Schizophrenia Flashcards
What is Schizophrenia?
A disease of neuronal disconnection
What are the causes of Schizophrenia?
Migration, infections, viruses and toxins. Could be family history - genes
What is the difference between Typical and Atypical treatments?
Typical treat just the positive symptoms and works just on dopamine exclusively. This is 1st generation
Atypical - Works on Dopamine, 5Ht-2a. This is 2nd generation drugs.
What is the peak age onset for Schiz?
Men: 21-26 years
Women: 25-32 years
What are the different models in Schiz?
Vulnerability model - stress precipitator, depending on personality, social network or environment
Developmental model - Prenatal and perinatal development key - also adolescence
Ecological model - External factors - social and cultural factors
Genetic model - Higher incidence in siblings
Transmitter abnormality model - Dopamine theory
What are positive symptoms of Schiz?
Positive symptoms add something to what wasn’t there .
Symptoms include:
These normally respond well to antipyschotics.
Hallucinations - sensing an external stimulus that isn’t there; any sense can be affected
Delusions - Believing in something that’s not true
Thought disorder - distorted or illogical speech, no logical chain of thought
Lack of insight - unaware that they are unwell
What are negative symptoms of Schiz?
Negative symptoms take away
Symptoms include:
Poor response to antipsychotics
- Apathy (lack of emotion, feeling, passion, concern)
- Self-neglect
- Emotional blunting / affective flattening
- Alogia
- Avolition (loss of motivation and initative)
- Social / occupational dysfunction
What are some rating sclaes to assess symptoms?
Brief Psychiatric rating schale; scales for the assessment of positive/negative symptoms (SAPS, SANS); Positive and Negative Syndrome Scale (PANSS)
What should be done if onset of psychosis is suspected in a patient?
The patient should be referred quickly to secondary care such as early intervention team, crisis resolution or home treatment teams, community mental health teams etc.
A mental health care professional needs to confirm psychotic symptoms; depending on risk assessment, presentation ect, the patient may be admitted to Hospital
What is needed for a Schiz patient to be admitted to Hospital?
Consent of patient OR the use of the Mental Health Act (e.g. to section the patient).
What is the management for Acute episodes / first episode psychosis?
- Offer oral antipsychotics - decision of which made by the service user and health care professional together
- Offer pyschological interventions (family intervention etc.)
Treatment is more effective when both of these are used together
What are the different classifications for antipsychotic medications with Schizs?
Metabolic - weight gain, diabetes
Cardiovascular - Prolonging the QT interval
Hormonal - Hyperprolactinaemia
Extrapyramidal - Akathisia, dyskinesia and dystonia
Other - Unpleasant subjective experiences such as dysphoria
What baseline investigations should be recorded before starting antipsychotic medications?
- Weight
- Waist circumference
- Pulse and blood pressure
- Fasting blood glucose or HbA1C
- Blood lipid profile
- Prolactin levels
- Assessment of movement disorders
- ECG
- Assessment of nutritional status, diet and level of physical activity
What are the NICE prescribing guidlines for Schiz?
NICE recommends starting treatment at lowest dose and increasing slowly if needed.
Antipsychotics medication should be used at optimum dosage for a minimum of 4-6 weeks before review.
Loading dose of antipsychotic should not be used and should not be prescribed concurrently except for short changeover periods
Small response to optimum dose should result in changing the class.
If bad side effects occur with typical antipyschotics, consider atypical
Polypharmacy should be reserved for inadequate therpay
How long should antipsychotic medications be taken for, for Schiz?
1-2 years, and withdraw gradually to reduce the high risk of relapse
Monitor for relapse for 2 years after medications have been withdrawn
What adherence must you consider for antipsychotic medications for Schiz?
- Poor tolerability - switch drug
- Poor memory - consider compliance aids, alarms etc
- Lack of insight or personal preference - depot/long-acting injection
What should be monitored and when?
Response to treatment including changes to symptoms and behaviour - Regularly and systemically throughout, especially during titration
Side effects of treatment - Regularly and systemically throughout, especially during titration
The emergence of treatment disorders - Regularly and systemically throughout, especially during titration
Weight - Weekly for the first 6 weeks, then at 12 weeks, at 1 year and then annually (plotted on chart)
Waist circumference - Annually
Pulse and blood pressure - At 12 weeks, at 1 year and then annually
Fasting blood glucose, HbA1c and blood lipid levels - At 12 weeks, at 1 year and then anually
Adherence - Regularly and systemically throughout, especially during titration
Overall physical health - Regularly and systemically throughout, especially during titration
How do typical and atypical antipsychotics work?
Typical works by blocking D2-receptors
Atypical are less potent at D2-receptors and also have an affinity of serotonin receptors (5HT-2A).
What do Typical antipsychotics affect?
It effects positive symptoms.
Not as effective on negative and may make it worse
What are the Typical pyschotics medications?
Phenothiazines are subdivided into 3 groups:
- Group 1 includes chlorpromazine - most sedating and causes photosensitivity reactions; can also cause hypersensitivity reaction. Lowers seizure threshold. Has moderate antimyscarinic and extra-pydramidal side effects.
- Group 2 includes pericyazine - has moderate sedative effects, marked antimuscarinic effects but less extra-pydramidal side effects than group 1 or 3
- Group 3 includes trifluoperazine - has fewer sedative effetcs, less antimuscarinic effects but more extra-pydramidal side effects than group 1 or 3
Butyrophenones - Haloperidol; optimal response around 10-12mg/day
Thioxanthines - Flupentixol and zuclopenthixol are usually prescribed as depots
Diphenylbutylpiperidines - Pimozide
Substituted benzamides
What are some atypical antipsychotics?
Clozapine - only effective when treating resistant schizophrenia. And effective in negative symptoms. Requires regular haematological and cardiac monitoring
Olanzapine - sedative, produces some postural hypotension and has anticholinergic side effects, weight gain – increased risk of diabetes and raised
plasma lipids
Risperidone: Adverse side effetcs at high doses, causes hyperprolactinaemia and has a first dose hypotensive effect, so increasing dosing regimen used over first few days
Quetiapine: Requires dose titration (like risperidone), causes raised plasma lipids and can induce hypothyroidism
Amisulpride
Aripiprazole, paliperidone (a metabolite of risperidone), lurasidone, cariprazine - THESE ARE NEWER
What are the side effects of Clozapine?
- agranulocytosis (0.8%)
- neutropenia (3%)
- thromboembolism
- cardiomyopathy
- myocarditis
- constipation
What must be considered for depot injections / long-acting injections?
Typical antipsychotics - deconoate ( “ x deconoate”) - require the administration of a “test dose”
before proceeding to access for tolerability
Administer typical depots at the longest possible licensed interval (usually 2-4
week intervals.
Always begin at lowest therapeutic dose
Atypicals such as risperidone, paliperidone, aripiprazole, olanzapine) - require a period of oral administration before proceeding to the long-acting injection. This is to test for tolerability and efficacy.
Atypicals can be administered at different time-intervals:
Risperidone:
- Risperdal Consta every two weeks
- Okedi every four weeks
Paliperidone:
- Xeplion every month
- Trevicta every three months
Aripiprazole (Abilify) every month
Olanzapine (ZypAdhera) every two to four weeks
After adequate period of assessment, adjust dose if needed.
What are the side effects of Antipsychotics?
Extra-pydramidal side effects (EPS, EPSEs)
Hyperprolactinaemia
Cardiovascular and Metabolic side
effects
Neuroleptic malignant syndrome
(NMS)
- Postural hypotension
- Anticholinergic side effects
- Reduced seizure threshold
What are the Extra-pyramidal side effects of Antipsychotics?
Dystonia, pseudo-parkinsonism, akathisia, tardive dyskinesia (TD).
Dystonia – oculogyric spasm and torticollis – treat with anticholinergic (e.g.
procyclidine).
Parkinsonian – tremor, rigidity etc - treat with anticholinergic, not dopamine
agonists.
Akathisia – motor restlessness 20-25% on typicals- switch to atypical if severe or add propranolol. Aripiprazole and lurasidone commonly cause akathisia
TD – reduce and discontinue anticholinergics as these worsen TD, reduce antipsychotic to minimum effective dose, switch to an atypical as they are less
associated with TD.
EPSEs much more common with typicals but can occur in higher doses in atypicals
What is hyperprolactinemia? And what medications can cause it?
A condition of too much prolactin in the blood of women who are not pregnant and in men.
All typicals have risk of hyperprolactinaemia.
Olanzapine has minimal effect.
Risperidone and amisulpiride have potent effects.
What are the Cardiovascular and Metabolic side effects of antipsychotic medications?
- Psychotropic-related QT prolongation
- Diabetes and impaired glucose tolerance
- Hyperlipidaemia
- Weight gain
What rare condition can antipsychotics cause?
Neuroleptic malignant syndrome
(NMS)
Caused by:
- Rapid blockade of dopamine receptors leading to a resetting of thermoregulatory systems and severe skeletal muscle spasm.
- Considerable heat load that cannot be dissipated
- And enormous load of muscle breakdown products leading to severe renal damage
Symptoms include:
- Mild to moderate hyperthermia
- Fluctuating consciousness
- Muscular rigidity
- Severe EPSE especially rigidity
- Increased serum creatine phosphokinase
leucocytosis and LFTs abnormal.
What must be done when withdrawing from Antipsychotic?
Slowly taper antipsychotic probably over at least 8 weeks
Slowly taper any anticholinergic that was started to treat antipsychotic-induced adverse effects.
Monitor mental and physical state regularly, especially in first month
If reducing off depots - Discontinue oral antipsychotics first if on any; Increase interval between injections up to 4 weeks before decreasing dose; Reduce dose by no more
than one third at any one time;
Special consideration is needed for Risperdal Consta due to it’s pharmacokinetic profile
What must be considered when thinking about switching Antipsychotic?
- The stability of the person’s mental health
- The emergence of intolerable adverse effects from the initial antipsychotic
- The emergence of new adverse effects from the next antipsychotic
- The pharmacokinetic and pharmacodynamic profiles of the two antipsychotics
What approaches can be done when switching antipsychotic?
One common approach is to taper off first drug, then gradually increase second drug with no drug-free interval.
Alternatively, taper off first drug with partial overlap with gradual increase of second drug.
