Complex cases

Question 1

7 ‘A’s of negative symptoms

Answer 1

1. Avolition: The lack of motivation or ability to do tasks or activities that have an end goal, such as paying bills
2. Apathy: lack of interest, enthusiasm, or concern
3. Alogia: poverty of speech
4. Anhedonia: inability to feel pleasure
5. Asociality: not social
6. Affective blunting: difficulty in expressing their emotions
7. Attentional impairment

Question 2

What is the difference between primary and secondary negative symptoms?

Answer 2

Primary:
Often occur prior to onset of positive symptoms
Respond poorly to antipsychotics

Secondary:
Caused by positive symptoms, depression, EPS, sedation.
Treat the primary cause

Question 3

Issues caused by persistent negative symptoms

Answer 3

Persistent negative symptoms are held to account for much of the long-term morbidity and poor functional outcome of patients with schizophrenia

Reduction in QoL, employment status, martial status, worsened overall symptom burden and treatment resistance

Question 4

Possible treatments for negative symptoms

Answer 4

Antipsychotics
Antidepressants
Alpha-adrenoceptor antagonists
Glutamatergic drugs
Minocycline
Gingko Bilboa

Question 5

What are the recommendations of treatment for negative symptoms?

Answer 5

1. Do not delay antipsychotics treatment
2. Avoid medication which causes sedation and extrapyramidal side effects
3. With persistent neg symptoms offer SGAs, Antidepressants and monitor EPSs
4. Treat depression when comorbid

Question 6

What is the believed cause of EPSs?

Answer 6

Due to the antagonistic binding of dopaminergic D2 receptors within the mesolimbic and mesocortical pathways of the brain.

However, the antidopaminergic action in the caudate nucleus and other basal ganglia may also contribute significantly

Question 7

Facts about EPSs

Answer 7

1. They can occur in 10-15% never-medicated patients
2. More common in FGA
3. Can be : Parkinsonism, Akathisia, Tardive Dyskinesia, Dystonia

Question 8

What is Akathisia?

Answer 8

Subjective feeling of motor restlessness, predominantly affecting lower limbs
Shuffling/stamping feet when seated
‘Hopping’ from foot to foot
Pacing
May be mistaken for agitation

Treatment:
Reduce dose of antipsychotic, switch to 2nd generation
Propranolol 30-80mg
Benzodiazepines

Question 9

What is Parkinsonism?

Answer 9

Tremor (classic pill-rolling tremor)
Cogwheel rigidity
Reduced facial expression

Treatment:
reduce dose, switch to 2nd gen
anticholinergics e.g. procyclidine, orphenadrine

Question 10

What is Dystonia?

Answer 10

Involuntary muscle spasm
Subtypes
Oculogyric crisis (eyes roll upwards)
Torticollis (neck twisted to one side)
Acute (within minutes) or tardive (months/years)

Treatment:
Anticholinergic drugs e.g. procyclidine
Botulinum toxin

Question 11

What is Tardive Dyskinesia?

Answer 11

Choreo-athetoid movements in arms and trunk (writhing, piano-playing)
Lip smacking
Tongue protrusion

Treatment
Switch to 2nd gen (may see transient exacerbation)
Stop anticholinergic
Switch to 2nd gen, ideally clozapine
Numerous treatments suggested but generally difficult to treat

Question 12

What are 2 mechanisms of hypertension?

Answer 12

1. Gradual increase as a result of weight gain
2. Sudden increase via action on alpha-2 receptors

Question 13

What is hyperprolactinemia?

Answer 13

Prolactin is a hormone released from the pituitary gland
Dopamine blockade stimulates prolactin release

It can cause:
Sexual dysfunction
Reduced bone mineral density
Amenorrhoea
Gynaecomastia and galactorrhea

Treatment:
Annual prolactin concentration checks
If elevated and symptomatic consider switching drugs - aripiprazole or clozapine
Addition or aripiprazole or metformin may reduce prolactin level
If very high investigate for pituitary adenoma

Greatest concern in young people (below peak bone mass and theoretical increased risk of CA breast), old (osteoporosis)

Question 14

Antipsychotic induced weight gain

Answer 14

Appears to result from increased food intake
May be associated with response
Risk factor for cardiovascular morbidity and diabetes
Affects self-image
Olanzapine, Clozapine, Quetiapine, Chlorpromazine: high weight gain (drugs that start with ‘fat’ letters O,C,Q)
Asenapine, Aripiprazole, Lurasidone, Cariprazine: little or no weight gain

Diabetes is linked with Schizo even in drug-naïve BUT APs increase that risk

Question 15

Diabetes monitoring and treatment

Answer 15

Monitor using glycosylated haemoglobin (HbA1c) or urine glucose
every 3-6 months for clozapine and olanzapine
Oral glucose tolerance test if abnormal
Treatment: switch drug, oral hypoglycaemics, insulin, metformin

Question 16

Pregnancy

Answer 16

High risk of relapse during and 20-fold increase in postpartum period (post-partum psychosis)

Generally poor data as RCTs unethical

Effects of a psychotic relapse may have devastating consequences including neglect and even infanticide

Weigh up risk versus benefit - but often very difficult to quantify and weigh up risks in practice

Risk-benefit balance may change, e.g. risk will often outweigh benefits in first trimester, but benefits may outweigh risks in third trimester due to high risk of postpartum psychosis