random facts Flashcards
what are the diagnostic criteria of schizophrenia
A. Two or more of these characteristic symptoms should be present for much of the time over the course of a one month period: one of them has to be 1,2 or 3
1) Hallucinations
2) Delusions
3) Disorganised speech featuring incoherence
4) Catatonic or grossly disorganised behaviour
5) Negative symptoms
B. Social or occupational dysfunction that affects work, personal relationships, or self care is noticeable and has been present since the onset of symptoms
C. Disturbances of behaviour should have been present for at least six months and symptoms must be present for at least one month of that six month period.
What are the negative symptoms
how to divide them
avolition, asociality, alogia, blunted effect, anhedonia
two main types:
1) the avolition, asociality, anhedonia
2) alogia, blunted effcet ones (will have negatuive symptoms)
What are the treatment used for negative symptoms
(name 3) and wad are the drugs mechanism
Abilify: partial d2 agonist
Amisulpride : low dose (50-300) -> selective dopamine D2 and D3 receptor antagonist
Cariprazine : partial d2 and d3 agonist
definition of resilience
ability to cope mentally or emotionally with a crisis or to return to pre-crisis status quickly.
Definition of burn out
A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.
1) Feelings of energy depletion or exhaustion
2) Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job
3) Reduced professional efficacy
Medication that affected by smoking
clozapine, olanzapine, haloperidol , to some extent faverin
What rating scales measures burnout
What measures resilience
burn out : Maslach Burnout Inventory (MBI) (self rated)
Resilience: resilience scale 14 (self rated)
Rating scales for negative syndrome (2)
1) withdrawal-retardation subscale of the Brief Psychiatric Rating Scale
2) the Scale for the Assessment of Negative Symptoms (SANS)
3) Positive and Negative Syndrome Scale (PANSS)
What is varenycline
partial agonist of the nicotinic acetylcholine receptor
Why varenycline was discontinued in singapore
contaminants with carcinogens
Three components of high EE
hostility, emotional over-involvement and critical comments
What are the non pharmalogical ways to stop smoking
5As of intervention
Ask - ask pt about tobacco use status
Advise -advise to quit
Assess -Assess willingness to quit
Assist -provide aid for pt to quit
Arrange -arrange follow up contact, Congratulate success during each follow-up
- non pharma-logical
- help with a quit plan, practical problem solving counselling, provide social support, give supplementary support
behavioral counselling, financial incentives, hypnotherapy, acupuncture
What are the pharmacological support for stopping smoking
varanicline, nicotine replacement therapy and bupropion
S/e and dosing regime of varanicline
varenycline: day 1-3: start 0.5mg once daily day 4-7: 0.5mg BD then maintenance 1mg BD At least 11 weeks
side effect: increased risk of cardiovascular events (AMI, angina, chest pain), disordered sleep (abnormal dreams and nightmares), somnambulism (sleepwalking), nausea/vomiting at higher doses, neuropyschiatric events (depression, suicidal ideation and behaviors), seizures (dose related)
what are the things that suggest bipolarity depression (8) as compared to unipolar depression
1) hypersomnia, inc daytime napping,
2) hyperphagia
3) other atypical depressive symptoms cush as leaden paralysis
4) psychomotor retardation
5) psychotic features
6) lability of mood, racing thoughts
7) Early onset of first depression, multiple prior episode
8) positive fh of bipolar disorder
what are the things that suggest unipolarity depression (5) as compared to bipolar depression
1) Initial insomnia, reduced sleep
2) poor appetite, weight loss
3) somatic complaints
4) Late onset of first depression
5) long duration of current episode
6) Neg fh of bipolar disorder
how to treat acute manic episode step wise
1) 1st line mono: lithium, quetiapine, valproate, abilify, risperidone (50% will respond within 4-3 week)
2) 1st line combi: +quetiapine, abilify, risperidone, lithium/valporate
-to observe for 1-2 weeks
3) 2nd line: add on or switch therapy
olanzapine, carbamazepine, haloperidol, olanzapine + lithium/valproate, ECT
4) 3rd line: mono chlorpromazine, mono clonazepam, mono or adjuvant clozapine, mono with tamoxifen (risk of uterine cancer), combi with carbamazepine
how to treat acute bipolar depression step wise
1) first line: quetiapine, lithium, lamotrigine, lurasidone
adjuvant lurasidone or lamotrigine
2) second line: olanzapine + fluoxetine, mono with valproate, antidepressant + lithium/valporate, ECT
3) third line: monotherapy carbamazepine, mono olanzapine, adjuvant abilify/levothyroxine, rtms, pramipexole, asenapine
Maintenance treatment with bipolar 1
Treatment for maintenance step wise
1st line: lithium, quetiapine, valproate, abilify + lithium/valproate, lamotrigine, abilify(for mania only)
2nd line: olanzapine, paliperidone, adjuvent lurasidone, carbamazepine, risperidone(mania only)
3rd line: abilify + lamotrigine, clozapine, gabapentin, olanzapine + fluoxetine
What is the percentage of wicnekle converting to korsakoff
80%
mechanism of schizophrenia
dopamine hypothesis: positive symptoms: mesolimbic pathway
negative symptoms: mesocorticalpathway
what is the age of late onset schizophrenia
40-60
What is the MOH CPG guideline for schizophrenia
the pharma bit and non pharma bit
MOH Clinical Practice Guideline for schizophrenia:
Should be offer oral anitpsychotics: 300mg-1g equivalent of chlorpromazine, should start from lower end and slowly titrate upwards, if inadequate response by 4-6 weeks or have s/e, to consider another type of antipsychotic
For maintenance phase, antipsychotic should be reduced gradually but not be lower than half of the effective dose during acute phase
Clozapine should be offer if pt cannot respond to two adequate doses of antipsychotic (of one to be atypical)
Clozapine 18 weeks weekly blood test
Non phamra: CBT, cognitive remediation, psycho-education, assertive community treatment for those with high rates of hospitalization
% of treatment resistant schizophrenia
% of schizophrenia in the population
Gender distribution
30%
1%
M=F
what is the kane study in 2019
about treatment resistant schizophrenia
Consensus treatment guidelines for TRS recommend that patients be reevaluated at 12 weeks after a first episode of psychosis (after 2 antipsychotic trials of ≥ 6 weeks in duration at an adequate dose [ie, ≥ 600 mg chlorpromazine equivalents/d]; Table 3). However, in some circumstances (eg, high risk of suicide), a treatment duration of 2 weeks may be sufficient before considering if additional clinical intervention is needed. The use of alternative pharmacotherapies, including clozapine, or nonpharmacologic adjunctive treatments (eg, CBTp, ECT, rTMS, HIT) should be considered if treatment response is not optimal.
Landmark study for schizophrenia (2)
1) catie (clinical antipsychotic trials for intervention effectiveness)
- compare SGA (olanz, risperidone, quetiapine) to FGA perphenazine
- olanzapine longer time to discontinuation, hence greater effectiveness
- phase 2: clozapine is more effective than other SGA
2) CUTLASS (cost utility)
- compare quality of life SGA vs FGA. NO disadvantage across 1 year in terms of QOL, symptoms or associated cost of care in FGA
% of schizophrenia relapse if no meds
80% in the first year
Schizophrenia scales (3) name three rating scales for EPSE
functional scale (1)
Cognitive
PANNS (The positive and negative syndrome scale)
BPRS
Brief negative symptoms scale
Simpson Angus EPSE scale
Abnormal involuntary movement scale
Barnes Akathesia Rating scale
SOFAS (social and occupational functioning assessment scale)
Brief assessment of cognition in schizophrenia
What to run through when one is not reacting to meds (5)
-med non adherence, drug drug interaction, check other things that evaluate metabolism (smoking), reevaluate diagnosis, cormobid diagnosis (substance use)
Resources for schizophrenia
specialised services: CHAT, SWAP, EPIP
Occupation: Octave, Fame club (Friendship And Mind Enrichment club)
Causes of hyperprolactinemia (7)
dopimine blocking meds, stress, pregnancy, lactation, seizure, renal impairment, prolactinoma
Symptoms of hyperprolactinemia
breast growth, changes in libido, changes in breast growth, reduction in bone mineral density and inc risk of breast ca
Higher risk of hyperprolactinemia for medication (5)
halo, CPZ, risperidone, sulpiride, paliperidone, amisupiride
Antipsychotic that are prolactin sparing (5)
low risk: clozapine, olanzapine, ziprsidone
sparing: Abilify, quetiapine
Name two ratings scales for suicide
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)
SADS PERSON SCALE
which side effect for clozapine is dose dependent
everything except for neutropenia
Titrate dosage for clozapine
What to do when miss a dose
Clozapine 12.5mg once a day then can inc to 12.5mg BD the next day, then inc by 25-50mg a day until a dose of 300mg is reached. Further inc is 50-100mg each week.
When clozapine need to start from scratch
When miss dose for more than 2 days but faster, if more than a week retitrate as if new inpatient
What are the target dose for clozapine
Target dose
250mg: female non smoker
350mg: male non smoker
450mg: female smoker
550mg: male smoker
Clozapine augmentation
evidence
When
What (5)
Evidence: small effect size with antipsyhcotic augmentation
When?: 3–6 months of optimised clozapine alone has not provided satisfactory benefit
Add wad? ECT, amisupride 400-800mg, abilify 15-30mg. haloperidol 2-3mg, lamotrigine 25-300mg, risperidone 2-6mg
What are the alternatives for clozapine
Alternative: allupurinol + antipsychotic, high dose olanzapine up to 60mg, CBT, donepezil + antipsychotic, memantine + antipsychotic, ECT
What is the target dose for clozapine in terms of clozapine blood level
Target threshold 350-420 ug/L
common s/e of clozapine
Side effect
Sedation may wear off to some extend
Hypersalivation
Constipation, highest risk in the first 4 months
Hypotension first 4 weeks
Tachycardia first 4 weeks, can give atenolol/bisoprolol
+fever, hypotension, chest pain may be indicative of myocarditis
Weight gain
Fever, first 4 weeks due to clozapine induced inflammatory response
Seizure, to give anticonvulsant if >600mg
Neutropenia first 18 weeks
Myoclonus
What to give for hypersalivation from clozapine (5)
Why
can give atropine, amisuplride, benzhexol, glycopyrrolate, ipratropium, metoclopramide
due to muscarinic agonism
Clozapine with serious side effect
serious s/e
agranulocytosis 0.8%
Thromboembolism 20x more
Cardiomyopathy, show of heart failure
Myocarditis 3% of patient , usually first 6-8 weeks, ECG signs: ST depression, eosinophilia
If CRP >100 and trop twice upper limit, to stop clozapine and repeat echo
colitis ?anticholinergic
Hepatic failure
Pancreatitis
Pericardial effusion : fatigue, chest pain, dyspnea, tachycardia. raised pro BNP< trop
What ECG show on myocarditis for clozapine
what other signs
ST depression
eosinophilia
Issues with clozapine and chemotherapy
Neutropenia, ethical issue to decrease clozapine
What is NMS
What is the mortality %
NMS is a life threatening neurologic emergency associated with use of neuroleptic agents and characterised by clinical syndrome of mental status change, rigidity, fever, dysautonomia.
20%
Med that cause NMS (3 categories)
antipsychotic agents
Antiemetic agents: metoclopramide, domperidone, promethazine
Withdrawal of l-dopa or dopamine agonist therapy
Risk of NMS (5)
recent or rapid dose escalation, higher doses, higher potency, male, catatonia, extreme agitation, substance abuse or neurologic disease
Symptoms of NMS
tetrad
- mental status change
- muscular rigidity
- hyperthermia >38
- autonomic instability (tachycardia, high bp, tachypnea, diaphoresis)
Labs signs of NMS (5)
elevated CK at leat 4 times upper limit
Low iron
Leukocytosis
Transaminase, lactate dehydrogenase elevation
Electrolyte imbalance: hypocalcemia, hypomagnesemia, hyperkalemia, hyper/hyponat
Myoglobinuric acute renal failure
Treatment of NMS
supportive (5) Medical treatment (4)
1) Stop causative agent
2) Supportive care:
- Maintain cardiorespiratory stability. Mechanic ventilation, antiarrhythmic agents, or pacemakers may be required
- Maintain euvolemic state using intravenous fluids. Insensible fluid loss from fever and from diaphoresis should also be considered. If creatine kinase (CK) is very elevated, high-volume intravenous fluids with urine alkalinization may help prevent or mitigate renal failure from rhabdomyolysis
- Lower fever using cooling blankets. More aggressive physical measures may be required: ice water gastric lavage and ice packs in the axilla.
- Lower blood pressure if markedly elevated. Clonidine is effective in this setting
- Use benzodiazepines (eg, lorazepam 0.5 to 1 mg) to control agitation, if necessary
Specific medical treatment:
benzodiazepine 10mg every 8 hours, dantrolene (muscle relaxant) 1-2.5mg/kg, bromocriptine(dopamine agonist) 2.5mg up to 40mg/day, and amantadine (dopaminergic and anticholinergic effects)
ECT
When and how to restart antipsychotic for NMS (3)
When and how to restart antipsychotic for NMS (3): wait for at least 2 weeks, use lower potency agents, start low dose and titrate upwards, avoid dehydration, cont monitor symptoms of NMS
Complication of NMS (7)
Complication of NMS
●Dehydration
●Electrolyte imbalance
●Acute renal failure associated with rhabdomyolysis
●Cardiac arrhythmias, including torsades de pointes and cardiac arrest
●Myocardial infarction
●Cardiomyopathy
●Respiratory failure from chest wall rigidity, aspiration pneumonia, pulmonary embolism
●Deep venous thrombophlebitis
●Thrombocytopenia
●Disseminated intravascular coagulation
●Deep venous thrombosis
●Seizures from hyperthermia and metabolic derangements
●Hepatic failure
●Sepsis
What are the psychological help for PTSD and what kind of intervention was included
Trauma focus CBT: cognitive processing therapy cognitive therapy for PTSD narrative exposure therapy prolonged exposure therapy.
EMDR: eye movement desensitization reprocessing therapy
What are the approved drugs for ptsd
other non label use?
SSRI: paroxetine and sertraline
Non labeled use: venlafaxine
Risperidone if not responding
PTSD dsm criteria
for age of more than 6 years old
criterion A: exposure to actual or threatened death, serious injury or sexual violence in
1) direct 2) witness in person as it occur to others 3) learning tat occur to a close family member or close friend 4) experiencing repeated or extreme exposure to aversion details of the traumatic event
B: intrusion 1 of 5
1) recurrent, involuntary, intrusive distressing memories of the traumatic event
2) Recurrent distressing dreams with is related to the traumatic events
3) Dissociation reactions (flashback), feels and acts as if the traumatic events were recurring
4) Intense or prolonged psychological distress at exposure to internal or external cues
5) Marked physiological reactions to internal or external cues
C: avoidance: 1 of 2
1) avoidance of or effort to avoid distressing memories, thoughts or feelings about or closely associated with the traumatic events
2) avoidance of or effort to avoid external reminders
D: negative altercation in cognition and mood 2 of 7
- inability to remember an important aspect fo the event
- Persistent and exaggerated negative belief or expectation
- Persistent, distorted cognition about the cause or consequences of the traumatic events that leads ppl to blame oneself
- Persistent neg emotional state
- Marked diminished interests in activities
- Feeling of detachment
- persistent inability to experience positive emotions
E: Hyper arousal: 2 of 6
1) Irritable behavior or angry outburst
2) Reckless or self destructive behavior
3) Hyper vigilance
4) Exaggerated startle response
5) Problems with concentration
6) Sleep disturbance
All more than 1 month
caused clinically sig impairment in social, occupational or other areas of functioning
Specifier for PTSD
With dissociative symptoms + have depersonalisation or derealisation
with delayed expression-> after more than 6 months
Risk factors for tardive dyskinesia (9)
Risk factors for tardive dyskinesia
Patient characteristics
Older age
Female sex
Drug exposure characteristics* First > second-generation antipsychotics Cumulative duration Higher dose Early occurrence of drug-induced movement disorders
Co-morbidities Schizophrenia and other psychotic disorders Intellectual disability Preexisting mood disorder Alcohol or substance use disorder Dementia Diabetes
Others
Prior electroconvulsive therapy
Causative agents for TD:
Causative agents: all dopamine receptor blocking agents Antipsychotic drugs metochlopramide, other emetics Amoxapine, aripiprazole
Meds for persistent moderate to severe TD
Meds for persistent moderate to severe TD
->For patients with persistent and bothersome TD, vesicular monoamine transporter type 2 (VMAT2) inhibitors (valbenazaine, tetrabenazaine, Deutetrabenazine) are the primary symptomatic therapy. Benzodiazepine therapy is sometimes helpful for mild symptoms but is unlikely to help more severe TD.
Other meds include amantadine, glingko Biloba, vit E, vit B6, beta blockers)
->For the subset of patients with tardive dystonia (eg, cervical and truncal dystonia, blepharospasm), botulinum toxin injections are a localized option that may spare the need for systemic drug therapy.
->Patients with refractory TD despite symptomatic therapies should be referred to a movement disorder specialist for consideration of deep brain stimulation (DBS).
Treatment for AD
pharmacological management of AD
NICE guideline, for donepezil, galantamine, rivastigmine monotherapy for mind to moderate AD
memantine monotherpy is recommended when mod AD who cannottake AChI or severe AD
KIV add memantine if oledi on an AChE
Treatment of lewy body dementia
Offer donepezil or rivastigmine to people with mild to moderate dementia with Lewy bodies.
Only consider galantamine for people with mild to moderate dementia with Lewy bodies if donepezil and rivastigmine are not tolerated.
Consider donepezil or rivastigmine for people with severe dementia with Lewy bodies.
Consider memantine for people with dementia with Lewy bodies if AChE inhibitors are not tolerated or are contraindicated.
Treatment of vascular and frontal lobe dementia
Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.
Do not offer AChE inhibitors or memantine to people with frontotemporal dementia.
Dosing for
1) donepezil
2) rigvastigmine (oral and patch)
3) memantine
Dosing for donepezil
2.5mg OM then max is 10mg Daily
rivastigmine
1.5mg bD or 4.6mg/24 hour patch
3-6mg BD dosing or 9.5mg/24 hour patch
Dosing for memanine
5mg then up to 20mg daily, inc 5mg weekly
S/E memantine
s/e for memantine: hepatic impairment and epilepsy/seizures, AGITATION, dizziness, bradycardia
S/E for Acetylcholinesterase inhibitor
s/e for cholineterase inhibitor: excess cholinergic stimulation can lead to nausea, vomiting, dizziness, insomnia and diarrhoea which is dose related
urinary incontinence, neuropsych symptoms, bradycardia, need ECG,
Drug Drug interaction with donepezil
drug drug interaction with donepezil: in with fluoxetine, paroxetine, dec by carbamazepine, alcohol, phenytoin
bradycardia, to watch out for beta blockers, calcium channel blockers
BPSD non drug measures (5)
BPSD
non drug measures:
check for underlying cause, medication side effects, pain assessment, sleep wake disturbances, depression, delusions
Snoezelen (specially designed rooms with a soothing and stimulating environment)
Exercise training in combination with caregiver education
aromatherapy
music therapy
Massage and touch therapy
Treatment for akathesia
pseudoparkinism
dystonia
treatment for akathesia
propanolol, clonazepam, 5-ht antagonist like trazodone, mirtazapine, cyproheptadine
no anticholinergic
Treatment for pseudoparkinism
anticholinergic
Treatment for dystonia
Benzodiazepine, anticholinergic
antipsychotic to giv if weight gain (5)
Haloperidol, amisulpride, sulpride, lurasidone, stelazine
lab test for catatonia (3)
There is no laboratory test specific for catatonia. However, malignant catatonia is associated with non-specific test results that include leukocytosis, increased creatine kinase, and low serum iron
Treatment for catatonia
Treatment for catatonia
Benzodiazepine
Then ECT if not getting better
Treatment for underlying disorder
supportive
Hyperthermia: rapid cooling
Hypertension
Hydration and ngt for feeding
Compression stockings, ant thrombolytic for DVT
Pressure ulcers treatment: frequent turning
Wad are the prolactin sparing antipsychotic drugs (4)
Wad are the high risk ones (4)
low:
- abilify
- asenapine
- clozapine
- quetiapine
high:
- FGA
- amisulpride
- risperidone
- Paliperidone
- Sulpride
How to approach hyperprolatinemia for ppl with antipsychotics
switch, is not successful, add adjustive abilify
If cannot, add dopamine agonist, amantadine, bromocriptine, or metformin
How to approach sexual dysfunction for peeps with antipsychotics
TReatment of secual dysfunction
1) physical pathology (diabetes, hypertension, cardiovascular disease, etc.) has been excluded
2) DEc dose or discontinue offending drug
3) switch to less propensity (abilify, lurasidone, quetiapine, asenapine)
4) add abilify 5-10mg to normalise prolactin
5) antidote drug eg: mirtazapine, cyproheptadine
6) sinedafil for erectile dysfunction
General recommendation of antipsychotic to switch
1) akathisia(3)
2) postural hypotension (3)
3) TD (3)
1) akathisia
olanzapine, quetiapine, clozapine
2) postural hypotension
amisulpride, lurasidone, abilify
3) TD
clozapine, abilify, quetiapine, olanzapine
Substance/ medication that cause mania
Substance: alcohol, Cocaine, amphetamines, phencyclidine, hallucinogens
Meds: antidepressants, methylphenidate, steroids
Wad r the components of interpersonal psychotherapy
Role transition, Role dispute, interpersonal deficits, grief
what is SSRI emotional blunting
ssri emotional blunting/emotional difference
- due to serotoninergic ability
- management: make sure is not depression first, then look into cutting dose, switching it over bupropion (may worsen psychosis), vortioxetine, agomelatonin, TCA
