Schizophrenia

Question 1

What are some of the positive symptoms of schizophrenia?

Answer 1

Delusions
Thought Disorder
Altered Behavior- Catatonic or Grossly Disorganised
Hallucinations

Question 2

What delusions are typically seen in schizophrenia?

Answer 2

Typically delusions of perception- there is normal perception but an abnormal interpretation

Delusions of persecution are common/paranoid delusions

Question 3

What hallucinations are typically seen in schizophrenia?

Answer 3

Auditory hallucinations/voices

Third Person Voices- Providing a running commentary on what the patient is doing.

Question 4

What are the negative symptoms of schizophrenia?

Answer 4

Absence of normal response/behaviours. This includes: flat effect, loss of interest in things, apathy (lack of interest or enthusiasm), reduced expression of emotion and avoilition (decreased motivation)

Question 5

How long should symptoms have been present for for a diagnosis of schizophrenia to be appropriate?

Answer 5

Symptoms present much of the time for at least 1 month

Continuous problems, with social or occupational functioning, over the last 6 months

Question 6

What symptoms predominate in patients with paranoid schizophrenic?

Answer 6

Prominent hallucinations/delusions relating to persecution and groups intending to harm them

Question 7

What symptoms predominate in patients with hebephrenic schizophrenia?

Answer 7

Disorganised thoughts and behaviour- without purpose

Question 8

What symptoms predominate in patients with catatonic schizophrenia?

Answer 8

Fluctuate between stupor and agitation
Patients have little awareness and little mobility at times
Unusual movements and behaviour

Question 9

What is residual schizophrenia?

Answer 9

History of psychosis but negative symptoms only present now

Question 10

What is undifferentiated schizophrenia?

Answer 10

Symptoms do not conform to any of the other subtypes, may have features of several

Question 11

What are the prodromal symptoms of psychosis?

Answer 11

Symptoms precede the first episode of psychosis by up to 18 months. Generally a gradual deterioration in functioning including:
Social withdrawal
Altered affect
Reduced interest in daily activities
Poor concentration
Out of character thoughts, beliefs and actions
Transient or reduced psychotic symptoms

Question 12

What is the main difference between typical and atypical anti-psychotics?

Answer 12

Typic APs are first generation and they are more likely to cause extra-pyramidal side effects

Question 13

What are some examples of first generation APs?

Answer 13

Thioxanthenes- Flupentixol, Zuclopenthixol
Phenothiazines- Chlroprmazine, Trifluoperazine
Butyrophenones- Haloperidol

Question 14

What are some advantages of typical antipsychotics?

Answer 14

Cheap
Long duration of use so effects are known
Available as injections- use in aggressive patients and for when compliance with oral meds is poor

Question 15

What are some disadvantages of typical anti-psychotics?

Answer 15

Side effect profile:
Increase in prolactin
Extra Pyramidal Side Effects
Anti-cholinergic S/Es
Histamine S/Es
Alpha S/Es
Weight gain--> Metabolic Syndrome

Question 16

What are the extra-pyramidal side effects?

Answer 16

Tardive Dyskinesia
Akanthisia
Psuedo-Parkinsonism
Acute dystonia

Question 17

How do APs cause galactorrhea?

Answer 17

Increase in prolactin secretion as dopamine usually reduces prolactin release but APs act to reduce the activity of dopamine

Question 18

What are the features of tardive dyskinesia?

Answer 18

Lip smacking
Tongue protrusion and rolling
Chewing motion
Involuntary movements of the body and extremities

(Irreversible side effect)

Question 19

What are the features of akanthisia?

Answer 19

Restless legs
Trouble standing still
Pacing around
Feetin in constant motion
(Side effect most associated with suicide)

Question 20

What are the features of pseudo-parkinsonism?

Answer 20

Bradykinesia
Pill rolling tremor
Shuffling gait
Cog-wheel rigidity

Question 21

What are the features of acute dystonia?

Answer 21

Facial grimacing
Muscle spasm of tongue, face, neck and back
Laryngeal spasm- risk of airway compromise

Question 22

What is the management of extra-pyramidal side effects?

Answer 22

Stop AP (Exercise caution)
Reduce dose
Different AP
Akanthisia and Parkinsonism:
- Anti-muscarinic (procyclidine) or anti-cholinergic (Benzatropine)
Akanthisia:
- Beta blockers (e.g. propanolol) and benzodiazepa

If Tardive dyskinesia stop cholinergics as it can make things worse

Question 23

What anti-cholinergic S/Es may be seen with APs?

Answer 23

Constipation
Blurred vision
Dry mouth
Confusion

Question 24

What histamine mediated side effect may be seen with APs?

Answer 24

Sedation

Question 25

What alpha 1 mediated side effects may be seen with APs?

Answer 25

Postural hypotension | Impotence

Question 26

Why are patients on anti-psychotic medication prone to weight gain?

Answer 26

AP medication is associated with an increased appetite and so weight gain. At risk of metabolic syndrome. Require monitoring of glucose, cholesterol, triglycerides, blood pressure and BMI.

Question 27

What is neuroleptic malignant syndrome?

Answer 27

Autonomic instability- fluctuating HR, temperature, blood pressure Confusion Muscle rigidity and increased tone- leads to release of CK and myoglobin (risk of renal injury)

Question 28

What is the treatment for neuroleptic malignant syndrome?

Answer 28

Supportive- Stop AP IV Fluids, Temperature Support (e.g. cooling blankets) Circulatory and ventilatory support Muscle relaxants- Dantrolene Dopamine agonists to reduce the blockade- Bromocriptine Benzodiazepine to control agitation

Question 29

What are some causes of psychosis?

Answer 29

Organic causes Schizophrenia Psychotic depression First episode psychosis

Question 30

What are some positive symptoms?

Answer 30

Delusions Hallucinations Disorganized speech Abnormal motor behavoir

Question 31

What are delusions?

Answer 31

Abnormal beliefs that are strongly held and are out of touch with the patients normal cultural background

Question 32

What kind of hallucinations are common in schizophrenia?

Answer 32

Auditory hallucinations that are often third person and persecutory

Question 33

What is word salad?

Answer 33

Speech that disorganised and makes little sense

Question 34

What abnormal motor behavior is seen in schizophrenic patients?

Answer 34

Catatonic behavior Agitation Pacing

Question 35

What are the negative symptoms of schizophrenia?

Answer 35

``` Flattened affect Reduced eye contact Reduced movement Reduced facial expression Reduced interest in activities and interaction Anhedonia ```

Question 36

What features help to differentiate schizophrenia from other psychotic symptoms?

Answer 36

Presence of negative symptoms

Question 37

What prodromal symptoms may be seen in schizophrenic patients?

Answer 37

Deterioration in functioning Withdrawn patient Out of character thoughts, beliefs and behavior Anhedonia Can proceed first episode psychosis by upto 18 months

Question 38

What might be some other causes of schizophrenia like symptoms?

Answer 38

``` Schizotypal personality disorder Delusional disorder First episode psychosis Psychotic depression Organic causes of psychosis Schizoaffective disorder Substance induced psychotic disorder ```

Question 39

What is schizoaffective disorder?

Answer 39

There is a combination of features of schizophrenia with mood disorder (depression or bipolar) but does not warrant a diagnosis of either alone

Question 40

What should the management for schizophrenia be?

Answer 40

A holistic approach is required- for first episode psychosis refer to EIS Pharmacological- Antipsychotics, Antidepressants, Anxiolytics Social support- Financial, Living arrangements, Job seeking Physiological- Therapy, CBT, Family therapy