Schizophrenia Flashcards by Jess Morgan

How is schizophrenia distinguished from other psychosis?

-Presence of specific types of delusions, hallucination and thought disorder
-The primary disorder is not one of effctive or organic aetiology
-The clinical course

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When does schizophrenia usually present?

In young adults - especially when they transition into independent living

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What does the course of schizophrenia look like?

-Prodromal period, preceding a first episode of psychosis
-Followed by an acute episode of marked by hallucinations, delusions and behavioural disturbance accompanied by agitation and distress
-Pharmacological intervention usually happens at this stage but negative symptoms can remain which lasts for years

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What is the prodromal period charcterised by?

-Deterioration of personal function
-Short lasting and mild psychotic symptoms
-Memory and concentration problems
-Unusual behaviour and ideas
-Issues with communication
-Social withdrawal, apathy and reduced interest in daily activities

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What symptoms follow the prodromal period of schizophrenia?

-An acute episode marked by hallucinations, delusiona nd behavioural disturbances accompanied by agitation and distress

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What are first rank symptoms?

-Thought insertion, echo, withdrawal or broadcasting
-Third person auditory hallucinations
-Running commentary
-Passivity of thought, feelings or action
-Delusional perception

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What are the characteristic symptoms of acute schizophrenia?

-First rank symptoms
-Bizarre delusions
-Odd behaviour
-Thought disorder
-Lack of insight
-Prodromal period of decline in perfromance and social withrdrawal

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What is duration criteria for acute schizophrenia?

Symptoms must persist for at least one month

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What is the exclusion criteria for schizophrenia?

-Not secondary to a mood disorder
-No organic cause (ampethamines, temporal lobe dementia)

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What are the subtypes of schizophrenia?

-Paranoid - persecutory, systematized delusions, hallucinations (usually audiory)
-Disorganised (though disorder, odd behaviour, bizarre delusions)
-Catatonic (motor signs) - this is now more rare

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What is the most common type of schizophrenia?

-Paranoid
Note: in this type personailty is normally resevred

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Examples of auditory hallucinations?

-Third person discussion
-Though echo
-Voice commenting on patients behaviour

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Examples of thought disorder?

-Thought insertion
-Thought withdrawal
-Thought broadcasting

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Examples of passivity phenomena?

-Bodily sensations being controlled by external influence
-Action/impulses/feelings experiences which are imposed on the individual or influenced by others

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How do delusional perceptions occur?

a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.

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What are some other features of schizophrenia?

-Impaired insight
-Negative symptoms
-Neologism
-catatonia

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What kind of symptoms are more prominent in chornic schizophrenia?

-Negative symptoms

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What is it called when the negative symptoms are prominent?

A deficit syndorme

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What are the “three clusters” of chornic schizophrenia?

-Relaity disortion (delusions and hallucinations)
-Disorganisation (thought disorder)
-Psychomotor poverty similar to negative symptoms

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What are the negative symptoms seen in schizophrenia?

-Flattened (blunted) mood
-Apathy and loos of drive
-Social isolation
-Poverty of speech
-Poor self care

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How is management of acute schizophrenia consdiered?

-According to stage of illness (acute vs chronic)
-According to intervention (physical, psychological , social)

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Why is gradual onset associated with worse prognosis?

-Psychosis is toxic, the longer a patient is psychotic the more it will affect their cognitive abilities
gradual onset delays diagnosis and treatment so worse prognosis

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Prevention/early intervention of psychosis?

-Early intervention in psychosis (EIP) service

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What is the aim of EIP service?

to enage patients with very early symptoms of psychosis from adulthood unitl 35
-Patients offered antipsychotics and psycholoigcal interventions
-Aim is to keep duration of untreated psychosis under 3 motnhs

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What is the earliest age a ateitn can be referred to EIP?

-14 -CAMHS can manage psychosis in children up to 17

Patient in EIP but needs urgent intervention?

-Crisis resolution team -Home treatment team

What is the mode of action of antipsychotics?

-Block dopamine (D2) receptors

Why does blockade of D2 receptors help with symptoms of psychosis?

It is thought that excessive dopamine in the mesolimbic system cause the symptoms of psychosis

How is an atypical antipsychotic descirbed?

An antipsychotic that does not produces extrapyramidal side effects (EPS)

Typical antipsychotics?

-Chlorpromazine -Haloperidol -Flupentixol decanoate

Atypical antipsychotics?

-Olanzapine -Risperidone -Quetiapine -Aripiprazole -Amisulpride -Clozapine ? though this is a unique antipsychotic

What are the main typical antipsychotics that are used?

-Haloperidol -Chlorpromazine

What are extrapyramidal side effects (EPS)?

Involuntary movements that patient is unable to control -MOTOR ABNORMALITY

Why do EPS occur with antipsychotic use?

-EPS are motor abnormalities that are related to dopaminergic receptor blockade in the basal ganglia

WHat are the four types of EPS?

1.Acute dystonia 2.Tardive dyskinesia 3.Akathisa 4.Parkinsonism

What is acute dystonia?

-Painful contraction of muscles in head, neck and jaw

What group of people are particularly vulnerable to acute dystonia when given antipsychotics?

Young men that are uven high doses

what is the onset of acute dystonia?

Happens within hours or days

What is the tretament for acute dystonia?

IM and IV anticholinergic

How does parkinsonism present?

-Decreased facial movements -Shuffling gait -Stiffness -Tremor

How are parkinsonism features managed?

-Reduce dose -Anticholingeric

what can parkinsonism features sometimes be confused with when giving antipsychotics?

-Depression -Negative symptoms of schizophrenia

What is akathisia?

-Feeling of restlessness and need to walk around NOTE: can be confused with psychotic behaviour

When do parkinsonism symptoms normally occur once given antipsychotics?

Early weeks of treatment

Management for symptoms of akathisia?

-Lowering dose -Propanolol

What is tardive dyskinesia?

-Uncontrollable grimacing movements of face, tounge and upper body -Very distressing and disabling

How common is tardive dyskinesia?

-Occur in 5% of people who take long term antipsychotics every year -No way of predicting who will develop it

Treatment for tardive dyskinesia?

-No reliable treatment -Sometimes irreversible

What are the two more rare but life threatening conditions?

-Neuroleptic malignant syndrome (NMS) -Prolongation fo QTc interval on ECG

What are the clinical features of neuroleptic malignant syndrome?

-Fever (pyrexia) -Stiffness -Autonomic instability (tachycardia and fluctuating BP)

What are charcterisitic lab features of neuroleptic malignant syndrome?

-Raised creatine kinase -Leukocytosis (increaseWBC) -Metabolic acidosis

What is the incidence of neuroleptic malignant syndrome?

-1 in 500

How serious is neuroleptic malignant syndrome?

-Life threatening -Fatal in around 10%

What antipsychotics does neuroleptic malignant syndrome occur with?

-Can occur with any -Particularly with high dose such as haloperidol -Can also occur following an increase of dose

After an episode of NMS how do you restrat antispychotic?

-Restart gradually with atypical antipsychotic and close monitoring

What does prolonged QTc on ECG predispose patient to and why does this occur?

-A serious arrhythmia - torsade de pointes - IT is thought to be related to inhibition of specific cardiac potassium channels -Thought to increase the low but increased incidence of sudden death in people using antipsychotics

Why are atypicals used over typicals in tretament of schizophrenia?

-Due to side effect profiles -There is no good evidence that atypicals are more effective than typicals

What atypical antipsychotic has best long-term evidence for efficacy?

Risperidone NOTE: availble as depot

What is the antipsychotic that has second best evidence for long term efficacy ? (aside form clozapine)

Olanzapine

What type of symptoms is amisulpride effective against?

Negative symptoms

Where is quetiapine particularly useful?

-Treatemnt of depressive epidosde in bipolar disorder

What particular side effct does quetipine have?

It is very sedating

How is aripiprazole different?

-It is a dopamine PARTIAL AGONIST - It stabilises dopamine antagonising it when levels are high and mimicking when levels are low

What are the side effects associated with atypical antipsychotics ?

-Weight gain -Hyperglycaemia and T2DM -Metabolic syndrome (comprises duslipidaemia and hypertension -Stroke

What antipsychotics are more likely to cause weight gain, hyperglycemia and T2DM?

-Olanzapine -Clozapine

What are other side effects of antipsychotics?

Hyperprolactinaemia -Galactorrhoea -Amenorrhoea -Gynaecomastia -Hypogonadism

What must you check before tretament with antipsychotic?

-History of hypertension, CVD, diabetes and obesity -BP and pulse -BMI -Waist and hip circumference -Glucose and lipid levels -HbA1c NOTE: GP will monitor and treat

What should be taken every clinic appointment in someone taking antipsychotics?

-BMI -Waist and hip circumference -BP and pusle

What should be monitored every three years for first year then annually?

-Glucose and lipid profile NOTE: glucose does not need to be fasting

What should be monitored annualy?

HbA1c

How do you manage abnormalities of antipsychotic use?

-Advice and information on diet and lifestyle -Can swtich to an antipsychotic less liekly to cause metabolic syndrome (if taking olanzapine or clozapine) -Treat diabetes, hypertension and hyperlipidemia as usual

What psychological management can be helpful in schizophrenia?

-CBT 16 weeks (useful positive symptoms -Social skill training for negative symptoms -Family therapy -Concordance therapy where patient is encouraged to consider pros and cons of treatment

What antipsychotic is used in patients with schizophrenia that has been resistant to other antipsychotics?

Clozapine

What is treatment resistance defined as in schizophrenia?

-Failure to respond to 2 or more antipsychotics at least one of which is an atypical, given at a therapeutic dose for 6 weeks

How effective is clozapine in individuals with treatment resistant schizophrenia?

30% of patients

What is clozapine thought to reduce in schizophrenia?

Suicide risk NOTE: no clearly greater efficacy against negative or cognitive symtpoms

What is the biggest risk that clozapine carries?

It causes agranulocytosis in 1-2% patients

Define agranulocytosis

-Absolute neutrophil count (ANC) is less than 100 neutrophils per microlitre of the blood

What must be monitored weekly in patients taking clozapine?

-WCC -Patients must be registered with clozapine monitoring service -Test weekly to check for early signs of neutropenia

Presentation of argunulocytosis?

Fever (normally >40) , chills, hypotension, swollen tender gums, increase RR, tachycardia,

Aside from agranulocytosis what other side effcts can clozapine cause?

-Weight gain -Hyperglycemia -T2DM -Metabolic syndrome -Hypersalivation -Weight gain -Seizure can also occur at high doses