Schizophrenia/Mania/Bipolar Flashcards
The strongest risk factor for developing a psychotic disorder (including schizophrenia) is
family history
Schizophrenia rx and FH
Having a parent with schizophrenia leads to a relative risk (RR) of 7.5.
Risk of developing schizophrenia monozygotic twin has schizophrenia = 50% parent has schizophrenia = 10-15% sibling has schizophrenia = 10% no relatives with schizophrenia = 1%
risk factors for psychotic disorders include
Black Caribbean ethnicity - RR 5.4
Migration - RR 2.9
Urban environment- RR 2.4
Cannabis use - RR 1.4
Schizophrenia - Schneider’s first rank symptoms
may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions
Schizophrenia - auditory hallucinations
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour
Schizophrenia - thought disorder
thought insertion
thought withdrawal
thought broadcasting
Schizophrenia - Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Schizophrenia - Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
Schizophrenia features intact insight
false
impaired
Schizophrenia features negative sx including
incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
Schizophrenia speech features
decreased speech
neologisms: made-up words
NICE published guidelines on the management of schizophrenia in 2009:
oral atypical antipsychotics are first-line
cognitive behavioural therapy should be offered to all patients
Schizophrenia close attention should be paid to which risk-factor modification
close attention should be paid to cardiovascular risk-factor modification
due to the high rates of cardiovascular disease in schizophrenic patients
Schizophrenia & cardiovascular risk modification is linked to?
Antipsychotic medication and high smoking rates
Schizophrenia: prognostic indicators
strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant
Bipolar disorder is a chronic mental health disorder characterised by
periods of mania/hypomania alongside episodes of depression.
Bipolar disorder - Epidemiology
typically develops in the late teen years
life time prevalence: 2%
Two types of bipolar disorder are recognised:
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
mania+hypomania both terms relate to
abnormally elevated mood or irritability
with mania there is
severe functional impairment or psychotic symptoms for 7 days or more
May require hospitalization due to risk of harm to self or others
May present with psychotic symptoms
hypomania describes
A lesser version of mania
Lasts for < 7 days, typically 3-4 days.
Can be high functioning and does not impair functional capacity in social or work setting
Unlikely to require hospitalization
Does not exhibit any psychotic symptoms
psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania/hypomania
mania
Bipolar disorder mx
psychological interventions specifically designed for bipolar disorder may be helpful
lithium remains the mood stabilizer of choice. An alternative is valproate
Bipolar disorder mx management of mania
consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
Bipolar disorder mx management of depression
talking therapies (see above); fluoxetine is the antidepressant of choice
Bipolar disorder why is it important to address co - morbidities
address co-morbidities - there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
if symptoms suggest hypomania then NICE recommend referral
routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression referral
urgent referral to the CMHT should be made
Lithium is mood stabilising drug used most commonly used when?
prophylactically in bipolar disorder but also as an adjunct in refractory depression
Lithium pharmacokinetics
It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.
Lithium Mechanism of action
not fully understood, two theories:
interferes with inositol triphosphate formation
interferes with cAMP formation
Lithium adverse effects
nausea/vomiting, diarrhoea fine tremor weight gain idiopathic intracranial hypertension leucocytosis
Lithium hypo/hyper thyroidism
thyroid enlargement, may lead to hypothyroidism
Lithium hypo/hyper parathyroidism
hyperparathyroidism and resultant hypercalcaemia
Lithium ECG effects
ECG: T wave flattening/inversion
Lithium nephrotoxicity occurs due to
polyuria, secondary to nephrogenic diabetes insipidus
Monitoring of patients on lithium therapy
after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
once established, lithium blood level should ‘normally’ be checked every 3 months
thyroid and renal function should be checked every 6 months
when checking lithium levels, the sample should be taken when
12 hours post-dose
lithium therapy patients should be issued with an information booklet, alert card and record book
true
The following symptoms are common to both hypomania and mania
Mood
predominately elevated
irritable
The following symptoms are common to both hypomania and mania
Speech & thought
pressured
flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play
poor attention
The following symptoms are common to both hypomania and mania
Behaviour
insomnia
loss of inhibitions: sexual promiscuity, overspending, risk-taking
increased appetite
