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Summary Notes Royal College > Schizophrenia > Flashcards

Schizophrenia Flashcards

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1
Q

Other adverse effects of clozapine?

A

Fever - 55%
Tachycardia - 25%
Hypersalivation - 30-80%
Night time enuresis - 21%

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2
Q

Clozapine range - WBC 3.0-3.5 Neutrophils 1.5-2

A

Continue Clozapine therapy with twice weekly blood tests

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3
Q

Clozapine range WBC < 3; Neutrophils <1.5

A

Stop immediately

Contact heme and Clozapine monitoring center

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4
Q

Clozapine range: WBC>3.5; WBC>2

A

Continue clozapine

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5
Q

Less common side effects of antipsychotics?

A

Pulmonary embolism
Stroke and cardiac events
Osteoperosis
Impulse control disorders

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6
Q

Mortality in Schizophrenia?

A

3x greater vs general population

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7
Q

Risk of diabetes in Scz

A

1.3 fold higher

2 fold greater risk premature death

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8
Q

Risk factors for NMS?

A 
use of high doses
parenteral administration
physical restraints
dehydration
older age
previous history
family history of catatonia
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9
Q

Cardinal symptoms of NMS ?

A

hyperthermia
rigidity
elevated CPK more than 4x
autonomic dysregulation

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10
Q

Schizophreniform DIsorder

A

Presence of at least two of the following:

  • onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior of functioning
  • confusion or perplexity
  • good premorbid social and occupational functioning
  • absence of blunted or flat affect
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11
Q

Further evidence for psychosocial interventions in schizophrenia?

A 
Family intervention
Supported employment
CBT
cognitive remediation
social skills training
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12
Q

Signs and symptoms of intracranial pathology

A

headaches
nausea and vomiting
seizure like activity
late age onset of symptoms

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13
Q

Schizophrenia - etiology and epidemiology - prenatal risk factors

A 
season at birth - winter > summer
exposure to influenza in utero
birth complications
paternal age >35
male gender
Urbanicity
Migration
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14
Q

Adult onset vs early onset Scz

A 
Adult onset = better prognosis
Early onset prognosis measures (worse):
- more severe illness
- lower premorbid functioning
- more severe negative symptoms
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15
Q

Neurophysiology findings in Scz

A 
Reductions in gray matter in these areas
- prefrontal 
- medial temporal
- superior temporal
- Enlarged ventricles
- reduced symmetry
gray matter loss related to inflammatory process during synpatic pruning via C4A cytokines
more grey matter loss in chronic patients
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16
Q

Neurophysiology findings in Sz

A

reduced amplitude of p300 p50 evoked potentials - very consistent findings
reduced sleep spindles on EEG
abnormal EEG present at baseline in 15-25% patients with first episode psychosis

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17
Q

Abnormal EEG findings at onset of illness is related to worse outcome at 3 and 5 year follow up measures:

A
  • Positive symptoms
  • Negative symptoms
  • Overall level of functioning (as measured by SOFAs)
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18
Q

What are neurochemical findings in Scz?

A

increased striatal dopamine on PET scanning in acute psychosis
NMDA receptors and loss of GABA -ergic functioning in cortical neurons - positive and negative symptoms
GLutamate is likely implicated
CBD may be protective

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19
Q

Good prognostic indicators for schizophrenia

A 
Shorter duration of untreated psychosis
Fewer negative symptoms
predominately only delusions and hallucinations as positive symptoms
Higher baseline premorbid functioning
Absence of ACE
No co-occuring psychiatric disorders (including substance use disorder)
Absent family history of schizophrenia
Present family history of mood disorder
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20
Q

History of childhood trauma - risk for psychosis?

A

3x

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21
Q

Possible causes of high level comorbidity scz and substance use disorders?

A

Temporary compensation of D2 blockade caused by antipsychotics
Share vulnerability to both illnesses
Self medication
Increased risk of psychotic illness secondary to drug use

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22
Q

What is the strongest predictor of social and vocational outcomes in Scz?

A

Cognitive deficits - 100% show vs premorbid level
Cognitive remediation
- 2 main approaches - restorative (through repetition)
- strategy circumventing deficits

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23
Q

Ultra High Risk - Prodrome

A

onset of attenuated positive symptoms not reaching threshold for psychosis
brief intermittent psychotic symptoms lasting less than 7 days
combination of trait (positive family history of psychosis in first degree relative) and significant decline in global functioning in previous year.
UHR - shown transition to psychosis at the rate of around 25-35% in the first year

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24
Q

Ultra High Risk

A

must be aged between 15-25 yerars old
must have been referred to a specialized service for help
meet criteria for one or more of the following three groups:
Attenuated Positive Symptoms
Brief limited Intermittent psychotic symptoms (BLIPs)
Trait and state risk factors

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25
Q

APS - attenuated positive symptoms

A

Group 1:
Presence of at least one of the following symptoms:
ideas of reference, odd beliefs, magical thinking, perceptual disturbance, paranoid ideation, odd thinking and speech, odd behavior and appearance
- Frequency of symptoms: at least several times a week
- Recency of symptoms: present within last year
- Duration of symptoms: present for at least 1 week and no longer than 5 years.

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26
Q

Brief limited intermittent psychotic symptoms (BLIPS)

A

Group 2:
Transient psychotic symptoms: presence of at least one of the following: IOR, magical thinking, perceptual disturbance, odd thinking
Duration of episode: less than 1 week
Frequency: at least several times per week, resolve spontaneously
Recency: must have occurred within last year

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27
Q

Trait and state risk factors

A

Group 3
Schizotypal personality disorder or first degree relative with ap ychotic disorder
Significant decline in mental state or functioning, maintained for at least 1 month not longer than 5 years
- This decline in functioning must have occured in teh past year

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28
Q

What is conversion rate of UHR?

A

10-18%

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29
Q

Treatment Guidelines?

Following resolution of positive symptoms of first episodes, what should be the duration of treatment for maintenance ?

A

the duration should be at least 18 months

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30
Q

What is the duration of treatment after relapse?

A

patients should be offered medication 2 to 5 years or longer

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31
Q

Risk of second episode of psychoses - Scz

A

At least 80% with first episode psychosis are at risk for second episode within first 3-5 years, recovery from second episode is slower

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32
Q

Predictors of relapse

A

Medication nonadherence - 4 fold
persistent substance use - 3 fold
careers critical comments - 2.3 fold
poor premorbid ajdustment - 2.2 fold

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33
Q

5 As schizohprenia

A

avolition, apathy, anhedonia, affect flat, asociality

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34
Q

Delusional disorder - risk factors

A
  • older
  • female
  • married
35
Q

Prenatal risk factors - Etiology and Epidemiology - Schizophrenia

A 
Winter births
Exposure to influenza
Paternal age > 35
Male gender
Urban
Migration
36
Q

Relative Risks for Schizphrenia:
Monozygotic twin
Both parents affected
Dizygotic twin

A

40-50x
30-50 x
9-18

37
Q

early onset schizophrenia

A

worse prognosis
more severe illness
more negative symptoms

38
Q

Strongest predictor of social and vocational outcomes?

A

cognitive deficits

39
Q

How long to continue AP after initiation?

A

2 weeks

If no response after 4 weeks, consider change

40
Q

Following resolution of positive symptoms, how long should the AP treatment be maintained?

A

at least 18 months

41
Q

How many patients will relapse - psychotic symptoms within 3 -5 years?

A

At least 80% of patients with first-episode psychosis
are at risk for a second episode within the first 3 to 5
years, and recovery from a second episode is slower
and often less complete

42
Q

How many times more likely is someone with PTSD to commit suicide?

A

6x more likely

43
Q

Are cortisol levels higher or lower in chronic PTSD?

A

lower

44
Q

Adjunct PTSD?

A

First line: Olanzapine, Risperidone

Secondl ine:

Carbamezapine
Gabapentin
Topirmate

45
Q

Not recommended in PTSD?

A

benzos

citalopram

46
Q

Stage oriented trauma treatment?

A

Stage 1 - stabilization
Stage 2 - Trauma focused therapy - grief work
Stage 3 - Reconnection

47
Q

Four components of DBT?

A

Individual therapy
Group skills training
telephone contact
Therapist consultation/support

48
Q

Four modules of DBT ?

A 
MIED*
Mindfulness
Interpersonal effectiveness
Emotion regulation
Distress tolerance skills
49
Q

What is a skill used in emotion regulation ?

A

Behavioral chain analysis

50
Q

Psychotherapies found to be effective in controlled PTSD trials ?

A

Prolonged exposure
cognitive processing therapy
narrative story telling
EMDR

51
Q

Biological relatives of schizophrenia person are most likely to have this personality disorder?

A

Schizotypal

52
Q

Typical illness course - schizophrenia

A

Initial predominant positive symptoms followed by progressively disabling negative symptoms

53
Q

obsessions vs delusions

A

delusions - syntonic

obsession - egodystonic

54
Q

Highest risk factors for suicide in schizophrenia?

A

hopelessness

high IQ

55
Q

First Rank Schneiderian symptoms

A
  1. Auditory hallucinations
  2. Passivity experiences
  3. Thought Withdrawal
  4. Thought Insertion
  5. Thought Broadcasting

NOT THOUUGHT BLOCKING!

56
Q

Negative symptoms - schizophrenia

A 
affective flattening
apathy
avolition
anhedonia
alogia
57
Q

Risk factors for post partum psychosis

A 
discontinuation of mood stabilizer 
obstetrical complications 
perinatal infant mortality 
previous BD, psychosis or post-partum psychosis (hx of PPP carries a 30-50% incr risk) 
Fhx Post-Partum psychosis 
Fhx BD 
sleep deprivation
increasing environmental stress 
lack of partner support
58
Q

Akithesia - treatment?

A

Benzo + Beta blocker (most evidence)

59
Q

Risk factors associated with delusional disorder

A 
Advanced age
Sensory impairment or isolation
Family history
Social isolation
Personality features
Recent immigration
60
Q

Most risk for violence?

A

persecutory delusions

61
Q

Delusional disorder

A

K & S - breeds true*

62
Q

Late onset schizophrenia

A

onset after 45 years
more frequently in women
predominance of paranoid sxs, less likely to have disorganized or negative symptoms
prognosis is favorable (preservation of affect and social functioning)
chronic course, but do well on antipsychotics
For those oldest age of onset (over 60), sensory deficits may be more common, pathogenesis unknown
Cognitive impairment may accompany clinical picture
more likely to be married, but more socially isolated and impaired to general population
Postmenopausal states, HLA subtypes, cerebrovascular disease possible risk factors

63
Q

Neuroimaging - Schizophrenia

A

Enlargement of ventricles
Thalamus - decreased volume
Increased basal ganglia size
Enlarged caudate

64
Q

women with schizophrenia

A

better premorbid functioning, more affective sx, paranoid delusions, hallucinations, better prognosis (fewer hospitalizations, shorter stays, shorter duration of illness, longer time to relapse, better response to neuroptics, better social and work functioning) – however LONGTERM outcomes (ie after menopause – more similar)

  • increased prolactin levels
65
Q

Delusional Disorder - Risk Factors

A 
-advanced age
sensory impairment or isolation
- family history
- social isolation
- personality features
-  recent immigration
66
Q

Paranoid Personality Disorder vs. Delusional Disorder

A

Paranoid personality does not have fixed delusion

67
Q

Prevalence of Schizophrenia in Specific Populations

A

General Population 1%
Nontwin sibling of a schizophrenic patient 8%
Child with one schizophrenic parent 12%
Dizygotic twin of a schizophrenic patient 12%
Child of two schizophrenic parents 40%
Monozygotic twin of a schizophrenic patient 47%

68
Q

Childhood onset schizohprenia have more?

A

cytogenic abnormalities

69
Q

Positive prognostic predictors first episode psychosis

Good prognosis

A 
Late onset
Obvious precipitating factors
Acute onset
Good premorbid social, sexual, and work Hx
Mood disorder sx (especially depressive disorders)
Married
FmHx of mood disorders
Good support systems
Positive sx
70
Q

Negative prognostic predictors - first epsode psychosis

A 
Young onset
No precipitating factors
Insidious onset
Poor premorbid social, sexual, and work hx
 Withdrawn/autistic behavior
Single, divorced, widowed
FmHx of schz
Poor support systems
Negative sx
Neurological signs and symptoms
71
Q

Late onset schizophrenia - RF

A
  1. insidious onset
  2. women over the age of 45
  3. more likely to have been married and have had a job than other schizophrenics, but . . .
  4. pre-morbid paranoid or schizoid personalities
  5. absence of dementia
  6. no clear stronger association with family history
72
Q

Most useful predictor of drug response

A

detailed history of prior drug response

73
Q

Schizoaffective d/o

A

more prevalent in females
better prognosis than schizophrenia
2 week period without mood symptoms - only psychotic
Anosognosia (poor insight) also prominent

74
Q

Predictors of violence

A 
substance use
male
young
history of previous violence
psychotic symptoms
75
Q

Bleuler - 4A

A

Associations (alogia)
Affect
Autism
Ambivalence

76
Q

Schizophrenia tx

A

If 2 separate episodes with resolution in between = 5 years

If continuous symptoms = 2 years

77
Q

Neuroimaging and neurophysiology changes in Schizophrenia

A
  • Reduction in gray matter volumes (prefrontal, medial temporal, superior temporla)
  • Enlarged ventricles
  • Reduced symmetry
  • At risk* individuals show these changes prior to onset of illness
  • Decreased amplitude of p300 p450
  • 15-25% have abnormal EEG at baseline
78
Q

Late onset schizophrenia

A

onset after 45 years
more frequently in women
predominance of paranoid sxs, less likely to have disorganized or negative symptoms
prognosis is favorable (preservation of affect and social functioning)
chronic course, but do well on antipsychotics
For those oldest age of onset (over 60), sensory deficits may be more common, pathogenesis unknown
Cognitive impairment may accompany clinical picture
more likely to be married, but more socially isolated and impaired to general population
Postmenopausal states, HLA subtypes, cerebrovascular disease possible risk factors

79
Q

Schizophrenia in elderly

A

About 20% show no active symptoms by age 65; 80% show varying degrees of impairment. Less marked psychopathology with age

80
Q

Supported employment - best evidence

A

Integration of mental health and vocational services

81
Q

Therapy Intervention in Schizophrenia

A

Family Intervention Therapy

  • Communication skills
  • Problem Solving
  • Psychoeducation
82
Q

Treatment resistant - Clozapine guidelines

A
  1. Clozapine should be offered to patients who have TRS. [SIGN (Grade A)]
  2. Clozapine should be considered for patients whose schizophrenia has not responded to two antipsychotics.
83
Q

Most effective for substance use disorders and scz

A

Clozapine

Summary Notes Royal College (16 decks)

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