CPT: Schizophrenia Flashcards
What is diagnosis of schizophernia?
Must have 2 or more of:
- Hallucinations
- Delusions
- disordered speach
- Negative symptoms
- Grossly disorganised or catationic behavioue
Must be continuous for 1 to 6 months
What are positive and negative symptoms?
Positive: exaxerbation of normal behaviour
- Hallucinations
- Delusions
- Disorganised thoughts and nonsenscial speach
- bizzare behaviour
Negative: Abscence of behaviour
- Flat affect (no emotion on face)
- Reduced social interaction
- Anhedonia (no feeling of enjoyment)
- Alogia (speaking less)
- Catatonia (moving less)
- Avolition (less motivation, focus, initiation)
When does this disorder normally occur?
Earlier in life
What are risk factors for the disorder?
- Genetic
- Enviomental:
- Cannabis use
- stress or traumatic life experiences
- Urban living
- Migration
- complications before or after birth
- older parental age at birth
- Exposure to the protozoan parasite toxoplasma gondi virus
How does this disorder effect lifespan?
It is assoicaited with premature death (suicide/ physical disorder)
- CVS disease - persistnad stress, genetic risk, lifestyle (poor diet, lack of exercise, smoking) and antipsychotic drugs
- Diabetes type 2 - lifestyle (lack of exercise, poor diet) and antipyschotics
- COPD - people with S disorder more likely to smoke and not go to smoking sensation advice therefore more likely to get illness relating to smoking such as COPD and therefore premature death
- Infections - Hepatitis C, tuberculosis, HIV
- Cancer - Increased risk of early death by late diagnosis and under treatment
What are social managements for this disorder?
- Psychotherapy/ councelling: patiennts/ family/ carers
- Community care: hostels, half way houses
- Rehabilitation: Above plus social workers, restraints, avoid instituioalisation
Management for acute schiziophrenia
- Nurse care
- Rapid tranquilizers in severe behaviour
- diturbances: lorazepam (Haloperidol or chloropromazine)
- Nice guidence on risk of self-harm
- famiy support
- compulsory admission ‘sectioned’ - if necessary
Chronic management
- Rehabilitation planning
- Family councelling
- Peophylatic medince
What is the prognosis?
Most people treated for acute schizophrenia make a full recovery
- 20% fully recover
- 70% improve but ocassionally still have relapses/episodes. May be due to stress, social isolation or poor compliance with treatment
- Relapses may occur due to sudden discontinuation of medicine
- Delayed treatmetn associated with slower or less complete recovery and increase risk of relapse and poorer outcome in subsequent years
Factors associated with poor prognosis
- Male
- Continued substance misue
- Family history with the disease
- low social class/ intellegance or social isolation
- A longer duration of untreated psychosis
- Early onset of disease
- negative symptoms
- Significant psychiatric history
What neurochemical causes lead to this disease?
- Dopamenergic over activity
- 5-HT over actvity
- adrenergic over activity
- GABA under activity
- Glutamate under activity
What drugs are given for treatment? What do they do?
Antipyschotics: neuroleptics
Control and/ or modulate positive symptoms as opposed to negative
What classes of neuroleptics is there?
- typical
- classical
- newer non-classical and atypical
What is the mechanism of action of antipyschotics
Dopamine antagonists
non-selective so also bind to 5-HT, adrenergic and histamine receptors
What can be said about atypical side effects
Have less extra-pyramidal side effects
What subclasses of Dopamine receptors are there?
What do they modulate?
5 cloned receptors D1-5 7TM GPC- linked to regulation of AC
- D1 like (D1,5) - post synaptic inhibtion. AC stimulation
- D2 like (D2,3,4) - pre and post synaptic inhibition. /AC inhibition
Where are dopamine receptors distributed and what do they control?
- Nigro-striatal pw: control of movement
- Mesolimbic-cortical pw: higher cortical functions
- Mesolimbic tract: locomotor activity, aourosal, affect, motivation
- tuberoinfundibular pw: pituitary and hypothalamic secretions
- Other: medulla (vagus) and hypothalamus (eating)
What are typical/ classic/ conventional antipyschotics?
- Group 1: chlorpromazine e.g. chlorpromazine and promazine
Side effects: anti adrenergic, anti histaminergic (sedation), moderate EPSP and moderate anti muscularnic
- Group 2 - thioridazine e.g pericyazine and pipotriazine
Side effects: less EPSE and Anti muscularinic
- Group 3 - trifluoperazine e.g. trifluoperazie, fluphenazine, pimozide
Side effects: EPSP (dose dependent)
Benefits and negatives of atypical antipyschotics
- Less EPSE and less likely to raise serum prolactin
- Significant weight gain clozapine, olanzapine
What side effects related to motor control are associated with antipychotics?
How can this be treated?
EPSE:
- Parkinsons symptoms seen within first 3 months as blocking dopamine receptors
- Rigidity and tremor
- Antimuscularinic or change anti-pyschotic
What drugs have less EPSP and why?
Clozapine and trioidazine
have strong antimuscularnic effects
Tardive dyskinesia is an adverse effect. What is this and how do you treat it>
Involuntary repetitive movements
Difficult to treat and almost irreversible. Change AP e.g. clozapine. Use diazepam (v short)
Akathisia is an adverse effect. What is this?
Need to be constantly in motion (restlessness). Accompanied by feeling of anxiety
Acute dystonia is an adverse effect. What is this?
substained muscle contraction
grimacing,neck twisting, facial distortion
Hyperprolactinaemia is an adverse effect. What is this?
Excess secretion of prolactin.
BReast enlargment, milk secretion, absence of menstuation
Anti histamine activity is an adverse effect. What would this lead to?
sedation
Anticholinergic effects are an adverse effect. What does this include?
dry mouth, constipation, blurred vision, prolongation of Q-T interval, weight gain (Nicotinic receptor)
Adrenergic adverse effects occur. What are these?
hypotension, failure to ejaculate, weight gain associated with atypical
Neuroleptic maligant sydrome can occur. What is this?
Muscle rigidity, body temp increase, autonomic dysfunction, confusion
Comma, death
When attempting to alter dose how should this be done?
- Increase dose slowlt and not more than once a week
Risks and monitoring
risks - obesity
ECG used to detect prolonged QT interval. ECG should be repeatedly periodically and dose reduced in QT increases.
Regular blood pressure, temperature checks and pulse checks
What drug should be chosen for a patient?
most appropriate drug and formulation used over group.
It is not essential to swap patient over to atypical drug if there drug is responsive and side effects acceptable.
Where symptoms are not controlled by 2 drugs (one of which should be an atypical) clozapine should be introduced as soon as possible
Why would an injection be used? how is it used?
INto large muscle (every 1 to 4 weeks)
If memory loss, poor compliance or failure to respond
