schizophrenia

Question 1

ICD 10 definition of schizophrenia

Answer 1

schizophrenia- severe mental illness charactersised by the desingegration of the process of thinking, contact with reality and emotional responsiveness
hallucination/delusions

ICD1-
A) 1> of scheiders 1st rank sx >1m duration
1) Delusions (false and fixed beliefs
2) Passivity (Delusion of control)
3) Tought disorder (insertion/withdraw/broadcast)
4) auditory disorder (echo -toughts out loud, 3rd person voice, running commentary)

OR
B) 2> of the following (these are subtypes)
paranoid-hallucinations (any) (most common)
Hebephrenic -inchoerant/irrelevant speech
Catatonic -cataonic behav- exctiment, posturing, wavy flex, negatism, mutsim, stupor
Simple -neg sx -apathy, paucity of speech, blunter emotional response

C) present >1m AND
D) Not caused by drugs or organic disease

Question 2

How does schizophrenia usually progress clinically

Answer 2

Start with prodrome/at risk mental state)
-social withdrawal, loss of interest in work and relation

Then acute phase (+ve sx dominant -high dopamine)
Delusions, hallucinations, thought interferance)

then chronic phase (-ve sx dominant - low dopamine)
apathy, blunted affect, anhedonia, poverty of thought/speech, social withdraw

Question 3

Aetiology and RF of schizophrenia

Answer 3

20m world wide affected -1% of pop in UK
15-45 y/o onset

Biological
Genetics -50% monozygotic twin concordance
Obstetric complic -pre eclamps, viral infect, pre-eclam, LBW
Substance missule (esp with VAL allele)
Neurodevelop - enlarged ventricules-lower premorbid IQ
Neutrotransmitter DA hypothesis -
or 5HT hypothesis -overactive
or Glutamate - dysreg

Psychoscial
social disadvantages -
urban life and birth -2x
Migrants (1st/2nd gen)-3x
Ethinic-black -4-6x higher
involved relative INCREASe relapse risk
Premorbid personality
adverse life experiences (sexual/phsical abuse)
Cognitive behaviouur
fear of madness

Question 4

Ix of schizophrenia

Answer 4

Collateral hx + physical exam
Bloods - FBC, UE, Lipids, LFT, STI (neuro syph)
Urine -drugs. MSU
MRI -hypofunction in pre-frontal

rating scale -brief psychatric rating scale
ADL assessment

ddx-
organic -drug, dementia, delirium, steroids, tumours
Acute -psychosis =/= scizophrenia
Mood disorder - depression and mania can have psychotic sx -check order
Schizoaffective - sx together and balanced
delusional disorder -only delusions
Schizotypal - eccentricity not fully scizo

Question 5

Mx of acute/emergency schizophrenia

Answer 5

Ugrent emergency -crisis resolution team, home treatment team, AMP, police

Non urgent emergency - early intervention in psychosis (EIP) (if over 14y/o)
psychosis is toxic-dont delay mx
aim to keep duration of untreatd psychosis (DUP) <3m
antipsychotics (details on other card) and psychosocial ix

rapid tranquilise can be needed-
1st line- lorazepam -oral -> IM
2nd - Haloperidol (5mg) and lora (1mg)

inpatient admission (can use 146/section 2/3)
risk to self, risk to others, risk to health
lack of capacity
need big medication change
Severe sx
adressing comorbidities

then Bio (medication)
+ psycho
1st line -CBT (16 sessions) -testing reality
family therapy (esp if young) -10 seshs, to control

+social -
Social skill training, education, benefits, housing
carecoordinator, psych nurse, OT/PT, GP, etc

risk assess - self, other, from other

prognosis -
good - sudden onset, late, with stress even, Higher IQ
Bad =gradual onset, early, no precipitant, FHX, low IQ

Question 6

What are the medication reccomendations for schizophrenia

Answer 6

1st line (6weeks) of atypical antipsychotics (start LOW, go SLOW)

less strong, less SE - Ariprazole (inital akathesia), Quietapine (sedation, weight gain)
Stonger, more SE ( Olanzapine (weight gain) and Risperidone (hyperprolactine, extrapyramidal SE, sedation)

so usually -
low dose aripriprazole / High dose olazapine
+m education/support

augment with -BDZ (diazepam) and mood stabiliser
if not comply -can have 1/m IM injection

2nd line 6 weeks- Typical antipsychotics (higher chance of extrapyramidals)

3rdline -clozapine
this is for resistance/failure ( fail to respond to >2 antipsychotic, 6 weeks each with 1 at least being atypical,
always try to avoid clozapine

lot of these cause weight gain and CVD SE-monitor

Question 7

What are the important things to monitor with schizophrenia

Answer 7

Baselines before starting any antiphsychotics -
Obs (with weight and waist circumferance)
BT - FBC, UE, LFT, HBA1c, lipids, prolactin
assess any movement disorders
assess of nutrition status
ECG -esp with medication

monitor every week for 6 weeks - esp weight, waiset, response and SE, adherence, movement, overall
12 weeks -all above + HR/BP
then annual -with the full