Schizophrenia and related disorders management Flashcards
What therapy should you offer to help with the negative effects of schizophrenia?
Arts therapies.
What is the difference between first gen (typical) and second gen (atypical) anti-psychotics?
Same efficacy, different side effects
Which generation tend to be offered in practice in the first episode of schizophrenia?
Second generation
Name the three dopamine pathways…
Mesocortical/mesolimbin, nigro-striatal, tubero-infundibular.
What are the mesocortical/mesolimbic pathways associated with?
Related to behaviour (anti-psychotic effect)
What is the nigro-striatal pathway associated with?
Coordination of voluntary movements (Extra-pyramidal side effects)
What is the tubero-infundibular pathway associated with?
Prolactin secretion
What are the anti-cholinergic side effects?
Can’t spit, can’t pee, can’t pooh, can’t see. Dry mouth, urinary retention, constipation and blurred vision.
What are the anti-adrenergic side effects?
Postural hypotension, sexual dysfunction
What are the anti-histamine side effects?
Sedation and anti-emetic.
Name the condition which has a prolonged QT interval?
Torsades de pointe/ VT
Why must you do an ECG before commencing someone on anti-psychotics?
Anti-psychotics cause QT prolongation.
What are the prolactin related side effects of anti-psychotics?
Amenorrhea, galactorrhea, gynaecomastia, impotence, weight gain, osteoporosis.
What are the ACUTE EPSE of anti-psychotics?
Parkinsonism (rigidity, tremor)- treat with anti-cholinergics, Dystonia (spasms, torticollis), treat with anti-cholinergics, akathasia (restlessness) adjust drug dose, change dose
What are the CHRONIC EPSE?
Tardive dyskinesia: Choreoathetoid movements- treatment for this is difficult
Which SGA has the best efficacy?
Clozapine
Who does NICE say clozapine should be offered to?
Offer it to people with schizophrenia who haven’t responded to adequate doses of at least 2 different anti-psychotic drugs, and one should be a non-clozapine SGA.
What receptors does clozapine target?
D2 receptors, has a high affinity for D4 dopamine receptors and targets all serotonin receptors
How does clozapine work?
It is a partial antagonist of the 5HT2A receptor. (so more serotonin). It also induces the release of glutamate and D-serine as an agonist at the NMDA receptor. Clozapine prevents impaired NMDA receptor expression caused by NMDA receptor antagonists
What are the main side effects of clozapine?
Agranulocytosis (so do regular FBC), myocarditis, weight gain, salivation, seizures, sedation.
What are the side effects of first generation anti-psychotics?
Higher risk of neuro side effects, tardive dyskinesia, extrapyramidal symptoms.
How do first generations work?
They are D2 antagonists.
What are extra-pyramidal symptoms?
These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), and tremor, and tardive dyskinesia (irregular, jerky movements).
What are the main side effects of second generations/atypical anti-psychotics?
Higher risk of metabolic side effects, hyperglycaemia, weight gain, dyslipidemia, 5HT2A/D2 antagonists.
How is the depot given?
IM and it provides slow release anti-psychotic preparation.
Why is the depot good for some people?
If they are chaotic with poor compliance.
Which drugs can you get via the depot?
Risperidone, paliperidone, olanzapine.
How often do you usually give the dose?
Give initial test dose, then usually monthly dose.
What is it about the half life of depot drugs?
They have a long half life so you have to give it weeks/months before you can see if it works or stop it.
What is the chance of relapse in people receiving continuous antipsychotic medication?
1/3
What are the risk factors for relapse?
The presence of persistent symptoms, poor adherence to the treatment regime, lack of insight and substance use. and dramatically stoping medication dramatically increases the risk of relapse in the short to medium term.
Does CBT stop the patient hearing voices?
No, but it does help stop the stress associated with these hallucinations, it helps the patient develop understanding about their disorder, and its not the voices that are the problem usually, its the meaning they attach to it.
What percentage of schizophrenics need long term high dependance care?
10-20%
What are the poor prognostic factors for schizophrenia?
Single male, early age of onset, abnormal pre-morbid personality (schizoid), FH of schizophrenia, insidious (gradual) onset, negative symptoms, delay in treatment and substance abuse.
What family history is a good prognosis?
FH of affect disorders, with acute onset and affective symptoms
Who presents later men or women?
Onset tends to be later in women
`What can often happen to the train of thought in schizophrenia?
There may be breaks of interpolations in the train of thought resulting in incoherence or irrelevant speech of neologisms.
What is characteristic of catatonic behaviour?
Excitement, posturing, WAXY flexibility, NEGATIVISM, MUTISM and stupor
What are the negative symptoms of schizophrenia?
Marked apathy, paucity of speech and blunting or incongruity of emotional response, usually resulting in social withdrawal and lowering of social performance- to must be clear that these are NOT due to depression or to neuroleptic medication.
What is paucity of speech?
A general lack of additional, unprompted content seen in normal speech.
How long do symptoms have to be present for according to ICD10 to make a diagnosis?
1 month or more. Because of usually a prodromal phase preceding this, this 1 month time frame applies only to specific symptoms i.e. not to loss of interest, depression, anxiety etc.
What should you diagnose symptoms lasting less than a month?
Diagnosed in the first instance as acute schizophrenia-like psychotic disorder and reclassified as schizophrenia if the symptoms persist for longer periods.
When should the diagnosis of schizophrenia NOT be made?
In the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbances. Obvs not in overt brain disease and states of drug intoxication.
Which symptoms are NOT typically present in paranoid schizophrenia?
Disturbances of affect, volition and speech and catatonic symptoms are not prominent.
What can the mood of a hebephrenic schizophrenia be described as?
Shallow and inappropriate, often accompanied by giggling or self-absorbed smiling, mannerisms, pranks etc.
When does hebephrenic behaviour usually start?
Between the ages of 15 and 25
How is the affect described in hebephrenic schizophrenia?
Flattened
What does oneiroid mean? (seen in catatonic)
Dream like state (catatonic phenomena)
What is excitement?
Apparently purposeless motor activity, not influences by external stimuli
What is command automatism? (seen in catatonic)
Automatic compliance with instructions but not under conscious control performed without conscious knowledge.
