Schizophrenia Lecturer: Dr. Mohammed M.M. PhD Clinical Pharmacy

1. SchizophreniaLecturer: Dr. Mohammed M.M.PhD Clinical Pharmacy

2. 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’ and 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. Schizophrenia The affected person may: • Talk to himself • Gesture to himself • Dress in layers in any weather • Fail to bath and get a haircut • Gain an odd interest in ordinary things (like religion)

5. Schizophrenia The affected person may: • Be unable to work • Stop talking or greatly reduce conversation • Appear lazy, unmotivated and uninterested • May look like he has dementia • Lose the ability to get and keep friends

6. symptoms The symptoms of schizophrenia fall into three broad categories. Positive Symptoms are unusual thoughts or perceptions, that occur mainly in Acute psychotic illness, including: • abnormality of mood such as anxiety, depression, • irritability or euphoria • Delusions; unable to control of thoughts • thought disorder and disorder of movement. • Auditory hallucinations are the most common. • lack of insight into the illness.

8. Symptoms Between 60% and 80% of patients who suffer from an acute psychotic illness will suffer further illness and become Chronically affected Negative Symptoms refers to reductions in normal emotional and behavioral states such as: • Flat affect with immobile facial expression, monotonous voice. • Lack of drive or 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 may need help.

9. Symptoms 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).

11. 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.

12. 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.

14. Causes • 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 childhood, problems during birth, and psychosocial factors such as stressful environmental conditions.

15. Factors affecting diagnosis and prognosis • Age of onset, which, typically for schizophrenia, is late teenage to 30 years. • Reports of a childhood which indicate the individual did not mix or was a rather shy and withdrawn personality • Poor work record • The desire for social isolation • Being single and not seeming to have sexual relationships • Grossly disorganized behavior

16. Brain Function • Scientist feel it is likely that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine (abnormality of dopamine receptors and, in particular, D2 receptors), and glutamate plays a role in schizophrenia. • Neurotransmitters allow the brain cells to communicate with one another.

20. Treatment • There is a wide range of antipsychotic drugs available for the treatment of a psychotic illness. • Although most antipsychotic drugs are equally effective in the treatment of psychotic symptoms, some individuals respond better to one drug than another. • Theory postulates that the symptoms experienced in schizophrenia are caused by an alteration to the level of dopamine activity in the brain.

21. Treatment • It is based on knowledge that dopamine receptor antagonists are often effective antipsychotics. • While drugs which increase dopamine activity, such as amfetamine, can either induce psychosis or exacerbate a schizophrenic illness. • At least six dopamine receptors exist in the brain, with much activity being focused on the D2 receptor as being responsible for antipsychotic drug action

22. Antipsychotics • 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: • psychosis is induced by increased levels of dopamine activity • most antipsychotic drugs block postsynaptic dopamine receptors

23. 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 typicalantipsychotic produced side effects which made compliance difficult.

24. 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: ChlrpromazineTrifluoperazine FluphenazinePerphenazine Haloperidol Thioridazine Thiothixine

25. 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 typicalantipsychotic but can and do occur with all of them. • Extrapyramidal side effects include: • Tremor, akathisia, slurred speech, dystonia, bradykinesia, parkinsonism-like syndrome, and muscular rigidity.

26. 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.

27. 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.

28. Extrapyramidal Effects • Bradykinesia means "slow movement." essentially refers to a component of parkinsonism-like syndrome. • The full spectrum of parkinsonism, 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;

29. Antipsychotics • In the 1990’s, new drugs, called atypical antipsychotics, 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.

30. Antipsychotics • The atypical antipsychotics include: Clozapine Olanzapine RisperidoneQuetiapine AripiprazoleZiprasidone • Current treatment guidelines recommend using one of the atypical antipsychotics other than clozapine as a first line treatment option for newly diagnosed patients.

31. 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 (1%). 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.

32. Antipsychotics Side Effects • 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.

33. Antipsychotics Side 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.

34. Antipsychotics Side 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.

35. 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.

36. 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.