Farhan is a young boy of 23 years of age, single ,unmarried, educated upto Fsc. He is resident of district Chakwal and was referred to me by one of my senior colleague from Rawalpindi , in OPD on 26.9.2006. This is his first admission in PIMH .

Presenting ComplainsPresenting Complains

Aggressive abusive and irritable Aggressive abusive and irritable Suspicious to his family members, Suspicious to his family members,

Self talking , self laughing along with odd Self talking , self laughing along with odd behaviour.behaviour.

Disturbed sleepDisturbed sleep

Family HistoryFamily History No family history of any Psychiatric illness.No family history of any Psychiatric illness.

Personal HistoryPersonal History Poor performance in school Poor performance in school Asocial Asocial Down ward drift Down ward drift

Premorbid History Premorbid History Schizoid Schizoid

Drug HistoryDrug History

During his stay with us During his stay with us Following drugs has been givenFollowing drugs has been given SEP to NOV 2006 Risperidone upto SEP to NOV 2006 Risperidone upto

6mg /day but with poor response 6mg /day but with poor response DEC to 15JAN 2007 olanzapine DEC to 15JAN 2007 olanzapine

20mg/day but with poor response20mg/day but with poor response 15JAN to MARCH 2007 Zeldox400mg/day 15JAN to MARCH 2007 Zeldox400mg/day

but with poor response but with poor response Currently he is on Clozapine 400mg/day and Currently he is on Clozapine 400mg/day and

gradually increasing the dose (100mg/week)gradually increasing the dose (100mg/week)

Mental State Mental State ExaminationExamination

Appearance and BehaviorAppearance and Behavior

Young thin boy .wearing hospital Young thin boy .wearing hospital uniform, sitting comfortably in uniform, sitting comfortably in chair ,cooperative , making and chair ,cooperative , making and maintaining eye contact adequately maintaining eye contact adequately showing self smiling during interview.showing self smiling during interview.

MOOD Subjectively I am happy MOOD Subjectively I am happy MOOD Objectively EuthymicMOOD Objectively Euthymic

TalkTalk Verbatum of the Patient Verbatum of the Patient Verbatum is in urdu, It is translated in Verbatum is in urdu, It is translated in

English for your convenience.English for your convenience. I have been selected for president I have been selected for president First of all iwas Major General but iwas not First of all iwas Major General but iwas not

promoted to Brigadierpromoted to Brigadier I have the power of four knowledge'sI have the power of four knowledge's Religion KnowledgeReligion Knowledge Black knowledge (Magic)Black knowledge (Magic) Sky KnowledgeSky Knowledge Knowledge .which I developed myself.Knowledge .which I developed myself. There are army control room There are army control room They control my whole village.Also in my home They control my whole village.Also in my home

and control me.and control me. Army people have taken out my brain.Army people have taken out my brain. Now aday Iam General “Ghain” this name has Now aday Iam General “Ghain” this name has

been given to me by GHQ Rawalpindibeen given to me by GHQ Rawalpindi

In Navy Iam “QUTTAR In Navy Iam “QUTTAR KANDUCTOR”(invented word with no KANDUCTOR”(invented word with no meaning)meaning)

In air force Iam “DEAL LAKORA”(invented In air force Iam “DEAL LAKORA”(invented word with no meaning in urdu)word with no meaning in urdu)

Iam the GUL of whole world.Iam the GUL of whole world. Iam under women like magic they want to Iam under women like magic they want to

convert me in a girl.convert me in a girl. Ihave the knowledge of ideas that is very Ihave the knowledge of ideas that is very

powerful.I come to know each and every powerful.I come to know each and every thing through this thing through this

This is not for only muslims but also people This is not for only muslims but also people belonging to other religions.belonging to other religions.

People living in my village also have this People living in my village also have this knowledge. Thatpush different thoughts into knowledge. Thatpush different thoughts into my mind,rather they push my thought into my mind,rather they push my thought into the mind other peoplesthe mind other peoples

While describing all this talk, there was no While describing all this talk, there was no pressure of speech,no elation rather he was pressure of speech,no elation rather he was quite cold and devoid of any emotionquite cold and devoid of any emotion

Auditory Auditory HallucinationHallucination

Not foundNot found

Thoughts disorder Thoughts disorder Thought insertionThought insertion Broadcasting Broadcasting WithdrawlWithdrawl Delusion of grandeur / paranoidDelusion of grandeur / paranoid Passivity - positive Passivity - positive

Orientation and Orientation and ConcentrationConcentration

He is well oriented in time and space.He is well oriented in time and space.

InsightInsight According to patient, he is not suffering According to patient, he is not suffering

from any psychiatric illness and needs no from any psychiatric illness and needs no medication.medication.

D/DD/D In my opinion The most likely diagnosis isIn my opinion The most likely diagnosis is

SCHIZOPHRENIASCHIZOPHRENIA SCHIZOAFFECTIVE DISORDERSCHIZOAFFECTIVE DISORDER BADBAD CHRONIC MANIACHRONIC MANIA

Points in favour of Points in favour of first diagnosisfirst diagnosis

Continuous pattern of illness without Continuous pattern of illness without seasonal variation .seasonal variation .

Premorbid personality Premorbid personality Delusion of control and thoughts disorder Delusion of control and thoughts disorder

. . Absence of pressure of speech ,poor Absence of pressure of speech ,poor

emotional response while talking emotional response while talking NeologismNeologism

Precipitating FactorsPrecipitating Factors The poor performance in Fsc result in the The poor performance in Fsc result in the

initiation of the illness.initiation of the illness.

Maintaining FactorsMaintaining Factors Premorbid personalityPremorbid personality Poor drug compliancePoor drug compliance HEEHEE

MANAGEMENTMANAGEMENT I would like to manage this case on I would like to manage this case on

following aspectfollowing aspect PharmacologicalPharmacological PsychologicalPsychological SocialSocial

Along with pharmacological treatment, Along with pharmacological treatment, psychosocial education of the family is psychosocial education of the family is being carried out.being carried out.

SCHIZOPHRENIASCHIZOPHRENIA Schizophrenia is one of the group of psychiatric Schizophrenia is one of the group of psychiatric

disorders traditionally called the functional disorders traditionally called the functional psychoses.psychoses.

SCHIZOPHRENIASCHIZOPHRENIA NEGATIVE SYMPTOMSNEGATIVE SYMPTOMS

POSITIVE SYMPTOMSPOSITIVE SYMPTOMS

DIAGNOSISDIAGNOSISDSM-TR ICD-10DSM-TR ICD-10

PARANOID PARANOIDPARANOID PARANOID

DIORGANISED HEBEPHERNICDIORGANISED HEBEPHERNIC

CATATONIC CATATONICCATATONIC CATATONIC

UNDIFFERENTIATED UNDIFFERENTIATED UNDIFFERENTIATEUNDIFFERENTIATE

RESIDUAL SIMPLERESIDUAL SIMPLE

EPIDEMIOLOGYEPIDEMIOLOGY INCIDENCEINCIDENCE

.1%.1%

PREVALENCEPREVALENCE

Life time risk is 7-13% per 1000 population.Life time risk is 7-13% per 1000 population.

MORTALITYMORTALITY

Suicide is the most common cause of early death in Suicide is the most common cause of early death in schizophrenia (7-13%).schizophrenia (7-13%).

AETIOLOGYAETIOLOGYBIOLOGICAL FACTORSBIOLOGICAL FACTORS

BIRTH COMPLICATIONSBIRTH COMPLICATIONS

NEURODEVELOPEMENTAL NEURODEVELOPEMENTAL

POST NATAL INFECTIONS (VIRAL)POST NATAL INFECTIONS (VIRAL)

EXPOSURE TO DRUGSEXPOSURE TO DRUGS

CONTINUE…….CONTINUE…….ENVIROMENTAL FACTORSENVIROMENTAL FACTORS

HOME ATMOSPHEREHOME ATMOSPHERE

ROLL OF CAREGIVERSROLL OF CAREGIVERS

MIGRATIONMIGRATION

EARLY DEATHS OF PARENTSEARLY DEATHS OF PARENTS

UNUSUAL STRESSUNUSUAL STRESS

CONTINUE…..CONTINUE…..GENETIC FACTORS RISKGENETIC FACTORS RISK

IDENTICAL TWINS 46%IDENTICAL TWINS 46% NON IDENTICAL TWIN 12-15%NON IDENTICAL TWIN 12-15% REAL SIBLINGS 08%REAL SIBLINGS 08% BOTH PARENTS 40%BOTH PARENTS 40% ONE PARENT 12-ONE PARENT 12-

15%15% GENERAL POPULATION 1% GENERAL POPULATION 1% JUEL K(1993) MORTALITY AND CAUSES OF JUEL K(1993) MORTALITY AND CAUSES OF

DEATH IN FIRST ADMITTED DEATH IN FIRST ADMITTED SCHIZOPHERNIC PATIENTS BJP 163SCHIZOPHERNIC PATIENTS BJP 163

NEUROPSYCHOLOGICAL NEUROPSYCHOLOGICAL FINDINGSFINDINGS

NEUROIMAGININGNEUROIMAGINING

CT-SCAN/MRICT-SCAN/MRI

VENTRICULAR ENLARGEMENTVENTRICULAR ENLARGEMENT

AMYGDLA THICKENINGAMYGDLA THICKENING

CEREBELLAR ATROPHYCEREBELLAR ATROPHY

CONTINUED…..CONTINUED….. PET SCANPET SCAN

REDUCED CEREBERAL BLOOD FLOWREDUCED CEREBERAL BLOOD FLOW

AN APPROACH TO TREATMENT AN APPROACH TO TREATMENT RESISTANT SCEHIZOPHRENIARESISTANT SCEHIZOPHRENIADEFINITIONDEFINITION

FAILURE TO RESPOND TO 2 OR MORE FAILURE TO RESPOND TO 2 OR MORE ANTIPSYCHOTIC MEDICATION GIVEN IN ANTIPSYCHOTIC MEDICATION GIVEN IN THERAPEUTIC DOSAGE FOR SIX WEEKS.THERAPEUTIC DOSAGE FOR SIX WEEKS.

PREVALENCEPREVALENCE APPROX 30%APPROX 30%.. AETIOLOGYAETIOLOGY NEURODEVELOPEMENT FACTORS,COGNITIVE NEURODEVELOPEMENT FACTORS,COGNITIVE

IMPAIRMENT,DRUG NON COMPLIANCE.IMPAIRMENT,DRUG NON COMPLIANCE.

CONTINUE…CONTINUE… MANAGEMENTMANAGEMENT

CLARIFY DIAGNOSIS,ADRESS COMORBIDITY AND CLARIFY DIAGNOSIS,ADRESS COMORBIDITY AND NON COMPLIANCENON COMPLIANCE

PHARMACOLOGICAL INTERVENTIONPHARMACOLOGICAL INTERVENTION

ONLY CLOZAPINE IS APPROVED FOR TRS.ONLY CLOZAPINE IS APPROVED FOR TRS.

REHABILITATIONREHABILITATION

SIDE EFFECTS OF SIDE EFFECTS OF CONVENTIONAL CONVENTIONAL ANTIPSYCHOTICSANTIPSYCHOTICS

ACUTEACUTE ANTICHOLINERGIC SIDE EFFECTS,NMS,EPSANTICHOLINERGIC SIDE EFFECTS,NMS,EPS

SUB ACUTESUB ACUTE PIGMENTATION,WEIGHT GAIN,LFT,PIGMENTATION,WEIGHT GAIN,LFT,

CHRONICCHRONIC TARDIVE DYSKINESIATARDIVE DYSKINESIA

SIDE EFFECT PROFILE OF ATYPICAL SIDE EFFECT PROFILE OF ATYPICAL ANTIPSYCHOTICS(RISPERIDONE,OLANANTIPSYCHOTICS(RISPERIDONE,OLANZAPINE,ZAPINE,QUETIAPINE,ZYPRESSIDONE,CLOZAPINQUETIAPINE,ZYPRESSIDONE,CLOZAPINE)E)

SEDATIONSEDATION CHOLINERGIC VS ANTICHOLENERGICCHOLINERGIC VS ANTICHOLENERGIC WEIGHT GAINWEIGHT GAIN METABOLIC SYNDROME METABOLIC SYNDROME BLOOD DYSCRASIABLOOD DYSCRASIA ECG CHANGESECG CHANGES SEIZURESSEIZURES EPSEPS

APPROVED INDICATIONS APPROVED INDICATIONS FOR CLOZARILFOR CLOZARIL

TREATMENT RESISTANT SCHIZOPHRENIATREATMENT RESISTANT SCHIZOPHRENIA

REDUCING THE RISK OF RECURRENT SUICIDAL REDUCING THE RISK OF RECURRENT SUICIDAL BEHAVIOURBEHAVIOUR

PSYCHOSIS DURING THE COURSE OF PARKINSONS PSYCHOSIS DURING THE COURSE OF PARKINSONS DISEASEDISEASE

OTHER INDICATIONS OF OTHER INDICATIONS OF CLOZAPINECLOZAPINE

SCHIZOAFFECTIVE DISORDERS? SCHIZOAFFECTIVE DISORDERS?

BIPOLAR DISORDERS?BIPOLAR DISORDERS?

POST TRAUMATIC STRESS DISORDERS?POST TRAUMATIC STRESS DISORDERS?

THE ENDTHE END