Schizophrenia Flashcards
What is Schizophrenia?
Chronic relapsing condition, form of psychosis with distortion to thinking and perception and inappropriate or blunted affect
When does schizophrenia present?
15-30
Earlier in men than women
How long must symptoms be present for schizophrenia to be diagnosed?
1 month
What is Schizoaffective disorder?
Symptoms of schizophrenia with bipolar disorder
Patients have psychosis and symptoms of depression and mania
What is Schizophreniform disorder?
Same features as schizophrenia but less than 6 months
How would you explain schizophrenia to a patient?
Condition that affects how the brain processes information
Brain struggles to understand the world and makes mistakes deciding what information is important and organises thoughts in a confused way
This causes strong beliefs that do not fit with reality called delusions and experience voices that are not there called hallucinations
What is psychosis?
Individual is experiencing a reality different to everyone else
Lack of insight
How long does it take for a psychotic episode to happen?
Can begin suddenly or gradually
How long do psychotic episodes last?
Days, weeks or months
Longer the psychosis, more damaging effects
What is a hallucination?
Perception in the absence of an external stimulus
Are voices in the head psychosis?
No, pseudohallucination
What is formal thought disorder?
Problem of speech, which means each sentence does not follow on from the next
What can a psychotic episode cause?
Personality change
What can cause psychosis?
Psychotic depression
Stroke
Hyperthyroidism
Cushing’s syndrome
Huntington’s
Steroid induced’
Brain tumours
Drugs
Mania
What causes schizophrenia?
Genetic and environmental factors
Family member affected is a large risk factor
What is the chance of schizophrenia in identical twins if one twin is affected?
50%
Environmental factors also contribute to risk of development
How does schizophrenia first present?
Prodrome phase
Precedes full symptoms of psychosis
Patient experiences subtle symptoms
What are the central features of schizophrenia?
Delusions
Hallucinations
Thought disorder (disorganised thoughts causing abnormal speech and behaviour)
What is lack of insight?
Important feature of psychosis
Lack awareness that delusions and hallucinations are not based in reality
What are the key positive symptoms typical in schizophrenia?
- Auditory hallucinations
- Persecutory delusions (someone is going to harm them)
- Somatic passivity (external entity is controlling their sensations and actions)
- Thought insertion or withdrawal
- Thought broadcasting
- Ideas of reference (events or details relate to them)
- Delusional perceptions
What are the key negative symptoms of schizophrenia?
5 As
Affective flattening (minimal emotional reaction to emotive subjects or events)
Alogia (reduced speech)
Anhedonia
Avolition (lack of motivation towards goals)
Asociality (no desire for social interaction)
What is a delusional perception?
Delusion formed in response to external stimulus without any logical sense
e.g. watching TV and believing you were chosen to meet the president
What does a reduced level of functioning involve in schizophrenia?
Social engagement
Productivity and achievement at work or school
Self-care
What are the patterns of schizophrenia?
Continuous
Episodic
Single episode only
What is diagnosis of schizophrenia based on?
ICD-11 criteria only
Below is what DSM5 uses
Symptoms present for at least 6 months
Symptoms of active phase must be present for at least 1 month
How is schizophrenia managed?
Early intervention in psychosis
For first episodes of psychosis
Crisis resolution and home treatment teams
Urgent support for patients in a crisis
Acute hospital admission
Community mental health team
Ongoing monitoring and management
What are Schneider’s first rank symptoms of schizophrenia?
ABCD
Auditory hallucination, about the person in the 3rd person, a voice or voices giving running commentary on the patient’s actions or thoughts in 3rd person
Broadcasting of thought
Controlled phenomenon - feelings, actions or impulses controlled by something or someone else
Delusional perception
How is schizophrenia treated?
Antipsychotics
CBT
What are antipsychotics also called?
Neuroleptics
How do antipsychotic medications work?
Inhibiting dopamine receptors
D2 receptors
What pathways are targeted?
Mesocortical
Mesolimbic
Where do unwanted side effects of antipsychotic use come from?
Nigrostriatal
Tuberoinfundibular
What are some examples of oral antipsychotics?
Chlorpromazine
Haloperidol
Quetiapine
Olanzapine
Risperidone
What are depot antipsychotics and when are they used?
IM injections every 2 weeks-3 months
Useful when adherence is an issue
Aripiprazole
Risperidone
Paliperidone
What can happen with chlopromazine use?
Oculogyric crisis
Dystonic reaction, causes extrapyramidal effects
What do you give for extrapyramidal side effects? e.g. oculogyric crisis
Procyclidine
When is clozapine used?
When other treatments do not control symptoms
Only available orally
Very effective but significant adverse effects
What are the adverse effects of clozapine?
Agranulocytosis
Myocarditis
Constipation
Seizures
Excessive salivation
What are the common side effects of clozapine use?
Constipation
Excess salivation
Weight gain
Sedation
Metabolic disturbances
Before starting antipsychotics and during what is monitored?
- Weight and waist circumference
- BP and HR
- Bloods
- ECG
What are the side effects of antipsychotics?
- Weight gain
- Diabetes
- Prolonged QT interval
- Raised prolactin
- Extrapyramidal symptoms
What are the extrapyramidal side effects?
Akathisia (inability to stay still)
Dystonia
Pseudo-parkinsonism
Tardive dyskinesia (abnormal movements, particularly affecting face)
What can be given for tardive dyskinesia?
Tetrabenazine
T=Tardive
What is the difference in side effects between typical and atypical antipsychotics?
Typical
More likely to cause extra-pyramidal side effects
Dizziness
Sexual dysfunction
Binds to more muscarinic and histaminic receptors
Atypical
More serotonergic activity
Weight gain
Dyslipidaemia and diabetes
What are some examples of Typical antipsychotics?
Haloperidol
Chlopromazine
Flupenthixol
Zuclopenthixol
Sulpiride
What are some examples of Atypical antipsychotics?
Clozapine
Olanzapine
Quetiapine- used in BPAD, can increase risk of lithium toxicity
Risperidone
Amisulpiride
Aripipzaole
How does clozapine work?
D2 antagonist
5HT-2 antagonist
When is clozapine used?
In schizophrenia after two other antipsychotics have not been effective
How is clozapine monitored?
Agranulocytosis risk
Weekly FBC for first 18 weeks
Biweekly for up to a year
Then monthly
What is the highest cause of fatality in clozapine use?
Significant hypo-mobility of the bowels
Constipation causing fatal bowel obstruction
How is agranulocytosis treated?
Stop clozapine
Stop any other bone marrow suppressors e.g. sodium valproate
If antipsychotic needed give aripiprazole
Prophylactic ABx
Lithium to increase WCC and neutrophil count
Consider G-CSF
What is neuroleptic malignant syndrome?
Life threatening complication of antipsychotics
Typical Triad
Muscle rigidity
Hyperthermia
Altered consciousness
Autonomic dysfunction
What causes death in neuroleptic malignant syndrome?
Rhabdomyolysis
Renal failure
Seizures
What are the risk factors for neuroleptic malignant syndrome?
High potency dopamine antagonists (typical antipsychotics)
High doses
Young men
What are the key blood findings in neuroleptic malignant syndrome?
Raised creatine kinase
Raised white cell count
How is neuroleptic malignant syndrome managed?
Stop causative medications
Supportive care- cooling blankets, fluids etc
Bromocriptine (dopamine agonist) in severe cases with dantrolene (muscle relaxant)
How is rhabdomyolysis treated in neuroleptic malignant syndrome?
Fluids and sodium bicarbonate
Alkalises the urine
What is part of the mesocortical pathway and what does it do?
Ventral tegmental area
Prefrontal cortex
Executive functions
What is part of the nigrostriatal pathway and what does it do?
Substantia nigra
Caudate nucleus
Putamen
Motor function
Reward-related cognition
Associative learning
What is part of the tuberoinfundibular pathway and what does it do?
Hypothalamus
Pituitary gland
Prolactic secretion
Why can gynaecomastia develop in antipsychotic use?
D2 receptor inhibition in the tuberoinfundibular pathway
This causes a rise in prolactin as there is reduced regulation from reduced dopamine
Increase prolactin leads to gynaecomastia, galactorrhoea, reduced libido
What antipsychotic has the lowest risk of hyperprolactinaemia?
Aripiprazole
Why does olanzapine not work as well in patients who smoke?
Smoking can induce CYP450 enzymes in the liver
This causes increased breakdown up to 50% of olanzapine, so patients will need an increased dose
