March 30 - Schizophrenia

Question 1

What is neurosis?

Answer 1

An odd or unusual characteristic

Question 2

What is psychosis?

Answer 2

A mental state or symptom where someone doesn’t need a psychiatry degree to know something’s wrong

Question 3

What is schizophrenia?

Answer 3

A diagnosis of a complex and usually chronic illness

Question 4

Describe the initial treatment of schizophrenia

Answer 4

The number one goal is to ensure safety (of the patient, and also the surrounding people if necessary).
Secondary goals include: reducing agitation, hostility, anxiety, tension and aggression, normalizing sleeping and eating patterns. Also convey empathy, caring

Question 5

What are the major goals of therapy of schizophrenia?

Answer 5

Prevent harm
Bring thoughts and behavior under patient’s control
Restore contact with reality
Maximize functional recovery
Prevent relapse
Eliminating hallucinations and delusions may not be realistic or possible

Question 6

Describe the pathophysiology of schizophrenia

Answer 6

A chronic, heterogenous, spectrum disorder, often severe and/or disabling
Characterized by imbalances in structure, neural transmission, neurotransmitters leading to disordered thoughts and behavior.
It is very challenging to treat (and diagnose)
Focus is upon functional status, short-term and long-term
It is not the same as “split or multiple personality” (note the difference between an odd characteristic, a disordered state, and a chronic condition)

Question 7

What is characteristic of a patient with schizophrenia?

Answer 7

Persons with schizophrenia are often fearful, withdrawn, isolated and have gross impairment of capacity for relationships

Question 8

Describe the etiology of schizophrenia

Answer 8

Genetic (approx 45% if both parents are positive, 5-10% if one parent is positive)
Biologic (relative dopamine imbalance)
Developmental (viral illness during second trimester)
Psychosocial (stress, socioeconomic status, etc.)
Pathophysiology (brain asymmetry, abnormal neuronal pruning)

Question 9

Describe the clinical course of schizophrenia

Answer 9

Suicide risk is highest in the first 5 years, may be 15% lifelong
Chronic disorder with multiple (from 1 to 30) exacerbations and “recovery”
Wide range of functional status
Symptoms may change over time

Question 10

What is required for diagnosis?

Answer 10

A deterioration of function
6 month duration of symptoms
Typically onset before 45 years old
Rule out: affective disorders, M.R., organic disorders, substances

Question 11

Describe the functional impairment with schizophrenia?

Answer 11

It is the cornerstone of diagnosis and assessment of schizophrenia
It is often related primarily to prolonged impact of negative and cognitive symptoms
Degree of impairment correlates with time and severity of poorly-controlled symptoms
The first five years after diagnosis is critical

Question 12

Can we cure schizophrenia?

Answer 12

No, not right now. We can take steps to try and improve the imbalance and what they are coping with

Question 13

How do we confirm the diagnosis?

Answer 13

Part of it is time (if someone presents in a really psychotic state, then 2 days later they are fine, it’s more likely substance abuse). We can also do scans to rule out an organic cause (tumor, something hormonal, etc.)

Question 14

How does blocking dopamine receptors affect the brain?

Answer 14

In the nigrostriatal area, it causes movement disorders
In the mesolimbic area, it causes psychosis relief
In the mesocortical area, it causes psychosis relief and restlessness
In the tuberoinfundibular area, it causes an increase in prolactin
In the frontotemporal area, it causes cognitive impairment

Question 15

Why is dopamine important?

Answer 15

It is the first target of antipsychotic drugs (first generation antipsychotics)

Question 16

What type of neurotransmitter is dopamine?

Answer 16

Dopamine is mostly an excitatory neurotransmitter. In someone having a psychotic outbreak of schizophrenia, the patient has too much dopamine

Question 17

What other neurotransmitter systems does dopamine “interface”?

Answer 17

Serotonin, GABA and norepinephrine

Question 18

Why are we sure that dopamine is not the complete answer?

Answer 18

Because some people don’t respond well to dopamine blockers. And for many we can take the edge off with acute exacerbation with dopamine blockers, but it doesn’t help long term

Question 19

What are the two symptom clusters of schizophrenia?

Answer 19

Positive symptoms: elements of personality or character that are there that shouldn’t be
Negative symptoms: something’s missing that should be there

Question 20

What are many common positive symptoms schizophrenia?

Answer 20

Hallucinations, delusions, ideas of reference, illusions, agitation, anxiety, hostility, restlessness, bizarre actions/statements, distractible/tangential, paranoia, loose associations, suicidal

Question 21

Describe hallucinations

Answer 21

A common symptom of schizophrenia
Patient may experience in one or more senses - auditory, visual, tactile, olfactory
“Voices” - most common, may be multiple and varied in nature
May be present only in exacerbations or may persist in some form chronically

Question 22

Describe delusions

Answer 22

False, often fixed beliefs which persist despite “proof” of falseness or illogic
May be paranoid, bizarre, grandoise
Response to even favourable treatment may be minimal or poor

Question 23

Describe thought disorders

Answer 23

Disorganized, illogical
Garbled speech (trying to get words out faster than the mouth can physically handle)
Thought blocking or “removal”
Made up words (neologisms)

Question 24

What are many common negative symptoms of schizophrenia

Answer 24

Immobile facial expression, monotonous voice, lack of pleasure in everyday life, diminished ability to initiate and sustain planned activity, speaking infrequently, and with minimal and simplistic content, anhedonia, poor insight and judgement, poor hygiene, apathetic, amotivated, withdrawn, socially isolated, concrete (take things very literally), impaired concentration, suicidal

Question 25

Describe the cognitive symptoms of schizophrenia

Answer 25

Cognitive impairment (related to acute symptoms and to prolonged neurotransmission imbalance)
Impaired of executive function, sustained attention, working memory (may be significantly alter "functional" capabilities may not resolve along with other symptoms)

Question 26

How do we ensure maximal safety of patients on antipsychotics?

Answer 26

Appropriate dosages (enough to get symptoms under control, but giving too much gives a bag of side effects)
Monitor: heart rate, blood pressure, sedation, movement, weight, waist circumference, lipids, blood sugar, prolactin

Question 27

Describe the relationship between the effectiveness and timeframes of medication

Answer 27

Both antipsychotics and benzodiazepines can work quickly to “take the edge off” positive symptoms (with antipsychotics, largely side effect in nature)
True anti-schizophrenia effects: a more gradual onset (4 to 6 weeks may be a reasonable trial), but improvement likely to continue over months and/or years

Question 28

What is chlorpromazine?

Answer 28

A sedating phenothiazine with a particular value in acute psychosis (it replaced electroshock, insulin coma treatments, physical restraints). It has a lot antihistamines (causes sedation) and anticholinergic (causes dryness - dry eyes, dry mouth)

Question 29

What is clozapine?

Answer 29

The first second generation antipsychotic to reach clinical trials. It has an affinity for H1, 5HT2, a1, musc, D4, Beta, D1, D2 and alpha 2 receptors. Clozapine has the highest efficacy in people with “drug resistance” (it’s great for refractory patients)

Question 30

What is the difference between FGA and SGA?

Answer 30

First generation antipsychotics target dopamine blockade
Second generation antipsychotics have a lower affinity to block dopamine (5%) an a higher (4x greater) affinity at serotonin receptors

Question 31

What is the problem with clozapine? What is the solution?

Answer 31

It has the potential to kill people (it can wipe out white blood cells in 1% of patients). We have to do weekly blood tests to ensure patient safety

Question 32

What is the importance of serotonin?

Answer 32

Drugs with an affinity for serotonin 5HT2 receptor is the key to reducing the movement disorders (EPS) that are a risk with antipsychotic medications. An affinity for both serotonin and dopamine receptors correlates with favourable antipsychotic effectiveness (SGAs)

Question 33

Explain the importance of adherence education

Answer 33

Medications enable improved function
Sustained functional improvement enhances resistance to relapse
Adherence causes both ongoing improvements and decreased relapse risk
The insight, capability and buy-in of the individual are the counseling targets