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A 38 Year Old Male With A History Of Schizophrenia

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Age Of Onset Of Schizophrenia

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Since the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised ,lateonset schizophrenia has been defined as onset of symptoms after the age of 44,3 and accounts for approximately 15% to 20% of all cases of schizophrenia.4 Most patients with late-onset schizophrenia have onset of illness during middle age. Onset after age 65 usually signifies very-lateonset schizophrenia-like psychosis, which is typically secondary to general medical conditions, such as dementia or other neurodegenerative disorders.5 Women are more likely to have late-onset schizophrenia than men. In addition, persons with late-onset schizophrenia tend to have better premorbid functioning, fewer negative symptoms, and less severe neurocognitive impairments. Although the conventional wisdom has been that, the symptoms of schizophrenia progress with age, recent investigations have found that many symptoms of schizophrenia improve with age. Older patients typically have fewer and less severe positive symptoms than their younger counterparts6 negative symptoms, however, tend to persist, into late life.5 Finally, patients with late-onset schizophrenia typically require lower daily doses of antipsychotics compared with patients with an early onset of the disorder.7,8

Disturbances Of Early Development

Prospectively collected measures of premorbid function have consistently revealed neuromotor abnormalities and developmental delays. In the British 1946 Birth Cohort pre-schizophrenic children were found to have delayed motor and speech development by the age of 2 years. In the Northern Finland 1966 Birth Cohort the ages that children learned to stand, walk and become potty-trained were related to subsequent risk for schizophrenia and other psychoses earlier milestones reduced the risk, whereas later milestones increased it. Cannon et al.showed, in a birth cohort from New Zealand, that children who went on to develop schizophreniform disorder had persistently poor motor function over repeated measurements in childhood. In an innovative study using home movies filmed during childhood, pre-schizophrenic individuals could be differentiated from their healthy siblings by viewers who were blind to the psychiatric outcomes.

Hospitalizations Before And After Diagnosis

Psychiatric hospitalizations in patients later diagnosed with SSD were assessed during five years before diagnosis. The number and durations of hospitalizations for SSD and prevalence of other psychiatric diagnoses was also determined up to ten years after the index diagnosis. Psychiatric diagnoses were defined on ICD-10 basis . Information on diagnoses were collected from Hospital Discharge Register data and these diagnoses are recorded during hospitalization. Therefore, we use psychiatric diagnoses made during hospitalization as a reflection of total diagnoses.

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What Are The Symptoms Of Schizophrenia In Men

What are the symptoms of schizophrenia in men? Schizophrenia is a serious mental disorder characterized by a number of disturbing symptoms. It affects around 1% of the population and can be caused by several different things such as brain abnormalities, physical and hormonal changes, and a chemical imbalance in the brain. There is also a hereditary factor and schizophrenia is known to run in families.

Schizophrenia: The 7 Keys To Self

Seek social support. Friends and family vital to helping you get the right treatment and keeping your symptoms under control. Regularly connecting with others face-to-face is also the most effective way to calm your nervous system and relieve stress. Stay involved with others by continuing your work or education. If thats not possible, consider volunteering, joining a schizophrenia support group, or taking a class or joining a club to spend time with people who have common interests. As well as keeping you socially connected, it can help you feel good about yourself.

Manage stress. High levels of stress are believed to trigger schizophrenic episodes by increasing the bodys production of the hormone cortisol. As well as staying socially connected, there are plenty of steps you can take to reduce your stress levels. Try adopting a regular relaxation practice such as yoga, deep breathing, or meditation.

Get regular exercise. As well as all the emotional and physical benefits, exercise may help reduce symptoms of schizophrenia, improve your focus and energy, and help you feel calmer. Aim for 30 minutes of activity on most days, or if its easier, three 10-minute sessions. Try rhythmic exercise that engages both your arms and legs, such as walking, running, swimming, or dancing.

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The Public Health Challenge

A recent, report by Bartcls and colleagues examined the annual health care costs for adults with schizophrenia, depression, dementia, or physical illnesses in one small US state .2 In general, except, for dementia, costs of care increased with the age of patients, with those over 85 incurring the greatest per-capita expense. Among people aged 65 or over, annual per-person care for those with schizophrenia, $40 000 or more, was the most, costly: . The patients with schizophrenia incurred higher annual costs in all age-groups compared with depression or medical conditions. The cost-by-age data were different for patients with dementia, where younger patients incurred higher costs. However, among patients over age 65, the cost of care was higher for the patients with schizophrenia compared with those with dementia.

A Case Of Schizophrenia In A Young Male Adult With No History Of Substance Abuse: Impact Of Clinical Pharmacists Interventions On Patient Outcome

Josephine Mensah


1. Introduction

Schizophrenia is a chronic and severe mental disorder affecting more than 21 million people worldwide which is characterized by distortions in thinking, perception, emotions, language, sense of self, and behaviour. Common experiences include hallucinations mostly involving hearing voices or seeing things that are not there and delusions which involve having fixed, false beliefs .

Since schizophrenia is a chronic illness that influences virtually all aspects of life of affected persons, treatment planning has three goals which are to reduce or eliminate symptoms, to maximize quality of life and adaptive functioning, and to promote and maintain recovery from the debilitating effects of illness to the maximum extent possible .

Medications are invaluable in the management of patients with mental illnesses. Pharmacists are therefore indispensable in improving the quality of service rendered to patients with mental illnesses such as schizophrenia which contributes to reduction of the numerous problems associated with and faced by patients with mental disorders .

Another systematic review which evaluated the quantity and quality of medical literature examining the impact of pharmacists in mental health care from 1972 to 2003 reported that there were improvements in outcomes, prescribing practices, patient satisfaction, and resource use when pharmacists are involved in mental health care .

2. The Case

3. Discussion


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Premorbid Cognitive And Scholastic Performance

Schizophrenia patients, when considered as a group, have intellectual impairments, some of which predate the onset of psychotic symptoms. Individuals who later develop schizophrenia have been found to perform below average on standardized measures of intelligence in childhood, adolescence and young adulthood, and to show lower premorbid IQ than the general population The lower the IQ, the higher is the risk for later development of schizophrenia.

Poor school performance can be seen as a premorbid sign. Repeating a grade, difficulties in completing the final level of schooling, and social and behavioural difficulties have also been found to be risk factors for developing schizophrenia. In the Northern Finland 1966 Birth Cohort, 14-year-olds who were below their expected normal grade were three times more likely to develop schizophrenia than those in their normal grade, but low school marks did not predict schizophrenia. Developmental continuity, indicated by early developmental deviation in the first year of life associated with lower school performance at age 16 years, has been found to be stronger among children who develop psychoses later in life than among normal controls and those admitted to hospital for non-psychotic psychiatric disorder.

Medical Conditions In Older Persons With Schizophrenia

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Until recently, a topic that has arguably received inadequate attention is comorbid medical conditions in people with schizophrenia, including adequacy of medical care and the prevalence of comorbid conditions. Medical comorbidity is even more pertinent to older persons with schizophrenia, given the increase in age-related disorders. A series of articles by Druss and colleagues compared the care that, patients with schizophrenia received after suffering a myocardial infarction with the care received by persons with no mental illness.37,38 Using the proportion of patients who undergo cardiac catheterization post-MI as a measure of quality of care they reported that, compared with patients with no mental illness, patients with schizophrenia were 60% less likely to undergo a cardiac catheterization after an MI.37 A second report found that these same patients had a 30% greater 1-year mortality than non-mentally ill patients. Approximately half of this increased mortality was due to a lack of quality medical treatment after the MI.38

Unrecognized or poorly managed comorbid medical illness is a significant source of excess disability and mortality in older persons with schizophrenia. The organization and delivery of care in a coordinated manner may be a challenge. All these are important directions for new research.

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Family History Of Psychiatric Disorders And Clinical Factors Associated With A Schizophrenia Diagnosis

  • Psychotic Disorders in Children and Adolescents2001
  • The SAGE Encyclopedia of Intellectual and DevelopmentalDisorders2018
  • Clinical Psychology: Revisiting the Classic Studies2019
  • Essential Abnormal and Clinical Psychology2015
  • The SAGE Handbook of Mental Health and Illness2011
  • The SAGE Encyclopedia of Abnormal and Clinical Psychology2017
  • Rachel L. Loewy and more…Handbook of Clinical Interviewing with Children2007

Politicization In The Soviet Union

In the Soviet Union the diagnosis of schizophrenia has also been used for political purposes. The prominent Soviet psychiatrist Andrei Snezhnevsky created and promoted an additional sub-classification of sluggishly progressing schizophrenia. This diagnosis was used to discredit and expeditiously imprison political dissidents while dispensing with a potentially embarrassing trial. The practice was exposed to Westerners by a number of Soviet dissidents, and in 1977 the World Psychiatric Association condemned the Soviet practice at the Sixth World Congress of Psychiatry. Rather than defending his claim that a latent form of schizophrenia caused dissidents to oppose the regime, Snezhnevsky broke all contact with the West in 1980 by resigning his honorary positions abroad.

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Controversies Over Validity In The 1970s

In 1970 psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category and proposed that cases of schizophrenia where people recovered well were not really schizophrenia but a separate condition.

In the early 1970s, the diagnostic criteria for schizophrenia was the subject of a number of controversies which eventually led to the operational criteria used today. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe. This was partly due to looser diagnostic criteria in the US, which used the DSM-II manual, contrasting with Europe and its ICD-9. David Rosenhan’s 1972 study, published in the journal Science under the title “On being sane in insane places“, concluded that the diagnosis of schizophrenia in the US was often subjective and unreliable.

Diagnoses In Ancient Times

Accounts of a schizophrenia-like syndrome are thought to be rare in the historical record prior to the 19th century, although reports of irrational, unintelligible, or uncontrolled behavior were common. There has been an interpretation that brief notes in the Ancient Egyptian Ebers papyrus may imply schizophrenia, but other reviews have not suggested any connection. A review of ancient Greek and Roman literature indicated that although psychosis was described, there was no account of a condition meeting the criteria for schizophrenia.

Bizarre psychotic beliefs and behaviors similar to some of the symptoms of schizophrenia were reported in Arabic medical and psychological literature during the Middle Ages. In The Canon of Medicine, for example, Avicenna described a condition somewhat resembling the symptoms of schizophrenia which he called , which he distinguished from other forms of madness such as mania, rabies and manic depressive psychosis. However, no condition resembling schizophrenia was reported in Åerafeddin SabuncuoÄlu‘s Imperial Surgery, a major Ottoman medical textbook of the 15th century. Given limited historical evidence, schizophrenia may be a modern phenomenon, or alternatively it may have been obscured in historical writings by related concepts such as melancholia or mania.

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Course Of Schizophrenia In Late Life

The clinical presentation of older persons with schizophrenia differs somewhat from that of younger persons, and the course of this disorder into old age sheds light, on some unresolved cognitive and social issues. In this section, we discuss the clinical differences between patients with early- versus late-onset schizophrenia, review the emerging research describing changes in symptoms and neuropsychological deficits over time, and consider a new perspective on remission from schizophrenia.

Five Years Before Diagnosis Of Ssd

Most women and men had been hospitalized for another psychiatric disorder before the first hospitalization for SSD. 47.8% of women had been hospitalized for another psychotic disorder, and this resulted into a median of 56 hospital days , while the median number of hospital days for any psychiatric diagnosis was 81 . In men, the median number of hospital days for another psychotic disorder before SSD was 53 for 48.5% of men , with corresponding median of hospital days due to any psychiatric diagnosis of 65 .

Significant differences occurred in type of diagnoses in the trajectory before SSD, with more frequent mood disorders , anxiety disorders, eating disorders, post-traumatic stress disorder, dissociative disorder, personality disorder, suicide attempts, and self-harm in women . Men had more often substance disorder and more autism spectrum disorders. The largest gender differences were found for eating disorder and substance abuse, for which women had less than half the risk as men .

Table 1 The prevalence of psychiatric diagnoses before and after a schizophrenia-spectrum diagnosis was made, for men and women .

Gender differences in the age of first hospitalization were most pronounced for eating disorders, occurring much earlier in women . For women, mood disorder was the most common last diagnosis preceding SSD in 62% . For men, 34% was hospitalized for substance disorder preceding the SSD hospitalization .

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Informed Consent And Decisional Capacity

Patients with schizophrenia are routinely asked to provide informed consent for their antipsychotic medication treatment. However, because of the cognitive deficits, as well as insight, deficits, which are sometimes present among those with schizophrenia,9,20 some schizophrenia patients may lack the capacity to provide independent consent for treatment. On the other hand, empirical data document considerable heterogeneity among older as well as younger schizophrenia patients in terms of the level of decisional capacity,2123 and age is not itself a strong predictor of the level of decisional capacity among such patients.2325 Nonetheless, due to the increased likelihood of medical comorbidity and polypharmacy present, in the older population,26,27 together with the increased physical frailty of some elderly persons, and the still relatively limited empirical database on the safety and efficacy of antipsychotic medications for use with realworld elderly patients, the very nature of treatment decisions and consent may be particularly complex in the context of treating older patients with schizophrenia, and thus consent, issues are particularly salient.

Treatment Following The Autoenuclaetion

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After the incident, the dosing of the antipsychotic medication was raised once again. The best antipsychotic and mood stabilizing response was achieved with a combination of quetiapine , risperidone , haloperidol and valproate . In addition, she was briefly treated anxiolytically with lorazepam . However, the latent psychotic ideas persisted and appeared to diminish only after multiple electroconvulsive therapy treatments, following which haloperidol was discontinued without any psychotic relapse. Even after being discharged from the hospital 6 months later, the patient was unable to return to normal life and was, therefore, sent to a care home for the mentally ill.

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Early Warning Signs Of Schizophrenia

In some people, schizophrenia appears suddenly and without warning. But for most, it comes on slowly, with subtle warning signs and a gradual decline in functioning, long before the first severe episode. Often, friends or family members will know early on that something is wrong, without knowing exactly what.

In this early phase of schizophrenia, you may seem eccentric, unmotivated, emotionless, and reclusive to others. You may start to isolate yourself, begin neglecting your appearance, say peculiar things, and show a general indifference to life. You may abandon hobbies and activities, and your performance at work or school can deteriorate.

Risk Factors And Pathophysiology

Risk factors that are associated with developing psychotic disorders among olderadults include cognitive decline, poor health status, visual impairment, andnegative life events.39 In addition, female gender appears to be a risk factor for developinglate-onset schizophrenia and VLOS.40 Furthermore, being from an immigrant population, greater abnormalities inbrain structures, family history of schizophrenia or avoidant personality, paranoidor schizoid personality disorder, hearing loss, and being from a lower socioeconomicstatus are risk factors for VLOS.4 Premorbid educational, occupational, and psychosocial functioning appears tobe less impaired among late-onset than among early-onset individuals with schizophrenia.11

A recent study that compared the key risk factors among individuals withschizophrenia to identify trends according to the age of onset, comparingpresentations prior to 26 years , between 26 and 40 years , and after 40 years of age found that the older age of onset wasassociated with a weaker family history of schizophrenia, lower rates of substanceuse, better early psychosocial functioning, and higher educational achievement. Inaddition, female preponderance and comorbid physical health problems were notableamong the late onset group compared with the other groups.23 Furthermore, individuals in the later life schizophrenia group showed arelatively greater association with psychosocial factors proximal to the onset ofpsychosis, including unemployment.

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Development Of Treatments In The 20th Century

Harry Stack Sullivan applied the approaches of Interpersonal psychotherapy to treating schizophrenia in the 1920s viewing early schizophrenia as a problem-solving attempt to integrate life experiences, arguing that recovered patients were made more competent after a psychotic experience than before.:76

In the early 1930s insulin coma therapy was trialed to treat schizophrenia, but faded out of use in the 1960s following the advent of antipsychotics. The use of electricity to induce seizures was developed, and in use as electroconvulsive therapy by 1938.

Frontal lobotomies, a form of psychosurgery, were carried out from the 1930s until the 1970s in the United States, and until the 1980s in France, involving either the removal of brain tissue from different regions or the severing of pathways, widely recognized as a grave human rights abuse.Stereotactic surgeries were developed in the 1940s.

Antipsychotics were introduced to US hospitals in 1950s, following the discovery of chlorpromazine in 1952 and its trialing in French hospitals. Adoption was encouraged by advertising by the Smith, Kline & French company after it received permission to advertise use of the drug in 1954. Advertised under the brand name Thorazine, more than 2 million people had received the drug within 8 months. In the first report on chloropromazine’s use in the US, John Vernon Kinross-Wright suggested that the drug could be used as an adjunct to psychotherapy to improve its effectiveness.:33â35

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