Schizophrenia Flashcards
What are the primary symptoms of schizophrenia?
Thought Disorders
Delusions of control influence and passivity
Hallucinatory voices - running commentary or voices from distinct body parts
Persistent culturally inappropriate or impossible delusions.
What are the secondary symptoms of schizophrenia?
Persistent hallucinations in any modality for >1 month
Neologism incoherent or irrelevant speech
Catotonic behaviour waxy posturing and flexibility
Stupor
Negative symptoms
What are the negative symptoms of schizophrenia?
Blunted affect
Incongruity of emotional response
What are positive symptoms of schizophrenia?
Hallucinations
Delusions
Disorder of thought
Passivity phenomena
80% of schizophrenic patients are….
Paranoid
Hepephrenic schizophrenia
Shallow innapropiate mood Unpredictable fragmentary hallucinations and delusion Incoherent speech Social isolation Negative symptoms
Paranoid schizophrenic
1st rank symptoms
positive schizophrenia symptoms
20% of schizophrenic patients are…
Hepephrenic
Catotonic
Catotonic schizophrenia
Movement disorder - swing between hyperkinesis and stupor
Automatic obedience in Waxy posturing and flexibility
What is pathophysiology behind schizophrenia?
Excessive and abhorrent firing of dopaminergic neurones.
List the dopamine pathways found in the brain.
Mesolimbic Mesocortical Nigrostriatal Tuberoinfundibular Hypothalamospinal
What drugs are initially prescribed with a first episode of psychosis?
Haloperidol
Raclopride
Aripiprazole
If extra-pyramidal side effects are of a great concern or the psychosis is resistant to treatment what 2nd generation anti-psychotic is used?
Clozapine
Which medication when used in psychosis is linked to an increase in cognition and concentration?
Lurasidone
Dopamine Adrenoreceptor antagonist
Seretonin partial agonist
What medication is used in the treatment of Schizophrenia?
Anti-psychotics - usually antidopaminergic
What are the main symptoms of the antipsychotic drugs used in schizophrenia?
Extra pyramidal
Neuroleptic Malignant Syndrome
Hyperprolactinaemia
Akanthesia
Why do patients of antipsychotics develop extra pyramidal side effects?
Blocking of the nigrostriatal pathway
What are the main symptoms of the extra-pyramidal side effects?
Acute dystonia
Parkinsonism
Tardive dyskinesia
What is Acute dystonia?
Gradual increase in muscle tone
What is the time scale of acute dystonia ?
minutes to hours
What are the main symptoms acute dystonia?
Jaw locking
Eyes roll back
Tongue protrudes
Body twists to the side of the stronger muscles
What percentage of patients on antipsychotics reports extrapyramidal side effects?
50%
What are the main symptoms of Parkinsonism?
bradykinesia Cogwheeling rigidity Resting tremor Shuffling gait Dead pan face
What is tardive dyskinesia?
Involuntary repetitive orofacial movements, can involve trunk or limbs
Give some examples of common movements in tardive dyskinesia.
Blinking
grimacing
Pouting
Lip smacking
What is the time scale for tardive dyskinesia?
Long term side effect years of use
Often is permanent even with withdrawal
Why do patients of antipsychotics develop extra pyramidal side effects?
An imbalance between acetylcholine and dopamine within the brain.
How are the extrapyramidal side effects of antipsychotics treated?
Withdrawal of medication and replaced with clozapine.
Reducing levels of acetylcholine to balance levels, both low.
Why is clozapine the replacement if extra pyramidal side effects are a worry?
It is least likely to cause extra pyramidal side effects
What medication is used to reduce the levels of acetylcholine and restore the balance with dopamine?
Procyclidine Oral
Orphenadrine IM
Once the symptom of Tardive dyskinesia are present does it respond to removal of medication or anticholinergics?
No it is very unresponsive
Why do patients on antipsychotics sometimes develop Neuroepileptic Malignant Syndrome?
Hippocampal dopamine receptors are blocked
How many patients on Antipsychotics develop NMS?
Rare but 20 -30% of patients who develop it die
What is NMS?
Gradual increase in muscular tone
Pyrexia
Autonomic dysfunction
How does NMS kill you?
Autonomic dysfunction results in a massively varying BP HR.
Rhabdomyolysis leads to acute renal failure
Coma
Death
What investigation can aid in the diagnosis of NMS?
Creatine Kinase
What is the treatment for hypothalamic NMS?
STOP antipsychotic Rapid cooling Renal suport Skeletal muscle relaxants Dopamine agonists
What dopamine agonist is used in the treatment of NMS?
Bromocriptine
Why do patients of antipsychotics present with hyperprolactinaemia?
Dopamine inhibits prolactin release from the pituitary gland so reduced dopamine results in excess prolactin release.
Women with hyperprolactinaemi present with….
Galactorrhea Reduced libido arousal Anorgasmic Amenorrhea Anovulation
Men with hyperprolactinaemia present with…..
Gynaecomastia
Erectile dysfunction
Oligospermia
Reduced libido
Prolactin affects….
Boobs
Balls
Bones
Hyperprolactinaemia has what affect on the bones?
Reduced bone mineralisation density
Osteoporosis
What percentage of patients on antipsychotics complain of akathisia?
20%
What is the time scale of initiation of antipsychotic to side effect onset?
Days to weeks
What is Akathisia?
Restlessness
Pacing
Poor sleep
What is the particular risk associated to Akathisia?
Due to poor sleep there is an increased risk of suicide.
What mediation is used in the treatment of Akathisia?
Beta blockers - Propanolol
BDZ - for severe acute episodes
Due to there unknown effect on other receptors throughout the brain what other effects can Atipsychotic drugs have and why?
Anticholinergic - dry mouth constipation blurred vision
Anti-serotonergic - weight gain Type 2 diabetes
Anti adrenergic - postural hypertension
What are some other common side effects of Anti-psychotics?
Hepatotoxicity
Prolonged QT
Photosensitivity
What severe side effects are associated with clozapine?
Agranulocytosis
Myocarditis
Sever weight gain 10kg in 3 months
Severe constipation
What is agranulocytosis?
Dangerously low white blood cell count - leading neutropenic sepsis as unable to fight infection
What other side effects of clozapine are common?
Sedation
Sialorrhoea
Why is constipation considered a severe side effect of clozapine?
Leads to gastroperesis obstruction and perforation of the bowel
Apart from reduced risk of extra pyramidal side effects what are the benefits of clozapine?
Reduces risk of suicide
Good for negative symptoms of psychosis
How long does someone need to be on the titrated adequate dose before they can be reviewed for alternative treatment?
6-8 weeks
Alongside pharmacological treatments what else must be considered ?
optimising social supports
Psychological therapy
If someone is unresponsive to both 1st and 2nd generation drugs what must be considered?
Check diagnosis correct
Check compliance
If a patient has poor compliance what can be considered?
IM Depots in gluteal of deltoid muscle every 3 months
Haloperidol Risperidone
Why do patients with psychosis have many illnesses factors?
Poor diet Lack of support poor access to transport Chronic health condition poor concentration - missed appointments prescriptions etc Higher rate of smoking Co morbid drug use
When is a very rare age period for a diagnosis of schizophrenia?
Old age and adolescence
Is there any gliosis present in schizophrenia?
NO
What is the biggest risk factor for developing schizophrenia?
Family History
What are some other risk factors for developing schizophrenia?
2nd trimester viral illness
Obstetric problems - pre eclampsia foetal hypoxia
Childhood viral CNS infection
Substance misuse
Why does substance misuse increase your risk of developing schizophrenia?
Its multi factorial so patient may be genetically predisposed and the substances trigger schizophrenia.
What substances carry a particular risk of triggering schizophrenia?
Amphetamines
Cocaine
Cannabis
Synthetics - Spice Ivory wave
What may be seen in the brain of a patient with schizophrenia?
Enlarged ventricles
reduced frontal lobe volume and grey matter
Reduced activation of pre frontal regions
Subcortical dopamine hyperactivity leads to…
Psychosis
Mesocortical dopamine hypoactivity leads to…
Negative and cognitive symptoms
What genes are related to schizophrenia?
Neuregulin
Dysbindin
DISC-1
Neureglin
Signalling protein mediating cell to cell interaction
Dysbindin
Essential for adaptive neural plasticity
DISC-1
Involved in neural growth
Cortical development
