SCHIZOPHRENIA Part 3
HISTORY AND PHYSICAL, SIGNS AND SYMPTOMS, DIAGNOSTIC WORKUP, DIAGNOSIS AND TREATMENT.
Schizophrenia is a disabling mental illness, not a physical illness. There are no positive findings or signs on physical examination. Therefore, history is the most important diagnostic tool. However, history is full of wrong psychopathological utterances and abnormal behaviors, and the time and meaning of which are often denied by the patients. For this reason, a reliable history could only be taken with the help of family members. Patients’ family history is especially important because 80 percent of patients have a hereditary component.
In history taking, there are two sets of diagnostic signs and symptoms of schizophrenia:
1 – Positive symptoms, which include hallucinations (visual or auditory), delusions, paranoia and delirium. These symptoms are collectively called psychosis. Psychosis is the most commonly recognized diagnostic symptom and the most dangerous aspect of the disease. Fortunately, it only occurs on occasion.
2 – Negative symptoms, which include emotional flatness, social withdrawal, and isolation, disordered thinking, difficulties in learning, and many other cognitive deficiencies. These are nonspecific symptoms and could be seen in other illnesses.
Diagnostic workup in schizophrenia must include all routine blood work, a metabolic panel, a lipid profile, assessment of nutritional status, and brain imaging with MRI (fMRI) and PET to assess for structural, blood flow, and neurotransmitter activity changes in the brain. Additionally, a spinal tap must be done to obtain cerebrospinal fluid for examination for autoimmune antibodies to rule out “autoimmune encephalitis,” which could present as psychosis.
Post-mortem exam of the brains of schizophrenic patients has shown gray matter loss in the prefrontal and temporal cortices.
Treatment of the patients, depending on the seriousness of the clinical situation, usually starts with an antipsychotic (dopamine receptor blocker) in the hospital or on an outpatient basis. But it should be noted that all existing anti-psychotic medications are problematic with serious and sometimes devastating side effects, as we shall see in the case of my son. He initially refused to have a mental illness and to take any medication for it. He checked the medication and spat it out afterward. Eventually, he agreed to take a monthly IM injection of medications. Haldol was most effective in controlling his psychotic symptoms. He has been on this medication ever since. Haldol partly helped but also caused a plethora of side effects. It took away his sense of satiety; he started eating continuously without ever feeling full. His weight shot up from 185 to 460 lbs. He became diabetic, and later on developed metabolic syndrome.
For this reason, I assume that the feeling of satiety is also regulated in the brain with neurotransmitter activity.
Besides this morbid obesity, he developed metabolic syndrome with diabetes, hypertension, and hyperlipidemia, which required more medications.
The new popular GLP-1 agonist weight loss drug did not help a bit with his weight. He also developed Parkinsonian-like tremors in his hands. He can hardly move around with this amount of weight. He developed stasis dermatitis in both legs with chronic ulcerations.
We are unable to change his schizophrenia medication to the new FDA-approved medication called KarXT (Cobenfy), which has no weight gain side effects, because my son’s Medicare insurance and drug plan do not cover it.
Although old anti-psychotic drugs only partly control my son’s mental illness, the devastating drug side effects certainly will kill him. So, as a family, we are continuously suffering with him.
