Schizophrenia Flashcards
Schizophrenia - dx
A. Two or more of the following, each present for a significant portion of time during a 1mo period (or less if successfully treated), with at least one of these being 1, 2 or 3:
1. Delusions
2. Hallucinations
3. Disorganised speech (e.g. frequent derailment or incoherence)
4. Grossly disorganised or catatonic behaviour
5. Negative symptoms (e.g. diminished emotional expression or avolition)
B. Functioning impaired
C. Continuous signs of disturbance for >6mo (>1mo of symptoms + prodromal or residual symptoms)
D. Not schizoaffective disorder or bipolar disorder with psychotic features (e.g. no major depressive or manic episodes, or mood episodes only present for a minority of total duration of illness)
E. Not due to physiological effects of a substance (e.g. drug of abuse, medication) or another medical condition
F. ASD - special case
Schizophrenia - epi
Prevalence 1.5-2%
Schizophrenia - RF
- Complications during pregnancy, delivery and neonatal period; delayed walking and neurodevelopmental development
- Early social services contact and disturbed childhood behaviour
- Severe maternal malnutrition
- Cannabis use, especially during adolescence
- Family history - siblings, parents
Schizophrenia - etiology
- Dopaminergic overactivity
- Glutaminergic hypoactivity
- Serotonergic (5-HT) overactivity
- a-adrenergic overactivity
- GABA hypoactivity
Schizophrenia - categories
- Paranoid
- Disorganised (disorganised speech behaviour)
- Catatonic
- Undifferentiated
- Residual
Schizophrenia - ddx
- Substance-induced psychotic disorder
- Psychotic disorder due to general medical condition
- Mood disorders with psychotic features
- Acute/transient (brief) psychotic disorder and schizophreniform disorder
- Sleep-related disorders
Schizophrenia - ex (2)
- Full systematic physical examination - systemic comorbidities
- Neurological examination
Schizophrenia - ix
- Routine = FBEs, UEC, LFTs, calcium, FBG
- If suggested by history/examination = VDRL (for syphilis), TFTs, PTH, cortisol, tumour markers
- Radiological = CT, MRI (only in presence of suggested neurological abnormality or persistent cognitive impairment), CXR (only if comorbid respiratory or cardiovascular condition)
- Urinary drug screen, MCS
- EEG rarely necessary unless hx of seizure or symptoms suggest TLE
Schizophrenia - mx (prodromal stage)
Prodromal stage = deterioration in level of functioning + positive fhx, brief instances of positive symptoms
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Mx of first psychotic episode (3)
- Psychiatric hx, MSE, physical ex (with neurological focus), ix (FBE, UEC + ca, LFTs, FBG, serum lipids, TFTs, prolactin, urine toxicology, CT/MRI brain, immunological screen/EEG if indicated). Conduct blood tests before commencing antipsychotics, if possible
- Risk assessment - to themselves, risk of violence, insight + ability to accept treatment. Assess need for hospital admission and suitability of the ward environment (clinical condition of pt + availability of both community mental health resources and family or other social supports; be aware of drug-induced/drug-withdrawal state). Regular review in first 72 hours
- Emergency tx of behavioural disturbance (3):
a. Oral lorazepam 1-2mg + oral antipsychotic (e.g. haloperidol 10-20mg, chlorpromazine 50-100mg)
b. IM lorazepam + haloperidol if oral medication refused/failed
c. If immediate tranquilisation necessary (exceptional circumstances) = IV benzodiazepines (e.g. diazepam 10mg slow IV bolus
Schizophrenia - mx (maintenance - 3)
- Psychological and psychosocial therapies for schizophrenia (5):
a. Assertive community tx (assistance with medication concordance, social skills training, welfare support)
b. Psychoeducation
c. CBT (asks pt to examine evidence for psychotic belief and using problem-solving skills to challenge and decrease the salience and threat of their beliefs)
d. Behavioural therapy (altering dysfunctional habits or behaviours by changing the consequence of those behaivours)
e. Motivational interviewing and CBT - for substance use/dependence - Instigation of antipsychotic treatment (3):
- Oral second generation antipsychotic (SGA) other than sertindole or clozapine (reserved for special cases). Start with low dose, rising to initial target dose. Increase dose if no response within next 1-2 weeks or 3-4 weeks if response inadequate
- Long-acting BZD (e.g. diazepam) = controlling non-acute anxiety/behavioural disturbance
- Tx extra-pyramidal side effects with procyclidine orally (or alternative)
- Tx concurrent anxiety and depression, and comorbid abuse of alcohol, nicotine +/- illicit drugs
Schizophrenia - mx (relapse)
- Risk assessment - harm to self and others, degree of insight and disorganisation
- Consider commencing a depot antipsychotic if poor concordance despite tx intervetnion
- If obvious affective symptoms (especially manic-like), consider adding lithium, carbamazepine or sodium valproate to maintenance antipsychotic drugs
Drug list
- SGA= amisulpride, aripiprazole, asenapine, clozapine, olanzapine, paliperidone, quetiapine, risperidone, sertindole, ziprasidone (fewer extrapyramidal adverse effects and other movement disorders, as well as other side effects)
- FGAs = chlorpromazine, flupenthixol, fluphenazine, haloperidol, pericyazine, trifluoperazine, zuclopenthixol
