Schizophrenia

1. Schizophrenia Understanding the Disease

2. What is Schizophrenia Schizophrenia is a chronic and disabling brain disorder that has been recognized throughout recorded history. It affects about 1% of the population of the United States. Symptoms usually emerge for men in late teens to early 20�s. In females mid 20�s to early 30�s. Many people with this disorder have difficulty holding a job or caring for themselves. This creates a great burden for their families and for society.

3. Presentation Those with the disorder may hear voices that others don�t hear. They may believe that others are reading their minds, controlling their thoughts, or plotting to harm them. They may not make sense when they talk or they may seem perfectly fine until they start talking about what they are really thinking.

4. What are the symptoms? The symptoms of schizophrenia fall into three broad categories. Positive Symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder and disorder of movement. Auditory hallucinations are the most common.

5. Symptoms Continued Negative Symptoms refers to reductions in normal emotional and behavioral states such as: Flat affect with immobile facial expression, monotonous voice. Lack of pleasure in everyday life. Diminished ability to initiate and sustain planned activity. Speaking infrequently even when forced to interact People with the disorder often neglect basic hygiene and need help with ADL.

6. Symptoms Continued Cognitive Symptoms are subtle and often detected only when neuropsychological test are performed. Poor executive functioning. (the ability to absorb and interpret information and make decisions based on that information). Inability to sustain attention. Problems with working memory (the ability to keep recently learned information in mind and use it right away).

7. Suicide in Schizophrenia People with schizophrenia attempt suicide much more often than people in the general population. About 10% (especially young adult males) succeed. It is hard to predict which patients with the disorder are prone to suicide. Listen when they talk about harming themselves.

8. Causes The disorder is believed to result from a combination of environmental and genetic factors. It is well known that the disease runs in families, and is seen in 10% of people with a first degree relative. Identical twins have 40 to 60% chance of developing the disorder.

9. Cause Although there is a genetic risk for schizophrenia, it is not likely that genes alone are sufficient to cause the disorder. Interactions between genes and the environment are thought to be necessary for the disorder to develop. Many risk factors have been identified such as exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors such as stressful environmental conditions.

10. Brain Function Scientist feel it is likely that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate plays a role in schizophrenia. Neurotransmitters allow the brain cells to communicate with one another.

11. Schizophrenia vs Schizoaffective Disorder Schizoaffective disorder is characterized by both the psychotic thought problems of schizophrenia and the mood problems of depression or bipolar disorder. Two conditions must be meet to qualify as schizoaffective disorder: 1. Psychotic symptoms sufficient for the diagnosis of schizophrenia are present � specifically active hallucinations or delusions present for at least two weeks in a row.

12. Schizoaffective Disorder 2. One or more major depressive episodes, manic episodes, or mixed mood episode occur concurrent with the psychotic episode. Doctors differ on whether it is better to diagnose schizoaffective disorder, or to diagnose a bipolar or major depression and schizophrenia separately. It is not sure at this time if schizoaffective disorder describes a single disease entity or not.

13. Mechanism of Actionof Antipsychotics While the precise mechanism of action that accounts for the effects of antipsychotic medications is still unknown, the dopamine hypothesis is the predominate theory used to explain the action of these drugs. Schizophrenia is caused by an excess in dopamine activity in the brain, which is inhibited by blockade of the receptors There are two core components to the dopamine theory: (1) psychosis is induced by increased levels of dopamine activity and (2) most antipsychotic drugs block postsynaptic dopamine receptors

14. Antipsychotics Antipsychotic medications have been available since the mid 1950�s. These drugs have greatly improved the lives of patients with schizophrenia since their first development, but these medications do not cure the disease. The older antipsychotic medications effectively alleviate the positive symptoms of schizophrenia. These which are considered conventional or typical medications produced side effects which made compliance difficult.

15. Antipsychotics Most of these older "conventional" antipsychotics differed in the side effects they produced. Side effects such as orthostatic hypotension, sedation, anticholinergic effect and extrapyramidal effects. These conventional antipsychotics include chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril).

16. Extrapyramidal Effects Extrapyramidal Side Effects are a group of symptoms that can occur in persons taking antipsychotic medications. They are more commonly caused by the typical antipsychotics but can and do occur with all of them. Extrapyramidal side effects include: tremor, akathisia, slurred speech, dystonia, bradykinesia, and muscular rigidity

17. Extrapyramidal Effects Akathisia is a movement disorder characterized by inner restlessness and the inability to sit or stand still. Akathisia may appear as a side effect of long-term use of antipsychotic medications, Lithium, and some other psychiatric drugs. Persons with akathisia typically have restless movements of the arms and legs such as tapping, marching in place, rocking, crossing and uncrossing the legs. They may feel anxious at the thought of sitting down.

18. Extrapyramidal Effects Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, which force certain parts of the body into abnormal, sometimes painful, movements or postures. Acute dystonic reactions are characteristically sustained contraction of the muscles of neck (torticollis), eyes (oculogyric crisis), tongue, jaw and other muscle groups typically occurring within 10-14 days after initiation of the neuroleptic.

19. Extrapyramidal Effects Bradykinesia means "slow movement." Bradykinesia essentially refers to a component of parkinsonism. The full spectrum of parkinsonism is derived from the features of Parkinson's disease, which include bradykinesia, tremor, and rigidity. Rigidity is defined as hypertonia in which the following are true: The resistance to externally imposed joint movement is present at very low speeds of movement, does not depend on imposed speed, and does not exhibit a speed or angle threshold;

20. Antipsychotics In the 1990�s, new drugs, called atypical antipychotics, were developed. These medications appear to be equally effective for helping reduce the positive symptoms like hallucinations and delusions - but may be better than the older medications at relieving the negative symptoms of the illness, such as withdrawal, thinking problems, and lack of energy.

21. Antipsychotics The atypical antipsychotics include aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Current treatment guidelines recommend using one of the atypical antipsychotics other than clozapine as a first line treatment option for newly diagnosed patients.

22. Antipsychotics Clozapine (Clozaril) was the first atypical introduced. It treats psychotic symptoms effectively even in people who do not respond to other medications. It can produce a serious problem called agranulocytosis. This is a loss of the white blood cells that fight infection in the body. Patients who take clozapine must have their white blood cell count monitored weekly and then monthly for the extent of use. Even with this complication, it is still the drug of choice with those whose symptoms do not respond to the other antipsychotic medications, old or new.

23. Antipsychotics Side Effects � When patients first start to take the atypical antipsychotics, they may become drowsy or experience dizziness when they change positions (orthostatic hypotension). They may have blurred vision, or develop a rapid heartbeat, menstrual problems, a sensitivity to the sun, or skin rashes.

24. AntipsychoticsSide Effects Many of these symptoms will go away after the first few days but could last for up to one to two weeks. Advise your patients that if the symptoms do not go away after two to three weeks to notify the practitioner who prescribed the medication. Also advise them that they should not be driving until they adjust to their new medication.

25. AntipsychoticsSide Effects The atypical antipsychotics produce much less extrapyramidal symptoms but they can cause weight gain and metabolic changes associated with an increase risk of diabetes and cardiovascular disease. When starting these medications a baseline check is made for risk factors for diabetes. Baseline laboratory test: Fasting glucose, HDL, Triglycerides, Blood Pressure. BMI if older than 27 year old.

26. Monitoring On monthly visits monitor for things such as over eating, weight gain, polyuria (increase urination), polydipsia (increased thirst). When each of you see your clients, if they have recently been put on an antipsychotic, discuss the above symptoms with them. Have them notify the practitioner if they are having problems with any of these symptoms.

27. Summary Relapses occur most often when people with schizophrenia stop taking their antipsychotic medication. They may feel better, or their side effects or so bad they stop the medication. At times they don�t feel taking their medication regularly is important. It is our responsibility to education our patient to be compliant and monitor them to keep them healthy.