Schizophrenia Flashcards
1
Q
What are common side effects of antipsychotics?
A
- Hyperprolactinaemia: breast tenderness, breast enlargement and lactation
- Akathisia: sense of inner restlessness and inability to sit still
2
Q
What are the history questions for psychosis?
A
- When did they last feel their usual self? How have things changed since?
- Ask about friends, interests, family life
- If voices/hallucinations - do they ever see or hear things that other people may not see or hear?
- Does the TV/radio ever refer specifically to you?
- Do you ever feel people are against you or want to harm you?
- Recreational substances?
3
Q
What is the GP’s role in psychosis management?
A
- Should not prescribe antipsychotic treatment themselves
- GP can advise to reduce drug/alcohol intake
- Once they know the history can refer to specialist mental health services - Early Intervention in Psychosis team
4
Q
What are the physical causes differentials of psychosis?
A
- Thyroid disease
- Temporal lobe epilepsy
- High dose steroids e.g. corticosteroids
- Encephalitis
- Brain tumour
5
Q
What are the organic causes of psychosis?
A
- Acute confusion
- Dementia
- Temporal lobe epilepsy
- Infections of nervous system e.g. AIDS, encephalitis
- Brain injury
- Brain tumours
- Huntington’s
- Metabolic disorders e.g. Vit B12 deficiency, porphyria
- Endocrine and autoimmune disorders e.g. Cushing’s, thyroid, lupus
6
Q
What investigations should be done for psychosis?
A
- Physical exam: HR, BP (if high and new may be major risk), dehydration, recent injury or embolism/stroke
- FBC (anaemia + infection), U+Es, LFTs, TFTs, eGFR, HbA1c/blood glucose (check for causes of confusion)
- Bone profile
- MRI - if there are accompanying metabolic signs
- Weight + BMI (schizophrenic patients are increased risk of metabolic syndrome)
- ECG (acute evidence of any cardiac events or long term changes)
7
Q
What are the most common causes of psychosis?
A
- Schizophrenia
- Recreational drug use as part of acute intoxication (e.g. LSD, acid and other hallucinogenic drugs) or withdrawal symptoms (e.g. from alcohol)
- Bipolar disorder
- Acute confusion
8
Q
What is the management of psychosis?
A
With 1st episode of psychosis:
- Oral atypical antipsychotic medication (depot when bad compliance) in conjunction with
- Psychological interventions
- Family intervention: help families to understand the condition and respond to symptoms in the most supportive way
- Individual CBT: with a trained psychologist to focus on helping patients to understand their symptoms better and develop alternate ways of coping
9
Q
What are the main side effects of antipsychotics?
A
- Metabolic (weight gain, diabetes, metabolic syndrome, hyperlipidaemia)
- Sedation (common)
- Extra-pyramidal (i.e. movement disorders like akathisia, dyskinesia and dystonia)
- Cardiovascular (including prolonged QT interval)
- Hormonal (including increased plasma prolactin)
10
Q
What are the monitoring requirements for antipsychotics?
A
- Weight
- Waist circumference
- Pulse and BP
- Fasting blood glucose, HbA1c
- Blood lipids
- Prolactin levels
- Assessment of movement disorders, nutritional status, diet and physical activity
- ECG
11
Q
What are high potency typical antipsychotics?
A
- D2 dopamine receptor antagonists
- Higher risk of extrapyramidal side effects
- e.g. haloperidol, sulpiride, pimozide, fluphenazine, flupenthoixol
12
Q
What are low potency typical antipsychotics?
A
- Non-dopaminergic receptors and D2 receptors
- Cardiotoxic and anticholinergic side effects including sedation and hypotension
- e.g. chlorpromazine, thioridazine
13
Q
Describe the action of amisulpiride
A
- Atypical antipsychotic - highly selective for D2 and D3 limbic subtypes
- No serotonin action
- Weight gain and hyperprolactinaemia
14
Q
Describe the action of atypical antipsychotics
A
- Serotonin-dopamine 2 antagonists
- Every patient on these needs annual bloods, BMI, lipids, glucose
- e.g. risperidone, olanzapine, quetiapine, aripiprazole, clozapine
15
Q
Explain clozapine
A
- Regular tablet form
- Indication: treatment resistant schizophrenia
- Associated agranulocytosis - weekly bloods for 6 months, then every 2 weeks for 6 months
- Increased risk of seizures (especially + lithium)
- Sedation, weight gain, hypersalivation and deranged LFTs
- Increased risk of hypertriglyceridema, hypercholesterolaemia and hyperglycaemia
- Must be re-titrated after a gap of more than 48hrs
- In non-compliant, change to depot
16
Q
What are the symptoms of autonomic dysfunction?
A
- Hyperthermia
- Hypertension
- Hyperreflexia
- Tachycardia
- Tremor
- Agitation
- Irritability
- Sweating
17
Q
What is neuroleptic malignant syndrome?
A
- Symptoms: autonomic dysfunction, severe muscle rigidity, fever, confusion, elevated WBC and LFTs
- Complications: rhabdomyolysis, hyperkalaemia, kidney failure or seizures, leucocytosis
18
Q
What is the treatment for neuroleptic malignant syndrome?
A
- Discontinue medication
- ICU (may require circulatory/ventilatory support)
- Rx hyperthermia aggressively (active cooling)
- Dantrolene/bromocriptine/amantadine for rigidity
- Benzodiazepines for agitation
- May require aggressive IV hydration with diuresis (prevent renal failure)
19
Q
Describe section 2
A
- Admission for assessment for up to 28 days, not renewable
- Treatment can be given for the mental disorder itself or conditions directly resulting from the disorder against patient’s wishes
- Application by AMHP or nearest relative, recommendation by 2 doctors independent of each other (at least one has to be section 12 approved)
- Patient can appeal to tribunal, can be discharged by Responsible Clinician and Hospital Managers
20
Q
What is section 3?
A
- Admission detainment for 6 months (can treat for 3 months, but must get consent/2nd opinion after), which can be renewed
- Application by AMHP or nearest relative, recommendation by 2 doctors (section 12) - both have to have seen the patients within the past 24hrs
- Patient can appeal to tribunal, can be discharged by the Responsible Clinician, Hospital Manager or nearest relative
- Can be renewed after 6 months if still meets criteria
21
Q
What is section 4?
A
- 72hr emergency admission for treatment
- Treatment can only be given under common law
- Used as emergency when section 2 would involve unacceptable delay
- Application by AMHP or nearest relative, recommendation by doctor
- Cannot appeal, can only be discharged by responsible clinician
- Often changed to section 2 upon arrival at hospital
22
Q
What is section 5(2)?
A
- 72 hrs emergency holding order (patient already admitted to hospital on informal basis)
- Treatment only under common law
- Recommendation by doctor (FY2 or above) or approved clinician in charge of patient’s care or their nominated deputy
- Cannot appeal, can only be discharged by responsible clinician
23
Q
What is section 5(4)?
A
- Similar to section 5(2), a registered nurse can detain a patient who is voluntarily in hospital, for 6hrs
- Patient can’t appeal, only be discharged by responsible clinician
- They can do this is they consider there is an immediate risk if the patient were to leave hospital and if it is not practicable to immediately secure the attendance of a doctor who can submit a 5(2).
24
Q
What is section 17 and 17a?
A
17 - patients on section 2+3 can leave from, ward if approved by consultant in charge of care
17a - Supervised Community Treatment (CTO)
Can be used to recall a patient to hospital for treatment if they don’t comply with conditions of the order in the community, such as complying with medication
25
What is section 135?
- Can be used once for warrant to gain access to premises to remove patient to place of safety
- One doctor, AMHP and police
- Allows for further assessment
26
What is section 136?
- Allows police to remove person from public place to place of safety
- Only to be used for up to 24hrs whilst MHA assessment is arranged > section 2
27
What is the follow up from first episode of psychosis?
- Early Intervention and ward team to plan discharge carefully and detail how to get help in a crisis
- Allocate a care coordinator who can continue to co-ordinate follow-up care (community nurse or social worker)
- Care Programme Approach (CPA)
- Within 5yrs 80% will have at least one further episode of illness
28
What are risk factors for schizophrenia?
- Smoking cannabis
- FH of schizophrenia
- Birth complications
29
What are Schneider's first rank symptoms?
- Auditory hallucinations
- Thought disorder
- Passivitiy phenomena
- Delusional perceptions
30
Describe auditory hallucinations
- >/= 2 voices discussing the patient in 3rd person
- Thought echo (patient hears their thoughts as if they are being spoken out loud)
- Voices commenting on patient’s behaviour
31
Describe thought disorder
- Thought insertion
- Thought withdrawal
- Thought broadcasting
32
Describe passivity phenomena
- Bodily sensations being controlled by external influence
| - Actions/impulses/feelings - experiences which are imposed on individual/influenced by others
33
Describe delusional perceptions
2 stage process:
1. A normal object is perceived
2. A sudden intense delusional insight into the objects meaning for the patient e.g. 'traffic light is green so I'm King'
34
What are the second rank symptoms for schizophrenia?
- Impaired insight
- Incongruity/blunting of affect (inappropriate emotion for circumstances)
- Decreased speech (alogia)
- Neologisms - made up words
- Catatonia
- Apathy, avolition, anhedonia
35
What are the negative symptoms of schizophrenia?
- Incongruity/blunting of affect (apathy)
- Anhedonia
- Alogia (poverty of speech)
- Avolition (poor motivation) - leads to neglect of self care
36
What are the types of risk to self?
- Self harm: previous hx, context, severity, current/recent thoughts/actions
- Suicide: previous attempts, context, severity, current/recent thoughts/actions, protective factors, future planning/engagements
- Recklessness/impulsivity: previous hx, current mental state
- Neglect: precious hx, context, treatment/support required, current mental and physical state
37
What are the risks to others in a risk assessment?
- Aggression (verbal/physical): previous hx, severity, police contact/convictions, individuals affected, current mental state, recent behaviour and any threats, interactions during assessment
- Domestic violence: previous hx, severity, police contact/convictions, individuals affected, current partner, recent hx, threats, delusions regarding partner
- Children: previous hx, children under services, forensic hx, current access to children/caring responsibilities
- Arson: previous hx, current threats
- Terrorism: previous hx, contact with prevent, know radicalisation, current threats and mental state
38
What is the risk from others to be considered in a risk assessment?
- Neglect: requiring care of others (hx of neglect), current carer fatigue, evidence of neglect)
- Violence: DV relationship (s), relevant hx, gang affiliations/criminality, current social circumstances, expression of concern, known threats
- Exploitation (e.g. financial, sexual): hx of exploitation, cuckooing, learning difficulties, gang/criminal association, current social circumstances, expression of concern, known threats
39
What is the management of psychosis in the community?
- Alternatives to section 3 hosp admission are Crisis Team and Home Treatment
- Care Programme Approach (CPA)
- Care is overseen by care co-ordinate who should be involved in decisions about hospital (with family members)
- Supported housing schemes
- Psychological input e.g. CBT + family therapy
- Occupational therapy to address disabilities
- Employment and activities support
- Medical input: medication regimes and physical health
40
What are the long term consequences of schizophrenia?
- Around 20% of patients will develop a more chronic illness
- Characterised by severe ‘negative’ symptoms e.g. poor self care, difficulty budgeting, lack of motivation
- May be in and out of hospital and require rehabilitation services or supported housing
41
What is the criteria for detention under the MHA?
- The individual is suffering from a mental disorder
- Any disorder or disability of the mind
- The disorder is of nature +/or degree that warrants detention in hospital
- Nature refers to the type of illness and takes account of the longitudinal course of illness
- Degree is the severity of illness at that point of time
- The person ought to be detained: in the interests of their own health or safety OR with a view to protection of others
