Schizophrenia

=Schizophrenia=

What it is
Schizophrenia is one of a group of mental disorders known as psychoses. A person experiencing psychosis has a loss of contact with reality. Psychosis is characterised by difficulties with thinking and can include seeing or hearing things which other people cannot see or hear; these experiences are called hallucinations.

Psychosis can also include holding beliefs that are very odd or not true. These beliefs are called delusions. People with psychosis often feel that they want to withdraw from the outside world. Their energy and emotions are affected. They may feel a loss of vitality. They may also feel depressed or irritable.

The common onset of schizophrenia is in early adult life (often during the late teens or early 20s). People with mental disorders such as schizophrenia carry a high burden of medical morbidity, including diabetes, hypertension, smoking and obesity; these comorbidities are often unrecognised and suboptimally treated.

Symptoms
They include experiences such as loss of pleasure or interest in normal activities, loss of motivation, loss of interest in socialisation.
 * Positive symptoms** are experiences that happen in addition to normal experience. These include symptoms such as hallucinations (positive because they are additional perceptions).
 * Negative symptoms** incorporate a loss or decrease in normal functioning.

Positive symptoms: delusions, hallucinations, disorganised thoughts Negative symptoms: feeling unmotivated, not feeling social, feeling apathetic, not feeling any emotions Mood: irritability, suicidality, depression, elevated mood

Hallucinations and delusions are psychotic symptoms. Hallucinations can involve hearing, seeing, tasting, feeling or smelling something that does not exist and which the sufferer is unable to distinguish from reality. Similarly, delusions (unfounded beliefs of persecution, guilt or grandeur) seem utterly real to the person experiencing them. Thought disorders manifest as disconnected, illogical speech.
 * Hallucinations and delusions**

How to Treat
All antipsychotic drugs competitively block dopamine D2 receptors — this is the basis of their antipsychotic efficacy but also the mechanism by which they induce extrapyramidal adverse effects and increase prolactin concentrations. Hence, successful treatment depends on a balance between effectiveness and adverse effects. - In general, start with a low dose and titrate upwards at a rate and to a level that best suits the patient. Maintain treatment using the lowest effective dose. - Atypical antipsychotic drugs are preferred because of their lower risk of extrapyramidal adverse effects at therapeutically effective doses, compared with the typical antipsychotic drugs. However, this advantage lessens as the dose of the atypical antipsychotic drug is increased. Also, the lower risk of extrapyramidal adverse effects needs to be balanced against the problems of metabolic adverse effects.


 * never start antipsychotic therapy using a depot formulation, as appropriate dose titration is impossible and any acute adverse effect will be persistent
 * agitated patients respond better to drugs that are more sedating; withdrawn patients respond better to the less sedating or atypical agents
 * adding a benzodiazepine may allow antipsychotic dose reduction in acute psychotic states exhibiting acute agitation
 * withdraw antipsychotics slowly to avoid rapid relapse and withdrawal symptoms (tachycardia, sweating, insomnia) with those drugs that have prominent anticholinergic effects; benztropine may be used for several weeks in such an event

Reduce antipsychotic dose to avoid recurrent EPSE when possible. Anticholinergic drugs (eg benztropine)**:**
 * Extrapyramidal side effects:**
 * highest with haloperidol, fluphenazine, trifluoperazine and pimozide
 * lower with chlorpromazine, pericyazine
 * lowest with some of the atypical agents (at recommended doses).
 * should not be used as routine prophylaxis for EPSE, as not all patients will be affected
 * should be on hand for patients and their carers (who should know how to use them)
 * may add to the anticholinergic effects of some antipsychotics and worsen tardive dyskinesia
 * are occasionally misused in high doses for their euphoric effects

People with schizophrenia are at increased cardiovascular risk. Both older and newer antipsychotic agents (but particularly clozapine, olanzapine and quetiapine) have been associated with increased blood glucose, weight gain and dyslipidaemia. Manufacturers and guidelines suggest testing of those at increased risk of diabetes when they start atypical antipsychotics. Re-testing for diabetes should occur if patients gain weight during treatment.
 * Metabolic effects:**

Other advice
- Monitor for potential metabolic disturbances (weight gain, type 2 diabetes, dyslipidaemia) when starting or changing antipsychotic drug treatment, when increasing the dose of the drug, and during ongoing treatment - Monitoring parameters should include fasting (or random) blood glucose concentration for detailed guidelines), fasting lipids, weight, waist and hip circumference, body mass index and blood pressure - Consider a crossover phase of 1–2 weeks for non-acute patients. Reduce the dose of the first medication (or stop depot preparation) and gradually increase the dose of the second medication
 * Switching to a different antipsychotic drug**

Additional Resources
[|NPS - Case study: Antipsychotic Drugs for Schizophrenia]: about a 25yr old man diagnosed with paranoid schizophrenia [|RANZCP - Schizophrenia]: a handy booklet about the condition [|Better Health - Schizophrenia] [|Schizophrenia.com - Diagnosis]: indepth info about the symptoms [|AMH - Antipsychotics] [|Notes from TG - Schizophrenia]: talks about all the different medications //Pharmacology 301// [|Neuroleptic Drugs for Pharmacy]
 * Lecture Notes**