SCHIZOPHRENIA AND

OTHER PSYCHOTIC
DISORDERS
LECTURE

DR RACHEL KANG’ETHE
DEPARTMENT OF PSYCHIATRY
 ‘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
I. Schizophrenia
 SCHIZOPHRENIA
• Chronic, devastating psychotic disorder that occurs
in about 1% of the population & is characterized by:
– Periods of loss of touch with reality and thoughts
disturbances including
• Hallucinations
• Delusions
• Disorganized thoughts
– Disturbances of behavior, appearance & speech;
– Abnormal affect;
– Social withdrawal;
• Usually involves repeated psychotic episodes and a
chronic, downhill course over years
• 7-15% have only one episode and full remission
 Brief History
• From 1700’s: reports of psychotic symptoms
• Kraepelin (1856-1926):
– 1st to delineate on the condition as a specific diagnostic entity
dementia praecox with focus on early onset, negative symptoms, and
progressive intellectual decline
– Also focused on subtypes of schizophrenia
• Bleuler (1857-1939):
– Introduced the term “schizophrenia” “Splitting of the mind”
– focused more on symptoms -“splitting” of mental processes
– questioned “medical model” and assumption of inevitable decline –
• 1940’s:
– focus shifted to societal pressures
– social labeling; schizophrenogenic mother; double-bind situations
• 1950’s: Schneider (1950’s): 1st-rank markers of Schizophrenia
– auditory hallucinations; loss of boundary experiences & delusions of
perception (known today as ideas of reference)
– all positive symptoms
 SYMPTOMS OF SCHIZOPHRENIA
• Positive Symptoms
things additional to expected behavior:
– Delusions
– Hallucinations
– Agitation and talkativeness
• Negative Symptoms
- things missing from expected behavior :
– Lack of motivation,
– Social withdrawal,
– Flattened affect,
– Cognitive disturbances,
– Poor grooming, and poor (i.e., impoverished)
speech content.
1. Positive symptoms = represent excess or
distortion of normal behavior
• Delusions = disorder of thought content and
presence of strong beliefs that are
misrepresentations of reality
• Grandiose = belief that one has special importance
• Persecutory = belief that one is the subject of a
master plot; feeling of being mistreated
• Very common; not diagnostically specific
• Nihilistic = belief that something does not exist (e.g.,
one’s brain; part of the world)
• Religious = involves some religious theme
– Very common; not diagnostically specific
• Bizarre = belief in something that could not be true
based on the person’s culture
Very specific to Sz (almost pathognomonic)
• Hallucinations = perceptual disturbance in which things
are sensed, although they are not actually present
– Auditory - Most common type of hallucination
– Visual - Second most common type of hallucination
– Other senses (olfactory, tactile, gustatory)
• Disorganized speech = style of talking involving
incoherence and lack of typical logical patterns
– Clang association = rhyming words
– Neologism = made-up words or phrases
– Word salad = words/speech with no message
– Derailment = deviation in the train of thought
– Knight’s move = going from point A to point C without
making a connection through point B
2. Negative symptoms = deficits in normal
behavior
– Flat affect = emotionless demeanor when a
reaction would be expected
– Avolition = apathy or inability to initiate or
persist in important activities
– Alogia = deficiency in amount or content of
speech
– Anhedonia = inability to experience pleasure
 First Rank symptoms
1950’s - Schneider’s 1st Rank Symptoms:
1. Primary Delusion = ‘delusional percept’
2. Own thoughts spoken aloud = ‘thought echo’
3. Voices arguing or discussing
4. Running commentary voices
5. Thought withdrawal and/or thought block
6. Thought insertion
7. Thought broadcasting (others are thinking it at the same time
as you)
8. Made to feel… ‘passivity of affect’
9. Made to want… ‘passivity of impulse’
10.Made to do… ‘passivity of volition’
11.Done to my body ‘somatic passivity’ eg probed by aliens
– Some may occur in illnesses other than schizophrenia eg
mania
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
SCHIZOPHRENIA EPIDEMIOLOGY:
• Occurs in 1% of the population.
• Lifetime prevalence is about 1% worldwide
• Gender ratio about equal (slightly higher in males)
• Sex differences in onset, presentation, and course
• Markers on chromosomes 5, 11, 18, 19, 22 and
most recently, 6, 8, and 13 have been associated
with schizophrenia.
• 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.
• Etiology is not known, certain factors have been
implicated in its development.
SCHIZOPHRENIA

genetics
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
 Neural pathology
1. Anatomy
a. Abnormalities of the frontal lobes, as evidenced
by decreased use of glucose in the frontal lobes
on positron emission tomography (PET') scans
are seen in the brains of people with
schizophrenia.
b. Lateral and third ventricle enlargement,
abnormal cerebral symmetry, and changes in
brain density also may be present.
c. Decreased volume of limbic structures (e.g.,
amygdala, hippocampus) is also seen.

Neural pathology
 Neural pathology
2. Neurotransmitter abnormalities
a. The dopamine (DA) hypothesis of schizophrenia states that
schizophrenia results from excessive dopaminergic activity
(excessive DA receptors/concentration/hypersensitivity).
a. As evidence for this hypothesis, stimulant drugs that
increase DA availability (e.g., amphetamines and cocaine)
can cause psychotic symptoms.
b. Laboratory tests may show elevated levels of homovanillic
acid (HVA), a metabolite of DA, in the body fluids of
patients with schizophrenia.
• Serotonin hyperactivity is implicated in schizophrenia ‘cos
hallucinogens that increase serotonin concentrations cause
psychotic symptoms and because some effective antipsychotics,
such as clozapin, have anti-serotonergic-2 (5-HT2) activity.
a. Glutamate is implicated in schizophrenia ‘cos antagonists of
N-methyl-D-aspartate (NMDA) subtype of glutamate receptors
(e.g., phencyclidine) increase and agonists of NMDA receptors
alleviate psychotic symptoms.
 SEASON OF BIRTH
• The season of birth is related to the
incidence of schizophrenia. More people
with schizophrenia are born during cold
weather months (i.e., Jan. - April in the
northern hemisphere and July – Sept. in
the southern hemisphere).
• One possible explanation for this finding is
viral infection of the mother during
pregnancy, since such infections occur
seasonally.
 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).
Causes: Psychological and Social Influences
• Stress
– Activates vulnerability
– Increases relapse risk

• Family Interactions
– Ineffective communication
– High expressed emotion
– Criticism, hostility, intrusiveness
– Related to relapse risk
 Natural History of Schizophrenia
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

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
• Disorder may onset abruptly or gradually
• Onset is early to mid-20’s for men; late 20’s for women
• Women more mood symptoms better prognosis
•50% have a prodromal period  social withdrawal, lose interest in work
/school, deterioration of functioning. Prodromal - worse prognosis than the
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).
Early onset:
More likely male; Poor adjustment before onset;
Lower educational achievement
Evidence of more structural brain abnormalities
More prominent negative symptoms
More cognitive impairment and worse outcome
Late onset
More likely female;
Less evidence of structural brain abnormalities
Less cognitive impairment and better outcome
EXPRESSED
RELAPSE
EMOTION

• Criticism
• Hostility
• Emotional Overinvolvement
• (Warmth)
• (Positive Remarks)
 SUICIDE
• Suicide is common in patients with schizophrenia.
• More than 50% attempt suicide (often during post-
psychotic depression or when having hallucinations
"commanding" them to harm themselves), and
• 10% of those die in the attempt.
• The prognosis is better and the suicide risk is lower
– if the patient is older at onset of illness,
– is married,
– has social relationships,
– is female,
– has a good employment history,
– has mood symptoms,
– has few negative symptoms, and has few relapses.
• Better course in developing countries
SUBTYPES OF SCHIZOPHRENIA
 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
 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
 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-LIKE DISORDERS
2. OTHER PSYCHOTIC 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
 Therapeutic Principles
5 principles when using antipsychotic drugs:
1. The targeted symptoms should be defined.
2. An antipsychotic that has worked for the
patient in the past should be used again,
otherwise the antipsychotic is usually chosen
based on the adverse effect profile.
3. If the trial (4-6 weeks) is unsuccessful a
different antipsychotic drug can be used. If a
severe negative initial reaction occurs, the
antipsychotic drug can be switched in fewer
than 4 weeks.
 Therapeutic Principles cont.
4. The administering of more than one
antipsychotic drug at a time occurs rarely, if
ever; however, combining an antipsychotic
with other drugs may occur especially in
treatment-resistant patients.
5. The dosage of the medication should be 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
 Augmentation strategies have generally shown
modest results
 No one strategy is generally accepted

– Mood stabilizers

– Benzodiazepines

– Antidepressants

– Antipsychotic combinations

– ECT
 Other Drugs
 Combination therapy using an
antipsychotic drug with an adjuvant drug
may be tried if trials with one antipsychotic
drug are unsuccessful.
 The adjuvant drugs with the best data are
lithium, two anticonvulsants
(carbamazepine and valproate), and the
benzodiazepines.
 Lithium
 It further reduces psychotic symptoms in up
to 50 percent of patients.
 It is 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.
 It also helps schizophrenia patients with
mood swings.
 Anticonvulsants
 Carbamazepine or valproate is usually
used with lithium or an antipsychotic.
 They reduce episodes of violence but have
not been shown to reduce psychotic
symptoms on their own.
 They affect blood levels because of effect
on hepatic enzymes.
 SCHIZOPHRENIA TREATMENT
Psychosocial treatments:
- Psychotherapy: individual, family, and group
- Psychoeducation with activity of patients or
enhancing motivation to the treatment
- Social support
Treatment: Psychosocial Interventions
• Psychosocial Approaches
– Behavioral (i.e., token economies)
• Inpatient units
– Community care programs
– Social and living skills training
– Behavioral family therapy
– Vocational rehabilitation

• Necessary adjunct to medication