Schizophrenia Flashcards
Positive symptoms:
Hallucinations:
- 3rd or 2nd person
- Types - 3
Delusions - types - 4
Thought disorder - types - 5
3rd
Thought echo (thoughts repeated back to them)
Running commentary
Overhead conversations
Persecutory
Reference
Interference
Passivity
Derailment Poverty of thought Circumstantiality Perseveration Blocking
Negative symptoms?
Apathy/loss of energy Self-neglect Social withdrawal Emotional blunting Anhedonia - Inability to feel pleasure in normally pleasurable activities.
Prodrome symptoms
Social withdrawal
Reduced function i.e. work or studies
Poor self-care
Low mood or blunted affect
ICD-10:
How long must symptoms last for?
According to the criteria, they must have any 1 of these 4 symptoms. What are they?
According to the criteria, they must have any 2 of….
> 4 wks
(1) Thought echo/insertion/withdrawal/ broadcasting
(2) Delusions of thought control/ influence/ passivity; delusional perception
(3) Hallucinatory voices (running commentary or discussing patient between themselves), or other types of hallucinatory voices coming from some part of the body
(4) Persistent delusions of other kinds that are culturally inappropriate and completely impossible
ICD-10:
According to the criteria, they must have 2 or more of these 4 symptoms. What are they?
Persistent hallucinations (any modality), accompanied by delusions
Neologisms, breaks/ interpolations in the train of thought incoherence or irrelevant speech
Catatonic behaviour (e.g. excitement, posturing, waxy flexibility, negativism, mutism and stupor)
“Negative” symptoms (it must be clear that these are not due to depression or to neuroleptic medication)
How many different subtypes of schizophrenia are there?
Subtypes - Catatonic schizophrenia:
Define:
Waxy flexibility
Negativism
Mutism
Stupor
5 subtypes /////////////// A decreased response to stimuli and a tendency to remain in an immobile posture.
Negativism - lacks verbal responses
Mutism - little to no verbal communication
Stupor - lack of response to stimuli
Subtypes - Disorganized/hebephrenic schizophrenia:
How is mood and behaviour affected?
What is the prognosis?
- Inappropriate mood and behaviour including silliness, shallowness, and irresponsible actions.
- Fragmented delusions and/or hallucinations
Poor
Subtypes - Paranoid schizophrenia:
Why is this important?
Subtypes - Simple schizophrenia:
What type of symptoms dominate, negative or positive?
The commonest type of schizophrenia
Negative symptoms
Risk Factors:
Perinatal - 3
Economic - 2
Race - 2
FH
Pre-term
In-utero viral infection
Hypoxic birth injury
Urban living
Low socio-economic class
Immigrants
Non-white
Schizophrenia illness pattern:
Group 1
Group 2
Group 3
Group 4
Only one episode - no impairment
Several episodes with no or minimal impairment
Impairment after the first episode with subsequent exacerbation and no return to normality.
Impairment increasing with each of several episodes and no return to normality.
Investigations:
What should be done to assess the patient:
- 2 histories
- 1 verbal examination
- 1 physical examination
For differentials, if indicated:
- Endocrine - 2
- Infectious - 2
- What can be found in a urine drug screen, weeks or even months after cessation?
- Neurological - 4
Full history and MSE
Neurological examionation
Collateral
TFT, cortisol
Syphilis
HIV
Cannabis - weed
CT
MRI
LP
EEG
Management:
Where should patients with their first episode of schizo or at risk of psychosis be referred to?
EIP - early intervention in psychosis
Management - Biological - Antipsychotics:
1st line:
- Route - 2
- What type of APs should be used?
2nd line:
- Typical AP starting with C?
- Why is this one used?
- When is it started?
Oral or depot
1st or 2nd - 2nd should be one of the two
Clozapine
More effective than others but does have other SE’s
2 different
2 different APs have been ineffective
Management - Biological - Antipsychotics:
What type of administration can be used for patients with poor adherence?
How should APs be started and how long do you wait to look for effectiveness?
When is the only time you cross-taper meds?
Depot drugs (e.g. risperidone, haloperidol, olanzopine)
Start low and titrate up
4-6 wks
If you are switching them onto other drugs
Management - Biological - Antipsychotics:
Basic tests at baseline and annual checkup:
- Bloods - 3
- What 2 things need to be monitored?
FBC, U&E, LFTs
Metabolic monitoring - fasting glucose, HbA1c
CV monitoring - Lipids, weight, waist circumference, BP,, ECG
Management - Psychological:
What should psychological therapies be offered in conjunction with?
What type of CBT is done?
How many sessions?
Aim of CBT?
What other people should be thought about?
What other therapies are available?
APs + CBT
Individual CBT
16 sessions
Focusing on re-evaluating abnormal thoughts and perceptions and reducing the distress resulting from symptoms.
Family intervention
Art therapy - helps self-expression and is delivered in groups, thus alleviating social isolation.
Management - Psychological - Prevention:
What signs are there of someone at risk?
What can be offered to prevent the need of APs in full-blown schizo?
Distress and impaired social functioning
Plus transient/mild psychosis
1st degree relative with psychosis
CBT +/- family intervention
Management - Social:
Lifestyle changes - 3
Assistance for….?
Type of support - 1
What may be good for those who feel socially isolated?
Healthy eating
Physical activity
Smoking cessation
Mainstream education, work or training
Peer support - given by recovered and stable patients who have had schizophrenia or psychosis.
Day centres
Management - Social:
Options available for smoking cessation?
What do support carers do?
Nicotine replacement
Bupriopion or varenicline
Offer a formal assessment of their needs by mental health services, and provide support as needed.
Complications - 4
Bad prognostic factors
Drug use
Risk of criminal victimisation, including violence
Suicide
Early death from meds SE
Early or insidious onset
Continued exposure to precipitants
Family FH of schizophrenia or mood disorder or family member with high expressed emotion
Low IQ
First Generation Antipsychotics:
Drugs - Oral examples:
C, H, T, S, P, P, L
Drugs - Depot examples:
H, F, F, Z
Chloropromazine Haloperidol ****** Trifluoperazine Sulpiride Pimozide Prchlorperazine Levomepromazine /////////////////////////////////////// Haloperidol ****** Fluphenazine Flupentixol Zuclopenthixol
First Generation Antipsychotics:
MOA
Extrapyramidal side effects (EPSE):
- The ain one
- Signs of tardive dyskinesia? When does it tend to happen? How may it be treated?
- Akathisia - what is it? why is it important?
- Acute dystonia - what is it?
Parkinsonism
Lip-smacking Rocking Rotating ankles Marching in place Repetitive sounds
Chronic use
Tetrabenazine - monoamine uptake inhibitors - used to treat hyperkinetic movements disorders.
An inner state of restlessness - increases suicide risk
Painful, sustained muscle spasm, especially of neck, jaw or eyes.
FGA vs SGA:
Which one causes greater EPSE?
What is a severe side effect of antipsychotics?
FGA WAS thought to cause more side effects, but it was only consistently shown in haloperidol.
Now thought to be quite equal!!!!!
/////////////////
Neuroleptic malignant syndrome (NMS)
First Generation Antipsychotics:
Other side effects:
- What does dopamine inhibition increase the secretion of? - P
- Anti-histaminergic effects - 2
- Weight?
- Metabolic - 1
- CVD - 2
- Anticholinergic effects
- BP
- Which drugs cause long QT syndrome?
- Which drug causes sexual dysfunction?
Prolactin
Sedation and apathy
Weight gain
T2DM
Stroke and VTE
Dry mouth, retention etc.
Postural drop in BP
Haloperidol and pimozide
Haloperidol
Second Generation Antipsychotics:
Drugs - oral examples:
- A, A, C, O, R, Q
Drugs - depot examples:
- O, R
Amisulpiride Aripiprazole Clozapine Olanzapine ****** Risperidone ****** Quetiapine
Olanzapine **
Risperidone **
Second Generation Antipsychotics:
- What does dopamine inhibition increase the secretion of? - P
- Anti-histaminergic effects - 2
- Weight?
- Metabolic - 1
- CVD - 2
- Anticholinergic effects
- BP
- Which drug causes long QT syndrome?
- Which drug cause sexual dysfunction?
Prolactin
Sedation and apathy
Weight gain
T2DM
Stroke and VTE
Dry mouth, retention etc.
Postural drop in BP
Quetiapine
Risperidone
Second Generation Antipsychotics:
Clozapine:
Why is this drug controversial?
Common side effects - 4
What common GI effect do you get?
It is the most effective but the ‘dirtiest’ antipsychotic, with lots of side effects.
Sedation, metabolic syndrome, low BP, anticholinergic effects.
Constipation
Neuroleptic malignant syndrome:
HARD mneumonic for tetrad - what is it?
What else may present with this leading to cocacola coloured urine and kidney dysfunction?
Cause:
- Main cause?
How soon after the first dose does it present?
Inv - What may be found on bloods?
Management:
- Main Rx
- What can be done for rigidity?
- What can be done for psychomotor agitation?
Hyperthermia - Fever
Altered mental status - confusion, delirium
Riigidity (tremor, akinesia)
Dysautonomia - tachycardia, labile BP and sweating
Rhabdomyolysis
Antipsychotics
2 wks after
=====
Electrolyte imbalances
Raised CK
========
Discontinue antipsychotic
Give dantrolene - prevents release of calcium in striated muscle - less contractions
Benzos
HISTORY:
Q’s to ask about auditory hallucinations?
Do you ever hear noises or voices when there is nobody else there?
Are the voices like you hear mine right now?
Can you hear them in your ears, or are they in your mind?
How many voices are there?
Do you recognise the voices?
What do they say?
Do they tell you to do things? (Do you obey?)
Do they tend to comment on what you are doing/thinking?
Are they present all the time?
Does anything make them better or worse?
Do you ever find yourself having a conversation with them?
Do you smell or see anything at the same time that you hear these voices?
HISTORY:
Q’s to ask about thought disorder? - 3
Do you feel able to think clearly?
Do you ever experience you thoughts suddenly stopping as though there were no thoughts left?
What is it like? How do you explain it?
HISTORY:
Q’s to ask about thought withdrawal? - 1
Q’s to ask about thought insertion? - 2
Q’s to ask about thought broadcasting? - 2
Is there anyone or anything taking thoughts out of your head?
///////////
Are you thoughts your own?
Is there anyone/anything putting thoughts into your head that you know are not your own? //////// Can anyone hear your thoughts? For example, can I head what you are thinking right now?
Do you ever hear your own thoughts echoed or repeated?
