Schizophrenia: Clinical Case Flashcards
Marcus is a 21 year-old university student who was transferred to your
unit from the Emergency Department (ED). He believes that his
roommate is jealous of his ability to communicate telepathically with
aliens and has installed cameras throughout their apartment that he
has been using to secretly watch his every move in order to “take him
out”, he has also begun to accuse his roommate of poisoning his food.
His family brought him to the ED after he locked himself in his room
and refused to eat.
What symptoms of psychosis is MA demonstrating?
Persecutory delusions:
“[His roommate ] has installed cameras throughout their apartment
that he has been using to secretly watch his every move”
“He has also begun to accuse his roommate of poisoning his food.”
Grandiose delusions:
“He believes that his roommate is jealous of his ability to communicate
telepathically with aliens
ID: 21 y/o M, brought in to the ED by his parents after refusing to eat
secondary to psychotic symptoms (NOS).
NOS – Not otherwise specified
What additional information do we need to rule out other explanations
for his psychosis?
D. Schizoaffective disorder and mood disorder with psychotic features have been
ruled out because either: (1) no major depressive, manic, or mixed episodes have
occurred concurrently with the active-phase symptoms; or (2) if mood episodes
have occurred during active-phase symptoms, their total duration has been brief
relative to the duration of the active and residual periods.
No past psychiatric history
E. The disturbance is not due to the direct physiological effects of a substance (eg, a
drug of abuse or medication) or a general medical condition
No past medical history
No current medications
Substance use: Uses cannabis once weekly – 2-3 joints shared with friends
Does MA have schizophrenia?
Why or why not?
C. Continuous signs of the disturbance persist for at least six months. The six-month period
must include at least one month of symptoms (or less if successfully treated) that meet
Criterion A (ie, active-phase symptoms) and may include periods of prodromal or residual
symptoms. During these prodromal or residual periods, the signs of the disturbance may
be manifested by only negative symptoms or two or more symptoms listed in Criterion A
that present in an attenuated form (eg, odd beliefs, unusual perceptual experiences).
Collateral information
* Active symptoms began about 1 month ago
* Roommate reports:
* MA has stopped attending classes and work (increased frequency over the past
year)
* MA has been less engaged with his friends, no longer showing up to planned
outings
* MA spends a lot of time in his room, doesn’t seem to be showering or eating
much
* “When I’m talking with MA, he seems to be out of it, I have to repeat simple
phrases several times before he understands”
* “He’s just been acting weird, it probably started about a year ago”
Psychotic Symptomology
Positive Symptoms:
* Delusions
* Persecutory
* Grandiose
Negative Symptoms:
* Social withdrawal
* Poor
hygiene/inability to
care for self
* Amotivation
Cognitive Symptoms:
* Impaired
concentration
* Impaired verbal
comprehension
Prodromal symptoms before the active phase of schizophrenia
Treating First Episode Psychosis (FEP)
- Patient is deemed a harm to himself
- Admitted involuntarily (Form 1, Form 3)
- Patient is refusing medical treatment
- Deemed incapable (Form 33)
- Parents act as substitute decision makers (SDM)
- Parents consent to treatment with antipsychotics (either PO or IM)]
- Recommend an antipsychotic to use first-line
- Why did you select this agent?
Recommend an antipsychotic to use first-line
* Why did you select this agent?
The family agrees to start aripiprazole, they consent to oral doses up to
30mg/d and the use of IM formulations in both loading and
maintenance doses.
Recommend an initiation regimen:
1. Oral test dose
2. Titrate oral dose to effect, OR
3. Initiate long-acting injection
aripiprazole. Family agrees to represent they consent to oral doses up to 30 mg a day. And the use of IAM formulations for both loading and maintenance dose is, I choose a peppers all because it’s available as LAI. It’s a second-generation antipsychotic, which we know all have relatively equal efficacies. I
More wieght neutral
Usually less sexual AE
the initiation doses have to be done in a deltoid muscles. This is because they distribute more rapidly and maybe could have concentrations faster when administered in deltoid ubsequent injections can be given to the gluteal deltoid
6 months later…
Discharge/follow-up:
ED presentation:
* He is brought in to the ED by police (BIBP) after he was found walking around
downtown Edmonton barefoot in his robe in -22 degree weather
* Delusions have returned, he is tangential, disorganized
* Poor grooming, malodourous
Non-compliance
ADR: Pt reports feeling restless, “can’t sit still”, preventing him from
sleeping
Akathisia EPS that is relatively common with aripiprazol
Stage 2
- Paliperidone 3 mg PO daily started titrated to 12 mg PO daily
- Well tolerated
- Transitioned to LAI (Invega Sustenna)
- Initiation/Loading Regimen:
- Paliperidone 150mg IM day 1
- Paliperidone 100mg IM day 8
- Maintenance: 150mg IM q4wks
Monitoring Parameters
1Objective*:
* Baseline: ECG, TSH, CBC, LFTs, SCr,
eGFR, UDS
* Weight, BMI: Baseline, 6wks, 3mo,
quarterly thereafter
* BP, HR: Baseline, 6wks, 3mo, quarterly
thereafter
* HbA1c: Baseline, 6wks, 3mo, 12mo,
annually thereafter
* Lipid Panel: Baseline, 3mo, 12mo,
annually thereafter
* Prolactin level: when clinically
indicated
Subjective:
* EPS: akathisia, dystonia, parkinsonism
(gait change, tremor, etc), Tardive
Dyskinesia
* Sexual dysfunction, breast tenderness
and/or gynecomastia
(hyperprolactinemia)
* Improvement/worsening in mental
status
* Anti-histaminergic: Sedation, appetite
change
* Anticholinergic: Constipation (can be
objective in some cases), dry mouth,
blurred vision, etc..
*unless more frequent monitoring is warranted
Non-Pharmacological Parameters
- Referred to ACT Team
- Psychiatrist
- Social Worker
- Medication Administration – home visits
- Case Worker
- Parents referred to family/caregiver support group
Follow-Up: 4 months later
* 2 months ago:
* Delusions began to present
* Withdrew from school
* Moved home with parents
* Minimal social interaction
Now what?
Treatment-Resistant Schizophrenia
* 2 previous trials
* Aripiprazole
* Paliperidone
* Adequate Dose
* Aripiprazole 400mg q4wks
* Paliperidone 150mg q4wks
* Adequate duration
* Aripiprazole: 6 months
* Paliperidone: 4 months
* Persistent symptoms > mild severity
Clozapine
Initiation:
* 12.5 mg PO X 1 day, then
* 25 mg PO X 1 day
* Titrates up by 25 mg each night until 300 mg PO QHS
Maintenance dose: 350mg PO qHS
Additional disposition planning:
* ACT team psychiatrist to prescribe clozapine
* Community pharmacy registered to dispense clozapine
* ACT team to transport patient to lab for blood work monitoring
Follow-up: 4 weeks
Efficacy:
* +++ improvement in delusions,
gains insight
* Self-care begins to improve
* Some residual cognitive
symptoms
* Plans to enroll back in school
and live at home
Safety:
* Dry mouth
* Sedation
* Constipation
* Weight gain (BMI = 28)
Adverse Effect Management
Benefits»_space;> Harms
Constipation laxatives
Dry mouth ↑ water intake
Sedation Ensure medication is qHS, tolerance may develop with time
Weight gain dietitian referral, promote healthy lifestyle habits,
consideration of off-label use of pharmacological agents
cardiac workup because of the cardiac side effects associated with clozapine. So sometimes for myocarditis monitoring, we do it here. We’ll do CRP and troponin as part of the weekly blood work for the first four weeks.
