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Summary Notes Royal College > Schizophrenia > Flashcards

Schizophrenia Flashcards

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
APS - attenuated positive symptoms
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.
26
Brief limited intermittent psychotic symptoms (BLIPS)
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
27
Trait and state risk factors
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
28
What is conversion rate of UHR?
10-18%
29
Treatment Guidelines? | Following resolution of positive symptoms of first episodes, what should be the duration of treatment for maintenance ?
the duration should be at least 18 months
30
What is the duration of treatment after relapse?
patients should be offered medication 2 to 5 years or longer
31
Risk of second episode of psychoses - Scz
At least 80% with first episode psychosis are at risk for second episode within first 3-5 years, recovery from second episode is slower
32
Predictors of relapse
Medication nonadherence - 4 fold persistent substance use - 3 fold careers critical comments - 2.3 fold poor premorbid ajdustment - 2.2 fold
33
5 As schizohprenia
avolition, apathy, anhedonia, affect flat, asociality
34
Delusional disorder - risk factors
- older - female - married
35
Prenatal risk factors - Etiology and Epidemiology - Schizophrenia
``` Winter births Exposure to influenza Paternal age > 35 Male gender Urban Migration ```
36
Relative Risks for Schizphrenia: Monozygotic twin Both parents affected Dizygotic twin
40-50x 30-50 x 9-18
37
early onset schizophrenia
worse prognosis more severe illness more negative symptoms
38
Strongest predictor of social and vocational outcomes?
cognitive deficits
39
How long to continue AP after initiation?
2 weeks | If no response after 4 weeks, consider change
40
Following resolution of positive symptoms, how long should the AP treatment be maintained?
at least 18 months
41
How many patients will relapse - psychotic symptoms within 3 -5 years?
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
How many times more likely is someone with PTSD to commit suicide?
6x more likely
43
Are cortisol levels higher or lower in chronic PTSD?
lower
44
Adjunct PTSD?
First line: Olanzapine, Risperidone Secondl ine: Carbamezapine Gabapentin Topirmate
45
Not recommended in PTSD?
benzos | citalopram
46
Stage oriented trauma treatment?
Stage 1 - stabilization Stage 2 - Trauma focused therapy - grief work Stage 3 - Reconnection
47
Four components of DBT?
Individual therapy Group skills training telephone contact Therapist consultation/support
48
Four modules of DBT ?
``` MIED* Mindfulness Interpersonal effectiveness Emotion regulation Distress tolerance skills ```
49
What is a skill used in emotion regulation ?
Behavioral chain analysis
50
Psychotherapies found to be effective in controlled PTSD trials ?
Prolonged exposure cognitive processing therapy narrative story telling EMDR
51
Biological relatives of schizophrenia person are most likely to have this personality disorder?
Schizotypal
52
Typical illness course - schizophrenia
Initial predominant positive symptoms followed by progressively disabling negative symptoms
53
obsessions vs delusions
delusions - syntonic | obsession - egodystonic
54
Highest risk factors for suicide in schizophrenia?
hopelessness | high IQ
55
First Rank Schneiderian symptoms
1. Auditory hallucinations 2. Passivity experiences 3. Thought Withdrawal 4. Thought Insertion 5. Thought Broadcasting NOT THOUUGHT BLOCKING!
56
Negative symptoms - schizophrenia
``` affective flattening apathy avolition anhedonia alogia ```
57
Risk factors for post partum psychosis
``` 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
Akithesia - treatment?
Benzo + Beta blocker (most evidence)
59
Risk factors associated with delusional disorder
``` Advanced age Sensory impairment or isolation Family history Social isolation Personality features Recent immigration ```
60
Most risk for violence?
persecutory delusions
61
Delusional disorder
K & S - breeds true*
62
Late onset schizophrenia
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
Neuroimaging - Schizophrenia
Enlargement of ventricles Thalamus - decreased volume Increased basal ganglia size Enlarged caudate
64
women with schizophrenia
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
Delusional Disorder - Risk Factors
``` -advanced age sensory impairment or isolation - family history - social isolation - personality features - recent immigration ```
66
Paranoid Personality Disorder vs. Delusional Disorder
Paranoid personality does not have fixed delusion
67
Prevalence of Schizophrenia in Specific Populations
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
Childhood onset schizohprenia have more?
cytogenic abnormalities
69
Positive prognostic predictors first episode psychosis | Good prognosis
``` 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
Negative prognostic predictors - first epsode psychosis
``` 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
Late onset schizophrenia - RF
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
Most useful predictor of drug response
detailed history of prior drug response
73
Schizoaffective d/o
more prevalent in females better prognosis than schizophrenia 2 week period without mood symptoms - only psychotic Anosognosia (poor insight) also prominent
74
Predictors of violence
``` substance use male young history of previous violence psychotic symptoms ```
75
Bleuler - 4A
Associations (alogia) Affect Autism Ambivalence
76
Schizophrenia tx
If 2 separate episodes with resolution in between = 5 years | If continuous symptoms = 2 years
77
Neuroimaging and neurophysiology changes in Schizophrenia
- 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
Late onset schizophrenia
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
Schizophrenia in elderly
About 20% show no active symptoms by age 65; 80% show varying degrees of impairment. Less marked psychopathology with age
80
Supported employment - best evidence
Integration of mental health and vocational services
81
Therapy Intervention in Schizophrenia
Family Intervention Therapy - Communication skills - Problem Solving - Psychoeducation
82
Treatment resistant - Clozapine guidelines
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
Most effective for substance use disorders and scz
Clozapine

Summary Notes Royal College (16 decks)

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