schizophrenia

Question 1

Q1: a concerned mother brings her 21 y.o. daughter, Julie, to her GP.

since returing from uni for the holidays, Julie has been behaving oddly. she stays in her room all the time and is constantly mumbling to herself. she believes that she is being chased by a government security agency and that they can hear her thoughts.

(a) list 4 of Schneider’s first rank sx of schizophrenia

Answer 1

1. auditory hallucinations
   
   • 3rd person or running commentary
   • 2 or more voices discussing about the pt
   • hearing own thoughts i.e. thought echo
2. delusional perceptions
3. thought insertion / withdrawal / broadcast
4. made feelings, actions or somatic passivity (delusions of external control)

Question 2

(b) what may Julie have been doing at uni, which is a known precipitating factor for schizophrenia?

Answer 2

marijuana

Question 3

(c) name 2 of the 4 dopamine pathways in the brain

Answer 3

1. nigrostriatal
2. tuberoinfundibular
3. mesocortical
4. mesolimbic

Question 4

Julie is prescribed a conventional (typical) neuroleptic drug.

3 months later she returns with her mother, who is upset that she has developed a tremor.

(d)(i) why is this?

Answer 4

typical antipsychotics act at D2 receptors and produce extrapyramidal SEs

Question 5

(d)(ii) name 2 other signs you may see because of this side-effect

Answer 5

parkinsonism:

• bradykinesia
• rigidity

Question 6

Julie’s mother attends the surgery alone to ask about the treatment and what the prognosis is for getting back to uni

(e) explain in less than 40 words, what you would tell them

Answer 6

• as Julie has capacity, you are legally obligated to follow her wishes
• Julie has not made it clear that her mother can be informed about specifics of her rx
• you are unable to discuss Julie’s case with her without Julie present and consent being given
• HOWEVER, as a general rule of thumb, 1/3 recover, 1/3 relapse and 1/3 will never recover

Question 7

you refer Julie to a psychiatrist. after 1 month, she has failed to respond to 2 neuroleptics and clozapine is prescribed. he explains to you that Julie should now attend the GP surgery for regular blood tests as part of routine monitoring.

(f) what test should be done and what abnormality is being looked for?

Answer 7

FBC (WCC, neutrophils)

agranulocytosis

Question 8

Q2: a 23 y.o. has recently received a dx of schizophrenia. she has been prescribed haloperidol. 3 days after commencing it, she complains of pain in her neck and is noticed to have her face twisted to one side.

(a) what medication side effect is she suffering from?

Answer 8

acute dystonia

Question 9

(b) what is the underlying medication action that causes this side-effect and in which brain region does it occur?

Answer 9

D2 receptor antagonism

the nigrostriatal dopamine pathway in the brain

Question 10

(c) list other types of side-effect caused by the same drug action

Answer 10

1. tardive dyskinesia
2. akathisia (restlessness)
3. parkinsonism

Question 11

(d) name 2 management strategies to counteract these side-effects?

Answer 11

1. stop haloperidol and switch to an atypical antipsychotic e.g. aripriprazole
2. lower the dose of haloperidol

Question 12

(e) name 2 antipsychotic drugs least likely to cause these side-effects

Answer 12

1. aripripazole
2. clozapine