Schizoprehnia

Question 1

Etiology

Answer 1

1. 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.

Question 2

Epidemiology

Answer 2

1% population Men=women Men tend to present earlier Women have better prognosis

Question 3

Learning theories

Answer 3

Learn irrational reactions and ways of thinking by imitating parents with own emotional problems

Question 4

Psychosocial/psychoanalytical theories

Answer 4

Distortion in ego development, the various symptoms seen to have importance/meaning to the patient +Expressed emotion

Question 5

Does a specific family dynamic predispose to developing schizophrenia

Answer 5

No evidence to suggest this

Question 6

Premorbid

Answer 6

1. Few friends 2. Passive, odd behaviour 3. Lack funtional 4. Altered speech 5. +Interest in abstract ideas, cultural, religion 6. Abnormal affect

Question 7

MSE

Answer 7

1. 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

Question 8

Criteria

Answer 8

1. 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

Question 9

Subtypes

Answer 9

1. Disorganised 2. Paranoid 3. Catatonic 4. Residual 5. Undifferentiated

Question 10

Disorganised

Answer 10

Younger Regression ++Thought disorder Appearance disheveled Poor social behaviour Inappropriate responses Incongruous grinning

Question 11

Paranoid

Answer 11

Younger Auditory hallucinations Delusions Persecutory, gradiose delusions

Question 12

Catatonic

Answer 12

Marked motor disturbance Stupor Mannerisms Extremes of excitement

Question 13

Residual

Answer 13

not meeting criteria, however have emotional blunting, social withdrawal, eccentric behaviour, illogical thinking, loose associations

Question 14

Investigations in first psychotic episode

Answer 14

1. 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)

Question 15

Management of first psychotic episode

Answer 15

1. 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

Question 16

Recovery, relapse and prevention ongoing management

Answer 16

1. 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

Question 17

Management of prodromal and progression

Answer 17

1. Monitoring 2. CBT 3. Low dose antipsychotic 33% will progress to psychosis within a year

Question 18

What must you actively ask about with schizophrenic on medication

Answer 18

1. Motor 2. Weight gain 3. Appetite 4. Breast enlargement 5. Sexual dysfunction

Question 19

What are the 6 A’s of negative symptoms

Answer 19

Affect blunted Alogia Anhedonia Asocial Avolition Attention impaires

Question 20

When is clozepine used

Answer 20

Suitable for treatment resistanct ++Suicidal ideation Substance abuse EPSE Aggression

Question 21

Adverse effects of clozepine

Answer 21

1. 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

Question 22

How long to treat with antipsychotics

Answer 22

If first psychotic episode->1-2 years When recurrent->5 years

Question 23

Prognostic factors: good and bad

Answer 23

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

Question 24

Management overview in hospitalisations

Answer 24

1. Diagnose 2. Stabilise on medication 3. Food, clothing, shelter 4. Establish contact between GP, community, family

Question 25

Side effects of antipsychotics and management

Answer 25

1. 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

Question 26

Management of metabolic

Answer 26

1. Monitor: lipids, weight, glucose, BP, waist, cholesterol 2. Education: healthy eating, physical activity, weight loss 3. Switch->antipsychotic with fewer CV effects

Question 27

Management of movement disorders

Answer 27

1. Akathisia->propranolol 2. Acute dystonias->benztropine 3. Parkinsonism->benztropine 4. Tardive dyskinesia->prevention, ensure SGA, clozepine

Question 28

Components of psychosocial therapies

Answer 28

1. Behavioural skills training 2. Motivational interviewing 3. Employment supprot 4. Family therapies 5. Psychoeducation 6. Assertive community treatment 7. CBT

Question 29

Behavioural skills trainign

Answer 29

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

Question 30

Family oriented therapies

Answer 30

Avoiding troublesmoe situations Resolve problems quickly Education Talking openly abut psychotic symptoms Manage the excessive expression of emotion

Question 31

Psychoeducation

Answer 31

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.

Question 32

CBT

Answer 32

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.

Question 33

Management of clozapine side effects

Answer 33

1. Sedation->usually wears off in 4 weeks. Consider dose reduction if persistent
2. Hypersalivation->first 4 weeks, wears off. Benztropine, glycopyrrolate
3. Constipation->usual recommendations
4. Hypotension->first 4 weeks. Take tie when standing, consider dose reduction
5. Hypertension->monitor, consider atenolol
6. TachyC-> very common early, monitor, may indicate myocarditis
7. Weight gain-> diet + lifestyle
8. Fever->first 3 weeks, antipyretic, check FBC
9. Seizures->dose related, withold for one day, restart at reduced dose.
10. Nausea->first 6 weeks, antiemetic->avoid metoclopramide if previous EPSE
11. Nocturnal enuresis->manipulate dosing schedule, avoid fluids before bed, desmopressin if severe

Question 34

In relation to antipsychotic use, why is it important to know if a smoker

Answer 34

Nicotine can reduce level of antipsychotic

Question 35

Six categories of schizoaffective disorder

Answer 35

1. Patients with schizo + mood
2. Mood + schizo
3. Both mood and schizo
4. Other psychotic + mood
5. Continnuum between schizo and mood
6. Continuum of the above

Question 36

Epidemiology of schizoaffective

Answer 36

<1 %

Bipolar type-> M= W, +young

2X W depressed type, +older