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Our Interactive Cardiovascular Library has detailed animations and illustrations to help you learn about conditions, treatments and procedures related to heart disease and stroke. Popular Articles 1 Understanding Blood Pressure Readings 2 Sodium and Salt 3 All About Heart Rate (Pulse) 4 What are the Symptoms of High Blood Pressure? This site complies with the HONcode standard for trustworthy health information: verify here.
Feel free to take a look around, meet the Waverunners, and see how the foundation is being set in place, by building a softball powerhouse in Indiana! Schizophrenia is a chronic and disabling neuropsychiatric illness possibly best characterized as a syndrome rather than as a single disease entity. The point prevalence of schizophrenia is 1% to 1.5%, a finding that has been fairly constant across time, cultures, races, and continents. Accumulating evidence shows that genetic and neurodevelopmental factors are associated with greater susceptibility to schizophrenia. The birthrate of patients with schizophrenia is 5% to 8% higher worldwide than the birthrate of the general population in the winter and spring months.
Population density, industrialization, emigration, and low socioeconomic status at birth have been proposed as possible influences on the development of schizophrenia. Although not described as a separate entity in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),2 acute psychosis refers to a symptom complex that includes disturbance of thought processes and behavior. The median age at onset for the first psychotic episode of schizophrenia is the early to mid-20s for men and the late 20s for women. The prodromal phase of schizophrenia is characterized by social avoidance, emotional flattening, eccentricity or magical thinking, idiosyncratic speech, and peculiarities of attitude and behavior that fail to meet criteria for a specific psychiatric illness. Factor analysis has identified three main psychotic symptom dimensions in schizophrenia: positive, negative, and cognitive.
Accurate diagnosis of schizophrenia is often challenging because symptoms are nonspecific and progression to full illness is gradual. If symptoms are not specific and signs and symptoms do not last for 6 months as required for diagnosing schizophrenia, the clinician is obliged to eliminate other important diagnostic considerations.
Acute psychosis, although not recognized as a diagnostic term in DSM-5 is commonly used to describe a rapid deterioration of behavior associated with hallucinations and delusions. Schizoaffective disorder is a chronic mental illness that includes prominent features of both schizophrenia and a mood disorder. A diagnosis of mood disorder with psychotic features is made if psychotic symptoms occur solely during episodes of mood disturbance.
Acute psychosis caused by substance use or medication toxicity is distinguished from schizophrenia by clear-cut evidence of substance use leading to symptoms. The successful treatment of schizophrenia requires simultaneous attention to medical variables and psychosocial factors relevant to the patient. The primary care physician’s principal role is to recognize the illness, initiate treatment, and refer to a psychiatrist. Proper medical care is another important consideration in the comprehensive management of the schizophrenic patient. Antipsychotics are considered to be the first line of therapy in the pharmacologic treatment of schizophrenia. Note: First-generation antipsychotics are no longer considered first-line treatment for schizophrenia unless an atypical antipsychotic is not available, and then either haloperidol or chlorpromazine should be considered. The SGAs affect several receptor typesa€”serotonin, histamine, noradrenergic, and muscarinic-in addition to the D2 receptors.4 The multiplicity of receptors targeted by SGAs contributes to their efficacy and side-effect profiles.
The use of antipsychotics in elderly patients with dementia-related psychosis has been associated with a 1.7-fold increase in risk of death.
The dosage of medication used to achieve remission or optimal control in the acute phase should be continued for at least 6 months to prevent relapse. Have the patient sit on a firm, armless chair with hands on knees, legs slightly apart, and feet flat on the floor.
Developed in the late 1960s, assertive community treatment provides the patient with around-the-clock support in the community, thereby significantly reducing the time spent in hospitals. The quality of the therapeutic alliance may be the best predictor of compliance and outcome. The schizophrenic patient’s behavior can trigger a vicious cycle of conflict between the patient and family. The principles of learning theory are used to improve social skills such as interpersonal relationships, employment, and leisure.
Workshops and part-time employment programs help the patient acquire greater functionality.
Most prevention efforts are in the realm of secondary and tertiary prevention, or reducing the number and severity of episodes. Populations with special needs include patients with pervasive developmental disorders and mental retardation, women with childbearing potential, children, the elderly, and the homeless.
Schizophrenia is a treatable neuropsychiatric disorder present in approximately 1% of the general population. The etiology is multifactorial and includes genetic, developmental, and possibly environmental causes. The signs and symptoms of schizophrenia are nonspecific, warranting a thorough evaluation for other medical and psychiatric disorders that can manifest with psychosis.
The primary care physician should be familiar with the use, benefits, and potential adverse effects of antipsychotic medications used to treat schizophrenia. Metabolic syndrome is a common comorbidity, especially since the introduction of atypical (second-generation) antipsychotics.
Lieberman JA, Stroup TS, McEvoy JP, et al; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. This site complies to the HONcode standard for trustworthy health information: verify here.
Polycystic ovarian syndrome (PCOS) is among the most frequent causes of infertility in adult women. It is estimated that 5%-10% of reproductive age women have PCOS, and this includes adolescents, although accurate data on the prevalence and incidence in this population is unavailable.
The exact cause of PCOS is unknown, however the main abnormality is excessive ovarian androgen production. It is well documented that these phenomena occur in adolescence; however, they may begin as early as fetal life. In healthy adolescents, about one-half of menstrual cycles remain anovulatory for 1 to 2 years after menarche.
Adolescents generally have increased terminal hair growth and acne and this transient hyperandrogenism is a normal characteristic of puberty.
Trans-vaginal ultrasound is not feasible in a non-sexually active adolescent; and therefore, abdominal ultrasounds are recommended, and may result in decreased sensitivity.
PCOS is an extremely variable entity, and adolescents may present with many or just 1 of the features.
Hirsutism is a key component of PCOS and is defined as excessive terminal hair growth in androgen-dependent areas. Anovulatory symptoms are also seen in about two-thirds of adolescents with PCOS;[3] however, in adolescents, this may be a normal component of puberty.
A polycystic ovary is found in the majority of adolescents with PCOS; however this may not occur until years after menarche and may also be present in adolescents without PCOS as a normal pubertal variant. In general, these adolescents have significant abdominal fat known as an android distribution, even if they are not obese.
In addition to metabolic abnormalities, if untreated, the chronic anovulation of PCOS will result in endometrial hyperplasia and increased risk of endometrial carcinoma. Other adrenal disorders resulting in over-production of steroids, such as Cushing syndrome, must also be considered.
Hyperprolactinemia affects adrenal androgen production and metabolism, resulting in hirsutism, amenorrhea, and possibly galactorrhea.
Hypothyroidism may cause menstrual irregularities and weight gain, and lowers the level of sex hormone binding globulin. Given the heterogeneous nature of PCOS, the evaluation and treatment also varies among endocrinologists.
Similarly, weight loss of at least 5% has significant beneficial effects in women with PCOS, including improvement in hirsutism, acne, and return of ovulation and normal menstrual cycles.[13-14] These studies were performed in adult women, and there are no such comparable studies in adolescents. Metformin, a biguanide, is a well-known oral antidiabetic that reduces hepatic glucose production and improves insulin sensitivity, which thereby results in reduced androgen and LH levels.


However, the majority of pediatric endocrinologists prescribe metformin in obese adolescents with PCOS and about one-third advocate the use of metformin in all adolescents with PCOS. Oral contraceptive pills (OCPs) are generally regarded as the first-line therapy for treatment of adolescents with PCOS.
Of the progestin components noted above, drospirenone has both anti-androgenic effect and mineralocorticoid activity, which may reduce some of the bloating and water weight gain seen with use of other OCPs. OCPs normalize androgen levels within a few weeks, however reduction in terminal hair may not be appreciated for as long as 9 months after initiation of treatment. It is generally recommended that OCPs as first-line therapy be utilized for at least 6 months prior to considering the addition of an anti-androgen. Spironolactone is the most commonly used anti-androgen in the American adolescent population. Cosmetic treatments: As many of the above medications require months to produce clinical results, patients may seek cosmetic treatments, such as topical anti-androgens or hair removal.
Although recognizing PCOS in adolescents is inherently challenging, early identification and treatment can help prevent infertility, type 2 diabetes, and other serious consequences of this disorder. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The abnormal, often bizarre behavior that typifies schizophrenia is a product of disturbances in cognition, perception, and volition.
Mounting evidence supports a strong genetic contribution, but genetic factors alone do not fully account for the variance in cause. According to twin and adoption studies, up to 50% of identical (monozygotic) twins share a diagnosis of schizophrenia, compared with about 12% of nonidentical (dizygotic) twins. Modern neuroimaging techniques, however, including computed tomography (CT), magnetic resonance imaging (MRI), functional MRI, and positron emission tomography, demonstrate evidence of nonspecific structural and metabolic abnormalities in the frontotemporal cortices, especially in the prefrontal areas and periventricular limbic structures of the schizophrenic brain. The first agents to demonstrate promise in the pharmacologic control of schizophrenia were recognized to have dopamine-blocking properties. The presence of psychotic symptoms usually indicates an underlying organic or psychiatric condition. Prodromal symptoms that suggest social anxiety, panic, obsessive-compulsive or major depressive disorder, and antisocial behavior or substance misuse often lead to early misdiagnosis and unsuccessful treatment efforts. The acute phase of the illness features a predominance of positive psychotic symptoms, whereas the chronic phase is typified by negative and cognitive symptoms.
Relevant signs and symptoms must be present for at least 6 months before a diagnosis of schizophrenia can be made. These include psychiatric disorders, substance use, and general medical disorders (Boxes 2 and 3).
Schizophreniform disorder, brief psychotic disorder, and organic psychoses fall under this rubric.
The diagnostic criteria for schizoaffective disorder are characteristic symptoms of schizophrenia concurrent with a major mood disturbance (major depressive or manic episode). A multimodal approach encompassing biologic and psychosocial therapies as well as programs that offer rehabilitation and social reintegration has been found to be most effective. Acute psychosis, like schizophrenia, has a differential diagnosis that includes general medical, psychiatric, and substance-use disorders, (see Boxes 2 and 3). The patient’s idiosyncratic behavior, poor hygiene, or nonadherence to medical recommendations often interferes with attention to and successful management of medical problems.
This includes simultaneous attention to potentially life-endangering causes of acute psychosis or delirium (Box 4) and other psychiatric, substance-use (see Box 2), and general medical (see Box 3) causes. Typically, much of this information is either unavailable or difficult to obtain, and the clinician is forced to rely on rapid observation, clinical intuition, and laboratory measures (Table 1).
They are generally categorized as first-generation (typical) antipsychotics (FGAs) or second-generation (atypical) antipsychotics (SGAs). Food and Drug Administration for IV use, but off-label use is common when IV access is available. The choice of antipsychotic drug, dosage, and desired route of administration is based on phase of treatment, intensity of agitation, adherence to treatment recommendations, history of response to antipsychotic medications, and antipsychotic side-effect profile. The phenothiazines are more anticholinergic, cause more weight gain, and are more likely than butyrophenones to cause postural hypotension. The results of the oft-cited Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) demonstrated that FGAs and SGAs have similar efficacy, but both groups have potentially troublesome side effects that warrant careful monitoring and can disrupt otherwise effective treatment.4-7 Although SGAs are less likely to cause EPS, they are not risk free. Movements that occur only on activation merit 1 point less than those that occur spontaneously. There are no strict guidelines for the minimum antipsychotic dose required to prevent relapse. Optimal outcome requires additional use of psychosocial therapies and programs that foster recovery through vocational rehabilitation and social reintegration.
A team composed of a social worker, nurse, and case manager provides treatment in community settings. The emphasis is on education, support, and problem-solving, rather than on developing insight. Anger, criticism, and devaluing comments directed by family members at the patienta€”referred to in the literature as high expressed emotiona€”are associated with a greater increase of relapse even when pharmacologic management is optimal.
Behaviors such as odd facial expressions, lack of spontaneity, and inappropriate perception of others’ emotional states are targeted and modified. Public health education on schizophrenia helps to reduce stigma and resistance to seeking treatment. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Swamy, MDMedical Director and Program Co-director, Chicago Children’s Diabetes Center at La Rabida Children’s Hospital; Attending Physician, Endocrinology, Ann & Robert H.
PCOS is also the most common cause of menstrual dysfunction and hyperandrogenism in adolescents.[1] It is challenging, yet important, for pediatricians to identify and treat this condition when it presents in childhood and adolescence. As adolescents generally have anovulatory and abnormal cycles shortly after menarche, it is difficult to assess anovulatory symptoms in this population. It should be distinguished from hypertrichosis, which is generalized hair growth in a non-sexual distribution. Many small follicles develop, but not to the pre-ovulatory size, hence resulting in failure to ovulate. Other conditions share common features and need to be considered in the differential diagnosis. The laboratory samples must be drawn early in the morning, at peak time of androgen production, about 8 am. They are also generally limited in duration, and it is well known that the overwhelming majority of weight loss efforts are transient. It is approved by the Food and Drug Administration for children with type 2 diabetes aged 10 years and older, but not specifically for PCOS.
The American Society for Reproductive Medicine supports the use of metformin in adolescents with PCOS with abnormal glucose tolerance during oral glucose tolerance testing (OGTT).
As these medications have teratogenic potential, they should be used in conjunction with an oral contraceptive, and not as monotherapy. If the adolescent is still complaining of significant hirsutism after a 6-month trial of OCPs, discuss compliance as this may play a role and then consider addition of an anti-androgen. Comparison of efficacy of spironolactone with metformin in the management of polycystic ovary syndrome: an open-labeled study. We pride ourselves on hard work, dedication, and improvement; while enjoying the game of fastpitch softball. Clinical manifestations are believed to result from incompletely understood dysregulation of frontotemporal and limbic neurocircuitry. In the United States, about 2.5% of total annual health care expenditures are for schizophrenia.
As with other common illnesses such as hypertension, the risk of developing schizophrenia is a product of multiple genes interacting not only with one another but also with environmental factors. The strength of genetic factors varies across families, but approximately 10% of a patient’s first-degree relatives (parents, siblings, and children) are also schizophrenic, as are 50% of the children of two schizophrenic parents. There have been some correlates of gray matter changes in the left dorsolateral prefrontal cortex in patients with predominantly negative symptoms. Several neurotransmitter systems have been implicated, but the primary focus has been on dopamine and the brain structures that are high in its content (substantia nigra, ventral tegmentum, mesolimbic structures, and the tuberoinfundibular system).


Disruption of thought processes, hallucinations, delusions, agitation, and rapid deterioration in behavior are some of the common manifestations of acute psychosis. Acute psychosis, the hallmark of the acute phase, follows the prodrome insidiously or occurs abruptly and sometimes explosively.
The DSM-5 diagnosis of schizophreniform disorder depends on the persistence of schizophrenia-like symptoms for at least 1 month and exclusion of other causes of acute psychosis. Although mood symptoms and episodes must be present for a substantial portion of the total course of the illness, a diagnosis of schizoaffective disorder also requires that psychotic symptoms, such as delusions or hallucinations, have been present for a minimum of 2 weeks in the absence of an active mood disturbance. Schizophrenia generally does not occur in isolation but rather with other comorbid conditions, commonly alcohol or drug abuse, or both. At this point the primary care physician’s role may be to ensure safe transfer of the acutely psychotic patient to an emergency facility where appropriate evaluation and stabilization can be conducted.
Schizophrenic patients have a high incidence of cardiovascular problems such as hypertension and coronary artery disease, diabetes, and tobacco-related disorders.
An electroencephalogram should be obtained if one suspects organic psychosis such as delirium (encephalopathy). This was initially thought to be an atypical antipsychotic–specific phenomenon, but studies have shown that FGAs may pose a similar risk. Patients should be helped with the transition to life in the community and helped to adjust to their lives outside the hospital through realistic goal setting. For FGAs, the optimal dose is regarded as the minimum dose at which mild EPS are detectable on physical examination.
Services delivered include case management, initial and ongoing assessments, access to psychiatric services, employment and housing assistance, family support and education, substance-abuse services, and any other services and support critical to successful adaptation in the community. A therapist works with the family to reduce expressed emotion by educating them about schizophrenia and helping to modify the behaviors and attitudes that undermine the patient.
Family history of schizophrenia is an important indicator of risk that should increase vigilance for early detection and treatment of prodromal symptoms. Early identification and treatment of PCOS will help prevent long-term consequences, which in addition to infertility, include type 2 diabetes, endometrial hyperplasia and increased risk of carcinoma.
Also, adolescents are often embarrassed to discuss symptoms of hyperandrogenism, and may resort to cosmetic treatments so that the physician is unaware of the extent of hyperandrogenism. Insulin directly stimulates an increase in LH production, ovarian androgen production, as well as androgen production at the level of the adrenal glands. The non-classic form of congenital adrenal hyperplasia (CAH) may also present with androgen excess, menstrual irregularities and premature pubarche, and is not associated with ambiguous genitalia, like the classic form.
They should also be processed by a trusted laboratory with reliable assays, especially for measurement of free testosterone.
Its use in adolescents with PCOS remainsa bit controversial, given the lack of long-term data. The Endocrine Society’s clinical practice guidelines for treatment of hirsutism are an excellent resource, providing a detailed review of these medications, including evidenced-based support for their use, efficacy, and adverse effects. Doses of 25 mg BID – 100 mg daily of spironolactone have been proven to be effective in treating hyperandrogenism. Our goal as a team is to develop as softball players and build character within ourselves as well as represent our communities as responsible and classy individuals. The National Alliance on Mental Illness (NAMI), a patient- and family-oriented self-help group, has designated schizophrenia a brain disorder, emphasizing that schizophrenia is not simply a product of dysfunctional parenting or other psychosocial stressors.
It is also possible that specific risk factors predict occurrence of specific schizophrenia subtypes.
Reports indicate suggestive linkage on chromosomes 1,2, 3, 5, and 11 and on the X chromosome.
Acute psychosis can be a feature of schizophrenia, but the diagnosis of schizophrenia requires the fulfillment of a variety of other diagnostic criteria.
The natural history without treatment (and sometimes with) is for symptoms to wax and wane, punctuated by recurrent episodes of acute psychosis. Negative symptoms are believed to reflect neuroimaging evidence of reduced metabolic activity in the dorsolateral prefrontal cortex.
The diagnostic criteria for schizophrenia are symptomatic, functional, and time based, and they require exclusion of both medical and other psychiatric disorders that can mimic schizophrenia.
Brief psychotic disorder (often referred to as brief reactive psychosis) lasts less than 1 month, but more than 1 day. Failure to recognize and treat comorbid substance abuse is a common cause of treatment resistance in schizophrenia. Once the proper treatment regimen for a schizophrenic patient has been identified, the primary care physician may be called on to prescribe maintenance medication, with specialist referral for assistance in managing recurrent illness episodes. Given that many schizophrenic patients are homeless, higher rates of tuberculosis, HIV infection, and problems associated with poor foot care are also common in this population.
Simultaneous administration of IM olanzapine and lorazepam is not recommended because the combination has been associated with respiratory failure. Haloperidol, the most widely prescribed butyrophenone, is associated with a high risk of all types of extrapyramidal symptoms (EPS). Once the diagnosis is made, the team should develop a comprehensive treatment plan that includes family involvement with goals of adhering to treatment and reducing symptoms. Swamy discusses metformin, which is approved for type 2 diabetes in children and used off-label to treat PCOS in adolescents. Insulin also decreases levels of sex hormone binding globulin (SHBG), thereby increasing levels of free androgen. In menstruating adolescents, it is best to draw samples in the early follicular phase of their cycle, days 4-10.
Studies have consistently shown, however, that both genetic and nongenetic factors play a role in the origin of schizophrenia. Blockade of the D2 receptor appears to have the greatest relevance to the antipsychotic efficacy as well as adverse effects of neuroleptic drugs. The pattern of symptoms can change over time, with progressive deterioration of function and cognition in some instances and progressive improvement of psychotic symptoms and function in others. It is typically regarded as a reaction to marked stress in persons with borderline or antisocial personality disorders.
Comprehensive management of schizophrenia, therefore, typically requires the involvement of a multidisciplinary team including a psychiatrist, social worker, case manager, individual or family therapist, and one or more family members. Although effective, the FGAs have fallen out of favor because of their side-effect profiles, especially their propensity to cause EPS (Box 5). Clozapine (Clozaril), the first SGA to be developed and marketed, has retained its reputation for being the most effective of all antipsychotics at treating negative symptoms. Assertive community treatment has been very effective at maintaining community and keeping patients out of the hospital. Table 1 provides a comprehensive list of recommended blood, urine and imaging tests, which should be tailored to each patient and her presentation.
Characteristic features of positive, negative, and cognitive symptoms are outlined in Box 1.
Episodes of illness can require treatment in multiple settings, including outpatient, intensive outpatient, hospital, and residential. Voluntary or involuntary hospitalization is often necessary for the first episode of psychosis in schizophrenia. Unfortunately, its tendency to cause bone marrow suppression, weight gain, and metabolic syndrome also distinguishes it from the other SGAs. Assiduous attention to substance abuse and abstinence is a key to a good outcome in schizophrenia. Extrapyramidal symptoms can be attributed to D2-receptor blockade in the substantia nigra and ventral tegmentum, positive symptom suppression to D2 blockade in mesolimbic structures, and hyperprolactinemia to D2 blockade in the tuberoinfundibular structures (dopamine is a prolactin-inhibiting factor). Comorbid substance abuse is common, prolongs the illness, and contributes to treatment resistance. The primary symptoms are rated based on their current severity (defined as most severe in the past 7 days) on a 5 point scale ranging from 0 (not present) to 4 (present and severe). The relationship to schizophrenia of serotonin, glutamate, gamma-aminobutyrate, neurotensin, and their relevant receptors is also under investigation.



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