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INTRODUCTION

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  • Schizophrenia is characterized by delusions, hallucinations, disorganized thinking and speech, abnormal motor behavior, inappropriate affect, negative symptoms, and impaired psychosocial functioning.

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PATHOPHYSIOLOGY

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  • Increased ventricular size and decreased gray matter, have been reported.

  • Schizophrenia causation theories include genetic predisposition, obstetric complications with hypoxia, increased neuronal pruning, immune system abnormalities, neurodevelopmental disorders, neurodegenerative theories, dopamine receptor defect, and regional brain abnormalities including hyper- or hypo-activity of dopaminergic processes in specific brain regions.

  • Positive symptoms may be more closely associated with dopamine receptor hyperactivity in the mesocaudate, whereas negative and cognitive symptoms may be most closely related to dopamine receptor hypofunction in the prefrontal cortex.

  • Glutamatergic dysfunction. A deficiency of glutamatergic activity produces symptoms similar to those of dopaminergic hyperactivity and possibly schizophrenic symptoms.

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CLINICAL PRESENTATION

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  • Symptoms of the acute episode may include: being out of touch with reality; hallucinations (especially hearing voices); delusions (fixed false beliefs); ideas of influence (actions controlled by external influences); disconnected thought processes (loose associations); illogical conversation (alogia), ambivalence (contradictory thoughts); flat, inappropriate, or labile affect; autistic thinking (withdrawn and inwardly directed thinking); uncooperativeness, hostility, and verbal or physical aggression; impaired self-care skills; and disturbed sleep and appetite.

  • After the acute psychotic episode has resolved, typically there are residual features (eg, anxiety, suspiciousness, lack of motivation, poor insight, impaired judgment, social withdrawal, difficulty in learning from experience, and poor self-care skills). Comorbid substance abuse and nonadherence with medications are common.

  • Positive symptoms—delusions, disorganized speech (association disturbance), hallucinations, behavior disturbance (disorganized or catatonic), and illusions.

  • Negative symptoms—alogia (poverty of speech), avolition, flat affect, anhedonia, and social isolation.

  • Cognitive dysfunction—impaired attention, working memory, and executive function.

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DIAGNOSIS

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  • The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), specifies the following diagnostic criteria:

    • ✓ Continuous symptoms that persist for at least 6 months with at least one month of active phase symptoms (Criterion A) and may include prodromal or residual symptoms.

      • ❖Criterion A: For at least 1 month, there must be at least two of the following present for a significant portion of time: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. At least one symptom must be delusions, hallucinations, or disorganized speech.

      • ❖Criterion B: Significantly impaired functioning.

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TREATMENT

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  • Goals of Treatment: The goal is to alleviate target symptoms, avoid side effects, improve psychosocial functioning and productivity, achieve compliance with the prescribed regimen, integrate the patient back into the community, prevent relapse, and involve the patient in treatment planning.

  • Before treatment, perform a mental status examination, physical and neurologic examination, complete family and social history, psychiatric diagnostic interview, and laboratory workup (complete blood count [CBC], electrolytes, hepatic function, renal function, electrocardiogram [ECG], fasting serum glucose, serum lipids, thyroid function, and urine drug screen).

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GENERAL APPROACH

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  • Available antipsychotics and dosage ...

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