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3153 psych > schizo > Flashcards

schizo Flashcards

1
Q

psychosis

A
  • Acute and severe episode (of mental condition)
  • Out of touch with reality (though process, beliefs, perceptions)
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2
Q

schizophrenia

A
  • Protracted psychosis
  • Heterogenous syndrome of disorganised and bizarre thoughts, delusions, hallucinations (textile, visual, auditory, gustatory, olfactory)
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3
Q

positive sx

A
  • Delusions (paranoid)
  • Hallucinations (exhortatory voices)
  • Thought disorder – feeling that thoughts are controlled by outside agency
  • Abnormal behaviors (stereotypical/ aggressive behaviors)
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4
Q

negative sx

A
  • Withdrawal from social contacts
  • Flattening of emotional responses
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5
Q

predisposing causes of schizo

A
  • Genetic factors
    • Susceptible genes identified in chromosomal regions:
    • DISC1, neuregulin-1, dysbindin-1, catechol-O-methyl transferase (COMT)
    • Not all schizophrenics share same mutations of susceptible genes
  • Environmental factors
    • Neurodevelopmental abnormalities
    • Maternal viral infection during preg
    • Obstetric complications
  • Myelination of cortico-cortical pathways
    • Onset in late adolescence/e arly adulthood
  • Enlarged ventricles, abnormalities in laminar organization of cortical cells
    • Neurodevelopmental disorder?
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6
Q

struc abnormalities (observable in MRI)

A

incr ventricular size, decr brain size & cortical size, decr hippocampal vol, decr axonal, dendritic comm

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7
Q

precipitating factors of schizo

A
  • Cerebral tumors or injury
  • Drug/ substance induced psychosis
    • Alcohol
    • Benzodiazepines
    • Barbiturates
    • Antidep
    • Corticosteroids
    • CNS stimulants (amphetamines)
    • Hallucinogens (LSD, cannabis, volatiles)
    • BB (propranolol)
    • Dopamine agonist (levodopa, bromocriptine)
  • Personal misfortune
  • Environ of high expressed emotion
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8
Q

perpetuating factors of schizo

A
  • 2nd demoralisation
  • Social withdrawal
  • Lack of support/ poor socio-economic status/ environ
  • Poor adherence with antipsychotic meds
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9
Q

neurochemical theories

A

1) dopamine theory
* Amphetamine (overactive DA) produce similar sx to acute schizophrenia
* All antipsychotic drugs are D2 antagonists

2) 5HT theory (SGA inhibits)
3) glutamate theory (NMDA antagonist)

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10
Q

DSM-5 criteria dx of schizo

A
  • =/>2 of following. Persist > 1mnth
    * +ve and -ve sx
  • social/ occupational dysfunction
    * work / interpersonal relation/ self care (=/> 1 area below level prior to onset)
  • duration
    * signs of d/o for ≥ 6mnths (remission, prodromal)
    * 1mnth of continuous sx
  • scizoafective/ mood disorders excluded
  • not due to medical disorder/ sub abuse
  • hx of persuasive developmental disorder present, hallucinations/ delusions
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11
Q

schizo sx

DHDDN

A
  • Delusions
  • Hallucinations
  • Disorganised speech
  • Grossly disorganised or catatonic behaviour
  • Negative sx (affective flattening, avolition)

other assoc sx
* Cognitive sx: impaired attention, working memory
* Mood sx: depression, dysphoria, hopelessness, demolarisation

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12
Q

non pharm management

A
  • Individual
    • Supportive/ counselling
    • Personal therapy
    • Social skills therapies
    • Vocational sheltered: employment, rehabilitation (social interactions) —– Improve pt adaptive functioning
  • Grp cognitive behavioural
    • Interactive. Social
  • Cognitive behavioural therapy
    • Conjunct with meds & fam intervention
    • Esp for at risk grp
  • Neurostimulation
    • Electroconvulsive therapy for tx-resistant schizo
    • Repetitive transcranial magnetic stimulation (rTMS) reduce auditory hallucinations
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13
Q

pharmacotherapy
main class + adj

A
  • suitable APS (FGA/ SGA) not clozapine
    • PO, IM
    • adequate trial 2-6wks, therapeutic dose range
  • adjunct tx
    • BZP (agitation)
    • antidep
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14
Q

pharm tx flowchart

A

check for: adequate resp, tolerable SE, compliance

1) FGA/ SGA
2) another FGA/ SGA
3) clozapine
4) clozapine + FGA/ SGA/ ECT

5) FGA + FGA
FGA + SGA
APS + ECT/ mood stabilisers

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15
Q

pharm tx phases

A
  • acute stabilisation
    • minimise threat to self, others
    • reduce acute sx, improve functionings
  • stabilisation
    • minimise/ prevent relapse
    • promote med adherence
    • optimise dose, ADR
  • stable/ maintenance phase
    • monitor for prodromal sx of relapse, ADR
    • baseline functioning
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16
Q

APS indications

A
  • thought organisers
  • neuro-leptics, tranquilise w/o impair consciousness, calm disturbed pts
  • acute mania (bipolar)
  • adjunct w/ antidep (quet, aripip, brexipip)
  • antiemetic (palliative care)
  • motor tics, tourette’s, intractable hiccup (haloperidol)
  • irritability with autistic d/o (risperidone)
17
Q

APS MOA

A

1) mesolimbic tract: APS effect block D2 receptors, less overactivity (+ve sx)

relieve sx of hallucinatiions, delusions, prevent relapse

18
Q

D2 antagonism also has SE

A
  • prolactin (tuberoinfundibular): more prolactin
  • EPSE (nigrostriatal) : less purposeful movements
  • mesocortical: worsen -ve sx
19
Q

maintenace therapy with APS

A
  • long term tx after 1st ep to prevent illness from becoming chronic
    * most pts require life-long maintenace therapy
    * high risk of relapse if APS withdrawn inapp
  • relapse often delayed (wks): depot reservoir in adipose tissues
20
Q

overcome poor tx adherence

A
  • IM LA inj
  • comm psychiatric nurse - home visit, inject LAI
  • pt and fam, caregiver education
21
Q

pharm tx considerations

A
  • med selection is individualised (comor, past responses, pt needs, efficacy, SE)
  • compliance to adequate trial
    * 2-6 wks
22
Q

clozapine consideration

A
  • tx resistant (failed =/> 2 adequate trials of diff APS – one is SGA)
  • hamatological monitoring: Agranulocytosis
  • tx refractory evaluation: dx, sub abuse, med adherence, psychosocial stressors
  • CBT, non pharms, Psychosocial augmentation
23
Q

pop precautions to APS use

A
  • CVS!!!!!!
  • Parksinson’s: worsen EPSE
  • Epilepsy: seizure outbreak
  • Depression
  • Myasthenia gravis
  • Prostatic hypertrophy
  • Angle-closure glaucoma
  • Severe resp disease
  • Hx of jaundice
  • Blood dyscrasis (clozapine)
  • Elderly with dementia: risk mortality, stroke
24
Q

CVS pop and APS

A
  • IV halo, CPZ, zip, ilo, quet, risp
  • precautions: HTN, IHD, post-MI, CHF, AF, Brugada syndrome
  • QTc prolongation (CI: F >470MS, M > 440MS)
  • ECG required esp if
    • CVS risk actors
    • Personal hx of CVD
    • Admitted inpt and naïve to antipsychotics
25
Q

Adjunct for acute agitation

A
  • PO lorazepam 1-2mg
  • Oral antipsychotics
    • Haloperidol (tab, sol) 2-5mg (need ECG)
    • Risperidone (tab, orodispersible) 1-2mg
    • Quetiapine (tab, immediate release) 50-100mg
    • Olanzapine (tab, orodispersible) 5-10mg
26
Q

Adjunct for uncooperative agitation, remains aggresive

A
  • fast acting IM inj (BZP or APS)
    * IM lorazepam 1-2mg
    * IM olanzapine (immediate release) 5-10mg [2nd dose =/> 2h
    3rd dose =/> 4h]; Not given within 1h of lorazepam (CVS fatality)
    * IM arip (immediate relase 9.75mg)
    * IM promethazine (anti H1) 25-50mg
  • can be combined too
27
Q

adjuncts for catatonia

A
  • very disorganised, frozen in thoughts
    *BZP: PO/IM lorazepam
28
Q

adjuncts for depressive sx/ -ve sx of chronic schizo

A
  • antidep for dep sx
  • -ve sx: mild-mod can use antiddep (SSRI)
29
Q

therapeutic outcomes

A
  • Monitor effectiveness
    • Mental status exam
    • Psychiatric rating scales (BPRS 20-40% score reduction, PANSS)
  • Monitor ADR — tx acordingly
    • Metabolic parameters: BGL, BMI, BP
    • EPSE: presence, severity of any tx emergent EPSE
      Drug induced pseudo parkinsonism: Simpson-Angus rating sclae
      Akathisia: Barnes Akathisia scale
      Tardive dyskinesia: AIMS, DISCUS
  • Pt self assessment (freq of mood epi/ schizo sx)
    • maintain baseline functioning
30
Q

duration

A
  • Early improvement:
    ○ 1st wk: less agitation, aggression, hostility
    ○ 2-4wks: less paranoia, hallucinations, bizaare behaviours, improved org in thinking
  • Late improvements
    ○ 6-12wks: less delusions, neg sx may imrpove
    ○ 3-6mnths: cognitive sx may improve (w/ SGA)
  • adequate trial 2-6wks, therapeutic dose range
31
Q

efficacy

A
  • FGA, SGA: improve +ve sx (D2 antagonism)
  • SGA (maybe improve -ve sx)
32
Q

ADR trends

A
  • FGA: more EPSE
  • SGA: more metabolic
    * except ari, brex, cari, lura, zip
    * -ines (cloz, olan, quet): sedating, weight gain

3153 psych (11 decks)

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