Schizophrenia and Other

Psychotic Disorders
LECTURE

DR RACHEL KANG’ETHE
DEPARTMENT OF PSYCHIATRY
REFERENCES:

1.The African textbook of psychiatry &

mental health by Ndetei et al 2006

2.Kaplan and Saddocks Synopsis

Psychiatry : Clinical Psychiatry , 2007
 In this lecture we will cover
• What is schizophrenia
• Historical background of schizophrenia
• Symptoms of schizophrenia
• Types of schizophrenia
• Diagnostic criteria of schizophrenia
• Etiology of Schizophrenia
• Natural history of Schizophrenia
• Some of the more common treatments for
schizophrenia
Schizophrenia
 What is schizophrenia?
• Chronic, devastating psychotic disorder that
occurs in 1% of population.
• Often hear voices, believe media are
broadcasting their thoughts to the world or
believe someone is trying to harm them.
• In men it usually develops in teen years and
early 20s; in women it usually develops in
20s and 30s.
• 7-15% have only 1 episode and full
remission
 Schizophrenia - Historical Background
• From 1700’s: reports of psychotic symptoms
• Emil Kraepelin (1856-1926):
 In 1883, separated schizophrenia (which he called
dementia praecox) from manic-depressive psychosis) largely
on the basis of the clinical course of the syndromes.
 Viewed schizophrenia as a dementia or progressive
intellectual decline; focused on early onset, negative
symptoms and on subtypes of schizophrenia
• Eugene Bleuler (1857-1939):
 In 1911 coined the term schizophrenia, meaning
splitting of the mind. Note this is NOT intended to
imply “split personalities” but rather a split between thought
and emotion.
 Questioned “medical model”&inevitable decline assumption.
• Bleuler’s “Four A’s” (the Group of Schizophrenias, 1911)
– Autism
– Loose Associations
– Affective disturbance
– Ambivalence

• 1940’s:
– focus shifted to societal pressures; social labeling;
“schizophrenogenic mother”; double-bind situations

• 1950’s: Schneider : 1st-rank markers of Schizophrenia

– all positive symptoms
– auditory hallucinations; loss of boundary experiences
and delusions of perception
 Symptoms of Schizophrenia
• Profound disruption in cognition and
emotion, affecting the most fundamental
human attributes:
– Language
– Thought
– Perception
– Affect
– Sense of self
Schizophrenia: Positive symptoms
- Things additional to expected behavior:
- Appear to reflect an excess or distortion of
normal functions.
– Delusions
– Hallucinations
– Thought disorganization
– Catatonic behavior
– Inappropriate responses
– Grossly disorganized behavior.
Negative symptoms
• Things missing from expected behavior
– Blunted affect - decreased facial expression, vocal
inflection, eye contact, expressive gestures
– Alogia - reduced amount of speech, reduced
content of ideas, thought blocking, long latency
– Avolition/Apathy - poor grooming and hygiene,
impersistence at school or work, low energy
– Anhedonia/Asociality - loss of recreational
interests, decreased sexual activity, absence of
intimacy and personal relationships
– Inattention - socially uninvolved, “spacey,” poor
cognitive function
 Cognitive Symptoms
• Difficulties in concentration and memory:
– Disorganized thinking
– Slow thinking
– Difficulty understanding
– Poor concentration
– Poor memory
– Difficulty expressing thoughts
– Difficulty integrating thoughts, feelings,
behaviors
 Schneider’s “First-Rank Symptoms” (1950’s)
1)Delusional perception = Primary Delusion
2)Audible thoughts - own thoughts spoken aloud
3)More than one voice arguing or discussing patient
4)Running commentary voices
5)Thought insertion;
6)Thought withdrawal
7)Thought broadcasting
8)Made feelings;
9)Made impulses;
10)Made volition
11)Somatic passivity - e.g., probed by aliens
DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA

A. 2 (or more) of the following symptoms, each present for a

significant portion of time during a 1-month period:
(1). Delusions (2). Hallucinations
(3). Disorganized speech (derailment or incoherence)
(4). Grossly disorganized or catatonic behavior
(5). Negative symptoms-affective flattening/alogia/avolition
Note: Only one Criterion A symptom is required if delusions
are bizzare or hallucinations consist of a voice keeping up a
running commentary on the person's behavior or thoughts
(2nd person),
person) or two or more voices conversing with each
other (3rd person).
person)
B. Social/occupational dysfunction
Work, interpersonal relations or self-care impaired or in
child/adolescent failure to achieve academic/occupational
or interpersonal achievement
DSM-IV
DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA
C. Duration: Continuous signs of the disturbance persist
for at least 6 months. This 6-month period must include
at least 1 month of symptoms that meet Criterion A (i.e.,
active-phase symptoms) and may include periods of
prodromal or residual symptoms.
• During these prodromal or residual periods, the signs of
the disturbance may he manifested by only negative
symptoms or two or more symptoms listed in Criterion
A present in an attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
D. Schizoaffective and Mood Disorder exclusion: ‘Cos
(1). No Major Depressive, Manic or Mixed episodes
have occurred concurrently during active-phase
symptoms.

DSM-IV
DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA
E. Substance/general medical condition exclusion:
The disturbance not directly due to physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition.
F. Relationship to a Pervasive Developmental
Disorder. If there is a history of Autistic Disorder
or another Pervasive Developmental Disorder, the
additional diagnosis of Schizophrenia is made only
if prominent delusion, or hallucinations are also
present for at least a month.

DSM-IV
GOD BLESS KENYA
 Types of Schizophrenia
• Paranoid
• Hebephrenic
• Catatonic
• Residual
• Schizoaffective
• Undifferentiated
 SUBTYPES OF SCHIZOPHRENIA
Paranoid Type
A. Preoccupation with one or more delusions
or frequent auditory hallucinations.
B. None of the following is prominent:
disorganized speech, disorganized or
catatonic behavior, or flat or inappropriate
affect.

DSM-IV
 How
many
faces ?

How
many
faces ?
 SUBTYPES OF SCHIZOPHRENIA
Disorganized Type
A. All of the following are prominent:
(1) disorganized speech
(2) disorganized behavior
(3) flat or inappropriate affect
B. The criteria are not met for Catatonic
Type

DSM-IV
 SUBTYPES OF SCHIZOPHRENIA
Catatonic Type
The clinical picture is dominated by at least two of the
following:
(1) motoric immobility as evidenced by catalepsy (in­cluding
waxy flexibility) or stupor
(2) excessive motor activity (that is apparently purposeless
and not influenced by external stimuli)
(3) extreme negativism (an apparently motiveless
resistance to all instructions or maintenance of a rigid
posture against attempts to be moved) or mutism
(4) peculiarities of voluntary movement as evidenced by
posturing (voluntary assumption of inappropriate or
bizarre postures), stereotyped movements, prominent
mannerisms, or prominent grimacing
(5) echolalia or echopraxia
DSM-IV
 SUBTYPES OF SCHIZOPHRENIA

Undifferentiated Type

• A type in which symptoms that meet

Criterion A are present, but the criteria are
not met for the paranoid, disorganized, or
catatonic type.

DSM-IV
 SUBTYPES OF SCHIZOPHRENIA

Residual Type
• A. Absence of prominent delusions,
hallucinations, disorganized speech, and grossly
disorganized or catatonic behavior.
• B. There is continuing evidence of the
disturbance, as indicated by the presence of
negative symptoms or two or more symptoms
listed in Criterion A for schizophrenia, present in
an attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
DSM-IV
Etiology of Schizophrenia
Genetic predisposition
Prenatal infection,
Perinatal anoxia
Early environmental insults

Neurodevelopmental abnormalities
Substance abuse,
Psychosocial stressors
Later environmental insults

Further brain dysfunction

Psychosis

Neurodegeneration
Etiology of Schizophrenia
• Etiology is not known, certain factors have been
implicated in its development.
• Persons with a close genetic relationship to a patient
with schizophrenia are more likely than those with a
more distant relationship to develop the disorder.
• Genetic factors
– 10% risk to first-degree relatives
– 50% risk to monozygotic twins
– No specific genetic linkage has been
demonstrated
– Multiple genes are probably involved
1. Anatomy
a. Abnormalities of frontal lobes, as evidenced by decreased
use of glucose in the frontal lobes
b. Lateral and 3rd ventricle enlargement, abnormal cerebral
symmetry and changes in brain density also may be present.
c. Decreased vol. of limbic structures amygdala / hippocampus
2. Neurotransmitter abnormalities
a) Dopamine (DA) hypothesis of schizophrenia states that
schizophrenia results from excessive dopaminergic activity.
• Evidenced by stimulant drugs that increase DA (e.g.,
amphetamines and cocaine) cause psychotic symptoms.
• Laboratory tests may show elevated levels of homovanillic
acid, a metabolite of DA, in body fluids of schizophrenic pts.
b) Serotonin hyperactivity implicated ‘cos hallucinogens that
increase serotonin cause psychotic symptoms & ‘cos some
effective antipsychotics, such as clozapin, have anti-
serotonergic-2 (5-HT2) activity.
c) Glutamate also implicated in schizophrenia
 Infections and Schizophrenia
 Recent onset schizophrenia is associated with:
 Increased transcription of HERV-W
 Increased levels of antibodies to CMV
 Past infection with HSV-1 is associated with cognitive
impairment in individuals with stable schizophrenia and
bipolar disorder, but not in unaffected controls.
 Maternal exposure to infectious agents is associated with
an increased rate of schizophrenia in the offspring.
 The administration of valacyclovir can reduce symptoms in
some individuals with stable schizophrenia.
 The continued evaluation of the role of the prevention and
treatment of infection in the management of psychiatric
diseases remains a high priority.
 “DOWNWARD DRIFT" HYPOTHESIS
• No social or environmental factor
causes schizophrenia.
• However, because patients with
schizophrenia tend to drift down the
socioeconomic scale as a result of
their social deficits (the "downward
drift" hypothesis), they are often
found in lower socio­economic groups
(e.g., homeless people).
Psychological and Social Influences
• Stress
– Activates vulnerability
– Increases relapse risk

• Family Interactions
– Ineffective communication
– High expressed emotion
– Criticism, hostility, intrusiveness
– Related to relapse risk
EXPRESSED
RELAPSE
EMOTION

• Criticism
• Hostility
• Emotional Overinvolvement
• (Warmth)
• (Positive Remarks)
 Natural History of Schizophrenia
I. Premorbid features - 25-50%:
May be present from birth or may precede psychosis by month/years

– Poor social adjustment; Introversion; few friends

– Poor school and work performance; Impulsive behavior

– Peculiarities of thought or behavior

– Decrease emotional reactivity

– Social withdrawal; Suspiciousness

– Abnormal reactions to usual events and situations

– Problems with focusing attention for the longer time

 Natural History of Schizophrenia

2. Age of Onset
 Onset is usually defined by emergence of psychosis
 Peak age of onset for men is 17-30
 Peak age of onset for women is 20-40
 Childhood (<18 yrs) and late-life (>45 yrs) onset of
schizophrenia occur at a lower frequency
 Natural History of Schizophrenia
3. COURSE

50% Prodromal syndromes worse prognosis

than those with acute, sudden onset
The course:
55% - rather good,
45% - rather unfavorable, including 5% with
definitely unfavorable (15% in the past)
antipsychotic medications improve the course
(decreases symptoms) and reduces relapse
rate (40- 50% of reduction).
 Schizophrenia
Complications
• Suicide – 5-10% of deaths
• Depression - occurs in 50% of cases, often
after an acute episode
• Homelessness – 30-35% of homeless
• Crime: 4-fold increase in acts of violence
compared with the general population. These
patients are more frequently victims of both
violent and nonviolent crimes.
• Substance abuse
 Schizophrenia: Prognostic Features

Good Prognosis Poor Prognosis

Later onset Early onset
Obvious precipitating factors No precipitating factors
Acute onset Insidious onset
Good premorbid social and work history Poor premorbid social and work history
Preponderant positive symptoms Preponderant negative symptoms
Depressive symptoms Absence of depressive symptoms
Preservation of adequate affective expression Blunted or inappropriate affect
Paranoid or catatonic features Undifferentiated or disorganized features
Variable course Chronic course
Absence of neuropsychological impairment Presence of neuropsychological impairment
Absence of structural brain abnormalities Presence of structural brain abnormalities
Good social support systems Poor social support systems
Early adequate treatment No treatment or delayed/ inadequate treatment

Adapted from: Sadock BJ, Sadock VA: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 7th ed, Philadelphia,
Lippincott Williams & Wilkins, p. 1197
 SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS
• Medical illnesses that can cause psychotic
symptoms mimicing schizophrenia (i.e., psychotic
disorder caused by a general medical condition)
include: neurological infection, neoplasm, trauma,
disease (e.g., Huntington disease, multiple
sclerosis), temporal lobe epilepsy and endocrine
disorders (e.g., cushing syndrome).
• Medications that can cause psychotic symptoms
include analgesics, antibiotics, anti­cholinergics,
antihistamines, antineoplastics, cardiac glycosides
(e.g., digitalis), and steroid hormones.
SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS
A.Other psychotic disorders - characterized at some
point during their course by a loss of touch with reality.
However, the other psychotic disorders do not include all
of the criteria required for the diagnosis of schizophrenia:
– brief psychotic disorder
– schizophreniform disorder
– delusional disorder
– shared psychotic disorder
B. Mood disorders (e.g., mania, major depression).
C. Cognitive disorders (e.g., delirium, dementia)
D. Substance-related disorders
E. Schizotypal, paranoid and borderline personality
disorders are not characterized by frank psychotic
symptoms but have other characteristics of
schizophrenia, (e.g., odd behavior, avoidance of social
relationships).
 Schizophrenia: Summary
• Before a diagnosis the psychiatrist must
make a thorough evaluation including a
physical/medical exam, a mental status
exam, appropriate labs, and a full history.
• History includes changes in thinking,
behavior, movement, mood, etc. as seen by
the family.
• Early detection and treatment has the best
results/response to treatment.
Schizophrenia Treatment
• Therapeutic Goals
• minimize symptoms
• minimize medication side effects
• prevent relapse
• maximize function
• “recovery”
• Types of Treatment
• pharmacotherapy
• psychosocial/psychotherapeutic
Treatment
A. Antipsychotic medications
• “Typical” antipsychotic medications
• High Potency (2-20 mg/day)/(haloperidol, fluphenazine)
• Mid Potency (10-100 mg/day)/(loxapine, perphenazine)
• Low Potency (300-800+ mg/day)/(chlorpromazine)
– 70% of patients respond
• Atypical antipsychotics (risperidone, olanzapine, quetiapine,
ziprasidone, aripiprazole)
– Lower propensity to cause extrapyramidal side effects
– First-line drugs of choice - 70% of patients respond
– Atypicals may be better for negative symptoms
– Clozapine is effective in 35-50% of patients who do not
respond to other antipsychotics (80-85% of all patients)
 Medications
• In general it may take up to 6 months for
medications to show consistent effects.

• Meds include atypicals: Abilify, Geodon,

Clozapine, Risperidone, Seroquel,
Zyprexa.
– [Remember: a giraffe can really see a zebra]
ASANTE SANA
2. OTHER PSYCHOTIC DISORDERS
SCHIZOPHRENIA-LIKE DISORDERS
 ‘Psychosis’ - definition
Mental disorder in which:
• thoughts, feelings, affective response,
• ability to recognise reality and
• ability to communicate and relate to others
are sufficiently impaired to interfere grossly with
the capacity to deal with reality;
• The characteristics of psychosis are:
• impaired reality testing,
• hallucinations, delusions and illusions.
• Kaplan & Saddock “Comprehensive textbook of psychiatry” – 7 th ed, glossary p686
 Epidemiology:
• Schizophrenia – 1%
• Schizoaffective disorder - 0.5-0.8%

• Delusional disorder– 0.025 – 0.03%

General information
SCHIZOPHRENIA-LIKE DISORDERS
 SCHIZOPHRENIFORM DISORDER
Criteria A, D, and E of schizophrenia are met
An episode of the disorder (including prodromal,
active, and residual phases) lasted at least 1
month but less than 6 months (when the
diagnosis must be made without waiting for
recovery, it should be qualified as
“provisional”).
Specify if:
• Without good prognostic features
• With good prognostic features if evidenced by
two or more of the following:
DSM-IV
SCHIZOPHRENIFORM DISORDER
With good prognostic features if evidenced
by two or more of the following:
• onset of prominent psychotic symptoms
within 4 weeks of the first noticeable
change in usual behavior or functioning
• confusion or perplexity at he height of
psychotic episode
• good premorbid social functioning
• absence of blunted or flat affect

DSM-IV
 SCHIZOAFFECTIVE DISORDER
A. An interrupted period of illness during which, at
some time, there is either a Major Depressive
Episode, a Manic Episode, or a Mixed Episode
concurrent with symptoms that meet Criterion A for
schizophrenia.
• B. During the same period of illness, there have
been delusions or hallucinations for at least 2 weeks
in the absence of prominent mood symptoms.
• C. Symptoms that meet criteria for a mood episode
are present for a substantial portion of the total
duration of the active and residual periods of the
illness.
• D. The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.

DSM-IV
 SCHIZOAFFECTIVE DISORDER
Specify type:
• Bipolar Type: if the disturbance includes a
Manic or a Mixed Episode (or a Manic or a
Mixed and Major Depressive Episodes)
• Depressive Type: if the disturbance only
includes Major Depressive Episodes

DSM-IV
DELUSIONAL DISORDER (PARANOIA)
A. Nonbizarre delusions (i.e., involving situations that occur
in real life, such as being followed, poisoned, infected,
loved at a distance, or deceived by spouse or lover, or
having a disease) of at least 1 month’s duration.
B. Criterion A for Schizophrenia has never been met. Note:
Tactile and olfactory hallucinations may be present in
Delusional Disorder if they are related to the delusional
theme.
C. Apart from the impact of the delusion(s) its ramifications,
functioning is not markedly impaired and behav­ior is not
obviously odd or bizarre.
D. If mood episodes have occurred concurrently with
delusions, their total duration has been brief relative to
the duration of the delusional periods.
E. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drag of abuse, a medica­
tion) or a general medical condition.
DSM-IV
 DELUSIONAL DISORDER (PARANOIA)
Specify type (the following types are assigned based on the
predominant delusional theme):
• Erotomanic: delusions that another person, usually of higher
status, is in love with the individual
• Grandiose: delusions of inflated worth, power, knowledge,
identity, or special relationship to a deity or famous person
• Jealous: delusions that the individual's sexual partner is
unfaithful
• Persecutory: delusions that the person (or someone to
whom the person is close) is being malevolently treated in
some way
• Somatic: delusions that the person has some physical defect
or general medical condition
• Mixed Type: delusions characteristic of more than one of the
above types but no one theme predominates
• Unspecified Type

DSM-IV
 BRIEF PSYCHOTIC DISORDER
A. Presence of one (or more) of the following symptoms:
• (1) delusions
• (2) hallucinations
• (3) disorganized speech (e.g., frequent derailment or
incoherence)
• (4) grossly disorganized or catatonic behavior
• Note: Do not include a symptom if it is a culturally
sanctioned response pattern.
B. Duration of an episode of the disturbance is at least 1
day but less than 1 month, with eventual full return to
premorbid level of functioning.
C. The disturbance is not better accounted for b a Mood
Disorder With Psychotic features, Schizoaffective
Disorder, or Schizophrenia and is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.

DSM-IV
 BRIEF PSYCHOTIC DISORDER
Specify if:
• With Marked Stressor(s) (brief reactive
psychosis): if symptoms occur shortly after and
apparently in response to events that, singly or
together, would be markedly stressful to almost
anyone in similar circumstances in the person's
culture
• Without Marked Stressor(s): if psychotic
symptoms do not occur shortly after, or are not
apparently in response to events that, singly or
together, would be markedly stressful to almost
anyone in similar circumstances in the person's
culture.
• With Postpartum Onset: if onset is within 4 weeks
postpartum
DSM-IV
SHARED PSYCHOTIC DISORDER
A. Delusion develops in an individual in the context
of a close relationship with another person(s),
who has an already-established delusion.
B. The delusion is similar in content to that of the
person who already has the established
delusion
C. The disturbance is not better accounted for by
another psychotic disorder (e.g., Schizophrenia)
or a Mood Disorder with Psychotic Features and
is not due to the direct physiological effects of a
substance (e.g., a drag of abuse, a medication)
or a general medical condition.
DSM-IV
PSYCHOTIC DISORDER DUE TO … (INDICATE
THE GENERAL MEDICAL CONDITION)
• Psychotic Disorder Due to . . . (Indicate the
General Medical Condition)
• A. Prominent hallucinations or delusions.
• B. There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is the direct physiological
consequence of a general medical condition.
• C. The disturbance is not better accounted for
by another mental disorder.
• D. The disturbance does not occur exclusively
during the course of a delirium.

DSM-IV
SUBSTANCE-INDUCED PSYCHOTIC DISORDER

A. Prominent hallucinations or delusions.

B. There is evidence from the history, physical
examination, or laboratory findings of either (1)
or (2)
• the symptom in Criterion A developed during,
or within month of substance intoxication or
withdrawal
• medication use is etiologically related to the
disturbance

DSM-IV
SUBSTANCE-INDUCED PSYCHOTIC DISORDER
C. The disturbance ins not better accounted for psychotic
disorder that is not substance induced. Evidence that
symptoms are better accounted for the psychotic
disorder the is not substance induced may include
following:
• the symptoms precede the onset of the substance use
(or medication use);
• the symptoms persist for a substantial period of time
(e.g., about month) after cessation of acute withdrawal
or severe intoxication, or are substantially in excess of
what would be expected given the type or amount of
the substance used or the durations of use; or there is
other evidence that suggest s the existence of an
independent non-substance-induced psychotic
disorder (e.g. a history of recurrent non-substance-
related episodes).

DSM-IV
 Timeline of Major
Antipsychotic Therapies
Paliperidone

ECT, etc.
Olanzapine Aripiprazole
Chlorpromazine Quetiapine
Fluphenazine
Risperidone
Thioridazine Consta
Haloperidol Clozapine Ziprasidone

1950 1960 1970 1980 1990 2001 2003 2007

Consta = Long-acting injectable risperidone

 PHARMACOLOGIC TREATMENT
• Traditional antipsychotics [dopamine­2
(D2)-receptor antagonists] first generation
of antipsychotic medication
• Atypical antipsychotic agents –second
generation of antipsychotic medication
• Because of their better side-effect profiles,
the atypical agents are now first-line
treatments.
 Side Effects of Atypical Antipsychotics
INVEGA/
CLOZARIL RISPERDAL ZYPREXA SEROQUEL GEODON ABILIFY

Low Blood Pressure +++ + +/0 ++ 0/+ 0/+

Dry mouth,
constipation +++ 0 +/++ 0 0 0
Tremors, stiffness,
endocrine problems
0 +/++ 0/+ 0 +/0 0
Sedation +++ +/- ++ +++ 0 0
Weight gain ++++ + ++++ ++ -/+ -/+
Lipids +++ + +++ ++ 0 0
Blood sugar +++ + +++ ++ 0 0

CLOZ = clozapine; RIS = risperidone; OLZ = olanzapine; QUET = quetiapine; ZIP = ziprasidone; ARIP =
aripiprazole; Adapted from: Nasrallah HA, Mulvihill T. Ann Clin Psychiatry. 2001(Dec);13(4):215-227
Pharmacologic Treatment of Schizophrenia

Target Symptoms
 Active psychosis
– most common reason for hospitalization
– most responsive to medications
 Negative symptoms
– poor response to medication
– progress most rapidly during early acute phases of
illness
Pharmacologic Treatment of Schizophrenia

Target Symptoms
 Cognitive impairment
– may be improved or worsened by medications
– clinical effect of medications tends to be small
 Functional deterioration
– occurs mostly during acute episodes, which can be
prevented by medications
5 principles: antipsychotic drugs (AP):
1. The targeted symptoms should be defined.
2. AP that worked in the past should be used
again, otherwise AP chosen based on the
adverse effect profile.
3. If trial (4-6/12) is unsuccessful a different AP
used. If a severe negative initial reaction occurs,
antipsychotic switched in fewer than 4 weeks.
4. Combining an antipsychotic with other drugs may
occur especially in treatment-resistant patients.
5. Dosage of medication kept at the lowest possible
effective amount for the patient.
 Initial Workup
 Because antipsychotic drugs are
remarkably safe, they can be administered
(excepting clozapine) in an emergency
without a physical or laboratory
examination.
 A complete blood count with white blood
cell indexes, liver function tests, and an
electrocardiogram
 Major Contraindications
1. A history of serious allergic response
2. Possibility the patient has ingested something
that would interact with the antipsychotic
medication to cause CNS depression or
anticholinergic delirium
3. Presence of a severe cardiac abnormality
4. High risk of seizures from an organic or
idiopathic causes
5. Presence of narrow-angle glaucoma if
antipsychotic to be used has significant
cholinergic activity.
 Treatment of Refractory Illness
 In the acute state, nearly all patients
eventually respond to repeated doses of an
antipsychotic drug. If they do not an
organic lesion should be considered.
 Noncompliance and insufficient time for the
trial are often reasons for a failed drug trial.
 The dosage should not be increased and
the antipsychotic medication should not be
changed during the first 2 weeks of
treatment.
Treatment of Refractory Illness cont.

 If there is no change in the patient after 2

weeks, the reasons for drug failure should
be considered.
 Plasma levels of antipsychotic drugs
provide only a gross measure of
compliance, absorption, and metabolism.
 Neurological adverse effects are often a
reason for noncompliance, so the atypical
agents with more favorable adverse effects
may yield improved compliance.
 Antipsychotic Augmentation Strategies
Other Drugs
 Augmentation
 Combination therapy using
strategies have
an antipsychotic drug with
generally shown an adjuvant drug may be
modest results tried if trials with one
*Mood stabilizers antipsychotic drug are
unsuccessful.
*Benzodiazepines
*Antidepressants  Adjuvant drugs with best
*Antipsychotics data are lithium, valproate
*ECT carbamazepine and
benzodiazepines.
 Anticonvulsants
 Carbamazepine/valproate
used with lithium or
antipsychotic.
 Reduces violence
episodes but don’t reduce
psychotic symptoms on
their own.
 They affect blood levels
because of effect on
hepatic enzymes.
Lithium
 Reduces psychotic
symptoms in 50% pts.
 Typically taken with
antipsychotic medication the
patient is already taking, but
it may be an alternative for
patients who can’t take any
of the antipsychotic
medication
 Also helps schizophrenia pts
with mood swings.
Psychosocial treatments:
- Psychotherapy: individual, family, and group
- Psychoeducation with activity of patients or
enhancing motivation to the treatment
- Social support
• Psychosocial Approaches
– Behavioral (token economies) Inpatient units
– Community care programs
– Social and living skills training
– Behavioral family therapy
– Vocational rehabilitation
• Necessary adjunct to medication