Schizophrenia/Antipyschotics info

Question 1

Basic info

Answer 1

Psychosis: number of symptoms associated with significant alternations to a person’s perception, thoughts, mood, and behaviour.

Schizophrenia: disconnection/ splitting of the psychiatric functions.
People hear voices speak to them talk to them etc

MEDICATIONS DONT CURE BUT REMOVE SYMPTOMS - So symptoms can be resolved fully, recur intermittently with remission periods or persist.

Question 2

Aetiology, pathophysiology

Answer 2

Genetic or prenatal.

Genetic: 1st degree relatives at more risk
.

Prenatal: women malnourished or viral infection whilst pregnant, that child is at more risk of schizophrenia.
Neuroimaging - showed anatomical abnormalities like enlargement of ventricles and decreased brain volume in medial temporal areas.

Question 3

Diagnosis

Answer 3

Suspect if show positive & negative symptoms
- See if there is a prodromal period (when changes happen before any clinical symptoms of condition). Helps find when to treat/delay or prevent schizophrenia
In prodromal period expect:
- Transient low intensity psychotic symptoms
- Reduce interest in daily life
- Problems with mood, sleep, memory, conc., communication, affect, and motivation.
- Anxiety, irritability, or depressive features.
- Incoherent or illogical speech
During the prodromal period rule out other causes

People with family history be aware

Question 4

Symptoms

Answer 4

ACUTE EPS
Positive symptoms:
- Delusions,
- Hallucinations,
- Lack of insight,
- Ideation: false beliefs or concerns, - Disorganised behaviour, speech, and/or thoughts
- Bizarre behaviour,

Negative symptoms:
- Self neglect,
- Social withdrawal,
- Lack of energy/Flatness
- Lack of motivation/interest,
- Reduced speech

2nd gen better against Negative symptoms

Question 5

Treatment

Answer 5

1st line= oral antipsychotic drug + psychological therapy

DRUG EXAMPLES: 1st gen (typical) chlorpromazine, haloperidol
2nd gen(atypical) clozapine, risperidone

NON PHARMACOLOGICAL:
- Psychosocial therapy - CBT, social skill training, cognitive mediation, social cognitive training
- Social work- families can affect how patients react to schizophrenia
- Diet - antipsychotics cause weight gain = eat clean
- Activity - antipsychotics -weight gain -burn calories
- Vocal rehabilitation

PHARMACOLOGICAL:
- ANTIPSYCHOTICS - block Dopamine receptors = reduce flow of messages = reduce psychotic symptoms.
Start low dose and titrate up to minimum effective dose.
Receive drug for optimum dose for 4 to 6 weeks before becomes ineffective.

DRUGS:
1st line= oral antipsychotic drug + psychological therapy.
ALT if 2 different antipsychotics fail (given enough time to work) - try CLOZAPINE.
- Clozapine fail check adherence, diagnosis, plasma conc. Of clozapine b4 adding another antipsychotic.
BUT allow 8/10 weeks for clozapine to work.

Long acting injection can be used when non adhere needs to be avoided.

MORE INFO NEXT SLIDE

Question 6

Anti psychotics info

Answer 6

DRUG CHOICE = depends on EPS, CV AE, metabolic AE (weight gain and diabetes), hormonal AE (increase in prolactin conc.), and patient and carer preference.

ONLY 1 antipsychotic at a time because of:
- Extrapyramidal AEs (Akathisia = restless, dystonia, parkinsonism symptoms, tardive dyskinesia = involuntarily facial movements)
- QT prolongation
- Sudden cardiac death

However 2 can be give same time if changing med or clozapine augmentation.

ALT CLOZAPINE when 2 different antipsychotics dont work. try clozapine for 8 to 10 weeks.

Before starting offer ECG IF:
- Said in SPC
- Physical exam shows CVD risk
- Personal history of CVD OR
- Going to be inpatient

SIDE EFFECTS - ANTIPSYCHOTICS:
Phone pic
- EPS - >1st gen
- Hyperprolactinaemia - BOTH GENs
- Sexual dysfunction- Risperidone, haloperidol, and olanzapine more chance
- CV AEs - tachycardia, arrhythmias, and hypotension. QT prolongation esp. pimozide.
- Hypotension - clozapine and quetiapine = more likely
- Hyperglycaemia and diabetes - >in 2nd gen
- Weight gain - Clozapine/olanzapine more common

Question 7

CLOZAPINE and SCHIZO

Answer 7

Schizo intolerant/unresponsive to other antipsychotics and psychosis in Parkinsons. (EXAM Q).
If this still fails add another but b4 adding check diagnosis and plasma conc. Of cloazapine.
- Allow 8-10 weeks of treatment 1st
- Put PT on Clozapine monitoring service.

MHRA WARNING
1. Potentially fatal risk in intestinal obstruction, Faecal impaction, Paralytic ileus (oct 2017)
- Seek medical advice b4 next dose if constipation develops

2. Clozapine and other antipsychotics: Monitor blood conc. for toxicity (Aug 2020)(EXAM Q)
   - in CERTAIN clinical situations monitor Blood conc. (stop smoking, Switching to e-cigs, pneumonia/other serious infections, starting new meds that can affect clozapine conc.)
   - Helps manage agranulocytosis risk (Severely low levels of WBC)

CLose DA BLOODY door - Bloody for agranulocytosis, close for LAST.
Monitoring is the same as for others but more careful with blood.

FORMS:
Clozapine - Oral suspension, orodispersible tabs, tabs

• Suspension - Shake well for 90 secs when dispensing. when at home and stood for 24 hrs shake for 10 secs.
• Orodispersible - Place on tongue and allow to dissolve then swallow.

Question 8

Differential diagnosis EXTRA

Answer 8

PTSD, OCD, Autism, mood disorders, delirium, drug induced psychosis,