General Adult Psychiatry Flashcards
Prognostic factors in schizophrenia
Poor
Early age onset
Negative symptoms
Insidious onset
No precipitating factors
Single, divorced, widowed
Family history (weak)
Poor social network, family highly expressed emotion
Poor compliance
Neurological signs and symptoms
Hx of perinatal trauma; anoxia, low birth weight, pregnancy induced hypertension, premature rupture of membrane
Many relapses
History of violence
No remission in 3 years
Prognostic factors in schizophrenia
Good
Late onset
Obvious precipitating factors
Acute onset
Good premorbid adjustment
Affective symptoms (esp depression)
Married
Good social support
FH of affective disorders
Positive symptoms only
Good initial response to treatment
Median episode of treated depression
3 months
Median episode of untreated depression
6-13 months
Types of Bilpoar Affective Disorder
1 - Mania (+-/ depression)
2 - Hypomania and depression
3 - recurrent depression plus hypomania occurring solely in association with AD or other somatotherapy
4. Depression superimposed on a hyperthymic tempermant
Acute manic episode treatment - new
- Antipsychotics - olanazapine, quetiapine, haloperidol, risperidone
- rapid anti-manic effect. - If on anti-depressant therapy, consider
stopping. - Adjunctive benzodiazepine e.g. clonazpeam
Not advised as monotherapy
Acute manic relapse in known BPAD
- Increase the dose of mood stabiliser
- Check the serum lithium levels
- optimised Li levels
- consider adding in an antipsychotic
- Antipsychotic medication for those on
valproate - ECT - treatment resistant, severely manic, in
pregnancy
Bipolar depression - no medication
1st line - high intensity psychological therapy for
all
Moderate/severe
1st line - can consider olanzapine and
fluoxetine; quetiapine as monotherapy
(300-600 mg)
2nd line - lamotrigine
Long term lithium indications
- Manic episode involved significant risk or
adverse consequences - Bipolar 1 with 2 or more acute episodes
- Biploar 2 with significant functional
impairment or risk of adversities
1st line Lithium (anti- manic and depressive effect, probably more anti-manic)
2nd line: olanzapine, valproate, carbamazapine, lamotrigine
Those who respond well to lithium
- euphoric mania
- no rapid cycling
- full remission between episodes
- no co-morbidity
- no psychosis
- fewer lifetime episodes
- mania-depression-euthymia course
Median time to recover from a manic episode
4-5 weeks
Antidepressant most likely to precipitate mood switch from depression to mania
Tricyclics
1st line primary care antidepressants
Mirtazpine and paroxetine
Acute stress reaction
Follows a sudden severe stressor and symptoms resolve in 2-3 days. Rapid onset.
Dyssomnia
Primary sleep disorder affecting getting off to sleep, remaining asleep of excessive sleepiness during the day.
Primary insomnia
Primary hypersonic
Circadian sleep disorder
Narcolepsy
Breathing related sleep disorder
Sleep state misinterpretation
Parasomnia
A disorder which intrudes the sleep process
Arousal disorder - confusion arousal, sleep walking, sleep terrors
Sleep wake transition (sleep starts, sleep talking)
Rem sleep - REM behavioural disorder, nightmare, sleep paralysis
Non-REM - sleep terror, sleep walking
Schizotypal PS
Cold affect
Eccentric behaviour
Social withdrawal
Odd beliefs, magical thinking
Paranoid ideas
Obsessive ruminations without inner resistance
Illusions, dépersonnalisation, derealisation
Vague and circumstantial speech
Transient quasi-psychotic episodes
3/4 typical features in 2 years; never met criteria for schizophrenia
DIGFAST - bipolar criteria
D - distractibility
I - impulsivity
G - grandiose
F - Flight of ideas
A - goal-directed activity increased, psychomotor
agitation
S - sleep - decreased need for sleep
T - talkative
First episode psychosis
- 4/5 people show some response to treatment
in the first year - 1/5 have no further psychotic episodes in next
5 years - 15% symptoms which are unresponsive 2 years
after the acute episode
Schizophrenia prognosis explained
In 5 people with schizophrenia:
1/5 will get better within 5 years
3/5 relapse and remitting
1/5 difficult symptoms for a long period of time
Acute and transient psychotic disorders
Onset 2 weeks = acute
Onset 48 hours = abrupt
Complete recovery in 2-3 months
Acute polymorphic form = hallucinations and delusions changing in type and intensity from day to day, or same day
Schizoaffective
DSM V-
distinct period of just psychotic symptoms > 2 weeks
Features of schizophrenia and mood disorder in equal intensity
Meets criteria of moderate-severe mood disorder
Depressive, bipolar
ICD 10:
Definife schizophrenic and mood symptoms, equally prominent and simultaneously, or within a few days of each other
-depressive, manic, mixed
Mood-incongruent delusions are suggestive
Depression episode length
Most short, minority chronic (>2 years)
-10-20% chronic course, without remission
Untreated depression: 6-13 months
Treated depression: 3 months
Depression recurrence
Recurrence typical of mood disorders
20 episodes over 5-6 years
50% of people who have an episode of depression will then have a recurrence within 5 years.
75% probability of recurrence after 2 years
Risk of relapse or recurrence is higher in people with residual symptoms
Treatment length of depression first episode
6-9 months after resolution of symptoms
Treatment length for patients >2 episodes in recent past, or residual impairment
Continue for 2 years
Medication discontinuation FEP
74% of patients discontinued antipsychotic medication before 18 months in CATIE
82% Quetiapine
79% ziprasidone
75% perphenazine
74% risperidone
64% olanzapine
Late-onset schizophrenia
Develops over 40 yo
Insidious in presentation
Auditory hallucinations most common
In 20% only delusions are seen
BPAD and breast feeding
Should avoid carbamazepine, clozapine and lithium
Antipsychotics, avoid depot preparations, except when hx of non-compliance or responded well in past
Does not advise against lamotrigine, advises frequent levels
Treatment acute mania with antipsychotic
6 months
Treatment acute mania with antipsychotic
6 months
Schneider’s first rank symptoms
Delusional perception
3rd person, running commentary
Thought insertion, withdrawal, broadcast
Somatic hallucinations
Made affect, impulse or volition
Cognitive aspects of schizophrenia
All domains, disproportionate involvement of semantic memory, working memory and attention.
Executive function and attention appear to be core deficits.
Marked impairment in theory of mind.
Environmental risk factors and relative risk
Life events 3.2
Immigrant 2.9
Childhood trauma/adversity 2.8
Tobacco 2.2
Cannabis 2
Maternal/birth complications 2
Urban birth 1.9
Winter birth 1.1
Brain changes and imaging in schizophrenia
Decreased brain and intracranial volume
Enlarged lateral and third ventricles
Reduced hippocampus and thalamus
Thinner cortical grey matter
Altered white matter pathway (temporal and frontal lobe)
Decreased perfusion in frontal cortex vs posterior
Bold signal on fMRI - decreased frontal cortex activity
Antipsychotics best to use in hepatic impairment
Haloperidol
Amisulpride/sulpride (avoid in renal impairment)
Antidepressant in hepatic impairment
Imipramine; 25 mg & slow titrate
Paroxetine, citalopram. (Avoid sertraline)
Antipsychotics safest in renal impairment
Haloperidol 2-6 mg OD
Olanzapine 5 mg OD
Contraindicated; clozapine, amisulpride, sulpride
Stopping antidepressants
Mean time to onset; 2 days and normal resolution 5-8 days.
Most short and self-limiting, however for some they can last longer.
Serotonergic symptoms; flu-like, pins and needles, electric shock, dizzy, GI, lethargy, headache, sleep disturbance, mood change
MAOI; worsening anxiety/depression, confusion, psychosis
Highest risk of relapse after stopping antidepressants
1st 6 months
Consider life events
Tapering antidepressant
Minimum over 4 weeks
Can be several months if longer term prophylaxis
Psychotic depression
No known optimum duration of treatment with combination of AD and AP. Some evidence suggests continue both, no consensus.
Some evidence stopping antipsychotic can worsen the outcome.
