Schizophrenia & Psychosis Flashcards
Antipsychotics - Indications (3)
- Urgent Treatment of Severe Psychomotor Agitation (Violent Behaviour) to Continue Assessment.
- Schizophrenia.
- Bipolar Disorder (Acute Episodes of Mania/Hypomania).
Antipsychotics (Typical) - Indications (4)
- Psychomotor Agitation.
- Schizophrenia (when Metabolic Side Effects of Atypical Antipsychotics are Bad).
- Bipolar Disorder.
- Nausea & Vomiting (especially in Palliative Care).
Antipsychotics (Atypical) - Indications (3)
- Psychomotor Agitation.
- Schizophrenia (if Negative Symptoms).
- Bipolar Disorder.
Antipsychotics - Mechanism of Action
Dopamine Antagonists (Block Post-Synaptic D2 Receptors) - main effect is on Mesolimbic/Mesocortical Pathway.
Dopaminergic Pathways of CNS (3)
- Mesolimbic/Mesocortical (Midbrain - Limbic System/Frontal Cortex).
- Nigrostriatal Pathway (Substantia Nigra - Corpus Striatum of Basal Ganglia).
- Tuberohypophyseal Pathway (Hypothalamus - Pituitary Gland).
Why can you use Typical Antipsychotics in Nausea & Vomiting?
D2 Receptors are found in the Chemoreceptor Trigger Zone.
Why might Atypical Antipsychotics have a lower risk of Extrapyramidal Symptoms and increased efficacy against Treatment-Resistant Schizophrenia/Negative Symptoms? (2)
- Higher Affinity for Other Receptors e.g. 5-HT.2A Receptors.
- ‘Looser’ Binding to D2 Receptors e.g. Clozapine, Quetiapine.
What are Extrapyramidal Side Effects?
Movement abnormalities that arise from blocking the Nigrostriatal Pathway.
Give 4 Extrapyramidal Side Effects.
AANT
- Acute Dystonic Reactions (Involuntary Parkinsonian Movements/Muscle Spasms) = Use Anticholinergics e.g. Procyclidine.
- Akathisia (State of Inner Restlessness) = Reduce Dose and Add Propanolol/Benzodiazepine.
- Neuroleptic Malignant Syndrome = Reduce Dose and Add Procyclidine.
- Tardive Dyskinesia (months/years later - pointless, involuntary, repetitive movements e.g. lip-smacking) = Use Tetrabenazine (MAO Depletor).
Give 4 Features of Neuroleptic Malignant Syndrome.
CRAP
- Confusion.
- Rigidity (Lead-Pipe Muscle).
- Autonomic Dysfunction.
- Pyrexia.
Give 5 other Adverse Effects of Typical Antipsychotics.
- Drowsiness.
- Hypotension.
- QT-Interval Prolongation.
- Erectile Dysfunction.
- Hyperprolactinaemia (Tuberohypophyseal Pathway).
Give 4 Metabolic Side Effects of Atypical Antipsychotics.
- Weight Gain (especially Olanzapine).
- Hyperglycaemia = Diabetes Mellitus.
- Hyperlipidaemia.
- Hypercholesterolaemia.
Give 2 Side Effects of Clozapine.
- Agranulocytosis (Severe Deficiency of Neutrophils).
2. Myocarditis.
Give 4 Examples of Typical Antipsychotics.
- Chlorpromazine.
- Thiothixine.
- Haloperidol.
- Supiride.
Give 5 Examples of Atypical Antipsychotics.
CORAQ.
- Clozapine.
- Olanzapine.
- Risperidone.
- Aripiprazole.
- Quetiapine.
Give 4 cautions/contraindications of Antipsychotics.
- Elderly (Sensitive so use Low-Dose).
- Dementia (Avoid - Increased Risk of Death/Stroke).
- Parkinson’s (Typical - Extrapyramidal).
- Cardiovascular disease (Avoid if on other QT Prolongers).
Why is Compliance usually Poor with Antipsychotics? (2)
- Lack of Insight.
2. Unpleasant Side Effects.
How can Compliance be Improved?
Depot Injections (Deep IM Injections of Oily Suspensions - Effective for 2-4 Weeks) - Only Available for Typical Antipsychotics and Risperidone.
Definition - Psychosis
A severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality.
Clinical Features - Psychosis (3)
Delusions;
Hallucinations;
Lack of Insight.
Definition - Delusions
Fixed False Beliefs Despite Contrary Evidence and Out of Keeping With Patient’s Social/Cultural Background.
Definition - Hallucinations
Perceptions in Absence of a Stimulus - most commonly Auditory (Visual is common in Organic Psychosis).
Pseudohallucinations - patient realises that stimulus is not perceived from an external source e.g. “voices in my head”.
MSE - Psychosis (ABSTPCI)
A - Brightly Dressed (Hallucinations) B - Restless and Distractable S - Neologisms and Alogia T - Content : Delusions T - Form : Block/Withdrawal/Insertion; Passivity (External Control); Broadcasting (Others' are Aware); Disorder (e.g. Knight's Move Thinking, Loosening of Association, Word Salad). P - Hallucinations. C - Disoriented. I - Lack of Insight.
Delirium vs. Psychosis (4)
Delirium - Fluctuating consciousness, acute onset, visual hallucinations, co-morbidities.
Psychosis Management - At Risk Patients
CBT - 1st line.
Psychosis Management - Acute Episode
Oral Antipsychotic Medications.
Psychosis Management - Chronic Symptoms
1st Line - Oral 2nd-Gen Antipsychotics.
2nd Line - Oral 1st-Gen Antipsychotics.
3rd Line - IM 2nd/1st-Gen Antipsychotics.
With any line, give psychosocial interventions and health maintenance.
* - Antidepressants/Ginkgo Extract/Ondansetron - Negative Symptoms.
Definition - Schizophrenia
Chronic/Relapsing condition that presents in late teens or early 20s with psychotic symptoms; disorganisation symptoms and negative symptoms. These symptoms must occur for a significant part of a 1 month period and continuously over 6 months.
Risk Factors - Schizophrenia (5)
- Family History (Strongest).
- African-Caribbean Ethnicity (Misdiagnosis, Institutional Racism, Cannabis Use, Social Disorganisation, Social Exclusion).
- Migration.
- Urban Environment.
- Cannabis Use.
What are Schneider’s 1st Rank Symptoms of Schizophrenia? (4)
D-TAP :
- Delusions.
- Thought Disorders/Alienation (insertion, withdrawal, broadcasting).
- Auditory Hallucinations (2+ voices discussing in the 3rd person, thought echos).
- Passivity Phenomena (bodily sensations controlled by external influences).
Give 2 Theories about Schizophrenia Aetiology.
- Increased Dopaminergic Activity in Mesolimbic Pathway (Positive Symptoms) and Decreased Dopaminergic Activity in Prefrontal Cortex Pathway (Negative Symptoms).
- Neurodevelopment : Enlarged Ventricles and Smaller/Lighter Brains.
What are the Types of Schizophrenia?
- Type I - Acute, Positive Symptoms, Good Response to Neuroleptics, No Intellectual Impairment.
- Type II - Chronic, Negative Symptoms, Responds to Clozapine ONLY, Sometimes Intellectual Impairment.
Type I can progress to Type II after years.
Schizophrenia Management
1st Line - Oral Atypical Antipsychotics + CBT. Regular Monitoring (CVD Risk and Weight).
What is the commonest long-term adverse effect of Atypical Antipsychotic use?
Metabolic Syndrome :
Development of Glucose Dysregulation and Diabetes.
What is de Clerambault’s Syndrome?
Erotomania; Delusion that someone is in love with you.
What is Cotard Syndrome?
Delusion that you are dead.
What is Othello Syndrome?
Delusional Jealousy (usually of a partner).
What is Capgras’ Delusion?
Delusion that a close acquaintance has been replaced by an imposter.
What is Charles Bonnet Syndrome?
Recurring hallucinations in those with impaired vision.
What is an Oculogyric Crisis?
An acute dystonic reaction where there is sustained upward deviation of both eyes.
Which Antipsychotic can reduce the seizure threshold most making seizures likely?
Clozapine.
What can cause Clozapine levels to rise?
Smoking cessation. This should be discussed with a psychiatrist before stopping. Starting smoking or smoking more can reduce Clozapine levels.
Tar induces CYP450 Activity -> increased metabolism of Clozapine -> lower blood levels.
What is Torticollis?
An acute dystonic reaction where there is “wry neck”; unilateral pain and deviation of the neck with pain on palpation and restricted range of motion.
What is Echolalia?
Speech Disorder where the patient repeats the words or phrases used by another individual.
What is Clang Association?
Speech Disorder where the patient’s speech is based on ideas only related by rhymes or being similar sounding.
What is Catatonia?
The stopping of voluntary movement or staying still in an unusual position; commonly associated with Schizophrenia.
What is Delusional Parasitosis/Ekbom Syndrome?
Delusion that they are infested with bugs.
Give 5 poor prognostic factors of Schizophrenia.
- Strong Family History.
- Gradual / Late Onset.
- Low IQ.
- Prodromal Phase of Social Withdrawal (Negative Symptoms First).
- Lack of an Obvious Precipitant.
