Schizophrenia Flashcards
What are some interventions for a patient that isn’t compliant to antipsychotic medications?
Challenges to Compliance:
- Medication information
- Adherence therapy - behavioural training, hasn’t been proven to work.
- Choosing LAIM (see depot medications list) - long acting injectable medications
- Atypicals Depots to consider:
- Haloperidol - EPSEs profile depot less bad then tablets though
- Risperidone
- Zuclopenthixol decanoate
- Zuclopenthixol acetate for acute phase psychosis.
- Can be related to acute dystonic reactions and effect on heart - spasmodic torticolis, oesophageal spasm. Need test dose.
Side Effects from Atypical Antipsychotics?
- Neuroleptic Malignant Syndrome (NMS) – psychiatric emergency
- EPSE: Tx benztropine - resting tremor - dystonia (head and neck/painful) - oculogyric crisis - akathisia (restlessness) Tx Beta-blocker and benzos related - tardive dyskinesia - random tongue movements - treat with change to atypical antipsychotic (clozapine beneficial)
- ↑weight (largest SE - metabolic syndrome and T2DM) - most widely used ones: • Clozapine • Olanzepine
- Sedation/Insomnia/Agitation
- Anticholinergic - Constipation/Dry mouth
- Cardiological • Long QTc • Myocarditis ± Cardiomyopathy (esp. clonzapine)
Describe NMS and its effects
Develops over 24-72h – can be anytime in theory, but becomes ↓likely w. ↑time after FEVER or FARM acronyms:
FEVER =
- fever - hyperthermia (late sign)
- encephalopathy (confused, disorientated)
- Vital sign instability (autonomic instability - tachycardia, labile BP, RR)
- Enzyme elevation = CPK (rhabdomyolysis) and WCC elevation
- Rigidity - lead pipe
FARM = fever, autonomic reactivity, rigidity, mental status Δ
- Δ mental status occurs first
- Hyperthermia
- EPS = lead-pipe rigidity, brady/akinesia, dystonia, abnormal movement, posturing, dysphagia, tremor
- Autonomic = ↑HR, ↑BP, labile BP, sweating, ↑RR ○ CNS = drowsy, confused, coma, mutism, incontinence
Occurs due to excess DA blockage 5% mortality Looks like serotonin syndrome - difference is an antipsychotic causes it. More common in older drugs. Get raised WCC and CK level
Talk through the DSM5 criteria for Schizophrenia
- ≥2 of the following for a significant portion of time over ≥1mo (** must be ≥1 of these):
- Delusions
- Bizarre
- Thought insertion / withdrawal / broadcast
- Passivity
- Hallucinations
- Command
- Running commentary
- Talked about in 3rd person (people discussing you)
- Audible thoughts
- Somatic hallucinations
- Disorganised speech
- Disorganised / catatonic behaviour
- Derailment
- Thought blocking
- Negative syx = ↓emptional expression, anhedonia, apathy, avolition, attention deficit, impoverished speech / thought, social withdrawal, cognitive impairment… (4As)
- Fx / social / occupational dysfunction
- ≥6mo continuous signs of disturbance
- Excluded schizoaffective + mood disorders
- r/o depression / mania during active phase of syx
- Mood episodes during active phase were short-lived
- Exclude substance abuse / GMC
- If pervasive developmental disorder (e.g. autism spectrum / childhood onset communication disorder) → only dx if prominent delusions / hallucinations for ≥1mo (less if rx) specify the type of episode (prognosis)
MUST HAVE FUNCTIONAL IMPAIRMENT
What are the First Rank symptoms for Dx of Schizophrenia?
- Delusional perception = belief that a normal percept has a special meaning for him or her
- Command auditory hallucinations
- Narrative / commentary auditory hallucinations = 3rd person · Passivity phenomenon
- Thought withdrawal / insertion / broadcasting
- Somatic hallucinations
What are some RFs for Schizophrenia?
- M = F (females tend to present later in life than males – late 20s vs early 20s, respectively)
- Young onset = 21 (M), 27 (F)
- Late onset = >45yo • v. late onset = >65yo
- FHx • Parent 10% (50% if both) - Twin / sibling 10% (50% if identical)
- Cannibis use (dose-dependent) ± substance use
- Pregnancy
- Influenza A
- Maternal insult/stress
- Poor nutrition / anemia (esp. first trimester)
- Head injury in early life
- High latitude (distance from equator)
- Obstetric hx
- Social factors = childhood abuse, migrant status, psychological stress ~0.5-1% of popn
Pathophysiology of Schizophrenia?
Path • Neurodegenerative = ↓fx + communication • Neurodevelopmental = abnormal development of brain in prenatal life (failure of migration + apoptosis → abnormal connections) Aetiology • Genetic 50% in monozygotic twins, 10% if siblings • Neurochemistry = ↑mesolimbic / prefrontal cortex dopamine activity (+ dysfx of other NTs) - ○ positive symptoms with dopamine medications improve these. ○ Negative symptoms by dopamine deficits ○ Serotonin (LSD - hallucinogen) - atypicals largely block 5HT2 receptors • Neuroanatomy = ↓frontal fx, subtle thalamic, cortical, corpus callosum, ventricular change (+ cytoarchitecture) • Neuroendocrinology = Δ GH, prolactin, cortisol, ACTH • Neuropsychology = global Δ attention, language, memory → ? Lack of neural connectivity • Environmental = cannibis, geographical (urban), winter birth/early spring (only in northern hemisphere), obstetric cx, prenatal viral exposure Neurodevelopmental model - • Delayed social milestones More likely to have neurodevelopmental changes (low set ears, high arch palate)
List some Differentials for Schizophrenia
Organic psychosis:
- Drug induced - illicit substances:
- Psychoactive substances can - hallucination themes common (ICE, cannabis)
- Need clear temporal sequence.
- Resolve once stopping.
- Drug induced precipitation of relapse.
- Delirium ○ Intracranial malignancy
- Psychotic phenomena related to other conditions
Depression
Bipolar
Schizoaffective disorder:
- Affective and psychotic symptoms occur at different times over the course of the illness.
Delusional Disorders:
- Well circumscribed delusions - an understandable delusion in terms of context.
Pervasive Developmental Disorder
- Autism or Asperger’s
- Personality Disorder
- Schizotypal personality disorder (longstanding eccentricity, social withdrawal, and odd beliefs)
What are the Pharmacological Treatments for Schizophrenia?
- Antipsychotics = atypical (/ typical) ○ All drugs equally effective despite Δ potencies
- Initiate rx w. single drug
- Start low → gradually ↑dose until therepeutic response / SE 2.
- Benzos (short term) = immediate syx relief (insomnia, anxiety, agitation, aggression…)
- Depot -
- medications only indicated in ↓adherence and ↓tolerance of oral meds or Ø response to psychological rx
- May take 2-4mo to achieve steady-state [plasma]
- Often test oral medication first
- Monitor pt every 30min for 3h after every injx of olanzapine depot
- Clozapine = resistant cases – must have tried ≥2 other drugs first (cases agranulocytosis, myocarditis)
- ± ECT = esp. catatonic ± acute psychosis (if need to get pt better v. soon c.f. waiting for antipsychotics to take effect)
- ± Antidepressants ± Mood stabilizers Its important to differentiate between positive and negative symptoms. Negative symptoms need more antidepressants (fluoxetine best)
What would you do/consider if you put someone on a 2nd generation antipsychotic?
- BMI, cholestrol, BSL, - if weight gain is a problem put them on a 2nd gen that is more weight neutral (aripirazole, risperidone) - clozapine, olanzapine are bad for this (sedating too) - ECG (no longer echo) - QTc - clozapine very good for resistant. Agranulocytosis and cardiomyopathy. D2 blockade in dopamine - tubuloinfandibulum - prolactin milk secretion
What are the Positive, Negative and Cognitive Symptoms of Schizophrenia?
Positive:
- Hallucinations
- Delusions
- Disorganized speech
- Disorganized behavior
Negative (poorly treated by antipsychotics, except clozapine):
- Lack of motivation
- Poor self-care
- Blunted affect
- Reduced speech output
- Poverty of thought
Cognitive
- Impaired planning
- Impaired insight
- Impaired memory
- Reduced mental flexibility
- Mostly frontal lobe tasks - number of effects on what you do
What are some problems with Clozapine other than the side effects?
- prescribing, needs someone who can specifically prescribe it (not all doctors).
- rebound psychosis
- if you miss a dose the psychosis can get much worse
- miss 2 doses have to start from scratch and up-titrate again.
What are the negative symptoms of schizophrenia?
4 As of Schizophrenia:
Alogia
Amotivation
blunted Affect
Anergia
