From: Subject: Best Dx/Best Rx: Schizophrenia Date: Wed, 3 Jun 2009 21:51:05 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0269_01C9E495.64F86430" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0269_01C9E495.64F86430 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx1307.htm Best Dx/Best Rx: Schizophrenia



Schizophrenia

William T. Carpenter, Jr., M.D.
Gunvant K. = Thaker, M.D.=20 University of Maryland School of Medicine

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features

  • Chronic psychotic symptoms, especially = hallucinations=20 and delusions, appearing in late adolescence or early adulthood =
  • Disorganization of thought and behavior=20
  • Diminished emotional experience and = expression, low=20 drive, reduced speech in some patients=20
  • Subtle impairments in cognition, often = appearing early=20 in life=20
  • Deficit schizophrenia=20
    • Negative symptoms and psychosis=20
    • 15%-20% of all schizophrenia cases=20
    • Occurs predominantly in males =
  • Nondeficit schizophrenia: negative symptoms = are=20 absent
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Differential=20 Diagnosis

  • Schizotypal personality disorder=20
  • Affective disorders with psychosis=20
  • Delusional disorders=20
  • Depression=20
  • Mania=20
  • Substance abuse=20
    • Alcohol=20
    • Psychotomimetic drugs=20
    • Analgesics=20
    • Antibiotics=20
    • Anticholinergics=20
    • Cardiovascular drugs=20
    • Dopamine agonists=20
    • Endocrine drugs=20
    • H2 receptor antagonists=20
    • Stimulants and sympathomimetics =
  • Medical conditions=20
    • Cancer (e.g., CNS neoplasm, hyperviscosity = syndromes,=20 paraneoplastic syndromes)=20
    • Cardiovascular (e.g., anoxia, = encephalopathy)=20
    • Infections and sequelae (e.g., = encephalopathy, Lyme=20 disease, neurosyphilis)=20
    • Metabolic, endocrine (e.g., porphyria, = Addison=20 disease, Cushing disease, hepatic encephalopathy, hypoglycemia,=20 hypocalcemia/hypercalcemia, hypothyroidism/hyperthyroidism)=20
    • Neurologic (e.g., Alzheimer disease, complex = partial=20 seizures, Huntington disease, multiple sclerosis, stroke, Wilson=20 disease)=20
    • Nutritional deficiencies (e.g., folic acid, = niacin,=20 vitamin B12)=20
    • Lupus cerebritis =
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Best Tests =

DSM-IV Criteria

  • At least two of the following symptoms for = significant=20 period during 1 mo:=20
    • Delusions=20
    • Hallucinations=20
    • Disorganized speech=20
    • Grossly disorganized behavior=20
    • Negative symptoms (e.g., lack of emotion and = social=20 drive and engagement)
  • Deterioration in social/occupational = functioning in one=20 or more of the following areas:=20
    • Work=20
    • Interpersonal relationships=20
    • Self-care
  • Continuous signs of the disturbance for 6 mo, = including=20 ≥ 1 mo of positive symptoms=20
  • Exclusion of schizoaffective and mood = disorders=20
  • Exclusion of substance-induced or medical=20 disorder=20
  • In pervasive developmental disorders, presence = of=20 delusions or hallucinations for ≥ 1 mo

Physical Examination

  • Rule out psychosis caused by physical = ailments=20
  • Identify evidence of self-mutilation=20
  • Essential to guide drug treatment=20
    • Patients with motor abnormalities: select a = drug with=20 low potential for causing extrapyramidal symptoms or tardive=20 dyskinesia=20
    • Patients with obesity: avoid drugs that = increase=20 weight

Laboratory Tests

  • Toxicology screens=20
    • Provide alternative explanation for = psychosis=20
    • Confirm comorbid substance abuse =
  • Lipid profiles=20
    • Identify risk of hyperlipidemia (associated = with some=20 antipsychotic drugs)=20
    • Identify risk of diabetes
  • ECG: provides baseline for patients who take = drugs that=20 can prolong QT interval=20
    • EEG: may exclude temporal lobe = epilepsy=20
    • MRI of brain: rule out other causes of=20 psychosis
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Best = Therapy

Acute Treatment

  • Antipsychotic medication=20
  • Hospitalization, depending on patient safety = and=20 cooperation

Maintenance Therapy

Neuroleptics=20

  • Can produce neurologic side effects=20
  • Chlorpromazine=20
    • Dose: initially, 50-100 mg/day, up to 500 = mg/day in=20 two divided doses=20
    • Cost/mo: ~ $20
  • Fluphenazine=20
    • Dose=20
      • Initially, 2.5-5 mg/day in two or three = divided=20 doses, up to 20 mg/day=20
      • Decanoate formulation can be given I.M. = every 3=20 wk
    • Cost/mo: ~ $25
  • Haloperidol=20
    • Dose=20
      • Initially, 1-5 mg q.d. or b.i.d., titrated = upward=20 according to clinical response=20
      • Long-lasting I.M. formulation is = available=20
    • Cost/mo: ~ $20
  • Loxapine=20
    • Dose: initially, 10 mg/day in two divided = doses, up to=20 about 60 mg/day=20
    • Cost/mo: ~ $25
  • Mesoridazine=20
    • Dose: initially, 50 mg/day, up to 300-400 = mg/day in=20 two divided doses=20
    • Cost/mo: ~ $25
  • Molindone=20
    • Dose: initially, 50 mg/day, up to 200 mg/day = in two=20 divided doses=20
    • Cost/mo: ~ $30
  • Perphenazine=20
    • Dose: initially, 4 mg/day, up to 32-40 = mg/day in two=20 to four divided doses=20
    • Cost/mo: ~ $25
  • Pimozide=20
    • Dose: initially, 2 mg/day, up to 12 = mg/day=20
    • Cost/mo: ~ $130
  • Thioridazine=20
    • Dose: initially, 50 mg/day in two divided = doses, up to=20 400 mg/day=20
    • Cost/mo: ~ $20
  • Thiothixene=20
    • Dose: 5-10 mg/day in two divided doses, up = to 30-40=20 mg/day=20
    • Cost/mo: ~ $25

Atypical Antipsychotics

  • General characteristics=20
    • No more effective than neuroleptics for = reducing=20 positive psychotic symptoms, but fewer side effects=20
    • Reduced incidence of dystonia and tardive=20 dyskinesia=20
    • Some are associated with weight gain, = hyperlipidemia,=20 new-onset type 2 diabetes
  • Clozapine
    • Monitor for agranulocytosis=20
    • Superior efficacy=20
    • Dose: Initially, 25-50 mg/day in two divided = doses, up=20 to 600-800 mg/day=20
    • Cost/mo: ~ $155
  • Aripiprazole=20
    • Less likely to cause motor side effects than = the other=20 neuroleptics=20
    • Dose: initially 10-15 mg q.d., up to 30 = mg/day=20
    • Cost/mo: ~ $250
  • Olanzapine=20
    • Dose: initially, 5-10 mg/day in two divided = doses, up=20 to 30 mg/day=20
    • Cost/mo: ~ $300
  • Quetiapine=20
    • Dose: 50 mg/day in two divided doses, up to = 600=20 mg/day=20
    • Cost/mo: ~ $300
  • Risperidone=20
    • Dose=20
      • Initially, 2 mg q.d. or b.i.d., titrated = upward=20 according to clinical response up to 16 mg/day=20
      • Higher doses associated with motor side=20 effects=20
      • Long-lasting I.M. formulation = available=20
    • Cost/mo: ~ $250
  • Ziprasidone=20
    • Dose: initially, 20 mg b.i.d., titrated up = to 80 mg=20 b.i.d.=20
    • Cost/mo: ~ $250

Antianxiety Drugs

  • Reduce anxiety in schizophrenic = patients

Drugs for Depression and Mania

  • Those used in affective disorders can be = useful for=20 these symptoms in schizophrenia

Drugs for Aggression

  • Aggression caused by psychosis: antipsychotic=20 drugs=20
  • Aggression caused by akathisia as a side = effect of=20 antipsychotic drugs: change in drug or addition of another drug, such = as an=20 anticholinergic=20
  • Beta blockers=20
  • Atypical antipsychotic drugs

Electroconvulsive Therapy

  • Particularly effective for catatonic stupor, = excitement,=20 and acute psychotic conditions=20
  • Positive symptoms are reduced, but long-term = functional=20 impairments are not reversed=20
  • Limitations=20
    • Not widely available=20
    • Litigation and societal attitudes restrict = its=20 use=20
    • Therapeutic gains not easily = maintained=20
    • Little evidence of effectiveness in patients = who are=20 resistant to antipsychotic drugs

Psychosocial Interventions

  • Intensive psychotherapy less effective than = drug=20 treatment=20
  • Supportive psychosocial treatment with drug=20 treatment=20
  • Cognitive-behavioral therapy for = treatment-resistant=20 positive psychotic symptoms=20
  • Family therapy and education programs for = patients and=20 their families=20
  • Social and living skills training=20
  • Supported employment programs=20
  • Supervised residential living = arrangements=20
  • Crisis-management services as alternatives to=20 hospitalization during symptom exacerbation=20
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Best References

El-Sayeh HG, et al: Cochrane Database Syst Rev = CD004578,=20 2006 [PMID 16625607]

Kirkpatrick B, et al: Arch Gen Psychiatry 58:165, = 2001=20 [PMID 11177118]

Lieberman JA, et al: N Engl J Med 353:1209, 2005 = [PMID=20 16172203]



William T. Carpenter, = Jr.,=20 M.D., has served on the scientific advisory board of Janssen, L.P.; = Ortho-McNeil=20 Neurologics, Inc.; Merck & Co., Inc.; and Solvay Wyeth=20 Pharmaceuticals.

Gunvant K. Thaker, M.D., has no commercial = relationships=20 with manufacturers of products or providers of services discussed in = this=20 module.


December=20 2006
=A9 2008 BC Decker Inc. All rights reserved. =