% of the population over the age of 18; comparable rates worldwide Pathophysiology and Etiology Is the result of a complex interaction between genetic and environmental factors; risk factors for increased occurrence include prenatal infection or hypoxia, winter births, first-generation immigrants, older fathers, drug use, and genetic (velocardiofacial) abnormalities. Perceptual abnormalities, disturbed mental processes, and cognitive deficits are caused by overstimulation of mesolimbic dopamine D2 receptors, prefrontal dopamine deficiency, and aberrant prefrontal glutamate (NMDA) activity. Genetics There is an 8–10% (10-fold) risk of schizophrenia if a first-degree biological relative has it. Prevention Inform every patient about the dangers of marijuana use, but especially those who may be prodromal or have a family history of psychosis. Metabolic syndrome, diabetes mellitus, obesity, and infectious diseases like HIV, hepatitis B, and hepatitis C all occur at higher-than-expected rates. Nicotine dependence (>50%) and substance use disorders. Diagnosis Focus on recognizing a gradual loss in social and functional functioning over a period of around 6 months to distinguish schizophrenia from transient psychotic and schizophreniform disorders. For a minimum of one month, at least two of the following fundamental symptoms must be present: Delusions (constantly held false beliefs) Hallucinations (visual and auditory disturbances) Irregular speech (derailed or confused thought) Extremely chaotic or catatonic behavior (repetitive, hyper- or hypoactive motions) Negative symptoms, including reduced emotional expressiveness, poor speech and cognition, apathy, and lack of social interest clinical assessment There are no outward signs of the illness, but long-term use of neuroleptic medications can cause extrapyramidal symptoms like tardive dyskinesia (repetitive, uncontrollable movements), dystonia (sustained muscle contractions), akathisia (restlessness), parkinsonism (tremor), and stuttering gait. Multiple Diagnoses Schizophreniform disorder (symptom duration: 1 to 6 months) and brief psychotic disorder (symptom duration: 1 month) Disorientation and an altered degree of alertness raise questions about delirium. Psychotic disorder brought on by another medical disease. Alcohol, cocaine, hallucinogens (amphetamines, LSD, phencyclidine), cannabis (including synthetic), bath salts, or prescription drugs including steroids, anticholinergics, and opiates can all cause substance-induced psychosis. - In patients with substance-induced psychosis, schizophrenia develops in about 25% of cases. Cannabis use is linked to transition rates that are the highest. Personality disorders include borderline, schizotypal, schizoid, and paranoid disorders. Posttraumatic stress disorder, autism spectrum disorder, bipolar disorder, major depressive disorders with psychotic characteristics, or catatonia are some examples of mood disorders. Laboratory Results Imaging (MRI), EEG, LP, and laboratory testing may be necessary to rule out other causes and may be utilized when clinical presentation permits, but no tests are currently available to diagnose schizophrenia. Initial Examinations (lab, imaging) The following labs are frequently conducted to exclude a medical cause of psychotic symptoms: - Blood chemistries, complete blood count (CBC), and thyroid-stimulating hormone (TSH) - Vitamin levels (folate, methylmalonic acid/vitamin B12, thiamine, vitamin D, etc) - Blood and urine drug/alcohol screening, as well as urinalysis - Syphilis and HIV testing - Heavy metal exposure: mercury and lead - Ceruloplasmin and, when indicated, urine porphobilinogen - Antinuclear antibody and the rate of erythrocyte sedimentation the hepatitis B and C viruses ● Prior to starting an antipsychotic, the following labs are conducted to check for comorbidities and determine baseline values: - Baseline QTc electrocardiogram (ECG) - TSH, hemoglobin A1C, TSH, CBC, blood chemistries Lipid panel and, if necessary, a pregnancy test Tests in the Future & Special Considerations If taking antipsychotic drugs, routine clinical and laboratory examinations should be performed at least once a year: Weight, waist size, and blood pressure, as well as a CBC, hemoglobin A1C, and lipid panel. ECG, monitoring for QTc prolongation; pregnancy test; prolactin level, if necessary; clinical evaluation of extrapyramidal symptoms using a validated tool such the Abnormal Involuntary Movement Scale (AIMS) Diagnostic procedures and other neuropsychological testing are not typically included in assessments but can be used to determine cognitive functioning and the need for support. Interpretation of Tests No definitive pathologic features, however ventriculomegaly is typically observed on MRI, with whole-brain gray matter loss and selective white matter loss in regions in the medial temporal lobe. MEDICATION FOR TREATMENT First Line There are two categories of antipsychotic drugs: conventional and atypical. An atypical antipsychotic is used as the first line of treatment because to its lower risk of extrapyramidal adverse effects. - Dissimilar (second generation) (Parkinson disease-related psychosis) Risperidone, olanzapine, ziprasidone, aripiprazole, quetiapine, paliperidone, iloperidone, asenapine, lurasidone, clozapine, brexpiprazole, cariprazine, pimavanserin - Common (first generation) Fluphenazine, trifluoperazine, perphenazine, thioridazine, thiothixene, haloperidol, and chlorpromazine The selection of medication is based on the side-effect profile, clinical and subjective response (3). - Atypical sensitivity to extrapyramidal negative effects - Quetiapine and clozapine have the lowest risk of tardive dyskinesia. Aripiprazole, ziprasidone, lurasidone, perphenazine, and brexpiprazole had the lowest chance of developing the metabolic syndrome. Aripiprazole has the lowest risk of QTc prolongation. In patients with a prolonged QT interval, ziprasidone and thioridazine should not be used. Long-acting antipsychotics in injectable form may be utilized for patients with low adherence or a high risk of relapse. - Paliperidone, haloperidol, fluphenazine, risperidone, olanzapine, and aripiprazole Daily range for routine maintenance (The initial dose is frequently lower.) - Chlorpromazine: 200 to 800 mg divided into BID,TID, and QID each day Asenapine: 5 to 10 mg BID (sublingual), once daily patch (FDA authorized in October 2019) - Aripiprazole: 10 to 30 mg/day Lurasidone: 40 to 80 mg/day (with meal) Fluphenazine: 5 to 20 mg/day Haloperidol: 5 to 20 mg/day Paliperidone: 3 to 12 mg/day Olanzapine: 10 to 30 mg/day - 24 mg of perphenazine per day, divided BID/TID 200 to 400 mg BID of quetiapine - Ziprasidone: 20 to 80 mg BID (with lunch) - Risperidone: 2 to 8 mg/day Pimavanserin (for Parkinson disease-related psychosis): 34 mg/day Cariprazine: 1.5 to 6.0 mg/day Brexpiprazole: 2 to 4 mg/day Clozapine: 200 mg BID 300 to 600 mg/day, divided into BID doses, is the usual dosage range. Effective in treating people who are suicidal and the gold standard treatment for schizophrenia Registration with the National Clozapine Registry and weekly to monthly CBC monitoring with differential are required for patients who have a serious risk of agranulocytosis. At larger doses, there is a sizable chance of seizures Myocarditis, DVT, sialorrhea, tachycardia, and weight gain can all be symptoms of SE. ALERT There is a danger of weight gain, metabolic syndrome, and tardive dyskinesia with all antipsychotic medications. Controlling the negative effects of antipsychotics - Dystonic response (particularly of the head and neck): 25 to 50 mg IM diphenhydramine or 1 to 2 mg IM benztropine - Lorazepam 0.5 to 1.0 mg BID or propranolol 20 to 30 mg BID for akathisia (restlessness). Parkinsonism treatment options include amantadine 100 mg daily (up to 300 mg daily), trihexyphenidyl 2 mg BID (up to 15 mg daily), and benztropine 0.5 BID (1 to 4 mg/day). - Valbenazine (80 mg daily), tetrabenazine (25 to 50 mg TID), or deutetrabenazine (6 to 24 mg BID) are medications for tardive dyskinesia. - Neuroleptic malignant syndrome, which includes extrapyramidal symptoms, hyperthermia, and autonomic dysfunction; necessitates hospitalization and supportive care (IVF and stopping the offending neuroleptic). - Metformin and topiramate for metabolic syndromeAll antipsychotics come with a black box warning about an elevated mortality risk in older individuals with dementia. Benzodiazepines are used as adjunctive therapies. First-line for the treatment of catatonia Withdrawal reactions with psychosis or seizures; risk for dependence and cognitive impairment Best when used only briefly; high cumulative exposure to benzodiazepines is associated with a significantly increased risk of death in patients with schizophrenia. - Mood enhancers Valproic acid might be a useful supplement for people who behave violently or agitatedly. Lithium may be a useful supplement for patients who have severe emotional symptoms or suicidal thoughts. - Drugs for depression When added to antipsychotic monotherapy as opposed to adding a second antipsychotic, it is associated with a lower risk of mental hospitalization, which is helpful if concomitant depression and/or anxiety are present. Referral: Multidisciplinary care from a primary care clinician and a psychiatrist is advised in cases of suicidality, co-occurring substance use disorder, trouble engaging, or poor self-care. Families frequently gain from being directed to family advocacy groups like NAMI. Further Treatments • Psychoeducational and psychotherapeutic interventions for the patient and family, including targeted therapies to lessen the severity of psychotic symptoms, improve social functioning, and lower the risk of symptom exacerbation. Cognitive remediation is a new approach for cognitive retraining and psychosocial recovery. Vocational support programs have shown success in getting people back to work. Cognitive-behavioral therapy has been shown to be effective for certain symptoms of schizophrenia. Negative symptoms typically respond better to these nonpharmacologic interventions than they do to medications. Surgical Techniques Patients exhibiting catatonic symptoms, severe depression, aggressiveness, or suicidal ideation should be given electroconvulsive therapy (ECT) consideration. Admission The decision to enter is made based on the likelihood of danger to oneself or others, as well as the inability to take care of oneself. Monitoring is based on the evaluation of symptoms (including safety and psychotic symptoms), looking for the emergence of comorbidities, medication side effects, and prevention of complications. Long-term symptom management and rehabilitation depend on engagement in ongoing pharmacologic and psychosocial treatment. The risk of metabolic side effects such diabetes, hypercholesterolemia, and weight gain is increased when using diet antipsychotics. Prognosis: Although rare, there are reported cases of total remission and refractory sickness. The typical history is one of remissions and exacerbations. Positive symptoms are easier to manage with antipsychotics than negative ones, which are sometimes the most challenging. 20% of people attempt suicide, and 5-6% of those who do so do so fatally. Complications Combative conduct toward others (Note that only 5% of crimes are committed by people with mental illness, including psychosis, and the mentally ill are more likely to be victims of violence.) Medication side effects (tardive dyskinesia, orthostatic hypotension, QTc prolongation, metabolic syndrome). Substance use disorders that coexist
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