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PR3153 > IC11 Schizophrenia & Psychosis > Flashcards

IC11 Schizophrenia & Psychosis Flashcards

1
Q

What is psychosis?

A

Psychosis is when a person is out of touch with reality

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2
Q

What is schizophrenia?

A

Schizophrenia is when a person experiences psychosis for prolonged periods of time (at least 6 months).

Schizophrenia is a more severe form of psychosis.

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3
Q

What are possible causes of psychosis?

A
  1. Iatrogenic causes - mistake made in treatment
  2. Alcohol & psychoactive substance misuse
  3. Mood disorders - mania, severe depression
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4
Q

What are the 2 main theories that can lead to schizophrenia?

A

It is the dysregulation of:
1. Dopaminergic (DA) functions
2. Serotonergic (5HT) functions

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5
Q

What are common risk factors that increases the chance of a patient developing schizophrenia?

A
  1. Genetics
  2. Neurodevelopmental effects
  3. Personality
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6
Q

What are possible risk factors that can cause a patient to develop schizophrenia?

A
  1. Tumour or injury
  2. Drug / substance-induced psychosis
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7
Q

What are risk factors that prolong schizophrenia in patients?

A
  1. Poor adherence to antipsychotic medication
  2. Lack of support
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8
Q

What are the criteria to diagnose a patient with schizophrenia?

A

A. 2 or more of the following persisting for 1 month:
- delusions
- hallucinations
- disorganized speech
- disorganized appearance OR catatonic behaviour
- negative symptoms

B. Social / occupational dysfunction

C. Continuous signs of disorder for at least 6 months (inclusive of criteria A)

D. Other possible conditions have been excluded

E. Disorder is NOT due to a medical disorder or substance use

F. If there is pervasive developmental disorder - there must be hallucinations or delusions present for at least 1 month

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9
Q

What should we assess for a patient suspected with schizophrenia?

A
  1. History of present illness
  2. Psychiatric hx
  3. Substance Use hx
  4. Medication hx
  5. Family, occupational hx
  6. Any injury or trauma
  7. Assess for suicidal tendencies***
  8. Lab tests
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10
Q

What are the goals of therapy in treating schizophrenia?

A
  1. Minimize threat to self & others
  2. Minimize acute symptoms
  3. Prevent relapse
  4. Promote medication adherence
  5. Optimise dose and manage ADR
  6. Improve QOL & function
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11
Q

What are non-pharmacological management treatments that we can use?

A
  1. Social support & counselling
  2. Individual Cognitive Behavioural Therapy (CBT)
  3. Electroconvulsive therapy (ECT)
  4. Psychosocial rehabilitation program

CBT can be considered if patient is in a listening state.

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12
Q

What is the main class of drug to use for schizophrenia?

A

Anti-psychotics

Antipsychotics help to relieve symptoms of psychosis & prevent relapse.

Long-term treatment is often necessary

Antipsychotics can be used to treat mania.
Antipsychotics can also be used together with Antidepressants for pt w Major Depression.

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13
Q

How can we overcome the poor adherence to anti-psychotic medications?

A
  1. Use IM long-acting injections
  2. Educate pt & family
  3. Have community nurse provide regular home visits & administer the medication.
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14
Q

Recall what are the 4 dopamine pathways:

A
  1. Nigrostriatal pathway
  2. Mesolimbic pathway
  3. Mesocortical pathway
  4. Tuberoinfundibular pathway
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15
Q

What are the functions of the 4 dopamine pathways?

  1. Nigrostriatal pathway
  2. Mesolimbic pathway
  3. Mesocortical pathway
  4. Tuberoinfundibular pathway
A

Nigrostriatal pathway:
- Nigrostriatal pathway controls movement. Blocking the dopamine receptors in the nigrostriatal pathway will lead to extrapyramidal side effects (EPS)*

Mesolimbic pathway::
- Overactivity of dopamine receptors in this region leads to positive symptoms* of schizophrenia. Main MOA of anti-psychotics is to block dopamine receptor in the mesolimbic pathway

Mesocortical pathway:
- Dopamine blockade of the mesocortical pathway will lead to negative symptoms* in schizophrenia.

Tuberoinfundibular pathway:
- Dopamine blockade in this pathway leads to hyperprolactinemia*

Blockade of the nigrostriatal, mesocortical & tuberoinfundibular pathway will lead to ADR.

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16
Q

Based on your knowledge of the 4 pathways, what are the effects of using dopamine antagonist?
(Name both good and bad effects)

A

Good effect:
- Helps to reduce positive symptoms

Bad effects:
- Extrapyramidal side effects
- Hyperprolactinemia

17
Q

Based on research, dopamine antagonists are effective as antipsychotics if they block _____% of dopamine receptors.

(A) 50%
(B) 60%
(C) 70%
(D) 80%

A

Ans: 60%

If inhibition of dopamine receptors exceed 60%, there will be hyperprolactinemia and EPS.

18
Q

Can you list out the guideline to treat and manage schizophrenia?

A

Upon diagnosis of schizophrenia,

      1. Use a single* FGA or SGA (avoid clozapine)

      2. If it doesn't work, use another single* FGA & SGA (avoid clozapine)

      3. If it doesn't work, use clozapine*

      4. If clozapine doesn't work, use combination therapy
                - FGA + FGA
                - FGA + SGA

If any of the treatment is sufficient w tolerable side effects, we can continue using the same treatment without escalating.

19
Q

What are the rules to follow in the treatment guideline of schizophrenia?

      1. Use a single* FGA or SGA (avoid clozapine)

      2. If it doesn't work, use another single* FGA & SGA (avoid clozapine)

      3. If it doesn't work, use clozapine*

      4. If clozapine doesn't work, use combination therapy
                - FGA + FGA
                - FGA + SGA

If any of the treatment is sufficient w tolerable side effects, we can continue using the same treatment without escalating.

A

These are the rules to follow when using the treatment guideline:

  1. Medication selection is individualized
  2. Pt to be on a medication for at least 2-6 weeks at therapeutic doses, before we consider it as ineffective***
  3. Help patients to manage side effects. If intolerable, switch to another agent
  4. Consider long acting injectable anti-psychotics to improve compliance
  5. ***Only consider clozapine in treatment resistant pt that have failed ≥2 types of antipsychotics. Monitor pt on clozapine closely and regularly.
20
Q

What is the most significant ADR of clozapine?

A

Agranulocytosis

21
Q

What are adjunctive medications that we can use in:
(1) Cooperative patient
(2) Uncooperative patient

A

(1) Cooperative pt:
- Oral lorazepam
- Oral risperidone

(2) Uncooperative pt:
- IM lorazepam
- IM olanzapine
- IM haloperidol

22
Q

What are the 3 common characteristics of oral antipsychotics?

A
  1. 1-3 hours to reach peak concentration
    - Most oral antipsychotics take 1-3hrs to reach peak concentration
  2. Long half-life
    - Most oral anti-psychotics have long half-life
  3. Drowsiness
    - Most antipsychotics have drowsiness effect. Advice patient to take the medication at night.
23
Q

List out first generation antipsychotics (FGA) and second generation antipsychotics (SGA).

A

FGA:
1. Haloperidol
- Haloperidol often comes as haloperidol decanoate, where the phenol group of the compound is esterified

SGA:
1. Clozapine
2. Quetiapine
3. Risperidone

24
Q

What is the difference in terms of side effects between FGA & SGA?

A

In general, FGA have more SE than SGA.

  1. FGA has more EPS than SGA***.
  2. FGA has more severe hyperprolactinemia SE than SGA
  3. The FGA that we learn in this IC do not cause weight gain, whereas SGA medication - clozapine and olanzapine can lead to severe weight gain

All SE are dose dependent!

25
Q

How to manage these side effects:

  1. Dystonia (involuntary muscle contraction) - EPS
  2. Pseudo-parkinsonism - EPS
  3. Akathisia (inability to remain still) - EPS
  4. Tardive dyskinesia (involuntary movements of the tongue, lips, face, trunk, and extremities ) - EPS
  5. Hyperprolactinemia
  6. Metabolic
  7. CNS - neuroleptic malignant syndrome (NMS)
    • NMS is life-threatening and associated w muscle rigidity, fever, autonomic dysfunction, altered consciousness, ↑CK
  8. Haematological - ↓WBC, agranulocytosis, ↓absolute neutrophil count
A

[Those w * are ones I should prioritise memorising]

  1. Dystonia (involuntary muscle contraction) - EPS
    - *Use IM anticholinergics
  2. Pseudo-parkinsonism - EPS
    - ↓ antipsychotic dose OR switch to SGA
    - *Use anticholinergics PRN
  3. Akathisia (inability to remain still) - EPS
    - ↓ antipsychotic dose OR switch to SGA
    - *Clonazepam PRN
  4. Tardive dyskinesia (involuntary movements of the tongue, lips, face, trunk, and extremities ) - EPS
    - *Discontinue any anticholinergics
    - *Use valbenazine
    - ↓ antipsychotic dose OR switch to SGA
    - Clonazepam PRN
  5. Hyperprolactinemia
    - Switch to apriprazole - a SGA
  6. Metabolic
    - *Treat diabetes & hyperlipidemia
    - *Switch to lower risk agents
    - Modify lifestyle
  7. CNS - neuroleptic malignant syndrome (NMS)
    • NMS is life-threatening and associated w muscle rigidity, fever, autonomic dysfunction, altered consciousness, ↑CK
      - Use IV dantrolene
      - Switch to 2nd SGA
  8. Haematological - ↓WBC, agranulocytosis, ↓absolute neutrophil count
    - Discontinue antipsychotic if severe
26
Q

What can we use to monitor SE of antipsychotics use?

(Think of the ADRs and what we can use to monitor them)

A
  1. EPS exam
  2. BMI - to measure weight gain
  3. Fasting blood sugar - to monitor DM
  4. Lipid panel
  5. WBC & absolute neutrophil count (ANC)
27
Q

What are drugs that may interact with antipsychotics?

A
  1. Drugs with CNS depressant effects - e.g benzodiazepines, alcohol, opioids
  2. Drugs that inhibits M1, H1, a1-adrenoceptors
  3. Dopamine augmenting agents - e.g levodopa
  4. Anti-hypertensives - can worsen hypotensive effects
  5. CYP1A2 inhibitors - fluvoxamine, quinolones, macrolides
  6. Carbamazepine - avoid use w clozapine, can worsen agranulocytosis
28
Q

What are the improvements that we can observe in a patient initiated on antipsychotics after:

(1) 1 week
(2) 2-4 weeks
(3) 6-12 weeks

A

After 1 week of taking anti-psychotics:
- ↓ agitation, aggression

After 2-4 weeks of taking anti-psychotics:
- ↓ paranoia, hallucinations

After 6-12 weeks of taking antipsychotics:
- ↓ delusions, improvement in -ve symptoms

PR3153 (18 decks)

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