C.Z. Case Discussion
C.Z. presents with delusion, hallucination, trouble focusing, thought disorders, and speech difficulties. These symptoms suggest C.Z. has schizophrenia, as defined by the American Psychological Association (APA; 2020). Also, DSM-V include 2 or more criteria present for a significant portion of time during 1 month period, C.Z. has delusion, hallucination This paper describes schizophrenia’s etiology, course, associated abnormalities, and management.
Schizophrenia’s etiology includes several possible causes. Potential causes include heredity, stressful events, alcohol, and substances use, especially amphetamine and cannabis, and perinatal, neuroanatomic, and neurodevelopmental factors (Rosenthal & Burchum, 2021; Hany et al., 2022). Social isolation, childhood trauma, family history, and urbanization also heighten risk (Hany et al., 2022). However, the specific cause is unknown.
The course of schizophrenia is varied. Some patients may show subtle, gradual changes before schizophrenia symptoms manifest (Rosenthal & Burchum, 2021). Once the illness develops, acute episodes feature delusions and hallucinations symptoms (Rosenthal & Burchum, 2021). Patients may have less vivid residual symptoms after the acute episode, including suspiciousness, diminished judgment, reduced self-care capacity, and poor anxiety management (Rosenthal & Burchum, 2021). The condition’s long-term course features episodic acute exacerbations with partial remission intervals with progressive decline in social functioning and mental status becoming evident with time (Rosenthal & Burchum, 2021). Others may have continuous symptoms. Appropriate treatment can prevent long-term deterioration and reduce acute relapse risk.
Notably, schizophrenia is linked to structural and functional abnormalities. Imaging tests have shown structural abnormalities, including disrupted white matter integrity and reduced gray matter volume in parietal and temporal regions (Zhao et al., 2018). Functional abnormalities are present since schizophrenia is linked to a dysregulation of dopaminergic signaling and increased striatal activity (Zhao et al., 2018). Other functional abnormalities include abnormal neural activity and emotional and cognitive dysfunction (Zhao et al., 2018). Notably, the abnormalities occur over the disease’s course, with Zhao et al. (2018) observing abnormalities before symptoms emerge and becoming more evident with the onset of the illness.
Pharmacotherapy is recommended for schizophrenia for symptom management to enhance and maintain recovery. APA (2020) guidelines recommend antipsychotics for patients with schizophrenia (Keepers et al., 2020). Medications for this disorder could be classified typical and atypicals, the first one also by binding affinity with D2 receptor: low, medium, and high.
High potency we have by PO/IM/IV routes, Haloperidol 2,5-30 mg mg/d orally, half-life 12-38 hours.IM immediate release injection 2.5 mg each dose. LAI every 4 weeks 10-20 daily dose of oral. Overlap PO x 2-3 weeks. 100 mg limit for first dose.
Fluphenazine PO/IM 1-20 mg daily; half-life 15 hours. IM immediate release 1.25 mg initial doses. 2.5-10 mg/d q 6-8 hours. LAI 12.5-25 mg q 3 weeks.
Mid Potency: Perphenazine 4-8 mg TID or 8-16 mg BID, max 64 mg; IM release injection 5 mg. Loxapine: 10 mg BID, titrate over 1 week, 60-100 mg/d in divided doses.
Low Potency: Chlorpromazine PO/IM/IV dose 50-600 mg/day. IM formulation 50 mg/IM often used for agitation.
Second Generation Antipsychotics:”Atypicals”
*Serotonin antagonism more than dopamine antagonism, improve cognition, negative sx, and mood
Aripiprazole: 10-30 mg single dose (half-life 75 hours) LAI: 400 mg IM, q4 weeks.
Asenapine: 10-20 mg BID dosing
Clozapine: 25 mg daily, increase 25-50 mg daily, target dose 300-450 mg
LLoperidone: 8-32 mg daily, half-life 12-15 hours
Lurasidone: 40-160 mg daily
Olanzapine: 5-20 mg daily
Quetiepine: 25-50-400-800 mg daily
Risperidone: 1-2 mg/day, final 4-6 mg/d. half-life 3 hours. LAI 25-50 mg q2weeks, increase dose in 12.5 mg interval
The initial goal of acute treatment should be reduce acute symptoms, trying to return the patient to his baseline level. The choice of medication depends on many factors: patient treatment preferences and previous patient treatment response, presence of other cognitive impairment. Because a first episode of psychosis may respond more rapid and require less dose, the recommended dose is one-quarter to one-half of the usual dose.
Clinical experience suggests many patients are cooperative with Clozapine. The potential benefit of this recommendation outweigh the potential harms.
Patients must be monitored closely for response and side effects since this can influence treatment (APA, 2020). Notably, pharmacotherapy should be person-centered to enhance effectiveness, and that treatment should continue even when improvement is observed. Second generation antipsychotics have lower risk of EPS/TD but greater metabolic effect. Consider long-acting injectables right away.
Notably, pharmacotherapy is coupled with nonpharmacological interventions to enhance schizophrenia treatment. Address stress, family needs, supportive employment, social skills training, assertive community treatment. Family involvement and education, increase community connection, and minimize exposure to MJ, stimulants.
Cognitive-behavioral therapy for psychosis (CBT) is linked to benefits, including improved QoL and social, occupational, and global functioning while reducing illness-related symptoms (APA, 2020; Keepers et al., 2020). This intervention involves establishing a nonjudgmental, collaborative therapeutic relationship helping the patient learn how to monitor the link between their feelings, thoughts, behaviors, and symptoms while evaluating their beliefs, thought processes, and perceptions leading to those symptoms (APA, 2020). Notably, CBT can help patient’s alternative, realistic, and healthier explanations for their maladaptive cognitive assumptions helping stop the perpetuation of hallucinatory experiences and delusional beliefs (APA, 2020). Psychoeducation is also a helpful intervention (APA, 2020). The combined pharmacotherapy and non-pharmacotherapy interventions could cumulatively help C.Z. reach the treatment goal.
American Psychiatric Association. (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia (3rd ed.). American Psychiatric Pub.
Schizophrenia often begins in early adulthood and proceeds chronically without remission. It is a medical condition that affects the brain, making patients who suffer from it interpret reality abnormally. The exact causes of schizophrenia are unknown. Research suggests a combination of physical, genetic, psychological, and environmental factors which can make a person more likely to develop the condition. (Muller et al., 2018) Some people may be prone to schizophrenia, and a stressful or emotional life event might trigger a psychotic episode. Worldwide, schizophrenia is one of the top 20 causes of disability and the lifetime prevalence of schizophrenia is estimated to be 0.7% (Muller et al, 2018).
In this scenario, C.Z. displays symptoms of schizophrenia. Hallucinations and delusions mark this disorder. He believes the lag in his internet speed is due to his campus security and local police surveillance. A person with schizophrenia will display fluid-filled ventricles in the brain that are enlarged, and the brain is more diminutive. The brain that controls speech, language, and movement is abnormal in a person with schizophrenia. This illness is chronic. It is a severe mental illness that affects both males and females. Although schizophrenia can occur at any age, the average age of onset tends to be in the late teens to the early 20s for men and the late 20s to early 30s for women. It is uncommon for schizophrenia to be diagnosed in someone younger than 12 or older than 40. It is possible to live well with schizophrenia. Some people have episodes of illness lasting weeks or months with total remission of symptoms between each episode; others have a fluctuating course in which symptoms are continuous; others again have extraordinarily slight variations in their signs of illness over the period of years. (Stepnicki et al., 2018)
Treatment for people with schizophrenia includes cognitive behavioral therapy, cognitive remediation, psychoeducation, social and coping skills, family intervention, and assertive community treatment. Providers must use effective interviewing strategies the patient’s trust and allow the patient to share more information. Caregivers must learn to practice active listening to gain the patient’s confidence. When speaking to C. Z. he may be nervous, and we need to make him feel heard and understood. Providers must also remember the patient believes that the hallucinations and delusions are real. When treating the patient with medicines, antipsychotics are recommended as the initial treatment for the symptoms of an acute schizophrenia episode. Clozapine is the most effective antipsychotic in managing treatment-resistant schizophrenia (Stepnicki et al., 2018). This drug is approximately 30% effective in controlling schizophrenic episodes in treatment-resistant patients, compared with a 4% efficacy rate with the combination of chlorpromazine and benztropine. Antipsychotics work by blocking the effect of the chemical dopamine on the brain. Maintenance treatment has shown the newer-generation antipsychotics risperidone and olanzapine to be more efficacious and to have a more favorable side effect profile than conventional-generation antipsychotics (Stepnicki et al, 2018). If patients’ hallucinations and delusions can be controlled, they may have a better chance of living everyday life while following their treatment plan.
Müller, N. (2018). Inflammation in schizophrenia: pathogenetic aspects and therapeutic considerations. Schizophrenia Bulletin, 44(5),