Schizophrenia + psychosis Flashcards
voices history - what do you explore?
volume + number 2nd / 3rd person / commanding content recognition + gender exacerbating/relieving factors pattern over day
V2-CREP
things to ask about in schizophrenia history (thoughts)
insertion withdrawal broadcasting TV/radio refer to you out to get you? people against you/want to harm you powers?
IWB-TOP powers
what aspects of thought content are used to differentiate schizophrenia from psychosis due to depression etc?
insertion, withdrawal, broadcasting
also consider congruence of hallucinations + presence of negative symptoms
negative symptoms of schizophrenia
apathy + anhedonia sexual problems social withdrawal blunted/incongruous emotional responses lethargy inattention poverty of speech
ASS BLIP
differentials for what seems like negative symptoms
positive symptoms causing them eg hallucinations
medication SEs
schneider’s first rank symptoms
1 - Thought disorder (insertion, withdrawal, broadcasting)
2 - Auditory hallucinations (echo, commentary, discussion)
3 - Passivity phenomena
4 - Delusional perceptions
someones TAPD my brain
differentials for psychosis
schizophrenia schizoaffective depression (congruent) mania/bipolar (congruent) postpartum psychosis
drugs - toxicity or withdrawal
organic - tumour / injury / infection
organic causes of psychosis
brain tumour/injury/infection
alcohol + drugs
delirium + dementia
BAD
BADMAN: brain tumour/injury acute confusional state dementia medication SEs autoimmune - SLE, thyroid disease nervous system infection - neurosyphilis, encephalitis
differentiating bipolar mania from schizophrenia
schizophrenia - thought echo, running commentary etc
management of first presentation psychosis
oral antipsychotic
psychological interventions - CBT + family interventions
refer to EIT
schneider’s first rank symptoms - criteria for the auditory hallucinations
3rd person discussing pt
thought echo (hears thoughts spoken aloud)
running commentary
schneider’s first rank symptoms - criteria for thought disorder
insertion
withdrawal
broadcasting - to others, no longer private
schneider’s first rank symptoms - passivity phenomena
external agent is controlling mind/body - delusions of control
schneider’s first rank symptoms - delusional perceptions
normal object perceived > delusional insight into its meaning eg. light green > i am king
person believes that a normal percept has a special meaning for him or her
diagnostic criteria for schizophrenia
other causes ruled out
for 6mo + much of the time for 1mo + marked impairment in functioning:
1 clear or 2 less clear:
1 - thought insertion, broadcasting, withdrawal
2 - voices - running commentary or discussing patient
3 - delusions - perceptions, of control, influence or passivity
4 - persistent delusions of other kinds
OR at least 2 - PINC:
1 - persistent hallucinations (any type) - daily for weeks
2 - incoherent/irrelevant speech (breaks/interpolations in train of thought)
3 - negative symptoms
4 - catatonic behaviour
how does CBT help in schizophrenia?
help patient understand symptoms better + develop alternative ways of coping
how do family interventions help in schizophrenia?
help families understand condition + respond to symptoms in the most supportive way
CPA - what is it + how does it work?
MDT care coordinated by a keyworker
written care plan
says how to get help in a crisis
reviewed + updated every 6-12mo
psychosocial interventions for schizophrenia
supported work placements/employment support
rehabilitation
addresses issues with housing + benefits
what to use if antipsychotic compliance poor?
risperidone depot
what to do if poor response to antipsychotic?
cross-taper to a new drug
if that doesn’t work, combo therapy
checks required before starting antipsychotics
history - activity/diet, personal/FH (diabetes, heart, BP)
obs - obs, glucose, BMI, ECG
bloods - FBC, U+Es, LFTs, HbA1c, lipids
specifics - prolactin, examine for movement disorders
monitoring of antipsychotics
6-monthly
weight + HbA1c
U+E + LFT
prolactin
SEs antipsychotics
CNS - drowsiness + seizures
CV - weight, diabetes, CV risks, QTc prolongation
prolactin - sexual dysfunction
EPSEs less likely
clozapine - SEs (medical)
weight gain agranulocytosis - monitor FBC tachycardia constipation hypersalivation myocarditis increased/decreased/postural BP nausea drowsiness seizures
WATCH-MINDS - people with schizophrenia think people are watching their mind
specific anitpsychotic complications - olanzapine, zotepine, risperidone
olanzapine - stroke
zotepine - QTc prolongation
risperidone - hyperprolactinaemia - stiffness, swollen breasts, periods stopping
lithium - SE vs sign of toxicity
fine tremor - SE
coarse tremor - toxicity
EPSEs
akathisia - urge to move constantly
dyskinesia - abnormal/impaired voluntary movements
acute dystonia - abnormal muscle tone → spasms + abnormal posture
parkinsonism - bradykinesia, tremor, rigidity
tardive dyskinesia - involuntary movements of face + body
ADAPT to life on these drugs
when is clozapine used
when symptoms haven’t responded to 2 others
initiation of clozapine
dose needs to be titrated due to effects on BP + HR (can fatally drop BP)
48h rule - can only do 48h without it before retitrating
clozapine - SEs to counsel
serious - agranulocytosis (monitor FBC)
CNS - drowsiness + seizures
CV - BP, HR etc - come for checks
GI - nausea, constipation, weight gain, hypersalivation
schizophrenia/first episode psychosis - investigations + management
rule out other cause:
tox screen
full bloods (FBC, U+E, LFT, TFT, BoPr)
neuro exam + imaging if signs
risk assess
refer to early intervention team - CPA
atypical antipsychotic
CBT + family intervention
CV risk management
