Schizophrenia + psychosis

Question 1

voices history - what do you explore?

Answer 1

volume + number
2nd / 3rd person / commanding
content
recognition + gender
exacerbating/relieving factors
pattern over day

V2-CREP

Question 2

things to ask about in schizophrenia history (thoughts)

Answer 2

insertion
withdrawal
broadcasting
TV/radio refer to you
out to get you? people against you/want to harm you
powers?

IWB-TOP powers

Question 3

what aspects of thought content are used to differentiate schizophrenia from psychosis due to depression etc?

Answer 3

insertion, withdrawal, broadcasting

also consider congruence of hallucinations + presence of negative symptoms

Question 4

negative symptoms of schizophrenia

Answer 4

apathy + anhedonia
sexual problems
social withdrawal
blunted/incongruous emotional responses
lethargy
inattention
poverty of speech

ASS BLIP

Question 5

differentials for what seems like negative symptoms

Answer 5

positive symptoms causing them eg hallucinations

medication SEs

Question 6

schneider’s first rank symptoms

Answer 6

1 - Thought disorder (insertion, withdrawal, broadcasting)
2 - Auditory hallucinations (echo, commentary, discussion)
3 - Passivity phenomena
4 - Delusional perceptions

someones TAPD my brain

Question 7

differentials for psychosis

Answer 7

schizophrenia
schizoaffective
depression (congruent)
mania/bipolar (congruent)
postpartum psychosis

drugs - toxicity or withdrawal
organic - tumour / injury / infection

Question 8

organic causes of psychosis

Answer 8

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

Question 9

differentiating bipolar mania from schizophrenia

Answer 9

schizophrenia - thought echo, running commentary etc

Question 10

management of first presentation psychosis

Answer 10

oral antipsychotic
psychological interventions - CBT + family interventions
refer to EIT

Question 11

schneider’s first rank symptoms - criteria for the auditory hallucinations

Answer 11

3rd person discussing pt
thought echo (hears thoughts spoken aloud)
running commentary

Question 12

schneider’s first rank symptoms - criteria for thought disorder

Answer 12

insertion
withdrawal
broadcasting - to others, no longer private

Question 13

schneider’s first rank symptoms - passivity phenomena

Answer 13

external agent is controlling mind/body - delusions of control

Question 14

schneider’s first rank symptoms - delusional perceptions

Answer 14

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

Question 15

diagnostic criteria for schizophrenia

Answer 15

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

Question 16

how does CBT help in schizophrenia?

Answer 16

help patient understand symptoms better + develop alternative ways of coping

Question 17

how do family interventions help in schizophrenia?

Answer 17

help families understand condition + respond to symptoms in the most supportive way

Question 18

CPA - what is it + how does it work?

Answer 18

MDT care coordinated by a keyworker
written care plan
says how to get help in a crisis
reviewed + updated every 6-12mo

Question 19

psychosocial interventions for schizophrenia

Answer 19

supported work placements/employment support
rehabilitation
addresses issues with housing + benefits

Question 20

what to use if antipsychotic compliance poor?

Answer 20

risperidone depot

Question 21

what to do if poor response to antipsychotic?

Answer 21

cross-taper to a new drug

if that doesn’t work, combo therapy

Question 22

checks required before starting antipsychotics

Answer 22

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

Question 23

monitoring of antipsychotics

Answer 23

6-monthly
weight + HbA1c
U+E + LFT
prolactin

Question 24

SEs antipsychotics

Answer 24

CNS - drowsiness + seizures
CV - weight, diabetes, CV risks, QTc prolongation
prolactin - sexual dysfunction

EPSEs less likely

Question 25

clozapine - SEs (medical)

Answer 25

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

Question 26

specific anitpsychotic complications - olanzapine, zotepine, risperidone

Answer 26

olanzapine - stroke
zotepine - QTc prolongation
risperidone - hyperprolactinaemia - stiffness, swollen breasts, periods stopping

Question 27

lithium - SE vs sign of toxicity

Answer 27

fine tremor - SE

coarse tremor - toxicity

Question 28

EPSEs

Answer 28

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

Question 29

when is clozapine used

Answer 29

when symptoms haven’t responded to 2 others

Question 30

initiation of clozapine

Answer 30

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

Question 31

clozapine - SEs to counsel

Answer 31

serious - agranulocytosis (monitor FBC)
CNS - drowsiness + seizures
CV - BP, HR etc - come for checks
GI - nausea, constipation, weight gain, hypersalivation

Question 32

schizophrenia/first episode psychosis - investigations + management

Answer 32

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