Schizophrénie Flashcards
list the first rank symptoms of schizophrenia
auditory hallucinations
thought withdrawal, insertion or interruption
thought broadcasting
somatic hallucinations
delusional perception
feelings or actions controlled by external agents
list the four negative symptoms associated with schizophrenia
affective flattening
avolition
alogia
anhedonia
what are the core negative symptoms of schizophrenia
affective flattening
avolition
what is considered the appropriate standard wait time for a scheduled, non-urgent first episode referral psychosis by the CPA
2 weeks
in which patients do the guidelines recommend neuropsychological testing in the assessment of schizophrenia/related disorders
those presenting with first episode psychosis and those with poor responses to treatment
may be important for documenting cognitive deficits and for treatment and academic planning
what are signs and symptoms suggestive of autoimmune encephalitis (that may prompt MRI)
new focal CNS findings
seizures not explained by a previously known seizure disorder
rapid progression of working memory deficits over less than 3 months
what is the benefit of using the Calgary Depression Scale for Schizophrenia when assessing for depressive symptoms in schizophrenia/related disorders
reliable and valid
developed to assess depression in schizophrenia/related disorders INDEPENDENT of negative symptoms
do command hallucinations carry higher risk of suicide?
yes
is physical violence toward other people common in those presenting with first episode psychosis
no
is there established clinical superiority for a specific antipsychotic in first episode psychosis? what about antipsychotic class?
no establish superiority in either case in terms of clinical outcomes
however, there is differences in terms of side effect profiles (and this is often what guides treatment decision)
how long should a first trial of an antipsychotic be in first episode psychosis?
at least TWO WEEKS unless there are significant tolerability issues
how long should you wait after starting a medication in first episode psychosis before considering change in antipsychotic?
FOUR weeks
if no response to medication after 4 weeks, despite dose optimization, should consider change in agent
what do you do if there is a partial response to initial antipsychotic after 4 weeks but not robust response?
in this case, reassess after 8 weeks unless there are significant adverse events
what is an adequate trial of antipsychotic in terms of duration
between 4-6 weeks on adequate therapeutic dose (midpoint or beyond of the licensed dose range)
how long should someone be treated with antipsychotic agent after first episode of schizophrenia/related disorders
at least 18 months FOLLOWING resolution of positive symptoms
how much higher is the risk of first or second relapse in those not taking medication compared to those who are in schizophrenia/related disorders
risk of first or second relapse was 5x HIGHER in those not taking medication as compated to those who were
what maintenance dose of antipsychotic therapy should be offered to patients who suffer an acute episode of schizophrenia/related disorders (NOT first episode)
at low or moderate regular dosing of:
300-400mg of chloropromazine equivalents
/
4-6mg risperidone equivalents
how long should maintenance therapy be planned for after acute episode of schizophrenia/related disorders
2 years–> possibly up to 5 years
how does risk of rehospitalization change for those on LAI vs oral agents
risk of rehospitalization in patients on LAIs is 1/3 of that for patients on oral treatment according to a nation wide registry study
what % reduction in positive or negative symptoms is required in order to be considered to have responded favorably to a medication trial
at least 20% reduction in symptoms
list some of the benefits observed when employing CBT for psychosis
reduces symptom severity, hospitalization and relapse
also showed significant benefit on level of depression
what pharmacotherapy should be considered to help people with schizophrenia stop smoking
NRT for people with psychosis or schizophrenia
BUPROPRION for those with a diagnosis of schizophrenia
VARENICLINE for those with psychosis or schizophrenia
what should you warn patients about if you prescribe buproprion or varenicline for smoking
increased risk of adverse neuropsychiatric symptoms (particularly in first 2-3 weeks)
i.e sleep impairment, suicidality, reemergence of psychotic symptoms
which pharmacologic intervention currently has the most evidence for stopping smoking in those with schizophrenia
buproprion
(whereas for those without schizophrenia, varenicline seems to have the best evidence) –> thus buproprion is recommended first then varenicline for those with schizophrenia
for those who have ?substance induced psychosis that does not resolve rapidly with abstinence, how long do you treat with antipsychotics
not clear–> guidelines suggest following recommendations for first episode psychosis especially if risk factors are present
which medications for the treatment of alcohol use disorder have evidence in those with schizophrenia
naltrexone *most
disulfiram *limited
(no evidence currently for acamprosate)
are there currently any indicated pharmacotherapies for those with cannabis use disorder
no
*data has been NEGATIVE for mirtazapine, buproprion, nabilone, dronabinol
*there is also no evidence of specific psychosocial interventions despite well designed studies
what is the prevalence of childhood onset schizophrenia
quite rare
1.6-1.9 per 100 000 children
what is considered childhood onset schizophrenia
before age 12
after what age does the prevalence of schizophrenia increase rapidly
age 14 –> particularly in males
psychosis/schizophrenia accounts for what % of all psychiatric admissions in young people between ages 10-18
25%
how does age at onset of schizophrenia affect suicide risk
higher risk of suicide in those with earlier onset
in children and young people with first presentation psychosis, should antipsychotic medication be started in the primary care setting
no–> unless done in consultation with psychiatrist with CAP training
what proportion of all adults with schizophrenia have their onset of symptoms before age 18
1/3
is antipsychotic medication treatment as effective in kids as in adults
yes
which are the only antipsychotics currently approved in canada for children and adolescents with schizophrenia or bipolar disorder
aripiprazole
lurasidone
when is an ECG recommended before starting or changing and antipsychotic for a kid with schizophrenia
- it is specified in the health canada drug product database
- physical exam has identified a CV risk (i.e high BP)
- personal history of CV disease
- family history of CV disease such as premature cardiac death or prolonged QTc
how do you start an antipsychotic in a kid if it is not licensed for kids/teens
give dose BELOW LOWER END of the licensed range for adult (and AT the lower end if it IS licensed)
slowly titrate upwards
target dosing to efficacy rather than weight
which 3 risk factors that carry a poor prognosis are MOST strongly associated with poor outcomes (including risk of relapse)
cannabis use
other comorbidities (i.e depression)
medication nonadherence
how does using cannabis regularly in adolescence affect the risk of reporting psychotic symptoms of being diagnosed with schizophrenia during adulthood
DOUBLES the risk
how long should you monitor for signs and symptoms of relapse after discontinuing antipsychotic therapy
at least 2 years
why is it important to prevent relapses of psychotic symptoms, and treat them promptly when they occur
risk of persistent psychotic symptoms increases with repeated relapses
relapses may lead to REDUCTION IN GRAY MATTER which can reduce responses to meds and impair social, emotional and vocational attainment
what medications do the guidelines mention for aggression/agitation in youth with schizophrenia
benzos or antipsychotics (ideally one the kid is already on if they are being treated for schizophrenia)
which antipsychotic has the greatest risk of weight gain? (and what other 2 are also known to be particularly likely to cause weight gain)
olanzapine
(followed by clozapine and quetiapine)
which 3 antipsychotics have the greatest risk of neurological side effects like parkinsonism, akathesia and other EPS
risperidone
olanzapine
aripiprazole
list 3 antipsychotics as lower risk of clinically important weight gain
aripiprazole
asenapine
ziprasidone
what is a hypothesis for why antipsychotics cause weight gain
antipsychotic binding affinity for H1 receptors–> associated with change in eating behaviours and decreased sensation of satiety
there may also be genetic susceptibility that affects this
what is torsade de pointes
a malignant ventricular arrhythmia associated with syncope and sudden death and is associated with prolonged QTc
how does treatment with antipsychotics affect the risk for sudden cardiac death
those on antipsychotics (both FGA and SGA) had DOUBLE the rate of sudden cardiac death as those who were not
relationship was dose dependent
what other two factors, other than antipsychotic use, were found to have increased risk of QTc prolongation
female gender
CYP450 34A metabolized drugs
Dans quelles circonstances fait-on une imagerie cérébrale? (5)
Particularités de l’histoire, examen neuro, test neuropsycho, cas par cas
Sx pathologie intracrânienne (no, vo, céphalée)
Activité épileptique
Début tardif
Signes suggestifs encéphalite auto-immune (progression rapide déficit mémoire en moins de 3 mois, trouvailles SNC, convulsion)
Qu’est-ce que le syndrome 22q11?
Syndrome génétique (DiGeorge, syndrome vélo-cardio-facial) le plus fréquent après syndrome de Down
Prévalent chez les SCZ
Discours nasal
Difficultés apprentissage
Malformation cardiaque
Caractéristiques faciales (visage long/mince, fissure palpébrale étroite, joues plates, nez proéminent, petites oreilles et bouches, menton en retrait)
Qu’est-ce que le syndrome 22q11?
Syndrome génétique (DiGeorge, syndrome vélo-cardio-facial) le plus fréquent après syndrome de Down
Prévalent chez les SCZ
Discours nasal
Difficultés apprentissage
Malformation cardiaque
Caractéristiques faciales (visage long/mince, fissure palpébrale étroite, joues plates, nez proéminent, petites oreilles et bouches, menton en retrait)
À quelle fréquence devrait-on évaluer les sx positifs/négatifs chez un patient stable?
Au moins q3 mois
Nommez des éléments de ddx des sx négatifs de la SCZ (7)
Dépression
Effet drogues
Effets 2e
Interaction Rx
Anxiété
Altération cognitive
Trouble neurologique
Nommez des échelles pour l’évaluation continue des sx positifs et négatifs (3)
PANSS (positive and negative syndrome scale)
BPRS (brief psychiatric rating scale)
Calgary Depression Scale Schizophrenia
Quel est le risque de suicide à vie en SCZ?
5%
Quels sont les FDR les plus robustes pour le suicide en SCZ? (8)
ATCD dépression
TS antérieure
Abus drogues
Agitation motrice
Peur de désintégration mentale
Mauvaise adhérence au tx
Perte récente
Hallucinations impérieuses
Vrai ou faux
La peur de désintégration mentale est un fdr pour le suicide en SCZ
Vrai
Vrai ou faux
La mauvaise adhérence au traitement est un fdr pour le suicide en SCZ
Vrai
Combien de temps après une première introduction d’un antipsychotique doit-on minimalement le continuer (sauf si problème significatif de tolérance)?
Au moins 2 semaines
Monitoring de la dose et de la réponse
Si réponse insuffisante à Rx, évaluer adhérence et abus de substance avant de conclure à non réponse
Si pas de réponse après 4 sem malgré optimisation dosage, changement Rx à considérer
Si réponse partielle, réévaluer après 8 semaines sauf si événement adverse significatif
Que faire si on a une pauvre réponse à une première introduction d’un antipsychotique en traitement aigu d’une psychose?
Évaluer l’adhérence et l’abus de substance avant de conclure à non réponse
Optimiser la dose
Si pas de réponse après 4 semaines malgré optimisation dosage, changement Rx à considérer
Si réponse partielle, réévaluer après 8 semaines sauf si événements adverses significatifs
Quand considérer un changement d’antipsychotique en traitement de la psychose aigue?
Si non tolérance importante
Si pas de réponse Rx après 4 semaines malgré optimisation du dosage
Nommez des stratégies pour optimiser l’adhérence au traitement (7)
Psychoéducation
Dosage simplifié
Dosette
Support de proches aidants
Décompte des Rx
Dosage sanguin
Rx IM
Quelle serait la durée d’un essai pharmacologique adéquat lors d’un premier traitement antipsychotique?
Phase de titration sur quelques semaines, et période d’essai d’environ 6 semaines à dose thérapeutique adéquate
(Majorité de l’effet antipsychotique est évidente dans les premières semaines de traitement)
Combien de temps recommande-t-on de maintenir un traitement antipsychotique après un premier épisode psychotique?
Traitement de maintien de +/= 18 mois après la résolution des sx positifs
En exacerbation aigue de psychose, combien de temps devrait-on minimalement continuer le traitement antipsychotique (sauf si intolérance significative) après l’augmentation de la dose ou le changement Rx?
Rx devrait être continuée pour +/= 4 semaines
Si réponse partielle après 4 semaines, réévaluer après 8 semaines sauf si E2e significatifs
En exacerbation psychotique aigue, quoi faire si réponse partielle au Tx AP après 4 semaines?
Optimiser la dose
Réévaluer après 8 semaines, sauf si E2e significatifs
Quand dit-on qu’une schizophrénie est réfractaire au traitement?
Après échec de 2 essais adéquats clairement identifiés d’antipsychotique
Un patient a un dx de SCZ. Après une rechute, combien de temps devrait-on offrir un traitement de maintien avec antipsychotique?
Pour 2 ans
Possiblement pour plus de 5 ans
Quels sont les bénéfices d’une administration IM d’un antipsychotique en SCZ? (3)
Moins de rechutes
Moins de réhospitalisations
Meilleur contrôle des sx
Comment définit-on un essai adéquat d’un antipsychotique PO?
Traitement d’au moins 6 semaines au milieu au dans le haut de l’intervalle thérapeutique
Comment définit-on un essai adéquat d’un antipsychotique IM?
Au moins 6 semaines de tx après l’atteinte de l’état d’équilibre du Rx
Comment définit-on un essai adéquat de la clozapine?
Au moins 8 semaines (idéalement 12 semaines) à une dose +/= de 400 mg DIE
Et si possible, obtenir niveau sérique de +/= 350 ng/mL (110 nM/L ou +/= 250 ng/mL si prise divisée)
Vrai ou faux
On devrait doser la PRL à chaque 3 mois avec prise d’AP atypiques
Faux
On devrait le doser si indiqué, par exemple si sx suggestifs d’hyperPRL
Vrai ou faux
On devrait effectuer un bilan lipidique aux années lors de la prise d’AP atypiques
Vrai
La première année, doser à l’état de base avant de débuter l’AP, ensuite à 3 mois et ensuite aux années. On peut le doser après 1 mois d’usage si indiqué
Vrai ou faux
On devrait rechercher les SEP une fois par année
Faux
À chaque rencontre.
À l’état de base, après 1 mois, après 3 mois et à chaque an
Vrai ou faux
On devrait tester l’IMC une fois par année après l’introduction d’un AP atypique
Faux
Vrai ou faux
On devrait tester la TA une fois par année après l’introduction d’un AP atypique
Faux
Entre le risperdal et l’abilify, lequel offre le moins de risque de prise de poids?
Abilify
Nommez 3 AP atypiques qui ont un risque faible de prise de poids
Abilify
Asénapine
Ziprasidone
Nommez des AP qui ont un risque intermédiaire de prise de poids (6)
Latuda
AP 1ère génération
Paliperidone
Risperdal
Seroquel
Perphenazine
Nommez des AP qui ont un risque élevé de prise de poids (3)
Chlorpromazine
Clozaril
Zyprexa
Vrai ou faux
Les AP de 1ère génération on un risque faible de prise de poids
Faux
Risque intermédiaire
Nommez des AP qui prolongent davantage le QTc en ordre décroissant (7)
Amisulpride > ziprasidone > ilopéridone > risperdal > Zyprexa > seroquel > haldol
