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קבוצה מספר 7 Clozapine Resistant Schizophrenia

מנחים: בועז בלוך רימונה דורסט. דומני יואב יאסין עדאל פליוטקל נעים מירב בן ארויה נועה בואקני הישאם עבודי ענת קובלונוק יקטרינה. קבוצה מספר 7 Clozapine Resistant Schizophrenia.

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קבוצה מספר 7 Clozapine Resistant Schizophrenia

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  1. מנחים: בועז בלוך רימונה דורסט דומני יואב יאסין עדאל פליוטקל נעים מירב בן ארויה נועה בואקני הישאם עבודי ענת קובלונוק יקטרינה קבוצה מספר 7Clozapine Resistant Schizophrenia

  2. בן 29, לוקה בסכיזופרניה. לא השתפר עם מספר ניסיונות תרופתיים הוחלט לתת לו לפונקס במינון שנסבל על ידו. מגיב חלקית ללפונקסמה הטיפול "המוכח" הבא?

  3. Resistant Schizophrenia Kane’s criteria (Arch Gen psychiatry, 1988): ≥ 3 Antipsychotic Treatments, ≥ 2 Chemical classes, doses equiv 1000 mg/d chloropromazine, 6 weeks, without significant relief. Partial response to clozapine Psychotic symptoms despite a trial of 300-900mg/d, ≥ 8 weeks, and ≤ 6 months with plasma level reaching 350 ng/ml.

  4. Schizophrenia Algorithm Texas Medication Algorithm Project Procedural Manual, 2008

  5. Time Out • Re revaluation of Diagnosis (psychiatric disorders, medical condition, personality disorder e.g. schizotypal p.d) • Revision of all past medicines (duration, doses, side effects, reasons for changing) • Compliance !!! • Co morbidities (ax 1 2 3) • Ongoing psychosocial stress? Abuse? • Drug abuse

  6. What about Psychosocial interventions?!

  7. Psycho Bio Social

  8. Psycho-Social • Individual • Couple • Family • Group

  9. Psycho-Social • CBT • Supportive Psychotherapy • Dynamic • Family Intervention • Vocational Rehabilitation • Assertive Community Treatment

  10. CBT • A growing body of evidence supports the use of CBT for the TX of schizophrenia. • A course of CBT added to a Antipsychotic regimen is now considered to be an appropriate standard of care in the UK. • Turkington. D. et al Cognitive behavior therapy for schizophrenia, Am J Psychiatry 2006: 163:365-373

  11. CBT • The goal of CBT in not to try to persuade or force the patient to agree that he has symptoms of a mental illness • The goal is to reduce the severity of, or distress from, the symptoms Schizophr Bull2010Jan 36(1) 94-103 The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009.Kreyenbuhl et al.

  12. Family intervention • Family interventions should not be restricted to patients whose families are identified as having high EE

  13. Family intervention • Patients who have ongoing contact with their families should be offered a family psychosocial intervention which provides a combination of: education about the illness, family support, crisis intervention, and problem solving skills training.

  14. “Snoezelen treatment calms and relaxes pschizophrenic patients gives them a feeling of dignity, initiative and feeling of choice…” Harefuah 2007

  15. בישראל- סל שיקום • סיוע תעסוקתי • סיוע במציאת דיור- הוסטל, דיור מוגן, דיור לווין • סומך/ חונך

  16. Schizophrenia Algorithm Texas Medication Algorithm Project Procedural Manual, 2008

  17. Clozapine Augmentation Antipsychotic (typical & atypical) [Mouaffak F, Tranulis C et al. Clin Neuropharmacol ,2006. Travis M.J, Burns .t et all 2005.] ECT Mood stabilizers : Lamotrigine [Tiihonen j.4 february 2010] Topiramate(also good to induce weight loss)[Tiihonen J, Halonen P et al. J Clin Psychiatry 2005.] Omega 3 [Peet M. Schizophr Res 1998. Puri BK, Richardson AJ. Arch Gen Pschiatry, 1998]

  18. Schizophrenia Algorithm Texas Medication Algorithm Project Procedural Manual, 2008

  19. Stop Clozapine Start Antipsychotic not used in first stages Adjunctive Therapy: Lithium, Anticonvulsants,Antidepressants, Beta blockers,Glycine & D cycloserineGalantamine. N- acetylcysteine, • S Adenozil methionine • rTMS

  20. Take Home Message

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