On Mon, 2 Jun 2008 18:57:36 -0700, "Superman Hughes TrollKiller of
s*** 24bit & squarewheel" <BillHughes@[EMAIL PROTECTED]
> wrote:
>
>"Terry Dactille ©~®" <pterry@[EMAIL PROTECTED]
> wrote in message
>news:hrqf24tkudg2d7ee0m8o1o8uvfe6se69q6@[EMAIL PROTECTED]
>> On Sun, 18 May 2008 21:49:01 -0700, "Superman Hughes TrollKiller of
>> s*** 24bit & squarewheel" <BillHughes@[EMAIL PROTECTED]
> wrote:
>>
>> >
>> >"Superman Hughes TrollKiller of s*** 24bit & squarewheel"
>> ><BillHughes@[EMAIL PROTECTED]
> wrote in message news:...
>> >> I bet you're dreaming of sucking my *****, that's the only
reason a
>> >> faggot like you keeps following me around.
>> >> Today, 24bit/terryWimp wrote "nothing" under it's faggot buddy's
>> >threads
>> >> 54 times, and of course wants them posted to:
>alt.binaries.pictures.autos,
>> >> alt.binaries.automobile.pictures anyway.
>> >> You bet! And it'll take more than a faggot like you to shake my
>belief
>> >> in the moral majority to squash kooks like you.
>> >> God Bless America, Bill O|||||||O
>> >> mailto:BillHughes@[EMAIL PROTECTED]
>> >> http://www.billhughes.com/jeep_bookmark.htm
>> >>
>> >> "Terry Dactille©~®" <pterry@[EMAIL PROTECTED]
> wrote in message
>> >> news:vugiq31ionnrt288mhec7if1qt0qlnpp62@[EMAIL PROTECTED]
>> >> > On Sun, 10 Feb 2008 19:15:25 -0800, "Superman Hughes TrollKiller
of
>> >> > s*** 24bit & squarewheel" <BillHughes@[EMAIL PROTECTED]
> wrote:
>> >> >
>> >> > Speech patterns offer window into psychiatric disorders
>> >> > It's a scene typical of daytime talk shows, America's showcase for
>> >> > dysfunctional living. The woman who fell for her jailed pen pal is
>> >> > talking at length with no obvious purpose. The host prods for
details
>> >> > of the romance, but every answer is exasperatingly vague. "I just
>love
>> >> > him. He's so nice to me. I like to get his letters. I like to see
the
>> >> > mailman."
>> >> >
>> >> > Shows like this might not seem intellectually stimulating, but
listen
>> >> > closely to those arguments, taunts and teary confessions and you
>might
>> >> > hear a perfect illustration of a breakthrough in psychiatry.
School
>of
>> >> > Medicine researchers have discovered that people with certain
>> >> > psychiatric disorders also have distinctive language patterns that
>> >> > seem to reflect fundamental problems in thinking. The speakers use
>> >> > vague words and usually meander through conversations as if unable
to
>> >> > focus on the main point.
>> >> >
>> >> > These odd speech patterns, common on daytime talk shows, provide
>> >> > direct evidence that many people with antisocial personality
disorder
>> >> > and somatization disorder (once called hysteria) also have
imbalances
>> >> > in the brain.
>> >> >
>> >> > "Psychiatrists suspect these disorders are linked to brain
chemistry,
>> >> > but it hasn't been proven," said Carol North, M.D., an associate
>> >> > professor of psychiatry and lead author of a paper in a recent
issue
>> >> > of Comprehensive Psychiatry. "This study is one of the first to
link
>> >> > the disorders to the functioning of the brain."
>> >> >
>> >> > People with somatization disorder, almost always women, have
>> >> > never-ending complaints -- ranging from vomiting to paralysis
--that
>> >> > can't be linked to physical illness. People with antisocial
>> >> > personality disorder might lie, steal and commit vandalism in
>> >> > childhood and progress to more serious offenses such as burglary
and
>> >> > dealing drugs. Both disorders also seem to encourage poor
decisions
>in
>> >> > friends, mates and lifestyles. A woman who marries a known
>wife-beater
>> >> > may well have one of the disorders, North said.
>> >> >
>> >> > One or both of these disorders afflict about 8 million Americans
-- 3
>> >> > percent of the population. Both tend to run in families, and men
with
>> >> > antisocial personality disorder often have female relatives with
>> >> > somatization disorder and vice versa.
>> >> >
>> >> > Researchers compared the speech of 15 men and women diagnosed with
>one
>> >> > or both disorders with 10 men and women of similar ages and
>> >> > backgrounds who worked at a medical clinic. All of the subjects
were
>> >> > interviewed about topics such as the weather and news of the day.
>> >> > North played audiotapes of the interviews to psychiatrists who
didn't
>> >> > know the subjects or their mental-health status.
>> >> >
>> >> > She trained the psychiatrists to keep score of different speech
>> >> > patterns, including vagueness and meandering sentences. A subject
>> >> > would earn "vague points" by saying something like "Clinton's a
good
>> >> > guy. He does good things." If asked about the weather, a meanderer
>> >> > might mention his dog, his breakfast and his dentist before
getting
>to
>> >> > the humidity.
>> >> >
>> >> > The scorekeepers were able to see many real-life examples of these
>> >> > speech patterns before the study began. They all watched and
listened
>> >> > to daytime talk shows as part of their preparation.
>> >> >
>> >> > Women in the study showed strong differences in speech. Those with
>> >> > either antisocial disorder or somatization disorder were much more
>> >> > likely to use vague or meandering language. These language
patterns
>> >> > were even more pronounced in women with both disorders.
>> >> >
>> >> > The scorekeepers found no difference in speech patterns among the
men
>> >> > in the study, and there was a good reason why. The men in the
control
>> >> > group showed strong signs of antisocial personality disorder
>> >> > themselves, and two out of the five were actually diagnosed. "We
>still
>> >> > suspect that men with antisocial personality disorder do speak
>> >> > differently than other men," North said.
>> >> >
>> >> >
>> >> > Malfunctioning mind
>> >> > Researchers have long known that brain imbalances can alter
language.
>> >> > People with psychoses such as schizophrenia may sound as though
their
>> >> > sentences have been run through a blender. The jumbled speech,
>> >> > sometimes called "word salad" at its most extreme, clearly
reflects
>> >> > problems with brain chemistry and thinking. North believes vague,
>> >> > wandering speech also indicates a malfunctioning mind, and she
coined
>> >> > the term "nonpsychotic thought disorder" to describe the distinct
>> >> > language patterns of people with antisocial personality and
>> >> > somatization disorders. It is the first time that anyone has
formally
>> >> > linked unusual thought processes to nonpsychotic psychiatric
>> >> > disorders.
>> >> > "Dr. North has made a real contribution to the field," said
Richard
>> >> > Wetzel, Ph.D., professor of neurology, of neurological surgery and
of
>> >> > psychiatry and co-author of the study. "These are people who think
>> >> > things through in ways that aren't very helpful to themselves or
>> >> > society, and Dr. North has found a way to identify the kinds of
>> >> > problems they have with their thinking."
>> >> >
>> >> > North and Wetzel hope the recognition of distinct speech patterns
>will
>> >> > help mental health specialists diagnose personality and
somatization
>> >> > disorders. Too many people with the disorders are either labeled
>> >> > psychotic or aren't diagnosed at all, North said.
>> >> >
>> >> > Paying attention to the speech of these people might even lead to
>> >> > better treatment, she added.
>> >> >
>> >> > -- Chris Woolston
>> >> >
>> >> >
>> >> >
>> >> >
>> >> > > I bet you're dreaming of sucking my *****, that's the only
>reason a
>> >> > >faggot like you keeps following me around.
>> >> > > Today, 24bit/terryWimp wrote "nothing" under it's faggot
buddy's
>> >> threads
>> >> > >54 times, and of course wants them posted to:
>> >> alt.binaries.pictures.autos,
>> >> > >alt.binaries.automobile.pictures anyway.
>> >> > > You bet! And it'll take more than a faggot like you to shake
my
>> >> belief
>> >> > >in the moral majority to squash kooks like you.
>> >> > >Did you copy my picture at:
>> >> > >http://billhughes.com/SanDieguito/37-65Reunion/Sep20_61.jpg
and
come
>> >all
>> >> > >over it?
>> >> > > God Bless America, Bill O|||||||O
>> >> > > mailto:BillHughes@[EMAIL PROTECTED]
>> >> > > http://www.billhughes.com/jeep_bookmark.htm
>> >> > >"Terry Dactille©~®" <pterry@[EMAIL PROTECTED]
> wrote in
message
>> >> > >news:ic7iq350sudv02b3o1i3rruqvpnfn1vqm5@[EMAIL PROTECTED]
>> >> > >>
>> >> > >>
>> >> > >>
>> >> > >> Interesting image, put a big red X on the one who isn't you so
I
>can
>> >> > >> be sure, thanks.
>> >> > >>
>> >> > >>
>> >> > >> "A winner makes commitment. A loser makes promises."
>> >> > >>
>> >> > >> "The path of least resistance is the path of the loser."
>> >> > >
>> >> > --
>> >> >
>> >> > "A winner makes commitment. A loser makes promises."
>> >> >
>> >> > "The path of least resistance is the path of the loser."
>> >>
>> >>
>> >
>> --
>>
>>
>> "A winner makes commitment. A loser makes promises."
>>
>> "The path of least resistance is the path of the loser."
>
>
>
Schizophrenia is characterized by psychosis (loss of contact with
reality), hallucinations (false perceptions), delusions (false
beliefs), disorganized speech and behavior, flattened affect
(restricted range of emotions), cognitive deficits (impaired reasoning
and problem solving), and occupational and social dysfunction. The
cause is unknown, but evidence for a genetic component is strong.
Symptoms usually begin in adolescence or early adulthood. One or more
episodes of symptoms must last = 6 mo before the diagnosis is made.
Treatment consists of drug therapy, psychotherapy, and rehabilitation.
Worldwide, the prevalence of schizophrenia is about 1%. The rate is
comparable among men and women and relatively constant
cross-culturally. The rate is higher among lower socioeconomic cl*****
in urban areas, perhaps because its disabling effects lead to
unemployment and poverty. Similarly, a higher prevalence among single
people may reflect the effect of illness or illness precursors on
social functioning. The average age at onset is 18 yr in men and 25 yr
in women. Onset is rare in childhood, but early adolescent or
late-life onset (when it is sometimes called paraphrenia) may occur.
Etiology
Although its specific cause is unknown, schizophrenia has a biologic
basis, as evidenced by alterations in brain structure, such as
enlarged cerebral ventricles and decreased size of the anterior
hippocampus and other brain regions, and on changes in
neurotransmitters, especially involving altered activity of dopamine
Some Trade Names
INTROPIN
Click for Drug Monograph
and glutamate. Some experts suggest that schizophrenia occurs in
people with neurodevelopmental vulnerabilities and that the onset,
remission, and recurrence of symptoms are the result of interactions
between these enduring vulnerabilities and environmental stressors.
Neurodevelopmental vulnerability to schizophrenia may result from
genetic predisposition; intrauterine, birth, or postnatal
complications; or viral CNS infections. Maternal exposure to famine
and influenza in the 2nd trimester of pregnancy, birth weight below
2500 g, Rh incompatibility in a 2nd pregnancy, and hypoxia increase
risk. Although most people with schizophrenia do not have a family
history, genetic factors have been implicated. People who have a
1st-degree relative with schizophrenia have about a 10% risk of
developing the disorder, compared with a 1% risk among the general
population. Monozygotic twins have a concordance of about 50%.
Sensitive neurologic and neuropsychiatric tests suggest that aberrant
smooth-pursuit eye tracking, impaired cognition and attention, and
deficient sensory gating occur more commonly among patients with
schizophrenia than among the general population. These markers
(endophenotypes) also occur among 1st-degree relatives of people with
schizophrenia and may represent the inherited component of
vulnerability.
Environmental stressors can trigger the emergence or recurrence of
symptoms in vulnerable people. Stressors may be primarily biochemical
(eg, substance abuse, especially marijuana) or social (eg, becoming
unemployed or impoverished, leaving home for college, breaking off a
romantic relation****p, joining the Armed Forces); these stressors are
not, however, causative. There is no evidence that schizophrenia is
caused by poor parenting. Protective factors that may mitigate the
effect of stress on symptom formation or exacerbation include good
social sup****t, coping skills, and antipsychotics (see Schizophrenia
and Related Disorders: Treatment).
Symptoms and Signs
Schizophrenia is a chronic illness that may progress through several
phases, although the duration and patterns of phases can vary.
Patients with schizophrenia tend to develop psychotic symptoms an
average of 12 to 24 mo before presenting for medical care. In the
premorbid phase, patients may show no symptoms or may have impaired
social competence, mild cognitive disorganization or perceptual
distortion, a diminished capacity to experience pleasure (anhedonia),
and other general coping deficiencies. Such traits may be mild and
recognized only in retrospect or may be more noticeable, with
impairment of social, academic, and vocational functioning. In the
prodromal phase, subclinical symptoms may emerge, including withdrawal
or isolation, irritability, suspiciousness, unusual thoughts,
perceptual distortions, and disorganization. Onset of overt
schizophrenia (delusions and hallucinations) may be sudden (over days
or weeks) or slow and insidious (over years). In the middle phase,
symptomatic periods may be episodic (with identifiable exacerbations
and remissions) or continuous; functional deficits tend to worsen. In
the late illness phase, the illness pattern may be established, and
disability may stabilize or even diminish.
Generally, symptoms are categorized as positive, disorganized,
negative, and cognitive. Positive symptoms are characterized by an
excess or distortion of normal functions; negative symptoms, by
diminution or loss of normal functions. Disorganized symptoms include
thought disorder and bizarre behavior. Cognitive symptoms are deficits
in information processing and problem solving. A person may have
symptoms from one or all categories.
Positive symptoms can be further categorized as delusions and
hallucinations or thought disorder and bizarre behavior. Delusions are
erroneous beliefs. In persecutory delusions, the patient believes he
is being tormented, followed, tricked, or spied on. In delusions of
reference, the patient believes that passages from books, newspapers,
song lyrics, or other environmental cues are directed at him. In
delusions of thought withdrawal or thought insertion, the patient
believes that others can read his mind, that his thoughts are being
transmitted to others, or that thoughts and impulses are being imposed
on him by outside forces. Hallucinations may be auditory, visual,
olfactory, gustatory, or tactile, but auditory hallucinations are by
far the most common. The patient may hear voices commenting on his
behavior, conversing with one another, or making critical and abusive
comments. Delusions and hallucinations may be extremely vexing to the
patient.
Thought disorder involves disorganized thinking, with rambling,
non–goal-directed speech that ****fts from one topic to another. Speech
can range from mildly disorganized to incoherent and incomprehensible.
Bizarre behavior may include childlike silliness, agitation, and
inappropriate appearance, hygiene, or conduct. Catatonia is an extreme
behavior that can include maintaining a rigid posture and resisting
efforts to be moved or engaging in purposeless and unstimulated motor
activity.
Negative (deficit) symptoms include blunted affect, poverty of speech,
anhedonia, and asociality. With blunted affect, the patient's face
appears immobile, with poor eye contact and lack of expressiveness.
Poverty of speech refers to decreased speech and terse replies to
questions, creating the impression of inner emptiness. Anhedonia may
be reflected by a lack of interest in activities and increased
purposeless activity. Asociality is demonstrated by a lack of interest
in relation****ps. Negative symptoms often lead to poor motivation and
a diminished sense of purpose and goals.
Cognitive deficits include impairment in attention, processing speed,
working memory, abstract thinking, problem solving, and understanding
social interactions. The patient's thinking may be inflexible, and the
ability to problem solve, understand the viewpoints of other people,
and learn from experience may be diminished. Symptoms of schizophrenia
typically impair the ability to function and often markedly interfere
with work, social relations, and self-care. Unemployment, isolation,
deteriorated relation****ps, and diminished quality of life are common
outcomes. Severity of cognitive impairment is a major determinant of
overall disability.
Subtypes: Five subtypes of schizophrenia have been described:
paranoid, disorganized, catatonic, residual, and
undifferentiated.Paranoid schizophrenia is characterized by delusions
or auditory hallucinations, with preservation of cognition and affect.
Disorganized schizophrenia is characterized by disorganized speech,
disorganized behavior, and flat or inappropriate affect. In catatonic
schizophrenia, physical symptoms, including either immobility or
excessive motor activity and the assumption of bizarre postures,
predominate. In undifferentiated schizophrenia, symptoms are mixed. In
residual schizophrenia, there is a clear history of schizophrenia with
more prominent symptoms followed by a prolonged period of mild
negative symptoms.
Alternatively, some experts classify schizophrenia into deficit and
nondeficit subtypes based on the presence and severity of negative
symptoms, such as blunted affect, lack of motivation, and diminished
sense of purpose. Patients with the deficit subtype have prominent
negative symptoms unaccounted for by other factors (eg, depression,
anxiety, an understimulating environment, drug adverse effects). Those
with the nondeficit subtype may have delusions, hallucinations, and
thought disorders but are relatively free of negative symptoms.
Suicide: About 10% of patients with schizophrenia commit suicide.
Suicide is the major cause of premature death among people with
schizophrenia and explains, in part, why on average the disorder
reduces the life span of those affected by 10 yr. Patients who have
paranoid subtypes with late onset and good premorbid functioning—the
very patients with the best prognosis for recovery—are also at the
greatest risk of suicide. Because these patients retain the capacity
for grief and anguish, they may be more prone to act in despair based
on a realistic recognition of the effect of their disorder (see also
Suicidal Behavior).
Violence: Schizophrenia is a relatively modest risk factor for violent
behavior. Threats of violence and minor aggressive outbursts are far
more common than seriously dangerous behavior. Patients more likely to
engage in significant violence include those with substance abuse,
persecutory delusions, or command hallucinations and those who do not
take their prescribed drugs. Very rarely, a severely depressed,
isolated, paranoid person attacks or murders someone whom he perceives
as the single source of his difficulties (eg, an authority, a
celebrity, his spouse). Patients with schizophrenia may present in an
emergency setting with threats of violence to obtain food, shelter, or
needed care.
Diagnosis
No definitive test for schizophrenia exists. Diagnosis is based on a
comprehensive *****sment of history, symptoms, and signs. Information
from collateral sources, such as family, friends, teachers, and
coworkers, is often im****tant. According to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), 2 or
more characteristic symptoms (delusions, hallucinations, disorganized
speech, disorganized behavior, negative symptoms) for a significant
****tion of a 1-mo period are required for the diagnosis, and prodromal
or attenuated signs of illness with social, occupational, or self-care
impairments must be evident for a 6-mo period that includes 1 mo of
active symptoms.
Psychosis due to other medical disorders or substance abuse must be
ruled out by history and examination that includes laboratory tests
and neuroimaging studies (see Approach to the Patient With Mental
Complaints: Medical *****sment of the Patient With Mental Symptoms).
Although some patients with schizophrenia have structural brain
abnormalities on imaging, these are insufficiently specific to have
diagnostic value.
Other mental disorders with similar symptoms include several that are
related to schizophrenia: brief psychotic disorder, schizophreniform
disorder, schizoaffective disorder, and delusional disorder. In
addition, mood disorders can produce psychosis in some people. Certain
personality disorders (especially schizotypal) manifest symptoms
similar to those of schizophrenia, although they are usually milder
and do not involve psychosis.
Prognosis
During the first 5 yr after onset of symptoms, functioning may
deteriorate and social and work skills may decline, with progressive
neglect of self-care. Negative symptoms may increase in severity, and
cognitive functioning may decline. Thereafter, the level of disability
tends to plateau. Some evidence suggests that severity of illness may
lessen in later life, particularly among women. Spontaneous movement
disorders may develop in patients who have severe negative symptoms
and cognitive dysfunction, even when antipsychotics are not used.
Prognosis varies depending on the subtype. Patients with paranoid
schizophrenia tend to be less severely disabled and more responsive to
available treatments. Patients with the deficit subtype are typically
more disabled, have a poorer prognosis, and are more resistant to
treatment.
Schizophrenia can occur with other mental disorders. When associated
with significant obsessive-compulsive symptoms (see Anxiety Disorders:
Symptoms and Signs), it has a particularly poor prognosis; with
symptoms of borderline personality disorder (see Personality
Disorders: Cluster B), a better prognosis. About 80% of people with
schizophrenia will experience one or more episodes of major depression
at some time in their life.
For the 1st year after diagnosis, prognosis is closely related to
adherence to prescribed psychoactive drugs. Overall, 1/3 of patients
achieve significant and lasting improvement; 1/3 improve somewhat but
have intermittent relapses and residual disability; and 1/3 are
severely and permanently incapacitated. Only about 15% of all patients
fully return to their pre-illness level of functioning. Factors
associated with a good prognosis include good premorbid functioning
(eg, good student, strong work history), late and/or sudden onset of
illness, a family history of mood disorders other than schizophrenia,
minimal cognitive impairment, few negative symptoms, and paranoid or
nondeficit subtype. Factors associated with a poor prognosis include
early age at onset, poor premorbid functioning, a family history of
schizophrenia, and disorganized or deficit subtype with many negative
symptoms. Men have poorer outcomes than women; women respond better to
treatment with antipsychotics.
Substance abuse is a significant problem in up to 50% of patients with
schizophrenia. Anecdotal evidence suggests that use of marijuana and
other hallucinogens is highly disruptive for patients with
schizophrenia and should be strongly discouraged. Comorbid substance
abuse is a significant predictor of poor outcome and may lead to drug
noncompliance, repeated relapse, frequent rehospitalization, declining
function, and loss of social sup****t, including homelessness.
Treatment
The time between onset of psychotic symptoms and first treatment
correlates with the rapidity of initial treatment response, quality of
treatment response, and severity of negative symptoms. When treated
early, patients tend to respond more quickly and fully. Without
ongoing use of antipsychotics after an initial episode, 70 to 80% of
patients have a subsequent episode within 12 mo. Continuous use of
antipsychotics can reduce the 1-yr relapse rate to about 30%.
General goals are to reduce severity of psychotic symptoms, prevent
recurrences of symptomatic episodes and associated deterioration of
functioning, and help patients function at the highest level possible.
Antipsychotics, rehabilitation with community sup****t services, and
psychotherapy are the major components of treatment. Because
schizophrenia is a long-term and recurrent illness, teaching patients
illness self-management skills is a significant overall goal. (See
also the American Psychiatric Association's Practice Guideline for the
Treatment of Patients With Schizophrenia, 2nd Edition.)
Drugs are divided into conventional antipsychotics and 2nd-generation
antipsychotics (SGAs) based on their specific neurotransmitter
receptor affinity and activity. SGAs may offer some advantages both in
terms of modestly greater efficacy (although for some of the SGAs the
modest advantage is questionable) and reduced likelihood of
involuntary movement disorder and related adverse effects.
Conventional antipsychotics: These drugs (see Table 1: Schizophrenia
and Related Disorders: Conventional Antipsychotics) act primarily by
blocking the dopamine Some Trade Names
INTROPIN
Click for Drug Monograph
-2 receptor ( dopamine Some Trade Names
INTROPIN
Click for Drug Monograph
-2 blockers). Conventional antipsychotics can be classified as high,
intermediate, or low potency. High-potency antipsychotics have a
higher affinity for dopamine Some Trade Names
INTROPIN
Click for Drug Monograph
receptors and less for a-adrenergic and muscarinic receptors.
Low-potency antipsychotics, which are rarely used, have less affinity
for dopamine Some Trade Names
INTROPIN
Click for Drug Monograph
receptors and relatively more affinity for a-adrenergic, muscarinic,
and histaminic receptors. Different drugs are available in tablet,
liquid, and short- and long-acting IM preparations. A specific drug is
selected primarily based on adverse effect profile, required route of
administration, and the patient's previous response to the drug.
Table 1
Conventional Antipsychotics
Class
Drug
Daily Dose (Range)*
Usual Adult Dose
Comments
Phenothiazines Aliphatic
Chlorpromazine Some Trade Names
THORAZINE
Click for Drug Monograph
†‡
30–800
400 mg po at bedtime
Prototypic low-potency drug. Also available as a rectal suppository
Piperidines
Thioridazine Some Trade Names
MELLARIL
Click for Drug Monograph
‡
150–800
400 mg po at bedtime
Only drug with an absolute maximum (800 mg/day)—it causes pigmentary
retinopathy at higher doses and has a significant anticholinergic
effect. Warning added to label due to QTc prolongation
Piperazines Trifluoperazine†‡ 2–40 10 mg po at bedtime
Fluphenazine†‡ 0.5–40 7.5 mg po at bedtime Also available as
fluphenazine decanoate and fluphenazine enanthate, which are IM depot
forms (dose equivalents are not available)
Perphenazine Some Trade Names
TRILAFON
Click for Drug Monograph
†‡
12–64
16 mg po at bedtime
Dibenzoxazepines
Loxapine Some Trade Names
LOXITANE
Click for Drug Monograph
20–250
60 mg po at bedtime
Has affinity for dopamine Some Trade Names
INTROPIN
Click for Drug Monograph
-2 and 5-hydroxytryptamine (s*****onin)-2 receptors
Dihydroindo- lones
Molindone Some Trade Names
MOBAN
Click for Drug Monograph
15–225
60 mg po at bedtime
Possibly associated with weight reduction
Thioxanthenes
Thiothixene Some Trade Names
NAVANE
Click for Drug Monograph
†‡
8–60
10 mg po at bedtime
Has high incidence of akathisia
Butyrophenones
Haloperidol Some Trade Names
HALDOL
Click for Drug Monograph
†‡
1–15
4 mg po at bedtime
Prototypic high-potency drug; haloperidol Some Trade Names
HALDOL
Click for Drug Monograph
decanoate (IM depot) form is available. Akathisia common
Diphenylbutylpiperidines
Pimozide Some Trade Names
ORAP
Click for Drug Monograph
1–10
3 mg po at bedtime
Approved only for Tourette's syndrome
QTc = QT interval corrected for heart rate.
*Current recommended dosing for conventional antipsychotic agents is
to initiate at low range of displayed values and titrate upwards
gradually to a single dose; dosing at bedtime is recommended. No
evidence that rapid dose escalation is more effective.
†Available in an IM form for acute treatment.
‡Available as an oral concentrate.
Two conventional antipsychotics and one SGA are available as
long-acting depot preparations (see Table 2: Schizophrenia and Related
Disorders: Depot Antipsychotic Drugs). These preparations are useful
for ruling out drug noncompliance. They may also help patients who
because of disorganization, indifference, or denial of illness cannot
reliably take daily oral drugs.
Table 2
Depot Antipsychotic Drugs
Drug*
Dosage
Peak Level†
Fluphenazine Some Trade Names
PROLIXIN DECANOATE
PROLIXIN
Click for Drug Monograph
decanoate
12.5–50 mg q 2–4 wk
1 day
Fluphenazine Some Trade Names
PROLIXIN DECANOATE
PROLIXIN
Click for Drug Monograph
enanthate
12.5–50 mg q 1–2 wk
2 days
Haloperidol Some Trade Names
HALDOL
Click for Drug Monograph
decanoate
25–150 mg q 28 days (3–5 wk range is acceptable)
7 days
Risperidone Some Trade Names
RISPERDAL
Click for Drug Monograph
microspheres‡
25–50 mg q 2 wk
35 days
*Given IM with Z-track technique.
†Time until peak level after a single dose.
‡Because of 3-wk lag time between 1st injection and achievement of
adequate blood levels, patients should continue on oral antipsychotics
for 3 wk after 1st injection. *****sment of tolerability with oral
risperidone Some Trade Names
RISPERDAL
Click for Drug Monograph
recommended prior to initiating therapy.
Conventional antipsychotics produce several adverse effects, such as
sedation, cognitive blunting, dystonia and muscle stiffness, tremors,
elevated prolactin levels, and weight gain (for treatment of adverse
effects, see Table 3: Approach to the Patient With Mental Complaints:
Treatment of Acute Adverse Effects of Antipsychotics). Akathisia
(motor restlessness) is particularly unpleasant and may lead to
noncompliance. These drugs may also cause tardive dyskinesia, an
involuntary movement disorder most often characterized by puckering of
the lips and tongue and/or writhing of the arms or legs. The incidence
of tardive dyskinesia is about 5%/yr of drug exposure among patients
taking conventional antipsychotics. In about 2%, tardive dyskinesia is
severely disfiguring. In some patients, tardive dyskinesia persists
indefinitely, even after the drug is stopped. Because of this risk,
patients receiving long-term maintenance therapy should be evaluated
at least q 6 mo. Rating instruments, such as the Abnormal Involuntary
Movement Scale, may be used (see Table 3: Schizophrenia and Related
Disorders: Abnormal Involuntary Movement Scale). Neuroleptic malignant
syndrome, a rare but potentially fatal adverse effect, is
characterized by rigidity, fever, autonomic instability, and elevated
creatinine phosphokinase (see also Approach to the Patient With Mental
Complaints: Adverse effects of antipsychotic drugs).
Table 3
Abnormal Involuntary Movement Scale
Observe gait on the way into the room.
Have patient remove gum or dentures, if ill-fitting.
Determine if patient is aware of any movements.
Have patient sit on a firm, armless chair with hands on knees, legs
slightly apart, and feet flat on the floor. Now and throughout the
examination, look at the entire body for movements.
Have patient sit with hands unsup****ted, dangling over the knees.
Ask patient to open mouth twice. Look for tongue movements.
Ask patient to protrude tongue twice.
Ask patient to tap thumb against each finger for 15 sec with each
hand. Observe face and legs.
Have patient stand with arms extended forward.
Rate each item on a 0 to 4 scale for the greatest severity observed. 0
= none; 1 = minimal, may be extreme normal; 2 = mild; 3 = moderate; 4
= severe. Movements that occur only on activation merit 1 point less
than those that occur spontaneously.
Facial and oral movements
Muscles of facial expression
0 1 2 3 4
Lips and perioral area
0 1 2 3 4
Jaw
0 1 2 3 4
Tongue
0 1 2 3 4
Extremity movements
Arms
0 1 2 3 4
Legs
0 1 2 3 4
Trunk movements
Neck, shoulders, hips
0 1 2 3 4
Global judgments
Severity of abnormal movements
0 1 2 3 4
Incapacitation due to abnormal movements
0 1 2 3 4
Patient's awareness of abnormal movements (0 = unaware; 4 =
severe distress)
0 1 2 3 4
Modified from ECDEU *****sment Manual for Psychopharmacology by W.
Guy. Copyright 1976 by US Department of Health, Education and Welfare.
About 30% of patients with schizophrenia do not respond to
conventional antipsychotics. They may respond to clozapine Some Trade
Names
CLOZARIL
Click for Drug Monograph
, a 2nd-generation antipsychotic.
Second-generation antipsychotics: SGAs act by blocking both dopamine
Some Trade Names
INTROPIN
Click for Drug Monograph
and s*****onin receptors (s*****onin- dopamine Some Trade Names
INTROPIN
Click for Drug Monograph
receptor antagonists). SGAs tend to alleviate positive symptoms; may
lessen negative symptoms to a greater extent than do conventional
antipsychotics (although such differences have been questioned); may
cause less cognitive blunting; are less likely to cause extrapyramidal
(motor) adverse effects; have a lower risk of causing tardive
dyskinesia; and for some SGAs produce little or no elevation of
prolactin.
Clozapine Some Trade Names
CLOZARIL
Click for Drug Monograph
is the only SGA demonstrated to be effective in up to 50% of patients
resistant to conventional antipsychotics. Clozapine Some Trade Names
CLOZARIL
Click for Drug Monograph
reduces negative symptoms, produces few or no motor adverse effects,
and has minimal risk of causing tardive dyskinesia, but it produces
other adverse effects, including sedation, hypotension, tachycardia,
weight gain, type 2 diabetes, and increased salivation. It also may
cause seizures in a dose-dependent fa****on. The most serious adverse
effect is agranulocytosis, which can occur in about 1% of patients.
Consequently, frequent monitoring of WBCs is required, and clozapine
Some Trade Names
CLOZARIL
Click for Drug Monograph
is generally reserved for patients who have responded inadequately to
other drugs.
Newer SGAs (see Table 4: Schizophrenia and Related Disorders:
Second-Generation Antipsychotics*) provide many of the benefits of
clozapine Some Trade Names
CLOZARIL
Click for Drug Monograph
without the risk of agranulocytosis and are generally preferable to
conventional antipsychotics for treatment of an acute episode and for
prevention of recurrence. Newer SGAs are very similar to each other in
efficacy but differ in adverse effects, so drug choice is based on
individual response and on other drug characteristics. For example,
olanzapine Some Trade Names
ZYPREXA
Click for Drug Monograph
, which has a relatively high rate of sedation, may be prescribed for
patients with prominent agitation or insomnia; less sedating drugs
might be preferred in patients with lethargy. A 4- to 8-wk trial is
usually required to *****s efficacy. After acute symptoms have
stabilized, maintenance treatment is initiated, in which the lowest
dose that prevents symptom recurrence is used. Risperidone Some Trade
Names
RISPERDAL
Click for Drug Monograph
is the only SGA available in a long-acting injectable formulation.
Table 4
Second-Generation Antipsychotics*
Class
Drug
Dose Range
Usual Adult Dose
Comment†
Dibenzodiazepine
Clozapine Some Trade Names
CLOZARIL
Click for Drug Monograph
150–450 mg po bid
400 mg po at bedtime
First SGA, demonstrated efficacy in patients resistant to treatment.
Frequent WBC counts required because of risk of agranulocytosis;
increased risk of seizures, weight gain
Benzisoxazole
Risperidone Some Trade Names
RISPERDAL
Click for Drug Monograph
4–10 mg po at bedtime
4 mg po at bedtime
May cause extrapyramidal symptoms at doses > 6 mg; dose-dependent
prolactin elevation; only SGA with a long-acting injectable form
available
Thienobenzodiazepine
Olanzapine Some Trade Names
ZYPREXA
Click for Drug Monograph
10–20 mg po at bedtime
15 mg po at bedtime
Somnolence, weight gain, and dizziness are most common adverse
effects
Dibenzothiazepine
Quetiapine Some Trade Names
SEROQUEL
Click for Drug Monograph
150–375 mg po bid
200 mg po bid
Low potency allowing wide dosing; no anticholinergic effect. Dose
titration required because of blocking of a2 receptors, requires
twice-daily dosing
Benzisothiazolylpiperazine
Ziprasidone Some Trade Names
GEODON
Click for Drug Monograph
40–80 mg po bid
80 mg po bid
Inhibition of s*****onin and norepinephrine Some Trade Names
LEVOPHED
Click for Drug Monograph
reuptake may convey antidepressant properties. Shortest half-life of
new drugs; requires twice-daily dosing with food. IM form available
for acute treatment. Low tendency for weight gain
Dihydrocarostyril
Aripiprazole Some Trade Names
ABILIFY
Click for Drug Monograph
10–30 mg po at bedtime
15 mg po at bedtime
Dopamine Some Trade Names
INTROPIN
Click for Drug Monograph
-2 partial agonist, low tendency for weight gain
SGA = Second-generation antipsychotic.
*Monitoring for weight gain and type 2 diabetes recommended for this
class of antipsychotics.
†All 2nd-generation antipsychotics have been associated with an
increase in mortality in elderly patients with dementia.
Weight gain, hyperlipidemia, and elevated risk of type 2 diabetes are
the major adverse effects of SGAs. Thus, before treatment with SGAs is
begun, all patients should be screened for risk factors, including
personal/family history of diabetes, weight, waist cir***ference, BP,
and fasting plasma glucose and lipid profile. Patient and family
education regarding signs and symptoms of diabetes (polyuria,
polydipsia, weight loss), including diabetic ketoacidosis (nausea,
vomiting, dehydration, rapid respiration, clouding of sensorium),
should be provided. In addition, nutritional and physical activity
counseling should be provided to all patients beginning an SGA. All
patients undergoing ongoing treatment with an SGA require periodic
monitoring of weight, BMI, and fasting blood glucose and referral for
specialty evaluation of patients who develop hyperlipidemia or type 2
diabetes.
Rehabilitation and community sup****t services: Psychosocial skill
training and vocational rehabilitation programs help many patients
work, shop, and care for themselves; manage a household; get along
with others; and work with mental health professionals. Sup****ted
employment, in which patients are placed in a competitive work setting
and provided with an on-site job coach to promote adaptation to work,
may be particularly valuable. In time, the job coach acts only as a
backup for problem solving or for communication with employers.
Sup****t services enable many patients with schizophrenia to reside in
the community. Although most can live independently, some require
supervised apartments where a staff member is present to ensure drug
compliance. Programs provide a graded level of supervision in
different residential settings, ranging from 24-h sup****t to periodic
home visits. These programs help promote patient autonomy while
providing sufficient care to minimize the likelihood of relapse and
need for inpatient hospitalization. Assertive community treatment
programs provide services in the patient's home or other residence and
are based on high staff-to-patient ratios; treatment teams directly
provide all or nearly all required treatment services.
Hospitalization or crisis care in a hospital alternative may be
required during severe relapses, and involuntary hospitalization may
be necessary if the patient poses a danger to himself or others.
Despite the best rehabilitation and community sup****t services, a
small percentage of patients, particularly those with severe cognitive
deficits and those resistant to drug therapy, require long-term
institutional or other sup****tive care.
Psychotherapy: The goal of psychotherapy is to develop a collaborative
relation****p between the patient, family, and physician so that the
patient can learn to understand and manage his illness, take drugs as
prescribed, and handle stress more effectively. Although individual
psychotherapy in combination with drug therapy is a common approach,
few empirical guidelines are available. Psychotherapy that begins by
addressing the patient's basic social service needs, provides sup****t
and education regarding the nature of the illness, promotes adaptive
activities, and is based on empathy and a sound dynamic understanding
of schizophrenia is likely to be most effective. Many patients need
empathic psychologic sup****t to adapt to what is often a lifelong
illness that can substantially limit functioning.
For patients who live with their families, psychoeducational family
interventions can reduce the rate of relapse. Sup****t and advocacy
groups, such as the National Alliance for the Mentally Ill, are often
helpful to families.
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>
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