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Schizophrenia - Coggle Diagram
Schizophrenia
Diagnosis
A. 2 or more symptoms for a significant amount of time during 1 month period. Symptoms include: delusions, hallucinations, disorganised speech and negative emotional expressions.
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D. Must rule out schizoaffective disorder (different condition), medical or drug induced and substance abuse for accurate diagnosis.
Signs and symptoms
Postive symptoms: hallucinations, delusions, suspiciousness and disorganisation
Negative symptoms: lack fo motivation, bluted affect, reduced speech,, social withdrawal and poor self care
Cognitive symptoms: Impaired planning, memory, social cognition and mental flexibility
Potential causes
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Childhood factors: stress, malnutrition are potential factors
Environmental factors: urban areas have higher incidence, migration and living in low socioeconomical areas.
Pathophysiology: reduced brain mass, increase dopamine and different arrangement in brain structure.
Treatments
Non-drug
Patient education, CBT and disability management and assistance for homelessness and employment.
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Drug treatment
Antipsychotics are the cornerstone of treatment. Monotherapy preferred, adherence to treatment is key, preventing relapse is important to reduce complications and ADRs to consider. Assertive treatment for 5 years (main window for treatment)
Typical Antipsychotics (FGA): blocks D2 receptors
- Chlorpromazine, flupenthixol, fluephenazine, haloperidol, pericyazine, trifluoperazine and zuclopenthixol.
Atypical antipsychotics (SGA): different MOA and different receptors
- Amisulpride, apripiprazole, asenapine, clozapine, olanzapine, paliperidone, quetiapine, risperidone and ziprasidone.
First line for first episode: amisulpride (good for negative symptoms as well), apripiprazole, quetiapine IM or MR, risperidone.
Second line: Asenapine wafer, brexpiprazole, lurasidone and paliperidone MR
Third line: olanzapine
(Starting at low end of doses)
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ADRs and Risks
FGA: EPSE and movement disorders due to blocking D2 receptor MOA
SGA: Many ADRs, mainly metabolic ADRs like weight gain, dyslipidaemia, CVDs, T2DM etc.
Resistance treatment
Clozapine: effective for postive and negative symptoms and good against suicidal thoughts, severe EPS, aggressive behaviour and substance abusers.
Resistance defined as: severe positive and/or negative symptoms for 12 weeks or longer, moderate functional impairment, tried monotherapy of 2 drugs for 6 weeks and good adherence.
Clozapine is very effective but many ADRs: neutropenia, agranulocytosis, myocarditis, cardiomyopathy, GI stasis, hypersalivation, difficulty swallowing and seizure.
Requires persistant monitoring.
Agitation treatment
For agitating patients: Use diazapam, lorazepam or olanzipine to sedate patient, reducing harm risk.
- BZD can't be used, use suitable dose of patient's antipsychotic as PRN (oral) except clozapine
- use a different drug instead as PRN.
- Cannot oral: use zuclopenthixol IM (works in 2hrs and last for 2 days, must TDM for toxicities and S/E
Acute agitation IM: droperidol, olanzapine or midaolam is used.
IV used as last option and with expert advice + protocols but careful of airways collapse/restrictions.
Antipsychotics depots: use tolerated drug, and patient should be stable of the oral form first. If antipsychotic not available in depot, switch to oral, stabilise then switch to depot.
- Aripiprazole, paliperidone and risperidone are available as first line depots.
- Haloperidol second line.