Schizophrenia Flashcards
Non-pharmacological treatments
Family interventions: are effective in reducing relapse (family therapy has been shown to reduce relapse rates by over 50% compared with medication and case management alone); should be integrated at all stages and with all aspects of care; should include a psychoeducation, communication and problem solving modules.
Psychoeducation: for consumers reduces relapse, probably through improved adherence, increase patient’s satisfaction with treatment and improves knowledge; should be offered as a core intervention.
Cognitive interventions: CBT should be routinely available as it is highly effective in improving mental state and global functioning and is associated with reduced risk of relapse compared with standard care alone; CBT is effective in reducing symptoms in treatment refractory schizophrenia and should be utilized to target distress and co-morbidity; cognitive remediation/rehabilitation warrants further research although evidence so far is equivocal.
Social skills training: should be available for patients who are having difficulty with tasks of living and occupation; improves independent living skills; in association with longer term group psychotherapy improves symptoms; improves medication and symptom management skills; cognitive adaptation therapy which is a new approach with potential should be considered where neuropsychological testing is available since it addresses cognitive difficulties that impede the learning of life skills.
Vocational rehabilitation: reduces hospitalisation, improves insight, and enhances vocational function; becoming vocationally involved is likely to have positive psycho-social consequences; various models of vocational rehabilitation have shown different levels of success in placing people in competitive positions however supported employment is much more successful than other programmes.
Case management: is not an intervention per se but a model or way of delivering services and treatments; models can, in theory, be divided into those in which services are brokered and those in which the case manager provides the treatment themselves; assertive community treatment service (a team based approach) is an effective delivery model in schizophrenia and should be developed in a comprehensive and routine manner for a substantial subgroup of patients; standard CM and CMHT models should continue and be enhanced. Family interventions: are effective in reducing relapse (family therapy has been shown to reduce relapse rates by over 50% compared with medication and case management alone); should be integrated at all stages and with all aspects of care; should include a psychoeducation, communication and problem solving modules.
Psychoeducation: for consumers reduces relapse, probably through improved adherence, increase patient’s satisfaction with treatment and improves knowledge; should be offered as a core intervention.
Cognitive interventions: CBT should be routinely available as it is highly effective in improving mental state and global functioning and is associated with reduced risk of relapse compared with standard care alone; CBT is effective in reducing symptoms in treatment refractory schizophrenia and should be utilized to target distress and co-morbidity; cognitive remediation/rehabilitation warrants further research although evidence so far is equivocal.
Social skills training: should be available for patients who are having difficulty with tasks of living and occupation; improves independent living skills; in association with longer term group psychotherapy improves symptoms; improves medication and symptom management skills; cognitive adaptation therapy which is a new approach with potential should be considered where neuropsychological testing is available since it addresses cognitive difficulties that impede the learning of life skills.
Vocational rehabilitation: reduces hospitalisation, improves insight, and enhances vocational function; becoming vocationally involved is likely to have positive psycho-social consequences; various models of vocational rehabilitation have shown different levels of success in placing people in competitive positions however supported employment is much more successful than other programmes.
Case management: is not an intervention per se but a model or way of delivering services and treatments; models can, in theory, be divided into those in which services are brokered and those in which the case manager provides the treatment themselves; assertive community treatment service (a team based approach) is an effective delivery model in schizophrenia and should be developed in a comprehensive and routine manner for a substantial subgroup of patients; standard CM and CMHT models should continue and be enhanced.
Cognitive remediation therapy
To improve neurocognitive abilities such as attention, working memory, cognitive flexibility and planning, and executive functioning which leads to improved psychosocial functioning
Psychosis in Parkinson’s vs schizophrenia
The candidate should be able to describe the most common psychotic features associated with Parkinson’s disease (PD).
Visual hallucinations are the most common psychotic symptoms in PD followed by auditory hallucinations. Other types of hallucinations are considerably less common, but do occur. Visual hallucinations tend to be complex and formed, usually of animals or people. The hallucinations tend to be stereotyped, with the same person or group of people returning each time, dressed in the same manner. The hallucinations usually ignore the patient and disappear when approached.
Auditory hallucinations are often indistinct, with party sounds heard coming from another room, people talking indistinctly outside, music of various types. Sometimes the visual hallucinations talk to the patient and may carry on conversations. Delusions tend to be paranoid. The most common delusions are of stealing, thinking their house is not really theirs, spousal infidelity, and being abandoned.
Psychotic symptoms present in schizophrenia such as thought broadcasting, delusions of grandeur, control or religion, voices talking about the patient, are almost never seen other than in patients who have comorbid psychiatric problems.
The mechanism of psychosis in Parkinson’s disease is varied and a variety of factors, both intrinsic and extrinsic, contribute to their occurrence. The main ones identified are:
1. Dopamine: The role of dopamine in the genesis of psychosis is well established. Medication used in the treatment of Parkinson’s disease act through dopaminergic pathways.
2. Deficits in visual processing: These may result in an increased vulnerability to visual hallucinations.
3. Sleep disorders and sleep deprivation.
4. Lewy body dementia is often associated with Parkinson’s disease and increases the risk of psychosis.
5. Pre-existing psychotic illness or a psychosis independent of the Parkinson’s disease.
6. Co-existing physical illness such as an infection causing a delirium and psychotic symptoms.
7. Other medications such as opiates, hypnotics and antidepressants may contribute to the presentation.
Candidates should be familiar with the introduction of clozapine to the treatment of PD as it represents one of the most significant breakthroughs in treatment for PD. Until clozapine was available, the treatment for psychotic symptoms relied on drug reductions or treatment with first generation antipsychotics, all of which worsened motor function. Quetiapine and to a lesser extent ziprasidone are also effective.
A better candidate will recognise that drugs like clozapine are not approved for use in Parkinson’s disease, and that clozapine itself is only approved for schizophrenia. Despite the evidence supporting the use of clozapine in PD, when medicines are used in ways other than as specified in the NZ Pharmaceutical and Management Agency (Pharmac) or Australian Therapeutic Goods Administration (TGA) approved product information, documentation and evaluation should be undertaken with reference the Council of Australian Therapeutic Advisory Groups CATAG guiding principles for the quality use of off-label medicines (www.catag.org.au) and to any State based notices. Guiding principles include: use only when all other options, are unavailable, exhausted, not tolerated or unsuitable; involvement of patient/carer in shared decision-making; ensuring appropriate information is available at all steps of the management pathway; monitor of outcomes, effectiveness and adverse events; and consideration of liability and accountability when using medicines off-label.
A surpassing candidate will be knowledgeable about the most innovative treatment for psychosis in PD called pimavanserin, a pure 5HT2-A inverse agonist. The phase two trial of pimavanserin in the USA showed that that the drug would not impair mobility. Its effects on measures of psychosis were suggestive of a beneficial effect of improving hallucinations and psychosis. This product is not available in Australia or New Zealand.
Effective treatment is likely only if the cause of the psychosis is investigated and contributed factors determined and managed simultaneously, e.g. infections and electrolyte imbalance. Polyphamacy is a risk factor and all medications must be rationalized.
Reduction of the PD medication is usually required and a balance between motor symptoms and psychotic symptoms is the goal. Addition of antipsychotic agents may further worsen the PD symptoms. ECT is an effective treatment, but has its own risks in patients with comorbid physical conditions. Psychological approaches have a very limited role. Thus the treatment is often complex and results vary greatly. A compromise between physical and psychological symptoms needs to be discussed with the patient and family and may be the goal of management.
Finally, the stress on the caregiver must not be neglected and the need for nursing home placement be considered.
