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
When are EPSEs commonly seen?
Dose related, higher doses of high potency FGAs, less common in SGAs but still seen
What are the signs and symptoms of dystonia?
Uncontrolled muscle spasm in any part of the body:
-eyes rolling upward (oliguric crisis)
-head and neck twisted to side (torticolis)
Can be very painful
What is the prevalence of dystonias?
Around 10%
More common in:
-young men
-pts who haven’t had AP before
-high potency e.g haloperidol
What time does dystonias occur?
Acute- within hours of starting- even faster with IM
Tardive- after months/ years
What is the treatment for dystonias?
Anticholinergic- Oral, IM, IV (procylidine)
Switching
What are the signs and symptoms of Parkinsonism symptoms?
Tremor and/or rigidity- hands often
Bradykinesia
-decreased facial expressions, flat monotone voice
-slow body movements, inability to initiate movement
What is the prevalence for Parkinsonism symptoms?
Around 20%
More common in:
-elderly females
-pre-existing neurological damage
What time does Parkinsonism symptoms occur?
Days to weeks after started or dose increase
What is the treatment for Parkinsonism symptoms?
Decrease dose
Switch medication
Anticholinergic e.g procylidine
What are the signs and symptoms of akathisia?
Inner restlessness:
-constant pacing across room
-unable to sit down
-constant twitching or tapping of legs
What is the prevalence of akathisia?
Wide variation around 25% for acute FGA, lower for SGA
Common when starting aripiprazole
What is the time for akathisia?
Can occur hours or days after starting, or increasing dose
Can persist for several months
What is the treatment for akathisia?
Dose decrease
Switching
Short course of benzo- esp when staring aripiprazole
What are the signs and symptoms of tardive dyskinesias?
Wide variety
Lip smacking
Tounge profusion
Choreiform movements (playing piano)
Making noises/ facial expressions you can’t control
What is the prevalence of tardive dyskinesia?
Around 5% of patients per year
More common in:
-older age
-affective illness
-sz
-high doses
-acute EPSEs earlier on
What is the time of tardive dykinesias?
Times months/ years
What is the treatment for tardive dyskinesias?
Stop anticholinergic treatment
Decrease dose of AP
Switch to AP less likely to cause- clozapine or quetiapine
What is the monitoring recommended by NICE for metabolic syndrome?
Baseline then repeat at 12 weeks then annually
-waist circumference, fasting blood glucose, HbA1C, blood lipid level
Every 3 months for first year for clozapine and olanzapine
Weekly weight for first 6 weeks, at 3 months, 12 months then annually
Why does hyperprolactinamyia occur with APs?
Dopamine inhibits prolactin release therefore dopamine antagonists increase prolactin plasma levels
Which drugs are high risk of causing hyperprolactinamyia?
Amisulpridie
Palperidone
Risperidone
Sulpuride
FGAs
What are the symptoms of hyperprolactinamyia?
Often asymptomatic:
-sexual dysfunction
-menstrual disturbances
-breast growth
-galactorhoea
-delusions of preg
What are the long term complications of hyperprolactinamyia?
Decrease in BMD
Increase risk of breast cancer
What is the management of hyperprolactinamyia?
Decrease dose, switch to a prolactin sparing AP e.g aripirazole
Consider adding low dose aripirazole e.g 2.5-5mg day
Which are the most common APs causing sexual dysfunction?
Haloperidol and risperidone
Which are the least common APs causing sexual dysfunction?
Aripirazole
Quetiapine
What is the management for sexual dysfunction when using AP?
Monitor prolactin levels
Adjust dose- either decrease, omit selected or consider single daily
Switch or stop
Add 3-6 mg aripirazle (off license)
PD5i via specialist only
Which APs commonly cause sedation?
Common in low potency FGA and some SGA
Clozapine, olanzapine, quetiapine
What would be the management of sedation?
Review concurrent meds
Start low dose
Counsel on driving
Switching
Prescribing at night or bigger dose at night
Avoid psychostimulants like modafinil
Which APs cause anticholingeric SEs?
Low potency FGAs and clozapine
Olanzapine and quetiapine at higher doses
What are the central anticholinergic SEs of AP?
Cognitive impairment
Delirium
Hyperthermia
Confusion
What are the peripheral anticholinergic SEs of AP?
Dry mouth
Constipation
Blurred vision
Glaucoma
Urinary retention
What is the management for anticholingeric AP SEs?
Identify pts who have pre-existing condition e.g olanzapine CI in pts with arrow angle glaucoma
Review concurrent meds
Decrease, switch
What are the cardiac effects of APs?
2-3 fold increase in death
Orthostatic/ post hypo
Reflex tachycardia
Ventricular tachy
Torsades de pointes
Delayed cardiac depolarisation
MI
Myocarditis
Cardiomyopathy
What is the management of cardiac effects?
Dose titration, switch
Appropriate med to decrease HR
Review concurrent meds
If myocarditis suspected, AP should be stopped
What is the monitoring for the cardiac SEs of APs?
Baseline BP, pulse, ECG repeat at 12 weeks then annually
Name the serious side effects of clozapine:
CV:
-thromboembolism
-myocarditis
-cardiomyopathy
Haematological SEs- 0.4%
Constipation
Hypersalivation
Describe the clozapine SE myocarditis:
Incidence 1-4%
Most likely to occur in first 6-8 weeks
Monitor signs for:
-hypotension, tachy, fever/ flu, fatigue, dysponea, chest pain
Describe the clozapine SE cardiomyopathy:
Incidence 0.02-5%
Occurs later in treatment- around 9 months
How does clozapine cause constipation?
Anticholinergic and antihistaminic effects, plus antagonism at 5HT3r
What is the management for constipation due to clozapine?
Dietary and exercise
Laxatives- stim (1st line) + stool softeners
Avoid bulk forming as may cause impaction
Describe the SE of hyper salivation clozapine causes:
Early stages of treatment
Dose related
May improve over time
Contributory in the development of aspiration pneumonia, could be life threatening
What is the management for hyper salivation?
No licensed treatment
Consider dose reduction or switching
Antimuscarinic med can be used but consider constipation e.g hyoscine hydrobromide
What is the non drug treatment for hypersalivation?
Chewing gum
Elevating pillow
Placing a towel at pillow
What is neuroleptic malignant syndrome (NMS)?
An acute disorder of thermoregulation and neuromotor control
Rare but serious or even fatal
0.11-0.16% incidence
What are the signs and symptoms of NMS?
Fever
Diaphoresis
Rigidity
Fluctuating level of consciousness
Tachycardia
Fluctuating BP
Sweating
Elevated creatinine kinase, leukocytosis, altered LFTs
What are the risk factors for NMS?
High potency FGAs, recent or rapid dose increase/ reduction, abrupt withdrawl of ACH drugs, AP polypharmacy
Psychosis, organic brain disease, alcoholism, PD, hyperthyroidism
Male and younger age
What is the treatment for NMS?
Stop AP, monitor temp, pulse, BP
Consider benzo
Call ambulance- rehydration, bromocriptine, dantrolene, sedation with benzo, artificial ventilation
What does NMS stand for?
Neuroleptic malignant syndrome
What are the requirements of restarting an AP after a patient has had NMS?
Allow at least 5 days before attempting to restart
Start low
Consider AP that is structurally unrelated to causative agent or with lower dopamine affinity e.g quetiapine, olanzapine, aripirazole
AVOID depot or LAI
What are the AP that can cause QT prolongation?
Haloperidol
Quetipaine
Pimozide
Name other drugs that can cause QT prolongation:
Escitalopram, amiodarone
Mycin ABs
Citalopram
Tamoxifen
What other drugs cause neutropenia?
Carbamazepine
Sulfonamides
Chloramphenicol
What APs cause anticholingeric SEs:
Clozapine, chlorpormazine, trifluroperixine, zuclipenthixol
What is the interaction between APs and smoking?
Interaction with hydrocarbon in tobacco smoke, not nicotine
So vapes and NRT ok
Name the APs that interact with smoking?
Clozapine (50% decrease)
Olanzapine (50%)
Haloperidol (20%)
What are the requirements when someone is a smoker when taking clozapine?
Take plasma level before stopping or starting smoking and repeat after 1 week
When stopping smoking, decrease dose gradually (over 1 week) until around 75% of original dose reached, decrease further if needed
If restarting smoking increase dose to previous smoking dose over 1 week
What is the interaction between clozapine and caffeine?
Caffeine is an inhibitor of Cyp450 1A2
Increases clozapine levels up to 60%
Also affects olanzapine
Not an issue but need to monitor to make sure caffeine intake consistent
