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Psychiatry - 4th year > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

First rank symptoms

A
  1. delusions
  2. auditory hallucinations
  3. Thought disorder (insertion, withdrawal, broadcasting)
  4. Passivity experiences
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2
Q

Positive symptoms

A
  • hallucinations
  • delusions
  • tought disorder
  • catatonia
  • neologisms, word salad
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3
Q

Negative symptoms

A
  • apathy
  • anhedonia
  • alogia
  • avolition
  • poor self care
  • affective blunting
  • paucity of thought and speech
  • lack of insight
  • social withdrawal
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4
Q

how to make a clinical Dx of schizophrenia?

A

at least 1 first rank symptom OR 2 positive symptoms for at least 1 month

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5
Q

Schizophrenia - types

A
  • simple
  • paranoid
  • catatonic
  • hebephrenic
  • residual
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6
Q

Simple schizophrenia

A

Insidious development of:

  • Odd behaviour.
  • Social withdrawal.
  • Declining performance at work.

Clear symptoms are absent. Usually -ve symptoms, no +ves. Difficult to identify reliably and therefore needs to be a diagnosis of exclusion.

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7
Q

Hebephrenic schizophrenia

A
  • Behavioural disturbance - eccentric, crazy
  • Mood inappropriate, incongrous affect
  • Formal thought disorder prominent
  • Delusions not highly organised
  • Hallucinations not elaborate
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8
Q

Catatonic schizophrenia

A
  • Motor symptoms - eg psychomotor retardation
  • less commonly excitement, extreme agitation
  • Hallucinations and delusions less obvious.

Catatonia = Excitement, Posturing, Waxy flexibility*/rigidity, Negativism, Stupor**

  • put them in one position and they can’t move back at all
  • *complete loss of response to environement

Treatment - 1st line: benzo’s; 2nd line: ECT

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9
Q

Paranoid schizophrenia

A
  • most common type
  • Well organised delusions and hallucinations.
  • Thought process and mood relatively spared.
  • More genetic.
  • Later more acute onset.
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10
Q

Epidemiology

A

Prevalence:
1% of U.K population.
Incidence:
1 per 5,000 per year.

Male early 20s > Female late 20s

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11
Q

Risk factors

A
  • Family Hx (MZ twins - 45% concordance.
    DZ twins - 15% concordance)
  • Infections during pregnancy (e.g. influenza, toxoplasmosis from cat poo).
  • Birth complications (e.g. cerebral hypoxia).
  • Winter birth.
  • Brain damage / infection in childhood.
  • Illicit drug use, especially cannabis.
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12
Q

Treatment for people AT RISK of developing a psychotic disorder (NICE)

A
  1. individual CBT and/or family intervention.
  2. Treatment for co-existing anxiety disorders, depression, emerging personality disorders, or substance misuse (where appropriate)
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13
Q

Treatment for people with a psychotic disorder (NICE)

A

A therapeutic trial of an oral antipsychotic (first generation or second generation) in conjunction with any or all of the following:

  • Family intervention
  • Individual CBT
  • Arts therapies may be offered, particularly to help with negative symptoms.
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14
Q

Antipsychotic drug of choice

A

Route: Oral OR IM (long-acting depot preparations and short-acting IM injections in acute disturbance)

1st line: Atypical for four to six weeks.*
2nd line: Review the diagnosis, check compliance and for any concomitant drug use. Try a different atypical
3rd line - Treatment resistance: consider clozapine**

  • NICE says there is no evidence against starting with typical but vital slides say atypical
  • *check urine drug screen before starting
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15
Q

Any other meds?

A

Benzo’s –> Short-term use only; Inpatient setting
to manage disturbed behaviour
Lorazepam (PO or IM) or Diazepam (PO only)

Antidepressants –> depression is common in schizophrenia

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16
Q

What is a care plan?

A

A care plan (with a copy sent to the primary care team) that defines the roles of primary and secondary care and includes:

  • A crisis plan.
  • An advance statement — a written statement, drawn up and signed when the person is well, which sets out how they would prefer to be treated (or not treated) if they were to become ill in the future.
  • Key clinical contacts in case of emergency or impending crisis.
17
Q

What is a crisis resolution home treatment team (CRHTT) ?

A
  • Service that deals with acute mental health problem or crisis. NICE recommend referral to CRHTTs as the single point of entry to all acute services in the community and in hospitals.
  • An assessment/treatment is ideally carried out at home and when not possible the pt is admitted to hospital
18
Q

What is the Care Programme Approach?

A

Many people with a psychotic disorder including schizophrenia will be under specialist mental health supervision, usually with a Care Programme Approach that involves:

  • Assessing the person’s health and social care needs.
  • Writing a care plan that includes all those involved in the person’s care (for example GP and carer).
  • Nominating a Care Coordinator to keep in touch with the person and to monitor and coordinate their care.
  • Reviewing the person’s care plan, and their health and social needs.
19
Q

Typical antipsychotics adverse effects - EPSE

A

Extrapyramidal symptoms — They include:

  • Dystonic reactions (abnormal movements of the face and body - eg oculogyric crisis, torticollitis), pseudoparkinsonism (tremor, bradykinesia, and rigidity) — these can be alleviated by antimuscarinic drugs, such as procyclidine (should not be prescribed routinely).
  • Akathisia (motor restlessness)
  • Tardive dyskinesia — late-onset movement disorder characterized by rhythmical, involuntary movements, usually lip smacking and tongue rotating, although it can affect the limbs and trunk.
20
Q

Antipsychotic - Metabolic A/E

A
  • Weight gain — mostly atypicals. clozapine and olanzapine have the greatest potential
  • Dyslipidaemia — Offer dietary advice and consider treatment with a statin
  • Hyperprolactinaemia — most antipsychotics can cause hyperprolactenaemia that may lead to galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism, sexual dysfunction, and an increased risk of osteoporosis.
  • Impaired glucose tolerance
21
Q

Antipsychotic - CNS A/E

A
  • Sedation
  • Sleep apnoea syndrome — reported in patients using quetiapine.
  • Anticholinergic effects (such as dry mouth, blurred vision, urinary retention, constipation, and cutaneous flushing) — chlorpromazine and clozapine have potent anticholinergic effects.
  • Reduced seizure threshold —(the higher the dose, the greater the risk). Clozapine carries the greatest risk
22
Q

Neuroleptic Malignant Syndrome

A

Neuroleptic malignant syndrome (NMS) — is a rare but potentially fatal adverse effect of all antipsychotics. Signs and symptoms of NMS include fever, increased sweating, rigidity, confusion, fluctuating consciousness, fluctuating blood pressure, tachycardia, raised creatine kinase, leucocytosis, and raised liver function tests.

Treatment –> immediate cessation of the offending medication and provision of supportive measures (hydration and cooling). Rx: dantrolene, bromocriptine

23
Q

Antipsychotics - CVS A/E

A
  • Postural Hypotension
  • Hypertension - commonly with clozapine
  • QT interval prolongation —
    Avoid co-prescribing other drugs that are known to prolong the QT interval (for example tricyclic antidepressants, erythromycin, or antiarrhythmics), and monitor potassium levels at least annually.
    People taking antipsychotics who experience palpitations or any other symptoms that suggest cardiac disease should undergo electrocardiography.
  • Stroke risk — olanzapine and risperidone are associated with an increased risk of stroke in elderly
  • Venous thromboembolism (VTE) risk in elderly
24
Q

Monitoring for people on antipsychotic treatment

A
  • Ask about smoking status, alcohol intake and substance misuse.
  • Ask about the person’s diet, level of physical activity, check person’s weight, measure the waist circumference (plot both on a chart), and manage obesity.
  • Measure the person’s pulse, blood pressure, and assess and manage the person’s cardiovascular risk.
  • Perform the following blood tests: fasting glucose, HbA1c, lipids, U+Es, FBC, LFTs and prolactin
  • Check an ECG if appropriate
25
Q

Specific monitoring for Clozapine

A

Clozapine — people taking clozapine are managed exclusively in secondary care. Clozapine can cause neutropenia or agranulocytosis, and frequent monitoring of the FBC is required (weekly for 18 weeks after starting treatment, then every 2 weeks for the next 18 weeks, and then every 4 weeks thereafter)

Obs should also be monitored when clozapine is started (risk of tachycardia from myocarditis – rare)

26
Q

What are the different medical teams involved?

A
  • GP, A&E, police
  • Community mental health teams (CMHT)
    1. Early intervention team = offer CBT, check med compliance, social/financial help. Help prevention
    2. Crisis team
    3. Assertive outreach, aka complex care team (CCT) - provide intensive support if you have complex needs eg disabilities, violence, self harming

Psychiatry - 4th year (11 decks)

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