Schizophrenia II Flashcards
How can you describe what psychosis is [2]
A disturbance in distinguishing what is generated by your own mind and what comes from outside
A disturbance in the loss of ability to know what should pay attention to (i.e. increased attention to trivial stimulus)
Describe what a delusion is [1]
Beliefs that are not normal part of culture, don’t make sense to someone who is healthy, held with conviction (with no evidence for this)
What are the adverse effects of antipyschotics? [5]
Parkinsonism
Acute dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis)
Akathisia (severe restlessness)
Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
* Increased risk of stroke
* Increased risk of venous thromboembolism
Other side-effects
* Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
* Sedation, weight gain
* Raised prolactin: galactorrhoea, impaired glucose tolerance
* Neuroleptic malignant syndrome: pyrexia, muscle stiffness
* Reduced seizure threshold (greater with atypicals)
* Prolonged QT interval (particularly haloperidol)
Describe the lab. monitoring should give for patients recieving anti-psychotics [5+
Blood tests:
- Baseline full blood count (FBC), liver function tests (LFTs), renal function tests (RFTs), lipid profile and glucose levels are recommended before initiating treatment. These should be monitored throughout treatment according to British National Formulary guidelines.
- Clozapine requires more frequent monitoring including weekly FBCs for the first 18 weeks of treatment.
ECG:
- Baseline ECG should be performed in patients with cardiovascular risk factors before initiating antipsychotics, especially those known to prolong the QT interval.
- Regular monitoring is advised for these patients.
Body Mass Index (BMI):
- Patients on antipsychotics, particularly atypical ones, are at risk of weight gain. Monitor BMI regularly and provide lifestyle advice as necessary.
Prolactin levels:
- Antipsychotics can cause hyperprolactinaemia leading to symptoms such as galactorrhoea, amenorrhoea and sexual dysfunction. Monitor prolactin levels if these symptoms are reporte
Clozapine is used where other treatments do not control the symptoms. It can only be taken by mouth. Clozapine is very effective but comes with significant adverse effects. Patients taking clozapine have very close monitoring for evidence of complications. Key complications include: [5]
Agranulocytosis, with a severely low neutrophil count (predisposing to severe infections)
Myocarditis or cardiomyopathy, which can be fatal
Constipation (rarely to the point of intestinal obstruction)
Seizures
Excessive salivation
Antipsychotics may cause lengthens QT interval
Lethargy/drowsiness
Describe the differences in side effects between typical and atypical anti-pysc. drugs [+]
Antipsychotics may cause increased risk of ischaemic stroke
VTE
torticollis
hyperprolactinaemia
Antipsychotics in breastfeeding is considered safe to use
Which conditions can mimic schizophrenia? [+]
- Substance induced psychotic disorder (commonly drugs of abuse, but can be iatrogenic e.g. steroids)
- Organic psychosis caused by infection, brain injury and CNS diseases such as Wilson’s disease
- Metabolic disorder such as hyperthyroidism and hyperparathyroidism
- Dementia and depression can also co-occur with psychosis
What is the mechanism of action of Amisulpride? [1]
Amisulpride is a second-generation, ‘atypical’ antipsychotic that acts as a dopamine receptor antagonist
What is the psychiatric phenomenological term for the feeling that an external agency is controlling one’s actions or thoughts? [1]
Passivity phenomenon
For what condition is Clozapine used? [1]
Treatment-resistant schizophrenia
What is thought insertion diagnostic of? [1]
Paranoid schizophrenia
What are the key environmental risk factors in schizophrenia? [5]
Traumatic events in childhood (e.g. poor maternal affection and bonding, poverty, exposure to natural disasters)
Heavy cannabis use in childhood
Maternal poor health (including malnutrition and infections such as rubella and cytomegalovirus)
Birth trauma (hypoxia and blood loss in particular)
Living in the city
Living in/emigrating to more developed countries
What type of drug is used to treat paranoid schizophrenia first-line? [1]
Atypical or ‘second-generation’ antipsychotics
What is the mechanism of action of Olanzapine? [1]
Atypical antipsychotic, which acts as an antagonist at 5-HT2A, H1, M1, 5-HT2C, D2, alpha 1 and D1 receptors
Which investigations are indicated in a patient with a first episode of psychosis? [4]
CT/MRI head
HIV and syphilis screen
Drug testing
Routine bloods including FBC and TFTs
Describe the unique profiles of [2]
Aripiprazole
Cariprazine
Aripiprazole
- (antagonist at post-synaptic D2 receptors, agonist at pre-synaptic D2)
Cariprazine
- (partial D3 agonist, claims for negative symptoms and reducing cognitive effects)
Describe why 2nd gen AP are used before 1st line? [3]
Much lower risk of EPSEs
Lower risk of hyperprolactinaemia
Usually less sedating
What are the key side effects of anti-pyschotics (2nd gen) [2]
Weight gain
H1 and 5-HT2C antagonism
Diabetogenic (increased insulin resistance)
Weight gain
M3 antagonism
Olanzapine
Risperidone
Aripiprazole
Quetiapine
Amisulpride
Paliperidone
When would you specifically use clozapine as an anti-psyc? [1]
When two others have failed
Which medication would you give for acute agitation, refusal plans? [2]
Intramuscular haloperidol, olanzapine
Which medications are short, medium and long term IM anti-pysc drugs? [3+]
Short-acting for acute agitation, refusal plans, etc.
* Haloperidol, olanzapine
‘Medium-term’
* Zuclopenthixol acetate (Clopixol Acuphase)
Long-term (“depot”) antipsychotics
* Weekly to monthly regimes (newer ones up to 3/12 or 6/12)
* Better symptom control
* FGAs: haloperidol, zuclopenthixol, flupenthixol (cheap as chips)
* SGAs: risperidone, paliperidone, olanzapine, aripiprazole (Gucci-level expensive)
Lecture
What is the annual monitoring you would do for anti-pysc drugs? [4]
Lipid profile (hypercholesterolaemia)
HbA1c (diabetes)
Weight
ECG (QT prolongation)
- Haloperidol, quetiapine
What is another risk of clozapine (asides from agranulocytosis) [1]
Powerful smooth muscle relaxant
- Constipation –> toxic megacolon –> death
Rank the anti-psychotic medications with regards to side effects [+]
Describe how you monitor clozapine [3]
Weekly blood tests for 18 weeks
Then blood tests every other week till first year
Then monthly for rest of life
Which side effects need to consider with clozapine [3]
Agranulocytosis
Constipation - can cause bowel necrosis
Myocarditis
Which drugs can you use as depots? [4]
Clopixol, depixol, risperidone, aripiprazole
Anyone on antipsychotic medications should be offered which forms of monitoring? [4]
Blood tests for HbA1c
Cholesterol
ECG
Weight / BMI
