Schizophrenia Flashcards
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
When does schizophrenia usually present?
In young adults - especially when they transition into independent living
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
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
What symptoms follow the prodromal period of schizophrenia?
-An acute episode marked by hallucinations, delusiona nd behavioural disturbances accompanied by agitation and distress
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
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
What is duration criteria for acute schizophrenia?
Symptoms must persist for at least one month
What is the exclusion criteria for schizophrenia?
-Not secondary to a mood disorder
-No organic cause (ampethamines, temporal lobe dementia)
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
What is the most common type of schizophrenia?
-Paranoid
Note: in this type personailty is normally resevred
Examples of auditory hallucinations?
-Third person discussion
-Though echo
-Voice commenting on patients behaviour
Examples of thought disorder?
-Thought insertion
-Thought withdrawal
-Thought broadcasting
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
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’.
What are some other features of schizophrenia?
-Impaired insight
-Negative symptoms
-Neologism
-catatonia
What kind of symptoms are more prominent in chornic schizophrenia?
-Negative symptoms
What is it called when the negative symptoms are prominent?
A deficit syndorme
What are the “three clusters” of chornic schizophrenia?
-Relaity disortion (delusions and hallucinations)
-Disorganisation (thought disorder)
-Psychomotor poverty similar to negative symptoms
What are the negative symptoms seen in schizophrenia?
-Flattened (blunted) mood
-Apathy and loos of drive
-Social isolation
-Poverty of speech
-Poor self care
How is management of acute schizophrenia consdiered?
-According to stage of illness (acute vs chronic)
-According to intervention (physical, psychological , social)
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
Prevention/early intervention of psychosis?
-Early intervention in psychosis (EIP) service
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
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
