CASE STUDY ON PARANOID SHIZOPHRENIA

INTRODUCTION
Paranoid schizophrenia is the most common type of schizophrenia in most parts of the world.
The clinical picture is dominated by relatively stable, often paranoid, delusions, usually
accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances.
Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent.
Schizophreniais a serious mental illness characterized by incoherent or illogical thoughts, bizarre
behavior and speech, and delusions or hallucinations, such as hearing voices. Schizophrenia
typically begins in early adulthood.1

TYPES OF SCHIZOPHRENIA

Paranoid schizophrenia -- a person feels extremely suspicious, persecuted, or grandiose,

or experiences a combination of these emotions.

Disorganized schizophrenia -- a person is often incoherent in speech and thought, but

may not have delusions.

Catatonic schizophrenia -- a person is withdrawn, mute, negative and often assumes

very unusual body positions.

Residual schizophrenia -- a person is no longer experiencing delusions or

hallucinations, but has no motivation or interest in life.

Schizoaffective disorder--a person has symptoms of both schizophrenia and a major

mood disorder such as depression.1

EPIDEMIOLOGY

Schizophrenia is a severe form of mental illness affecting about 7 per thousand of the
adult population, mostly in the age group 15-35 years. Though the incidence is low (310,000), the prevalence is high due to chronicity.2

ETIOLOGY

The exact causes of schizophrenia are unknown, but research suggests that a combination
of physical, genetic, psychological and environmental factors can make people more
likely to develop the condition.

Research suggests schizophrenia may be caused by a change in the level of two

neurotransmitters, dopamine and serotonin. Some studies indicate an imbalance between
the two may be the basis of the problem. Others have found a change in the bodys
sensitivity to the neurotransmitters is part of the cause of schizophrenia.

Pregnancy and birth complications and other triggering factors like Stress and Drug
abuse.3

SIGNS AND SYMPTOMS:

The symptoms of schizophrenia may be divided into the following 4 domains:

Positive symptoms - Psychotic symptoms, such as hallucinations, which are usually

auditory; delusions; and disorganized speech and behavior

Negative symptoms - Decrease in emotional range, poverty of speech, and loss of

interests and drive; the person with schizophrenia has tremendous inertia

Cognitive symptoms - Neurocognitive deficits (eg, deficits in working memory and

attention and in executive functions, such as the ability to organize and abstract); patients
also find it difficult to understand nuances and subtleties of interpersonal cues and
relationships

Mood symptoms - Patients often seem cheerful or sad in a way that is difficult to
understand; they often are depressed.2

RISKS FACTORS

Having a family history of schizophrenia

Exposure to viruses, toxins or malnutrition while in the womb, particularly in the first and

second trimesters
Increased immune system activation, such as from inflammation or autoimmune diseases
Older age of the father.4

COMPLICATIONS:

Suicide
Any type of self-injury
Anxiety and phobias
Depression
Abuse of alcohol, drugs or prescription medications
Poverty
Homelessness
Family conflicts
Inability to work or attend school
Social isolation
Health problems, including those associated with antipsychotic medications, smoking and

poor lifestyle choices

Being a victim of aggressive behavior
Aggressive behavior, although it's uncommon and typically related to lack of treatment,
substance misuse or a history of violence.5

PATHOPHYSIOLOGY4

DIAGNOSTIC CITERIA
Characteristic symptoms: Two (or more) of the following, each present for a significant portion
of time during a 1-month period (or less if successfully treated):
delusions
hallucinations
disorganized speech (e.g., frequent derailment or incoherence)
grossly disorganized or catatonic behavior
negative symptoms, i.e., affective flattening, alogia or avolition
. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the
disturbance, one or more major areas of functioning such as work, interpersonal relations or self-

care are markedly below the level achieved prior to the onset (or when the onset is in childhood
or adolescence, failure to achieve expected level of interpersonal, academic, or occupational
achievement).
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month
period must include at least 1 month of symptoms (or less if successfully treated) that meet
Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual
symptoms. During these prodromal or residual periods, the signs of the disturbance may be
manifested by only negative symptoms or two or more symptoms listed in Criterion A present in
an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder
With Psychotic Features have been ruled out because either
(1) no major depressive episodes or Manic Episodes have occurred concurrently with the activephase symptoms; or
(2) if mood episodes have occurred during active-phase symptoms, their total duration has been
brief relative to the duration of the active and residual periods.
E. Substance/general medical condition exclusion: The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical
condition.5

STANDARD TREATMENT GUIDELINES

SOAP ANALYSIS
SUBJECTIVE DATA:
Going away from home
Not going to work
Decreased sleep and appetite since 10 days
OBJECTIVE DATA
Based on patient mental state examination.
Patients symptoms.

ASSESSMENT
Diagnosis: Paranoid schizophrenia
Etiology: Family history.
ASSESSMENT OF CURRENT THERAPY
T. Olanzapine 10mg 1/2-0-1
Category: Second Generation Antipsychotic
Indication : Agitation-Schizophrenia
Dose : 2.5 10 mg
Mechanism of action: Olanzapine is an antagonist at several different receptor types. It binds to
alpha1, dopamine, histamine H1, muscarinic, and serotonin type 2 (5-HT 2) receptors. Olanzapine
is an antagonist of moderate affinity for muscarinic receptors 15 and 5HT3 .
ADRs: Weight gain (5-40%), Somnolence, (6-39%), Extrapyramidal symptoms (EPS) (15-32%),
Xerostomia (9-22%), Constipation (9-11%) , drowsiness (52%), speech disorder (dysarthria 7%)
Interactions: Antihypertensive drugs, Carbamazepine, Fluvoxamine, Sedating drugs, alcohol,
Levodopa and other dopamine agonists.
Monitoring parameters: Assess mental status, BP, weight and BMI, fasting blood glucose and
cholesterol levels, onset of akathisia.
Counselling points:

Change positions slowly to minimise orthostatic hypotension.

Avoid driving & other activities requiring alertness
Frequent mouth rinses, sugarless gum/candy may minimise dry mouth.

S.No Drug

Brand
name

Manufacturer Available ROA

forms

1.

Olanzepine

Olandus

Zydus

2.

2.5mg

OlapinOl Crescent

OD

5,7.5,10,15,20 21.00

3.

eanzMan

Sun

IM:SA

mg

4.

za

Orchid

IM: ER

5.

Meltolan

Alkem

Tablet:

Strengths

Tablet 2.5,

Cost(Rs)
(10 tabs)
11.00
25.00
17.00
15.00

Inj .Haloperidol 5 mg SOS

st
Category: 1 generation antipsychotic
Indication:Psychiatricenergency
Dose: Moderate disease, 0.5-2 mg q8-12hr initially
Severe disease, 3-5 mg q8-12hr initially; not to exceed 30 mg/day
Mechanism of Action: Phenylbutylpiperadine; antagonizes dopamine D1 and D2 receptors in
brain; depresses reticular activating system and inhibits release of hypothalamic and
hypophyseal hormones
ADR:Akathisia, Dystonia, Muscle stiffness, Neuroleptic malignant syndrome (NMS; infrequent
but serious), Parkinsonism, Tardive dyskinesia, Sedation, Weight gain
Monitoring:

Improvement of schizophrenic signs and symptoms is indicative of efficacy

CBC frequently during the first few months of therapy in patients with a history of low
WBC or drug-induced leukopenia/neutropenia

Counselling Points:

Advise patient to avoid concomitant use of alcohol and other CNS depressants during

therapy.
Patient should avoid activities requiring mental alertness or coordination until drug

effects are realized, as drug can cause dizziness and somnolence.

Drug may impair heat regulation. Advise patient to use caution with activities leading to
an increased core temperature, such as strenuous exercise, exposure to extreme heat, or
dehydration.

S.No

Drug

Brand name

Manufactur
er

ROA

Cost(Rs)

1.

Haloperidol

SENOFORM

Sun

Tablet

5mg/ml-4.85

SERENACE

RPG LS

,inj

5mg/ml- 7.66

Inj.Promethazine 25mg SOS

st
Category: 1 generation antihistamine
Indication:Psychiatricenergency
Mechanism of action: Phenothiazine derivative with antidopaminergic effect: Blocker of
mesolimbic dopamine receptors and alpha-adrenergic receptors in brain
Antihistaminic effect: H1-receptor blocker
ADR:1-10% Sedation, Confusion, Disorientation
Drug Interactions:Cisapride, terfenadine, clarithromycin, dopamine, fluoxetine.
Monitoring Parameters:For any adverse effects like slow heartbeat, invoulantary muscle
movements, severe dizziness.
Patient Counselling:

Drink plenty of fluids-excessive sweating.

May make skin more sensitive to sun exposure so avoid prolonged exposure.

S.No Drug

1.
2.
3

Promethazin
e hcl

Brand
name

Manufact
urer

ROA

Strengths

Cost(Rs)

PHENERG

NICHOLAS

IM

25mg/ml

7.66 (2ml)

Oral

25mg

Oral

25mg

AN INJ
PROMASU
N tab
PHENERG
AN tab

SUN
PHARMA
NICHOLAS

2.44( 10)
20.25
(10)

PLANING
GOALS OF THERAPY:

To stabilize the patient by alleviating the signs and symptoms

Prevent the recurrence.

To prevent hospitalization.

To improve quality of life.

THERAPEUTIC MONITORING:

Monitor mood, speech and insight

TOXICITY MONITORING:

For any extrapyramidal symptoms due to the drugs like olanzapine

Anti-cholinergic effects like dry mouth

Involuntary movements (the recommended scale is the AIMS Abnormal Involuntary

Movement Scale)

Weight, waist measurement, pulse rate and blood pressure

Fasting glucose and lipids.

POINTS TO PHYSICIAN

As these drugs induce high frequency of side effects, requires careful monitoring.
Monitor laboratorty investigations( blood glucose , lipids)
POINTS TO PATIENT:

Drink plenty of fluids, sugar less gums for dry mouth.

Be cautious while driving, handling machinery

Measure weight periodically.

Advice on sleep hygiene, importance of medication adherence.

Do not abruptly discontinue medication on your own.

REFERENCES
1. http://www.helpguide.org/articles/schizophrenia/schizophrenia-signs-types-and2.
3.
4.
5.

causes.htm
http://www.medicalnewstoday.com/articles/192621.php
http://schizophreniabulletin.oxfordjournals.org/content/7/4/588.full.pdf+html
http://forums.hardwarezone.com.sg/-what-schizophrenia-4638924.html
http://www.mayoclinic.org/diseases-conditions/schizophrenia/basics/definition/con-

6.
7.
8.
9.

20021077
http://www.mentalhealth.com/home/dx/schizophrenia.html
Micromedex drug database
Medscape drug database
www.medlineindia.com

Remarks

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