Case 8 - Clinical Handout

Question 1

what is the criteria for schizophrenia

Answer 1

2 of:
- delusions
- hallucinations
- disorganised speech
- disorganised or catatonic behaviour
- negative symptoms

must include one of first 3 for most of the time for at least 1 month within an episode of illness lasting at least 6 months

Question 2

what is illness under six months classed as

Answer 2

schizophreniform disorder

Question 3

what is ICD10 and what is it based on

Answer 3

based on ‘core symptoms’ of;
- persistent delusions
- persistent hallucinations
- thought disorder
- experiences of influence, passivity or control
so must have persisted for a month or more to make the diagnosis without being caused by something else

Question 4

what passivity/influence experiences

Answer 4

impulses
sensations
intentions
emotions
thoughts

influenced directly by some kind of external agent

Question 5

what are control experiences

Answer 5

delusions that a particular agent is the cause

N.B thought alienation would be included somewhere under persistent bizarre delusions, passivity or control experiences but are not properly specified

Question 6

when is risk higher for schizophrenia

Answer 6

2nd generation ethnic minorities
commonest age of onset is 20
females outnumber males over age of 40

Question 7

what is genetic risk in 1st degree

Answer 7

7%

Question 8

what is risk in second degree

Answer 8

2-3%

Question 9

what’s risk for dizygotic co twins

Answer 9

10%

Question 10

what is risk for monozygotic twins

Answer 10

455

Question 11

what are the 3 groups of genes that affect risk of schizophrenia

Answer 11

• connected to glutamate, dopamine or GABA neurotransmitter function
• to neurone structure, plasticity or general synaptic function
• to inflammatory or immune response

Question 12

environmental factors

Answer 12

child sexual abuse or being taken into carte
cannabis misuse
being 2nd generation of UK ethnic minority
migration
peri-natal oxygen deprivation, maternal starvation
urban living, parental separation

Question 13

what is schziophrenia often precessed by

Answer 13

subtle social and cognitive impairment, even from infancy, so people with Sz often present with disability already present

Question 14

how does Sz symptoms progress

Answer 14

over years from negative symptoms to vague symptoms of depression, anxiety, insomnia, to vague but psychotic symptoms, then full psychosis

substance misuse increases risk of persistent psychotic symptoms

Question 15

what happens when the dose of treatment is too high

Answer 15

Parkinsonism

Question 16

what are the other adverse effects of treatment

Answer 16

akathisia - restless and constant movement, legs
tardiye dyskinesia - gradual developmental of abnormal movements, often chewing, often months or years after onset
hyperprolactinamyia at high doses causes sexual side effects and affects periods in women
neuroplectic malignant syndrome - rapid onset of coma, high temp, rigidity and death. often follows initiation or rapid increase in dose

Question 17

what is the treatment effect

Answer 17

begins to work as soon as dose is high enough, enough D2 receptors are blocked in the brain. symptoms start to reduce a little from day 1, more and more each day. mostly after two weeks some improvement is clear

Question 18

what is clozapine

Answer 18

used if two antipsychotics fail or can’t be tolerated at full doe

substantial symptoms reduction in 30-50% and maybe 75% after first episode.

appears to enable people to engage in rehab ability

Question 19

what are the side effects of clozapine

Answer 19

sedation, hunger and hyper salivation are the main side effects

Question 20

what happens if someone response poorly to clozapine

Answer 20

then a second anti psychotic is added - clozapine binds best to D4 so a clean D2/3 antagonist like sulpiride or amisulrpide ‘fills’ in the gap and 50% respond

Question 21

what does the early intervention services aim to do

Answer 21

intervene in a. non-stigmatising way as soon as possible after first episode, to minimise delay in first treatment and then concentrate on return to training and work; and reconstructing family relationships and social networks cover first 3 years of treatment 14-065yrs old

Question 22

after EIS service, where do patients go next

Answer 22

thereafter generally under community mental health teams with periods under home based treatment teams for home treatment of acute exacerbations

Question 23

what does individualised placement support do

Answer 23

helps chronic sufferers return to work

Question 24

who will have the worst prognosis

Answer 24

men and the young more likely to present with negative and disorganised symptoms, which predict poor outcome

Question 25

what is life expectancy of someone with Sz

Answer 25

60 years. 15-25 year reduction due to physical ill heath, limited effect of suicide. high rates of obesity, high cholesterol, substance misuse and inactivity

Question 26

what is section 2 of MHA

Answer 26

allows 2 doctors and an approved mental health professional to detain someone in hospital for 28 days for assessment if they believe they might have a mental illness of sufficient nature and degree and are not at risk of harming themselves or others.

Question 27

what is section 3 of MHA

Answer 27

allows the same progressional to detain someone in hospital for 6 months for treatment if they definitely have a specific mental illness that causes a risk to others or their own health and safety and there is appropriate treatment available

Question 28

what is a community treatment order

Answer 28

allows someone to be discharged from section 3 to be readmitted if they don’t obey specific conditions - adherence to mediation