Question:
Also I would like to know if brain scans (MRI, PET...) have any benefit in improving the diagnosis of a schizophrenic person. I'm not sure how we could persuade her to do the scans there (no PET in Indonesia, some MRI) but we would try our best if they are useful. My strategy is to present as much "objective" evidence as possible to her so that she would be willing to take her medicine. Not sure if this would work but it seems to be the best strategy now for her?
Answer:
I have a sister in Indonesia who was diagnosed with paranoid
schizophrenia a few years ago. She is still struggling with it now.
Her biggest problem is her unwillingness to take any medication. She
used to completely deny the fact that she is sick but after several
hospitalizations she seems now to silently realize that something is
wrong with her, although she still refuses to take any medicine.
Perhaps one of the unconscious (?) reason for her refusal is the side
effects that her medicine had given her. I don't know what drugs she
had been given in the past but currently here is her prescription:
trihexylpenydil, rizodal, perpenazine
I am posting this because except for perpenazine I couldn't google the
first two drugs. Google returned 0 result. Could anyone inform me what
are the US names (?) of these drugs (trihexylpenydil and rizodal) or
what would be the best way to search for information about them (and
perpenazine too)? Also are these drugs still "current" in US for
treatment of paranoid schizophrenia?
My best guess is that: perpenazine = perphenazine = Trilafon
rizodal = risperidone = Risperdal
trihexylpenydil = trihexylphenadyl = Artane
Trilafon is considered pretty old-fashioned in the US. It tends to
be sedating and to cause tremor (which is probably why she is also
taking the Artane, which is used to control tremor). Risperdal is a
much more current medication, if that is indeed what "rizodal" is. MRI and CT scans are not thought to be of significant utility in
diagnosing schizophrenia, except to rule out other possible causes
such as brain tumors, obstructive or normal pressure hydrocephalus,
etc. EEGs may also be done to rule out seizures. PET scans are
rarely done outside of research studies, but there is at least some
indication from research that there are some changes compared to a
"normal" brain. Other tests that are sometimes used include thyroid
function tests, liver function tests, electrolytes, tests for various
toxins and metals, etc. The diagnosis of schizophrenia is done mainly on symptomatic
grounds. The onset of symptoms, progression of the disturbances in
functioning, etc are all crucial to a good diagnosis- on some ways,
more important than the clinical prsentation of paranoia, delusions,
hallucinations.
The front line treatment are antipsychotic medications, most often
used singly but sometimes- as in possibly your sister's case,
combiantions of antipsychotics may be used. There are thought to be
multiple chemical systems involved and as a result people might be
treated with one or more antipsychotic as well as antianxiety and
antidepressant meds, and sometimes "mood stabilizers" such as
lithium, gabapentin, valproic acid, etc.
Also, you would want to rule out bipolar disorder and depression. Either
can have psychotic symptoms under some conditions (or in some forms, that is
to say.) One way of ruling them out is to determine if the medications
don't work. A modern treatment for bipolar disorder is a combination of an
anticonvulsant and an antidepressant, sometimes plus an atypical
antipsychotic. Seroquel gets good results in the greatest percentage of
cases. Do a google search on atypical antipsychotics. The atypicals are much
better than the older medications (called typicals) in that they have fewer
side effects, and treat negative symptoms in addition to the positive
symptoms. These days, the typical antipsychotics are given only because
they are cheaper.
I have only met her briefly recently when I returned to Indonesia.
What I notice is how confrontational she was, especially to people who
had had any hand in putting her to the hospital several times (and
that includes about everybody including my mother). She mostly locks
herself up in her room all day (well, we took away the key to the
door). But any little thing that other people do will start a hostile
barrage from her (why do you want to offer me food? why do you call
this or that person? why do you turn up the volume of that tv?). And
she does admit that she is hearing voices and perhaps hallucinates
(all she writes to me---her only sibling that she has a little trust
with, simply because I have never directly put her to the
hospital---is that she has "disturbances" that are beyond her
control). From what I heard her situation will dramatically improve if
she takes her medicine (and from what I heard the medicine does have
side effects like tremor). Any trick on how to persuade a paranoid schizophrenic to take her
medicine? She has used all kind of excuse not to take them, from some
objective ones like they will give her bad side effects to "strange"
ones like if God wants her to be what she is then it is ok with her
and it is all up to God to heal her (she always have a "thing" with
religion, and I don't know if it's the "faith" of her "normal" part or
if it's her schizophrenia talking, she had always been active in
church ever since she was a "normal" kid). If only she takes her
medicine then it seems the situation will get better. Otherwise her
symptoms will get worse and at some point in the future we will have
to take her back to the hospital, and she will hate us more for doing
it, and we will grow further and further apart... In the United States, if a person is a danger to themselves or others,
medication can be forced on them. Otherwise, they are free to refuse
treatment. (In the 1950's and earlier, there were abuses do to rules of the
opposite sort. Well people were hospitalized because they were in conflict
with others, or because their relatives wanted their money.) If medication is forced on a person, generally by injection, one must take
care that it is not an overdose. A high dose will have side effects, the
patient will hate it, and will stop taking medication as soon as they are
free to do so. It is better to titrate up from a lower dose, until one
finds the least dosage that is effective.
It is tempting for a public hospital to do just the opposite, to quickly
calm the patient and make their own work easier.
If there are actually side effects, sometimes changing or reducing the
medication can help that. If she ever gets the correct medicaton, in the correct dose, and it actually
works, she may be able to see that the medication is not her enemy, nor is
the hospital. However, with the mentally ill, it is common for them to go
off of medication again and again, for unexplainable reasons. Probably understandable if you think about it. Being forced into a
hospital against your will often means being forced away from that which
is comfortable, familiar, known, safe, etc. And one is forced into an
evironment where (as much as we try otherwise) there is less autonomy
and sense of self than one would like. It's been my experience, yes, that most people with schizophrenia are
able to benefit from medication. The side effect concern is real too.
Tremor can be an embarrassment, it can also contribute to the sense that
one has no control over one's life--"if I can't control something as
simple as my movements....." For males, taking some of the older meds,
there are sexual side effects. I've had more than one person tell me
that they would put up with the hallucinations and delusions for the
ability to perform sexually. The newer antipsychitics have fewer side
effects because they target only specific components of dopamine
recepters (dopamine also regulates aspects of motor control so when you
use the "shotgun approach" and just target dopamine, you get motor side
effects). If it is risperdal she is taking, there should be fewer of
these side effects. I find it very difficult to work with someone with paranoid
schizophrenia. Their belief system is all too real to them and it's very
hard to get into it to find a way to weaken it. If she were my sister, I'd encourage her to talk to her doctor about
maybe trying one drug (preferably one of the newer ones) to treat her
symptoms. I notice the post I made didn't make it, (hope my email did),
but I'd still encourage the idea of an experiment. Identify some
behaviors that she and the family can agree on that can be objectively
observed and is she different on or off the medicine.
