Schizoprehnia Flashcards
Etiology
- Genetics 2. Biochemical ++dopamine in mesocortex/mesolimbic, reduction elsewhere Serotonin excess->negative symptoms NE reduction->anhedonia GABA->loss of inhibitory (+DA) 3. Neuropathology: Excessive pruning of synapses. Reduced symmetry Enlarged ventricles Loss of density in limbic, BG, cortex, thalamus. Neural circuit abnormalities. Brain metabolism.
Epidemiology
1% population Men=women Men tend to present earlier Women have better prognosis
Learning theories
Learn irrational reactions and ways of thinking by imitating parents with own emotional problems
Psychosocial/psychoanalytical theories
Distortion in ego development, the various symptoms seen to have importance/meaning to the patient +Expressed emotion
Does a specific family dynamic predispose to developing schizophrenia
No evidence to suggest this
Premorbid
- Few friends 2. Passive, odd behaviour 3. Lack funtional 4. Altered speech 5. +Interest in abstract ideas, cultural, religion 6. Abnormal affect
MSE
- General Disheveled, agitation, violent, lack spontaneous speech, purposeless moveM, inappropriate dress 2. Mood and affect Hallucinations, illusions, anhedonia, inappropriate extremes of emotion 3. Thought content–>delusions (loss of ego boundaries), form–> loose associations, derail, tangentiality, concequentiality process–>flight of ideas, inattention, poverty of thought 4. Sensorium and cognition Orientation: well oriented Cognitive impairment Generally intact memory 5. Judgement and insight impaired
Criteria
- Symptoms 6 months with 1 month active including prodrome (negative + 2 attenuated) Delusions Hallucinations Disorganised speech Grossly disorganised or catatonic behaviour Negative (diminished emotional expression or avolition) 2. not affective/mood (not concurrent, or sx for minor duration), not substance, not GMC +impaired function, social withdrawal, Austism spectrum disorder
Subtypes
- Disorganised 2. Paranoid 3. Catatonic 4. Residual 5. Undifferentiated
Disorganised
Younger Regression ++Thought disorder Appearance disheveled Poor social behaviour Inappropriate responses Incongruous grinning
Paranoid
Younger Auditory hallucinations Delusions Persecutory, gradiose delusions
Catatonic
Marked motor disturbance Stupor Mannerisms Extremes of excitement
Residual
not meeting criteria, however have emotional blunting, social withdrawal, eccentric behaviour, illogical thinking, loose associations
Investigations in first psychotic episode
- full blood count; 2. serum electrolytes, 3. calcium, creatinine and urea concentrations; 4. liver biochemistry; 5. fasting blood glucose and 6. serum lipid concentrations; 7. thyroid function tests; 8. prolactin concentration; 9. urine toxicology; 10. computerised tomography (CT) / magnetic resonance imaging (MRI)
Management of first psychotic episode
- Risperidone 0.5 to 1 mg orally, at night initially, increasing to 2 mg at night. Maximum daily dose is 6 mg 2. For agitation/irritability->diazepam 5-10 mg PO 3. amisulpride 100 mg orally,nocte, increasing to 200 mg twice daily. Maximum daily dose is 1200 mg. Dose adjustment is required in patients with kidney impairment. Negative symptoms 4, Check response in 6-12 weeks->if not chlorpromazine 5. If still not managed->clozepine
Recovery, relapse and prevention ongoing management
- Physical, nutrition, smoking, alcohol, physical activity 2. Manage co-morbidities->obesity, diabetes, CVD, COPD. substance abuse 3. Antipsychotic 4. Psychosocial therapy 5. Manage side effects 6. Psychoeducation 7. Liase with GP and community teams
Management of prodromal and progression
- Monitoring 2. CBT 3. Low dose antipsychotic 33% will progress to psychosis within a year
What must you actively ask about with schizophrenic on medication
- Motor 2. Weight gain 3. Appetite 4. Breast enlargement 5. Sexual dysfunction
What are the 6 A’s of negative symptoms
Affect blunted Alogia Anhedonia Asocial Avolition Attention impaires
When is clozepine used
Suitable for treatment resistanct ++Suicidal ideation Substance abuse EPSE Aggression
Adverse effects of clozepine
- Haem->neutropenia, agranulocytosis, eosinophilia 2. CVS->myocarditis, cardiomyopathy->monitor troponins and CRP for first 4 weeks 3. Cardiometabolic->lipids, glucose, HTN 5. GIT: abnormal liver enzymes, pancreatitis, hypersalivation Resp: Pneumonia
How long to treat with antipsychotics
If first psychotic episode->1-2 years When recurrent->5 years
Prognostic factors: good and bad
Good 1. Late onset, obvious precipitants 2. Good premorbid functioning->social, sexual and work 3. Acute onset 4. Mood disorder 5. Married 6. FHx mood disturbance Poor 1. Young 2. No precipitating 3. Insidious 4. Poor premorbid functioning 5. Withdrawn 6. single, widowed, divorced 7. FHX schizo 8. -ve, neurol S&S 9. perinatal trauma 10. No remissions 3 years 11. +relapses 12. Hx of assaultiveness
Management overview in hospitalisations
- Diagnose 2. Stabilise on medication 3. Food, clothing, shelter 4. Establish contact between GP, community, family
Side effects of antipsychotics and management
- Metabolic syndrome 2. Hyperprolactinemia->switch 3. Anticholinergic->urinary retention, constipation, dry mouth, blurred vision->lower dose, change 4. Sedation->generally self limiting, reassure or lower dose/change 5. Movement disorders
Management of metabolic
- Monitor: lipids, weight, glucose, BP, waist, cholesterol 2. Education: healthy eating, physical activity, weight loss 3. Switch->antipsychotic with fewer CV effects
Management of movement disorders
- Akathisia->propranolol 2. Acute dystonias->benztropine 3. Parkinsonism->benztropine 4. Tardive dyskinesia->prevention, ensure SGA, clozepine
Components of psychosocial therapies
- Behavioural skills training 2. Motivational interviewing 3. Employment supprot 4. Family therapies 5. Psychoeducation 6. Assertive community treatment 7. CBT
Behavioural skills trainign
carefully defining the problem behaviours, measuring them and then manipulating aspects of the positive and negative reinforcements that help maladaptive behaviours persist. 1. Video tape watching, replaying, homework 2. Eye contact 3. Delayed responses 4. Odd facial expressions 5. Lack of spontaneity 6. Inaccurate perception of social cues
Family oriented therapies
Avoiding troublesmoe situations Resolve problems quickly Education Talking openly abut psychotic symptoms Manage the excessive expression of emotion
Psychoeducation
basic information about mental illness (the symptoms, the aetiology and treatment), the mental health care system (roles of mental health professionals and the relevant mental health legislation) and the principles of caring for oneself.
CBT
examine the evidence for a psychotic belief, and use reasoning, coping and problem-solving skills to challenge and decrease the salience and threat of their beliefs.
Management of clozapine side effects
- Sedation->usually wears off in 4 weeks. Consider dose reduction if persistent
- Hypersalivation->first 4 weeks, wears off. Benztropine, glycopyrrolate
- Constipation->usual recommendations
- Hypotension->first 4 weeks. Take tie when standing, consider dose reduction
- Hypertension->monitor, consider atenolol
- TachyC-> very common early, monitor, may indicate myocarditis
- Weight gain-> diet + lifestyle
- Fever->first 3 weeks, antipyretic, check FBC
- Seizures->dose related, withold for one day, restart at reduced dose.
- Nausea->first 6 weeks, antiemetic->avoid metoclopramide if previous EPSE
- Nocturnal enuresis->manipulate dosing schedule, avoid fluids before bed, desmopressin if severe
In relation to antipsychotic use, why is it important to know if a smoker
Nicotine can reduce level of antipsychotic
Six categories of schizoaffective disorder
- Patients with schizo + mood
- Mood + schizo
- Both mood and schizo
- Other psychotic + mood
- Continnuum between schizo and mood
- Continuum of the above
Epidemiology of schizoaffective
<1 %
Bipolar type-> M= W, +young
2X W depressed type, +older
