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Schizophrenia Flashcards

1
Q

What is schizophrenia?

A

A long-term mental health condition which causes a range of psychological symptoms including psychosis. It is thought to be caused by dysregulation of multiple pathways in its physiology, including the dopaminergic, glutamatergic, and GABAergic neurotransmitter systems.

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2
Q

What is the difference between positive and negative symptoms of schizophrenia?

A

Positive symptoms reflect an excess or distortion of normal function (e.g, delusions, hallucinations, disorganized behavior)
Negative symptoms refer to a diminution or absence of normal behaviors related to motivation and interest (e.g, lack of interest, avolition (lack of goals), asociality) or expression (e.g, blunted affect, quiet and withdrawn).

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3
Q

What is a prodromal period?

A

A period preceding pyschosis ranging from a few days to 18 months which is characterised by increasing distress and a decline in personal and social functioning.

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4
Q

What are some key signs of a prodromal period?

A

Transient, low-intensity psychotic symptoms.
Reduced interest in daily activities.
Issues with mood, sleep, memory, concentration, communication, and motivation.
Anxiety, irritability, or depression.
Incoherent or illogical speech.

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5
Q

What are risk factors for pyshosis?

A

Family history, especially a first-degree relative.
Stressful life events e.g., job loss, eviction, death, breakup
Childhood adversity e.g., abuse, bullying, parental loss or separation.
South Asian
Migration (especially from a developing country)
*Drug use, especially cannabis, but cocaine, ketamine, LSD etc can cause acute psychosis.
High dose corticosteroid use.
Parental age >40 and <20

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6
Q

If pyschosis or prodromal period is suspected, what should be done?

A

Review medical history to rule out use of prescribed drugs that can cause psychosis
Carry out a urine drug screen for use of recreational drugs.
Carry out a FBC if anaemia is potential cause of negative symptoms.

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7
Q

What prescribed drugs can cause psychosis?

A

Anticonvulsants
High dose corticosteroids
Levodopa/dopamine agonists
Opioids

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8
Q

What is some lifestyle advice for pyshosis/schizophrenia?

A

Offer combined healthy eating and physical activity programme.
Stop smoking.
Peer support worker (recovered and stable)
Self-management programmes - info/advice about condition, effective use of medicines, coping with stress, what to do in a crisis, how to prevent relapse.

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9
Q

How should a first episode of pyschosis be managed?

A

Following assessment by a pschiatrist:
Oral antipsychotic medication + pyschological interventions such as:
Family intervention - 10 sessions of supportive and educational therapy with problem solving and crisis mangement.
Individual CBT - follow a treatment manual to establish links between thoughts, feelings, and actions, and re-evaluate their perceptions, beliefs, and reasonings. Work to promote ways to cope with target symptoms, reduce distress and improve functioning.

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10
Q

When choosing an antipsychotic, what should be considered?

A

Metabolic e.g., weight gain and diabetes
Extrapyramidal e.g., akathisia, dyskinesia, and dystonia.
Cardiovascular e.g., QT interval prolongation
Hormonal e.g., hyperprolactinaemia.

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11
Q

What baseline testing should be done before starting antipsychotic medication?

A
  • Weight
  • Waist circumference
  • Pulse
  • BP
  • Fasting blood glucose or HbA1c
  • Blood lipid profile
  • Prolactin levels
  • Assessment of any movement disorders.
  • Nutritional status, diet, physical activity.
  • ECG – only if they have CVD risk/history, admitted as inpatient, or it is specified in the SPC for the chosen drug.
  • Creatine kinase
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12
Q

How should antipsychotics be prescribed?

A

Treatment of antipsychotics should generally be started at the lower end of the licensed range and titrated upwards within the dose range. A trial of the medication at optimum dosage for 4-6 weeks should be carried out.

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13
Q

What monitoring is required while on antipsychotics?

A
  • Response – changes in symptoms and behaviour
  • Side effects – consider overlap of side effects and schizophrenic symptoms e.g., akathisia, agitation, anxiety.
  • Movement disorders
  • Weight – weekly for 6 weeks, then at 12 weeks, at 1 year, then annually.
  • Waist circumference – annually
  • Pulse and BP – at 12 weeks, 1 year, then annually.
  • Fasting blood glucose or HbA1c and blood lipid levels – at 12 weeks, 1 year, then annually.
  • Prolactin – 6 months, then every 12 months.
  • LFTs – every 12 months.
  • Serum electrolytes and urea, including creatinine and eGFR – annually.
  • Creatine kinase baseline and if NMS suspected
  • Adherence
  • Overall physical health
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14
Q

What is the difference between 1st and 2nd generation antipsychotics?

A

1st generation - block dopamine D2 receptors in the brain (higher risk of EPSEs)
2nd generation - act on a range of receptors, including those in the acetylcholine, histamine, dopamine, noradrenaline, and serotonin pathway.

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15
Q

What are the key differences in side effects between 1st and 2nd generation antipsychotics?

A

1st gen - higher risk of EPSEs
2nd gen - higher risk of weight gain, glucose intolerance, and hyperprolactinaemia

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16
Q

Which antipsychotics are first line?

A

1st gen:
Haloperidol

2nd gen:
Quetiapine
Risperidone
Olanzapine

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17
Q

What are the pros and cons of depot/long-acting risperidone injections?

A

Pros:
Ensures regular reviews
Improves adherence

Cons:
Inconvenient
Uncomfortable/painful
Expensive
Risk of infection

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18
Q

How are risperidone depots used?

A

Dose is converted from oral dose.
Stored in fridge and away from light so must remove 30 mins before use.
Injected every 2 weeks into deltoid or gluteal muscle
Continue oral risperidone for first 3 weeks.

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19
Q

When is clozapine used?

A

In treatment-resistant schizophrenia, when patients haven’t responded to 2 other antipsychotics.

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20
Q

What are some signs of 2nd generation antipsychotics poisoning?

A

Drowsimess
Convulsions
EPSEs
Hypotension
ECG abnormalities

21
Q

What can be given if 2nd gen antipsychotic poisoning is suspected?

A

Activated charcoal within 1 hour of drug ingestion.

22
Q

How should antipsychotic be stopped?

A

Withdrawal after long-term therapy should be gradual over 1-2 weeks and closely monitored to avoid the risk of acute withdrawal syndrome or rapid relapse. Patients should be monitored for 2 years after withdrawal for signs of relapse.

23
Q

What conditions is Haloperidol contraindicated in?

A

Parkinson’s disease or Lewy body dementia
CNS depression
Cardiac disorders

24
Q

What are some common drug interactions of haloperidol?

A
  • Drugs known to prolong Qt interval e.g., SSRIs, tricyclic antidepressants, some antibiotics, anti-arrhymatics.
  • Drugs which cause electrolyte imbalance e.g., diuretics causing hypokalaemia – risk of ventricular arrythmias.
  • Enzyme-inducing drugs – carbamazepine, phenobarbital, rifampicin.
  • CNS depressants e.g., alcohol, hypnotics, sedatives.
25
Q

Why is clozapine administration different to other antipsychotics?

A

People taking clozapine are managed exclusively in secondary care. During initiation, patients require close medical supervision due to risk of hypotension and convulsions causing collapse.

26
Q

How is clozapine prescribed?

A

The dose is started very low and is increased in steps of 25-50mg over 2-3 weeks up to 300mg daily in divided doses. Maximum 900mg per day.

27
Q

When might clozapine serum concentration monitoring be required?

A

Situations which may increase risk of toxicity such as: smoking, use of medicines which increase clozapine plasma concentration, infection, or suspected toxicity.

28
Q

What monitoring does clozapine require?

A

Blood lipids - baseline, at 3 months, yearly.
Weight - baseline, at 3 months, yearly.
Fasting blood glucose - - baseline, at 1 month, then every 4-6 months.
FBC - causes neutropenia and agranulocytosis. Baseline, weekly for 18 weeks, then at least every 2 weeks. If stable for 1 year, this can be reduced to every 4 weeks (+4 weeks after discontinuation.

29
Q

What serious adverse effects are associated with clozapine?

A

Agranulocytosis and neutropenia - leucocytes <3000/mm3 or absolute neutrophil count <1500/mm3, stop clozapine immediately.

Fatal myocarditis - particularly in first 2 months. Assess risk before starting and monitor for persistent tachycardia in first 2 months.

Intestinal peristalsis - leading to constipation, intestinal obstruction, faecal impaction, or paralytic ileus.

30
Q

What are some symptoms of constipation which warrant immediate medical advice in clozapine patients?

A

Stools which are separate hard lumps and are hard to pass, or appear compacted and lumpy.
Straining to pass a stool.
Stomach aches which improve with bowel movement.
Feeling sick or bloated

31
Q

What are some red flag symptoms of intestinal peristalsis which warrant A&E in clozapine patients?

A

Medium-severe abdominal pain or discomfort which lasts over an hour
Swollen or distended stomach aka clozapine belly
Overflow watery diarrhoea (faecal impaction), particularly if there’s blood in the stools
Sickness or vomiting, particularly if it smells of stools.
Absent bowel sounds.
Symptoms of sepsis.

32
Q

When does a person taking clozapine require intervention for constipation?

A

No bowel movement in 2 days and intestinal obstruction has been excluded

33
Q

How is constipation in clozapine patients treated?

A

After 2 days no bowel movement:
1. Stimulant laxative such as senna or bisacodyl

If no improvement in 24 hours:
2. Add an osmotic laxative (macragol, lactulose) or stool softener (docusate sodium)
3. Increase laxative dose every 48 hours until resolution of symptoms.
4. Suspected faecal impactionL high dose macrogol or repeated doses of suppositories

34
Q

Which laxatives should never be used in clozapine patients?

A

Bulk forming - higher risk of faecal impaction

35
Q

What lifestyle advice can be given for constipation in clozapine patients?

A

Increase fibre - at least 30g
Drink at least 2g of water a day
Avoid caffeine - usually has laxative effect but increases clozapine plasma levels so has opposite effect in these patients
Increase mobility or exercise

36
Q

What is procyclidine?

A

Antimuscarinic which blocks central cholinergic receptors to reduce effects of cholinergic excess that occurs as a result of dopamine deficiency. It is used to treat parkinsonism, drug-induced EPSE, and dystonia.

37
Q

What side effects can procyclidine cause?

A

Constipation - don’t use with clozapine
Dry mouth
Urinary retention
Blurred vision
Sedation - avoid driving and alcohol

38
Q

What are extrapyramidal side effects?

A

Akathisia – restlessness
Dystonia – involuntary movements
Parkinsonism – tremor, stiffness
Tardive dyskinesia – permanent involuntary facial movements. Discontinue treatment immediately.

39
Q

What is neuroleptic malignant syndrome?

A

Life-threatening neurologic emergency associated with the use of antipsychotic (neuroleptic) agents dueto dopamine d2 antagonism and characterized by a distinctive clinical syndrome of mental status change, muscle rigidity, fever, and dysautonomia.

40
Q

What is the key difference between NMS (life threatening side effect) and EPSEs?

A

Both cause rigidity, restlessness, and tremors, but NMS causes a fever while EPSEs don’t/

41
Q

Which side effects of antipsychotics apply to all of the main ones?

A

EPSEs - especially haloperidol
Weight gain - especially clozapine and olanzapine.
Dyslipidaemia
Reduced seizure threshold - clozapine
Hyperglycaemia
QT interval prolongation
VTE
NMS
Hepatitis

42
Q

In aggressive patients, what non-medicinal techniques should be used to de-escalate?

A

Recognise early signs of agitation, irritation, and aggression.
Take a one-on-one approach between a staff member and the patient, to form a relationship and trust.
Use emotional regulation and self-management techniques to control anxiety or frustration.
Use a designated area to reduce emotional agitation.

43
Q

What is the steps of de-escalation?

A
  1. Verbal approaches
  2. Manual restraint
  3. Mechanical restraint
  4. Rapid tranquilisation
44
Q

What is used for rapid tranquilisation?

A
  1. IM lorazepam
  2. IM haloperidol with IM promethazine
45
Q

Why is lorazepam generally first line over haloperidol for rapid tranquilisatoin?

A

Risk of QT prolongation and EPSEs

46
Q

What should be monitored following rapid tranquilisation?

A

Consciousness
Respiratory rate
Hydration level
Pulse rate
Systolic BP
Temperature

Usually, at least every hour until no more concerns. Evert 15 mins if they have taken drugs/alcohol, have a pre-existing health issue, or experienced harm during intervention.

47
Q

Which sections allow someone to be detained?

A

Section 135 - allows police to enter someones home and hold them in a safe place until they have been assessed by a HCP, for a maximum of 36 hours.
Section 136 - allows police to find someone in public and hold them in a safe place until they have been assessed by a HCP, for a maximum of 36 hours.

Section 5(4) - if patient is in hospital, certain nurses can detain them for up to 6 hours until the doctor can make a further decision.
Section 5(2) - doctors can detain someone in hospital for 73 hours while they receive an assessment to determine if they can be detained under the mental health act.

Mental health act:
Section 2 - up to 28 days
Section 3 - up to 6 months, with further renewals.

48
Q

While detained, can patients leave?

A

Generally, no. However, under section 17 under the MHA, patients can leave under certain conditions for a fixed period if authorised by a doctor. This can be revoked at any time.

49
Q

How is medicine administration goverened under the MHA?

A

People detained under the mental health act can be held and treated against their will. If under section 3, medicines can be given for 3 months from the first dose. If they are detained under section 2 then section 3, the 3 months doesn’t restart. A capacity assessment and consent to treatment form must be done

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