Source: Crismon ML, Argo TR, Buckley
PF. Schizophrenia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR,
Wells BG, Posey LM, eds. Pharmacotherapy:
A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7987911.
Accessed June 8, 2012.
- Chronic heterogeneous syndrome of disorganized and bizarre
thoughts, delusions, hallucinations, inappropriate affect, cognitive
deficits, and impaired psychosocial functioning.
- Unknown, but evidence suggests genetic basis.
- Psychosis may result from hyper- or hypoactivity of dopaminergic
processes in specific brain regions.
- Deficiency of glutamatergic activity produces symptoms similar
to those of dopaminergic hyperactivity and possibly symptoms seen
- Schizophrenic patients with abnormal brain scans have higher
whole blood serotonin (5-hydroxytriptamine [5-HT])
concentrations that correlate with increased ventricular size.
- Prevalence ranges from 0.6–1.9% using
strict diagnostic criteria.
- Worldwide prevalence is similar among most cultures.
- Onset usually in late adolescence or early adulthood; rarely
occurs before adolescence or after age of 40 years.
- Prevalence equal in males and females, but illness onset tends
to be earlier in males.
- Positive symptoms:
- Disorganized speech (association disturbance)
- Behavior disturbance (disorganized or catatonic)
- Negative symptoms:
- Alogia (poverty of speech)
- Affective flattening
- Social isolation
- Cognitive dysfunction:
- Impaired attention
- Working memory
- Executive function
- Residual features after resolution of acute episode:
- Lack of volition
- Lack of motivation
- Poor insight
- Impaired judgment
- Social withdrawal
- Difficulty in learning from experience
- Poor self-care skills
- Diagnostic and Statistical Manual
of Mental Disorders, 4th ed., text revision (DSM-IV-TR) criteria:
dysfunction lasting longer than 6 months.
- Two or more symptoms (present for at least 1 month), including:
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms
- Significantly impaired functioning (work, interpersonal, or
- Other psychoses (e.g., delusional disorders, atypical
- Manic episodes
- Obsessive-compulsive disorder
- Psychotic depression
- Drug intoxication and abuse
- Thyroid, adrenal, and pituitary disorders
- Alleviate target symptoms.
- Avoid medication side effects.
- Improve psychosocial functioning and productivity.
- Achieve patient adherence with prescribed regimen.
- Involve patient in treatment planning.
- Prior to starting treatment, perform:
- Physical and neurologic examination
- Family and social history
- Psychiatric diagnostic interview
- Laboratory workup:
- Complete blood count (CBC)
- Hepatic function
- Renal function
- Electrocardiogram (ECG)
- Fasting serum glucose
- Serum lipids
- Thyroid function
- Urine drug screen
- First-line agents: second-generation antipsychotics (SGAs),
- SGAs cause few extrapyramidal side effects and less effect
on serum prolactin than first-generation antipsychotics (FGAs) but
have increased risk for metabolic side effects, including:
- Weight gain
- Diabetes mellitus
- Antipsychotic selection should be based on:
to avoid certain side effects
- Concurrent medical or psychiatric disorders
- Patient or family history of response
- Negative symptoms generally less responsive to antipsychotic
therapy than positive symptoms.
- If partial or poor adherence, consider long-acting or depot
injectable antipsychotic, for example:
- Paliperidone palmitate
- Extended-release olanzapine
- Haloperidol decanoate
- Fluphenazine decanoate
- Psychosocial rehabilitation programs
- Cognitive behavioral therapy
- Figure 1: algorithm for management of first episode ...