8 - clinical management of schizophrenia Flashcards
link between Sz and substance misuse
substance misusers (except tobacco):
- have a greater chance of persistent low grade psychotic symptoms
- have a greater chance of later Sz
- earlier start and heavier use increases risk more
- become ill 2-5 years younger
- then have worse outcomes in every respect
what early signs are seen in young people in development who go on to develop Sz later in life?
- walk, talk, potty train later
- less attentive in school
- less likely to have a friend
- develop non-specific symptoms such as anxiety, depression, poor sleep, general disorganisation (start of an at risk mental state ARMS)
> have a gradual decrease in global function compared to peers
males vs females Sz <40yo
> 40yo?
males outnumber females 2:1 under 40
over 40 — very similar
what’s the most common age of Sz presentation?
20
there is a 2nd peak in common Sz presentation — when is it and who is it more common in?
- mid 40s-50s
- particularly women
is there a pattern in presentation of psychosis severity by age and sex?
no particular pattern
is there a pattern for negative symptom severity at presentation in terms of age and sex?
-ve symptoms worse the younger you are and if you’re male
is there a pattern for disorganisation severity at presentation in terms of age and sex?
disorganised thinking and odd behaviour less severe in older patients
is there a pattern for excitement symptom severity at presentation in terms of age and sex?
older = more hostile and agitated (younger more severe excitement)
the longer time ill without treatment……
the lower the response to initial treatment
suicide in Sz?
- almost 1% per year initially, eventually 4-6% but this is probably an underestimate (more around 8% in some studies)
- maybe half serious DSH occurs before 1st treatment
- more likely if substance misuse, recent suicidal ideation, feel hopeless, trapped and alienated, stop meds
40% of people who commit homocide do so when?
before 1st treatment
what is the mainstay of treatment?
antipsychotic drugs
how do all antipsychotic drugs work?
reversible D2 receptor antagonists
dose of antipsychotic drugs is predicted by what?
affinity for receptor
> _______% occupancy of D2 in ______ has an antipsychotic effect
> 60%
associative striatum
> _______% occupancy of other D2 causes what? where are these other D2 receptors?
- > 75%
- causes motor side effects and hyperprolactinaemia
- in motor striatum, hypothalamus, pituitary
what medication can be taken for agitation?
benzodiazepines (sedative, enhance GABA, reduce anxiety)
how can motor side effects of antipsychotic drugs be treated?
reduce dose or anticholinergics, propranolol (beta blocker and 5-HT1a partial agonist)
how is depression between Sz episodes treated?
antidepressants
there is less response to antipsychotic drugs for what type of symptoms?
-ve symptoms
clozapine showed a substantial symptom reduction in 30-50% of what type of Sz?
treatment resistant schizophrenia
what else does clozapine reduce and enable people to do?
- reduce impulsivity ; violence, self harm, drug use
- enables people to engage in rehab activity, improves QoL
however clozapine has lots of side effects
what fraction of people relapse after taking antipsychotics? how does this change if long-acting injectable medications are used?
- 1/4
- 1/6 with long-acting injectable meds
CBT for psychosis is not as good as antipsychotic for what?
preventing relapse
what form of therapy is good for relapse prevention?
family intervention
social support in Sz
- supported accommodation
- families
- groups — meaningful activity, support
- vocational interventions, employment
- education and training
what kind of symptoms are extremely disruptive and harder to treat?
-ve symptoms
who is most likely to relapse?
people who have less insight and are more severely ill
what is a bad predictor for adherance?
poor insight
insight and adherance
- 40% non-adherent with APS at any given time
- roughly 60% miss 1 week at some point
- increases relapse odds x5
- predicted by:
> don’t see a medication benefit
dont think will relapse
dont like medication and internal LoC (locus of control)
poor insight, poor relationship with prescribe
how is life expectancy altered in Sz and why?
- reduced by 15-25 years
- many have unhealthy lifestyles — drug misuse, inactive, weight gain, smoking (2/3 patients with Sz smoke)
- also suicide
up to ____% respond to treatment initially and ___% remit
about ___% relapse, most develop persistent symptoms
after 15-20 years ____% improve again
95% respond 60% remit
80% relapse
15-20% improve again
who is most likely to have negative side effects and a bad outcome?
male, young, poor premorbid function
antipsychotics are best combined with what?
psychosocial interventions
DSM 5 vs ICD 11 classification of schizophrenia
DSM 5 = american classification. 2 of:
- delusions, hallucinations, disorganised speech, disorganised or catatonic behaviour, negative symptoms
—> must include 1 of the first 3 most of the time for at least 1 month with an episode of illness lasting at least 6 months (under 6 months - schizophreniform disorder)
ICD 11 = based on “core symptoms” of:
- persistent delusions, persistent hallucinations, thought disorder, and experiences of influence, passivity or control
—> at least one symptom must have persisted for a month or more to make the diagnosis, without being caused by something else
what do passivity/influence experiences include?
impulses, sensations, intentions, emotions or thoughts influenced directly by some kind of external agent
____ in every 100,000 adults come to services with new Sz each year
10-20/100,000
what % of adults in the Uk habe Sz at any one point?
0.4%
the proportion of Sz is higher in who?
2nd generation ethnic minorities
what is the lifetime risk of Sz for the general population?
1%
male:female Sz overall?
1.4 : 1
(but females outnumber males over 40)
genes associated with an increased risk of Sz fall into what 3 categories?
- connected to Glu, DA or GABA neurotransmitter function
- to neurone structure (often at synapses), plasticity or general synaptic function (eg. some calcium channels)
- to inflammatory/immune response
what environmental events increase the risk of Sz?
- child sexual abuse, being taken into care
- cannabis or other substance misuse
- being 2nd generation of UK ethnic minority
- migration
- peri-natal O2 deprivation (ie. birth asphyxia), maternal starvation while in utero
- urban living, overcrowding, parental separation, general deprivation as a child
list the main Sz symptoms
- psychotic — delusions, hallucinations
- disorganised — incoherent speech, bizarre, unpredictable behaviour
- negative — apathetic, unsociable, enjoying little, speaking little, not looking after oneself but not depressed
- excitement and agitation
- depression sometimes
during psychosis too much _____ is made and released in a certain brain area called the _____
- dopamine
- dorsal striatum
adverse effects of antipsychotics due to effects on the DA system — CHAPART
C - constipation
H - hyperprolactinaemia (at high doses causes sexual side effects and affects periods in women)
A - anti-nausea effect
P - parkinsonism (when doses are too high)
A - akathisia
R - rarely, Neuroleptic Malignant Syndrome (NMS) (rapid onset of coma, high temp, rigidity and potentially death. often follows initiation or rapid increase in dose of potent antipsychotic like risperidone, haloperidol)
T - tardive dyskinesia
akathisia vs tardive dyskinesia
akathisia — inner restlessness and constant movement, usually involving the legs. know they’re moving
tardive dyskinesia — gradual development of abnormal movements, often chewing, tongue or arm/leg movements often months, years or decades after onset dont realise they’re moving
what are the cholinergic SE?
- urinary retention
- dry mouth
- blurred vision
- constipation
- tachycardia
when is clozapine used?
licensed for Treatment Resistant Schizophrenia (TRS) — if 2 antipsychotics fail or cant be tolerated at full dose
what are some of the many side effects of clozapine?
- sedation
- hunger
- hypersalivation
- diabetes
what is a rare SE of clozapine?
agranulocytosis — hence rigorous blood monitoring regime
clozapine cant be dispensed without what?
a clear FBC
what does clozapine bind best to? what is the clinical importance of this?
- binds best to D4
- therefore if respond poorly to CLZ, add a second APS, a clean D2/D3 antagonist like sulpiride/amisulpride to “fill in” the gap
men and the young are more likely to oresent with what symptoms?
negative and disorganisation
life expectancy in SZ?
around 60
section 5(2) vs section 5(4) of the Mental Health Act?
- section 5(2) — allows a consulatant or their “nominated deputy” to detain an inpatient for 72hrs until further assessed
- section 5(4) — allows a nurse to do this
section 2 of the MHA
allows 2 doctors (either, both specially trained in the MHA and mental health, or one psychiatrist and the patient’s GP) and an “approved Mental Health Professional” (usually social worker) to detain someone in hospital for 28 days for assessment (inc assessing response to a treatment) if they believe they might have a mental illness or “sufficient nature and degree” and are at risk of harming themselves or others
section 3 of MHA
allows same professionals as in section 2 to detain someone in hospital for 6 months for treatment if they definitely have a specific mental illness that causes a risk to others pr their own “health or safety” and there is appropriate treatment available
what is a Community Treatment Order?
allows someone discharged from section 3 to be readmitted if they don’t obey specific conditions (usually adherence to medication)
deterioration in working memory SE?
antagonism of DA receptors in the mesocortical pathway
sedation SE?
antagonism of H1 and alpha-adrenergic receptors
weight gain SE?
antagonism of histamine H1 and serotonin 5-HT2c receptors plus effects on leptin
