Mental Health Clinical Schizophrenia Flashcards
Name positive symptoms of sz:
Hallucinations
Delusions
Thought insertion/echo/withdrawl/broadcasting
Disorganised speech
Disorganised or catatonic behaviour
Name negative symptoms of sz:
Flattened (blunted) mood
Avolition- lack of goal directed activities
Apathy- lack in sense of caring
Alogia- speech may be reduced in quantity
Anhedonia- failure to enjoy + emotional or pleasurable experiences
Slow movements
Poor self care or neglect
Name the cognitive symptoms of sz:
Memory, attention and executive functions e.g decision making
Not affected by AP treatment
What are the consequences of negative and cognitive symptoms?
Affect around 40-80% of sz patients
Strong predictors of poor outcome
More consistent, worsen with duration of illness and response poorly to AP
Describe the ICD-10 diagnosis of sz:
At least ONE of the main
At least TWO of the other
Last at least a month
Describe the DSM 5 diagnosis of sz:
Two symptoms present for at least a month:
-delusions, hallucinations, disorganised speech, grossly disorganised catatonic behaviour, negative symptoms
Social/ occupational dysfunction
Duration- continuous for at least 6 months
Name differential diagnosis’ of sz:
Substance induced psychotic disorder
Psychotic disorder due to medical conditions:
-sepsis -cerebral tumour
Severe mood disorder
PTSD, OCD
Personality disorder
ASD or communication disorders
Dementia
Describe the features of FGA’s:
Chlorpromazine
D2 antagonist
Similar SE profile- EPSEs
Same efficacy but different SEs
Describe the features of SGA’s:
Chemically related to TCA
5HT2A antagonism, fast D2 dissociation (less D2 specific), 5HT1A antagonism
Possibly superior efficacy against -ve symptoms
Different SE profile:
-lower EPSEs but increase metabolic syndrome
Name some SGAs licensed to treat mood disorders:
Risperidone
Quetiapine
Olanzapine
Aripirazole
Name classes and examples of FGAs:
Phenothiazine:
-chlopromazine, pericyazine, levopromazine
Butyrophenones:
-haloperidol, benpenidol
Thioxanthenes:
-flupentixol, zuclopethixol
Substituted bezamides:
-sulpride, amisulpride
Name different examples of SGAs:
Clozapine
Risperidone
Quetipaine
Aripirazole
Lurasidone
How does the long acting injection (LAI) and depot work of an AP?
Admin by deep IM injection
Form a depot at injection site which the antipsychotic released fairly steady rate into blood
What are the requirements when using a FGA LAI?
A small test dose is given to test for sensitivity to EPSEs and to the oil base
What are the requirements when using a SGA LAI?
Oral treatment is required first, to see if it works and SEs as can’t reverse after injected
Why would you offer a LAI over an oral antipsychotic?
If patient preference or to avoid covert non-adherence
What is the problem with olazapine LAI?
Post injection syndrome- needs to be monitored for 3 hours after
What are the advantages of LAI?
Assured medication delivery and continuous coverage
Pt doesn’t need to remember every day
Clinicians aware if patient non adherence
Drug remains in system for 1-2 weeks after missed dose
Decrease relapse freq and hospitalisation
Avoid first pass metabolism
Smoother release profile- decrease SEs
What are the disadvantages of LAI?
IM injection- painful
Conversion oral to LAI not straight forawrd
Preparation needed
Dose titration more difficult and take longer
SEs persist for longer
Risk for poor injection technique
What is high dose antipsychotic therapy (HDAT)?
When a single AP is prescribed above BNF max
OR
2 or more AP prescribed concurrently that, when expressed as a % of their max daily dose total to more than 100%, includes PRN
What should occur if a patient is on HDAT?
Clinical needs to review and document:
-target symptoms
-SEs
-therapeutic response
-close physical monitoring inc ECG
What are the aims of rapid tranquillisation?
Decrease suffering to patient
Decrease risk of harms to others
To do no harm by prescribing safety
Not to induce sleep or unconsciousness but to sedate them while enabling them to still participate in further assessment
What is the NICE recommend drugs for rapid tranquilisation?
IM lorazepam on its own
IM haloperidol with IM promethazine
What are the monitoring requirements of rapid tranquilisation med?
SES
Pulse/BP
Resp rate
Hydration
Conscious levels
Every 15 mins if max dose exceeded
Every hour if not
What is treatment resistant psychosis?
A lack of satisfactory clinical improvement despite use of adequate doses of at least 2 different APs, including SGAs prescribed for at least 4-6 week trial
What is the AP used in treatment resistant psychosis?
Clozapine only AP licensed
How does clozapine work?
Relatively weak antagonist at the D2r
Acts relatively strongly at the 5HT2Ar and it has a strong anticholinergic, antihistaminic and a1 adrenergic blocking properties
What are the monitoring requirements when starting on clozapine?
Pt must be registered with an approved clozapine blood monitoring service to minimise risk of agranulocytosis and neutropenia
Blood monitoring before starting then weekly for first 18 weeks, then twice weekly until 1 year, then monthly after
Can only be supplied if valid blood result
What is the green blood result for clozapine?
WBC count ≥3500/mm3 or the neutrophil ≥2000/mm3
Means it can be supplied
What is the amber blood result for clozapine?
WBC 3500-3000/mm3 or the neutrophil between 2000-1500/mm3
Repeat twice weekly until either green or red- can still supply
What is the red blood result for clozapine?
WBC below 3000mm3 and/or absolute neutrophil below 1500mm3
Immediate cessation of therapy sample blood daily until pt has recovered
No further prescribing allowed unless error occurred or consultant takes full responsibility
What are the discontinuation symptoms of APs?
Occur within 4 days and may last 1-2 weeks
N&V, sweating, muscle pains, insomnia, restlessness, anxiety, seizures, EPSEs, akathisia dystonia, dyskinesia
What occurs if you stop an AP with significant anticholinergic effects?
Cholinergic rebound
Excessive sweating, headache, diarrhoea
What would be the drug management for withdrawl symptoms of AP?
Benzo for anxiety/ sleep
Anticholinergic drugs for cholinergic symptoms
Original AP can be restarted and taper down slower
What are the adverse effects of FGAs?
Neurological SEs:
EPSEs
Acute- akathisia, dystonia, Parkinsonism
Tardive dykinesia
What are the adverse effects of SGAs:
Metabolic SEs:
-weight gain
-hyperglycaemia
-hyerlipidaemia
What are the adverse effects of all APs:
Anticholinergic
Cardiac
Hyperprolactinamia
Sexual dysfunction