Psychotic Disorders Flashcards
What is schizophrenia?
A chronic disease of relapsing and remitting pattern defined by observed signs of psychosis
When is late onset schizophrenia?
> 45 years onset
Typical age of presentation for schizophrenia
Male: 10-25 years old
Female: 25-35 years old
Which neurotransmitter and receptor is affected I’m schizophrenia?
NMDA R and glutamate
Affected brain regions in schizophrenia
Frontal = planning and organising thoughts
Temperol = wernickes area overactive - auditory hallucinations (hear voice in head as coming from outside)
Limbic = agitation
Basal ganglia = hallucinations and paranoia
Occipital lobe = difficulty interpreting complex images, reading emotions
Hippocampus = learning and memory affected
Stages of schizophrenia
Stage 1: @risk = environmental exposure and genetic risk, poor cognition and behavioural problems in childhood (no proven treatment)
Stage 2: prodromal stage of schizophrenia = bizarre thoughts (not delusions yet), social isolation, low cognition (cognitive training, family support, polyunsaturated FA)
Stage 3: Onset of psychosis = positive sx, negative sx, cognitive sx (pharmacological and psychotherapy)
Stage 4: chronic disability stage = socially disabled (homeless, unemployed, incarcerated), functionally impaired, psychiatric deficits, increased suicidal rate, increased obesity and smoking
DSM criteria for schizophrenia
Criteria A: >/=2 of the following sx with at least 1 being 1-3, prominent for significant portion of 1 month (1: hallucinations 2: delusions 3: disorganised speech 4: disorganised behaviour 5: negative symptoms)
Criteria B: social and occupational dysfunction
Criteria C: continuous signs of disturbance >6 months
Criteria D: exclusion of schizoaffective, depression and bipolar disorder with psychotic features
Criteria E: not due to MMS
Criteria F: if Hx of ASD/communication disorder of childhood, addictions diagnosis of schizophrenia can only be made if prominent hallucinations and delusions as well as other criteria for schizophrenia are present for at least 1month
Positive symptoms of schizophrenia
Hallucinations
Delusions
Disorganised thought/speech
Negative symptoms in schizophrenia
5A’s
Alogia = decreased flow and quantity of speech
Anhedonia = decreased pleasure in doing things previously pleasurable
Asociality = hesitancy, disengagement
Affect blunted = restriction of expression
Avolition = decreased motivation to interaction with environment (eventually need help with self care)
Cognitive symptoms in schizophrenia
Attention
Memory
Executive functioning
Good prognostic features for schizophrenia
Late onset
Acute onset
Obvious precipitating factors
Mood disorder symptoms
Good premorbid functioning
Married
Family history of mood disorders
Good support system
Positive symptoms
Poor prognostic features of schizophrenia
Early onset
No precipitating factors
Insidious onset
Poor premorbid functioning
Withdrawn, autistic behaviour
Single/divorced
Family history of schizophrenia
Poor support system
Negative symptoms
Neurological signs and symptoms
History of perinatal trauma
No remission in 3 years
Multiple relapses
DSM for schizoaffective disorder
Criteria A: uninterrupted period of illness where schizophrenia criteria A met with concurrent major mood episode (has to include depressed mood if depressive mood sx)
Criteria B: to exclude mood disorders with psychotic features, there has to be at least a 2 week period where there are no mood symptoms but there are hallucinations and delusions
Criteria C: the sx that meet criteria for major mood disorder are present for majority of active and residual illness
Criteria D: not due to AMC or substance
DSM for Delusional disorder
Criteria A: presence of non-bizarre delusions for at least 1 month
Criteria B: criteria A for schizophrenia is not met and has never been met (if hallucinations are present, related to delusions and are not prominent)
Criteria C: functioning not markedly impaired and delusions are not bizarre
Criteria D: if mood sx are present, not present for majority of the disease (brief relative to delusional symptoms)
Criteria E: not physiological caused by AMC or substance
When do you refer a schizophrenic patient?
Treatment resistant (on 2 antipsychotics)
Comorbidities (substance abuse, mood disorder)
Lack of support/resources at primary level
How long do you continue prophylactic antipsychotic treatment
1st episode = 2 years
2nd episode = 5 or more years
When can you say the psychosis is treatment resistant?
On at least 2 antipsychotics (including 1 atypical) with no/minimal response after adequate dose for 12 weeks
What are extrapyramidal side effects
A collection of movement disorders caused by disruption in the dopaminergic pathways in the basal ganglia resulting in bradykinesia, rigidity, dystonia, akathisia, tics, tremors, chorea and ballismus
How do you treat acute dystonia
Biperidine 5mg IV/IM
Treatment of Parkinsonism EPSE
Admin anti cholinergic (Biperidine)
Decrease antipsychotic dose or change to atypical antipsychotic if severe
Treatment of akathisia EPSE
Ensure not aggressive/agitated patients
>beta blocker 10-30mg tds
>benzo
>change to low potency antipsychotic or atypical
What is Tardive dyskinesia
Abnormal voluntary movements - oral movements (rabbit), tongue protrusion, grimaces, chlreoatesosis, abnormal posture = long term antipsychotic treatment
Treatment for Tardive dyskinesia
Not alleviated by anticholinergic drugs
Treatment = decrease dose and stop anticholinergics
Can try clozapine or other atypical
What is neuroleptic malignant syndrome?
Unknown mechanism of advanced Parkinsonism and catatonic features which appears in the 1st week of taking antipsychotic drugs
Signs and symptoms of Neuroleptic malignant syndrome
FALTER
Fever
Autonomic dysregulation (diaphoresis, incontinence)
Leukocytosis
Tremor
Elevated enzymes (CK and transaminases)
Rigor
Dysphagia
Change in LOC (delirium)
Mutism
Management of neuroleptic malignant syndrome
Stop all antipsychotics
Admit to ICU - monitor renal fxn and electrolytes
Exclude other serious conditions
Supportive care - hydration, cool, monitor vitals, NG tube
Symptomatic
>muscle rigidity = diazepam
>DVT prophylaxis (avoid anticholinergics)
Be aware of renal failure (CK and myoglobin)
Last treatment option = dandrolene (muscle relaxant)
No response = ECT
Rechallenge = lower dose of atypical antipsychotic, ECT after 2 weeks
