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Module 202 Theme 3 > Schizophrenia and its causes symposium > Flashcards

Schizophrenia and its causes symposium Flashcards

1
Q

List the features of psychosis

A

Positive symptoms - Delusions, hallucinations, disorganized speech, catatonia

Negative symptoms - Affective flattening, Alogia, Avolition, Anhedonia

Cognitive symptoms - attention, memory, executive functions

Mood symptoms - dysphoria, suicidality, helplessness

Affects social, work, family and self care

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2
Q

Describe the genetics of schizophrenia

A

Relatives of affected subject with psychosis have an increased risk of psychosis themself
Effects shown in monozygotic twins 50% chance
In adoption there is an increase risk if biological parents have schizophrenia

Major histocompatibility complex on chromosome 6 gene encoding micro RNA mi147 associated with neuronal development. 
TCF4
CSMD1
Region of chromosome 10
NGRN
In joint with bipolar disorder - ZNF804A, CACNA1C and ANK3
Copy note variants identified 
Likely multiple genes of small effect
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3
Q

List some environmental/biological stresses causing schizophrenia

A

Obstetric complications - Premature birth, low birth weight, perinatal hypoxia
Intrauterine infection 1st/2nd trimester
Antepartum bleeding
Immune activation

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4
Q

List some environmental/psychological stresses causing schizophrenia

A 
Life events
Migration
Social isolation
urban living
Upbringing - high emotional expression in families - critical comments, hostility, overinvolvement
Early experience of trauma
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5
Q

List some macro neurological abnormalities reported in schizophrenia

A 
Enlargement of ventricles
Widening of cortical sulci
Cortical grey matter loss
Loss of asymmetry 
Decrease limbic structure and thalamic volume
Progressive deficits in some and not all
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6
Q

List some micro abnormalities reported in schizophrenia

A 
Cortical glial loss
Increased neuron density 
Aberrant neuron migration
Synaptic loss
Decreased dendritic complexity
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7
Q

Neuropsychology abnormalities

A 
Deficits in : 
Arousal
Working memory
Executive function
Eye movements
Social cognition
Theory of mind
Loss of functional asymmetry
Receptive language function
Subtle motor function, speech and IQ
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8
Q

What happens to striatal dopamine synthesis and storage in schizophrenia?

A

Increases

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9
Q

What is associated with increased dopamine secretion in the striatum?

A

Reduced glutamate function in the frontal lobes

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10
Q

What symptoms is reduced frontal glutamate associated with?

A

Negative symptoms

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11
Q

What symptoms is increased striatal dopamine associated with?

A

Positive symptoms

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12
Q

What does hypoactivity in the PFC lead to?

A

Increased dopamine release in nucleus accumbens

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13
Q

Which symptoms in particular is glutamate associated with?

A

Cognitive

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14
Q

List some drugs associated with psychosis

A 
L-Dopa				
Amphetamine			
LSD
Cannabis 
Cocaine
Ketamine
MDMA         
PCP  
other novel psychoactives
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15
Q

List affective psychosis disorders

A

Bipolar disorder
Depressive psychosis
Schizoaffective disorder

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16
Q

List organic psychosis

A

Epilepsy (temporal lobe)
Infections: encephalitis, subacute sclerosing panencephalitis, neurosyphillis, HIV
Cerebral trauma
Cerebrovascular disease
Demyelination: MS, Schilder’s disease, metachromatic dystrophy
Neurodevelopmental disorders: velocardiofacial syndrome
Endocrine: thyroid disorders (hyper and hypo), Cushing’s syndrome,
Metabolic: hepatic failure, uraemia
Immunological: SLE, Autoantibodies to brain receptors NMDA
Drugs
Toxins eg. lead
Dementias

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17
Q

What is the differential diagnosis of psychosis?

A

Affective psychosis
Organic psychosis
Personality disorder

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18
Q

What do antipsychotic drugs treat?

A

Dopamine dysregualtion

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19
Q

What does CBT treat?

A

Cognitive salience errors

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20
Q

Which classes of drugs are used to treat psychosis?

A

Typical and Atypical antipsychotics

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21
Q

Compare the efficacy of typical vs atypical antipsychotics

A

Appears equal in first psychotic episode however atypical antipsychotics may be more useful in chronic illness

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22
Q

Which drug has greatest efficacy in resistant cases?

A

Clozapine

23
Q

How long does it take till clinical evidence of efficacy can be seen in patients?

A

2 Weeks

24
Q

How are side effects predicted?

A

By receptor affinity of the drug

25
Q

List the adverse effects of drugs which bind to D2 Dopamine receptors

A

Parkinsonism, tardive dyskinesia, raised prolactin

26
Q

List the adverse effects of drugs which bind to 5FT2 serotonin receptors

A

Sedation, metabolic weight gain, glucose intolerance, increased triglycerides, raised prolactin, hypotension, arrhythmia, neutropenia

27
Q

List the adverse effects of drugs which bind to H1 histamine receptors

A

Sedation

Weight gain

28
Q

List the adverse effects of drugs which bind to M1 cholinergic receptors

A

Antagonism - constipation, urinary retention, blurred vision
Agonism (clozapine only) - saliva overproduction

29
Q

List the adverse effect of drugs which bind to alpha 1 norepinephrine receptors

A

Postural hypotension

30
Q

List some typical antipsychotics

A

HALOPERIDOL

CHLORPROMAZINE

31
Q

List some typical antipsychotics

A 
AMISULPRIDE
ARIPIPRAZOLE
CLOZAPINE
RISPERIDONE
OLANZAPINE
QUETIAPINE
LURASIDONE
32
Q

List some long acting injections

A

DEPIXOL PALOPERIDONE (RISPERIDONE
CLOPIXOL (OLANZAPINE)
PIPORTIL ARIPIPRAZOLE

33
Q

How do the typical (old) antipsychotics work?

A

Potently block dopamine D2 receptors

34
Q

List the side effects of typical antipsychotics

A

Sedation
Extrapyramidal symptoms Parkinsonian symptoms
Dystonia
Akithisia
Tardive dyskinesia
Cardiac: Hypotension, Arrhythmias
Temperature dysregulation
Neuroleptic malignant syndrome
Anticholinergic side effects (affect many different organs)
Weight gain (less than atypicicals)
Raised prolactin (galactorrhoea, ↓sexual fn, osteoporosis)

Less frequently jaundice, lens opacities, skin discolouration, blood dyscrasias

35
Q

Describe the action of atypical (new) antipsychotics

A

Primary action not at D2 receptors, often more potent at 5HT2 receptors

36
Q

List the side effects of atypical antipsychotics

A

Sedation (olanzapine, clozapine, quetiapine) (least for aripiprazole)

Metabolic weight gain, glucose intolerance, ↑triglycerides (olanzapine / clozapine more than others; least for aripiprazole)

Raised prolactin :galactorrhoea, ↓sexual fn, osteoporosis (risperidone, amisulpride)

Cardiac: Hypotension (quetiapine) Arrhythmias (less than typicals)

Neutropaenia with clozapine in 1% hence requires regular blood monitoring

37
Q

Describe the NICE standards for antipsychotic use

A

Joint choice of drug with patient / carer / Dr
Use Clozapine if no response to 2 others (including 1 atypical)
Log acting (depot) injections useful in those who prefer them or to help covert non adherence
Develop advance directives
Avoid high dose or prescription of two antipsychotics together

38
Q

Describe clozapine

A

Oral medication taken daily.
Clear benefit in treatment resistant schizophrenia.
Little Parkinsonian effects or tardive dyskinesia.
Sedation, weight gain, dribbling common.

39
Q

What monitoring is required in clozapine use?

A

Licensed with regular neutrophil monitoring.
Neutropenia in approximately 1% of cases but progression slow so ceasing medication significantly reduces risk.
Slow titration to optimal dose with monitoring of pulse, BP and neutrophil count necessary.

40
Q

Describe the use of electroconvulsive treatment

A

Not a primary treatment of psychosis

Very effective in psychosis associated with depression or with catatonia

41
Q

What is metabolic syndrome and how does it relate to schizophrenia?

A

Exacerbated by atypical antipsychotic drugs
Appears more prevalent in schizophrenia pre treatment
than the general population
Associated with higher rates of coronary heart disease,
cerebrovascular pathology and earlier death

Hence routine screening, appropriate treatment
and giving routine advice about diet & exercise in
psychiatric practice

42
Q

Why not just medication?

A

Treatment resistant symptoms
Partially resistant symptoms
Where side effects limit doses of medication
Service user choice

Comorbidity….anxiety, depression, PTSD
psychologically informed case management.- relapse prevention

43
Q

What is the ethos of early interventional service?

A

Hopeful
Collaborative
Empowering
Social recovery prioritised….achieving work, relationships

44
Q

Describe CBT informed case management

A

Timeline of events leading to psychosis
Relapse signature
Early warning signs
Crisis plan

Problem solving

Psychoeducation about illness and possible treatment options

Self management , advance directives

45
Q

List some NICE recommended psychological treatments in schizophrenia

A

Offer Cognitive behavioural therapy for psychosis CBTp
Offer Family interventions for families
Consider Art therapy
Assess for PTSD and follow PTSD guidelines

46
Q

List some treatments for the comorbidities of schizophrenia

A 
Depression... behavioural activation
Bipolar……mood management
Trauma…..trauma related work. EMDR
Anger management
Anxiety….relaxation, graded exposure work

Medication concordance

47
Q

Describe CBT for psychosis

A

12-20 sessions
Treatment resistant symptoms
Alternative to medication for distressing symptoms
Aim is to relieve distress and increase function rather than “treat” delusions or “get rid” of hallucinations.

48
Q

What is the CBT model

A

Thoughts
Feelings
Behaviour

49
Q

What does CBT work on?

A 
Appraisal of a situation
Jumping to conclusions
Working on delusional belief
Changing appraisal of experiences
Work on reasonable biasness
Work on self esteem 
Work on appraisal of meaning of having psychosis
50
Q

Describe family interventions

A

Psychoeducation for families

Support for families, friends and family groups.

Specific coping strategies

Specific psychosis based family intervention

51
Q

What is behavioural family therapy?

A

Highly structured therapy
Based on work of Vaughn and Leff 1976 on expressed emotion and risk of relapse.
12-16 sessions
2 therapists
Ideally patients who have relapsed and are in close contact with family

52
Q

What does behavioural family therapy involve?

A

Sharing Information about mental health problems and treatment
Problem solving
Crisis management
Managing medication compliance
Demonstrating and working on good communication between family members
Encouraging family members to refocus on own lives rather than the individual with the psychosis.

53
Q

List some family therapy techniques

A

Sculpting
Reframing
Circular questions
Reflecting teams

54
Q

What is art therapy useful for?

A

Negative symptoms
Concentration
Isolation
Self confidence

Creative medium to help explore and articulate feelings rather than speaking about them. safe space and relationship with therapists.

Module 202 Theme 3 (11 decks)

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