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year three exam 2 > schizophrenia clinical > Flashcards

schizophrenia clinical Flashcards

1
Q

what are the positive symptoms of schizophrenia

A

abnormal behaviours
hallucinations
delusions
though insertion/withdrawal/echo/broadcasting
disorganised speech
disorganised or catatonic behaviour

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2
Q

what are the negative symptoms of schizophrenia

A

absence of normal behaviours
flattened mood
no motivation
apathy
alogia
anhedonia
social isolation
slow movements
self-neglect

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3
Q

how is 1CD10 used to diagnose schizophrenia

A

at least one of the following for 1m
- Thought insertion/echo/broadcasting/withdrawal
- Delusions of control
- Hallucinatory voices
- Culturally inappropriate persistent delusions
OR at least two of the following
- Persistent hallucinations of any modality occurring every day for weeks/months
- Breaks of interpolations in train of thought resulting in incoherence
- Catatonic behaviour – excitement, posturing, mutism, stupor
- Negative symptoms such as apathy, poverty of speech
- Significant change in loss of interest, aimlessness, idleness, self-absorption and social withdrawal

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4
Q

how does DSM5 diagnose schizophrenia

A

Two or more of the following (with one of 1/2/3), each present for a significant amount of time over a 1m period
1. Delusions
2. Hallucinations
3. Disorganised speech
4. Grossly disorganised or catatonic behaviour
5. Negative symptoms
Social/occupational dysfunction
- For a significant amount of time since onset
- Level of functioning in one or more major areas is remarkedly below the persons level prior to onset
Continuous signs for 6m that must include 1m of symptoms 1/2/3

Exclusions
- Schizoaffective disorder or bipolar disorder ruled out
- Presentation is not attributable to the physiological effects of a substance (e.g. drug of abuse, medication) or other medical condition.

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5
Q

what are the differential diagnosis for schizophrenia

A

substance misuse
physical illness
severe mood disorder
PTSD
OCD
personality disorder
ASD/communication disorder
dementia

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6
Q

how do 1st gen antipsychotics work

A

D2 antagonists with H1, muscarinic and alpha 1 activity

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7
Q

what are some 1st gen antipsychotics

A

Phenothiazine
- Chlorpromazine
- Pericyazine
- Prochlorperazine
Butyrophenones
- Haloperidol
Thioxanthenes
- Flupentixol
- Zuclopenthixol
Substituted benzamides
- Sulpiride
- Amisulpride

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8
Q

what are the most common s/e witth 1st gen antipsychotics

A

neurological s/e
EPSEs
anticholinergic
cardiac
hyperprolactinaemia
sexual dysfunction

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9
Q

how do second gen antipsychotics work

A

5HT2 antagonists, fast D2 dissociation and 5HT1A agonism

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10
Q

what are some examples of 2nd gen antipsychotics

A
  • Clozapine
  • Olanzapine
  • Risperidone
  • Quetiapine
  • Aripiprazole
  • Lurasidone
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11
Q

what are the main side effects of 2nd gen antipsychotics

A

metabolic syndrome
anticholinergic
hyperprolactinemia
sexual dysfunction

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12
Q

how are antipsychotic depot/LAI used

A

1st gen need IM test - ESPEs and oily carrier
2nd gen need oral meds first but no IM

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13
Q

which antipsychotics can be given as depo

A

haloperidol - 4 weekly
flupentixol
zuclopenthixol
aripiprazole - oral/IM loading dose required
risperidone - 2/3 week delay, oral meds
olanzapine - post inj syndrome, monitor for 3 hrs

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13
Q

what are the advantages to using depot injection antipsychotics

A
  • Continuous coverage
  • Better for patients
  • Immediate notification of non-adherence
  • Remains in system 1-2 weeks after missed dose
  • Avoids first pass
  • Reduced relapse rates
  • Smoother release profile
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14
Q

what are the disadvantages of using depot antipsychotics

A
  • Painful, can cause site reactions
  • Oral to IM conversion not always straightforward
  • Stigma
  • Dose titrations harder
  • Adverse effects can persist until drug is cleared
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15
Q

what are the general monitoring requirements for antipsychotics

A

QTc - ECG
BP
pulse
plasma glucose
lipid panel
weight/BMI

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16
Q

what is rapid tranquilisation and what medicines are used for it

A

use of IM meds when oral is not available or suitable and urgent sedation is needed
IM lorazepam or haloperidol with promethazine

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17
Q

what are the monitoring requirements for rapid tranq

A

pulse
BP
RR
temp
hydration
consciousness

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18
Q

what is used to treat treatment resistant schizophrenia

A

clozapine - weak D2R antagonist with action at 5HTAR, anticholinergic, antihistaminergic and alpha 1 adrenergic properties

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19
Q

when would a patient be considered for clozapine treatment

A

no response to 2 antipsychotics - one being 2nd gen- after treatment for at least 4/6 weeks

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20
Q

clozapine monitoring requirements

A

Register with approved clozapine blood monitoring service (weekly for 18, 2 weekly until 1 year and then monthly)

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21
Q

what do clozapine blood test results of WBC >3500/mm3 and ANC >2000/mm3 suggest

A

routine tests - continue as normal

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22
Q

what do clozapine blood test results of WBC between 3500 and 3000/mm3 or the ANC between 2000 and 1500/mm3 suggest

A

repeat test twice weekly until improvement or decline - continue treatment

23
Q

what do clozapine test results of WBC below 3000/mm3 and/or absolute neutrophils below 1500/mm3 suggest

A

immediate cessation of treatment - blood tests daily until resolution - no further prescribing unless error occurred or prescriber takes accountability

24
Q

what are the symptoms of antipsychotic withdrawal

A

N&V
sweating
muscle pains
insomnia
restlessness
anxiety
seizures
EPSEs
- akathisia
- dystonia
- dyskinesias
may have cholinergic rebound

25
Q

what EPSEs are associated with antipsychotics

A

dystonia - switch/give procyclidine
parkinsonisms- dose reduction, procyclidine or switch to 2nd gen
akathisia- dose reduction, benzo course or switch
tardive dyskinesia - stop anticholinergics, reduce dose or switch to clozapine or quetiapine

26
Q

what is metabolic syndrome and which antipsychotics cause it

A
  • Weight gain, increased insulin and glucose and dyslipidaemia - 2nd gens (olanzapine/clozapine)
27
Q

what are the monitoring parameters for metabolic syndrome in antipsychotic use

A

waist circum
fasting BM
HbA1c
lipid panel
- before, a2 wks, annually (3m for clozapine and olanzapine)

28
Q

what are the symptoms and management of hyperprolactinaemia associated with antipsychotics

A

can be asymptomatic
- sexual dysfunction, menstrual issues, breast growth, loss of bone mineral density, increased breast cancer risk
manage by reduce dose, switch to prolactin sparing (aripiprazole) or add low dose aripiprazole (off license)

29
Q

how is sexual dysfunction as a result of antipsychotics managed

A
  • Monitor prolactin
  • Consider spontaneous resolution
  • Adjust dose
  • Switch
  • Add 3-6mg aripiprazole (unlicensed)
  • Specialist – sildenafil or priapism
30
Q

how is sedation as a result of antipsychotics managed

A
  • Review all meds
  • Use minimum effective dose
  • Counsel
  • Diminish with longer use
  • Trial dose reduction
  • Switch
  • Prescribe at night
  • Avoid psychostimulants – can worsen
31
Q

what are the central anticholinergic effects that can be seen with 1st gen antipsychotics and clozapine

A
  • Cognitive impairment
  • Delirium
  • Hyperthermia
  • Confusion
32
Q

what are the peripheral anticholinergic effects that can be seen with 1st gen antipsychotics and clozapine

A
  • Dry mouth
  • Constipation
  • Blurred vision
  • Glaucoma
  • Urinary retention
33
Q

how are anticholinergic s/e of antipsychotics managed

A
  • Identify patients who have pre-existing conditions (narrow angle glaucoma etc)
  • Review other meds
  • Low and slow
  • Trial dose reduction
  • Switch
34
Q

what are the cardiac s/e associated with antipsychotic use

A
  • Orthostatic/postural hypotension (alpha1 antagonists)
  • Reflex tachycardia (alpha1 antagonists and anticholinergic)
  • Ventricular tachycardia
  • Torsades de pointes
  • Delayed cardiac repolarisation
  • Myocarditis
  • Myocardial infarction
  • Cardiomyopathy
35
Q

what cardiac monitoring is required for antipsychotics

A
  • BP and pulse baseline
  • ECG
  • Repeat at 12 weeks and then annually
36
Q

how are cardio side effects of antipsychotics managed

A
  • Education
  • Gradual dose titration
  • Dose reduction
  • Switching
  • Add in appropriate medication to reduce HR
  • Review concurrent medication that may exacerbate effects
  • If myocarditis is suspected - STOP and refer as appropriate
37
Q

what are the cardiac side effects of clozapine

A

thromboembolism
myocarditis - 6-8wks of treatment - hypotension, tachycardia, fever, flu, fatigue
cardiomyopathy - 9m of treatment

38
Q

what are the haematological side effects of clozapine

A

Agranulocytosis (0.4%)
- Managed by enrolment onto clozapine monitoring system
- WBC & platelets at baseline and weekly for 18, 2 weekly until 1yr – monthly

39
Q

what are the constipation side effects of clozapine

A

dose reduction
- Anticholinergic, antihistaminergic and 5HT3 antagonism
stimulants/softeners - no bulk

40
Q

what are the hypersalivation side effects of clozapine

A

dose related- may improve over time
- reduce or switch
- antimuscarinics - can worsen other S/E
lifestyle

41
Q

what is Neuroleptic malignant syndrome

A

Acute disorder of thermoregulation and neuromotor control

42
Q

what are the symptoms of neuroleptic malignant syndrome

A
  • Fever
  • Diaphoresis
  • Rigidity
  • Confusion
  • Fluctuating consciousness and BP
  • Tachycardia
  • Elevated CK
  • Altered LFTs
  • Leucocytosis
43
Q

what are the risk factors for neuroleptic malignant syndrome

A
  • High potency 1st gen
  • Recent/rapid dose increase/reduction
  • Abrupt anticholinergic withdrawal
  • Antipsychotic poly pharmacy
  • Male
  • Young
  • Dehydration
  • Psychosis
  • Brain/Parkinson’s disease
  • Alcoholism
  • Hyperthyroidism
44
Q

how are antipsychotics restarted after neuroleptic malignant syndrome

A
  • Allow at least 5 days before restarting
  • Low and slow
  • Consider an antipsychotic that is structurally unrelated to the causative agent or one with lower dopamine affinity (quetiapine, clozapine or aripiprazole)
  • Avoid Depot or LAI
45
Q

which antipsychotics cause QT prolongation and what do they interact with

A

haloperidol/quetiapine
- (es)citalopram
- Eryth/clarithromycin
- Tamoxifen
- Sotalol
- Amiodarone
- Venlafaxine

46
Q

which antipsychotics cause neutropenia/agranulocytosis and what do they interact with

A

clozapine
- Carbamazepine
- Cytotoxics
- Chloramphenicol

47
Q

which antipsychotics cause sedation and what do they interact with

A

Chlorpromazine, Clozapine, Olanzapine, Quetiapine ,Pericyazine, Zuclopenthixol

  • Alcohol
  • Benzos
  • Mirtazapine
  • Antihistamines
  • Opiates
  • Trazadone
  • TCAs
48
Q

which antipsychotics cause anticholinergic s/e

A
  • Chlorpromazine
  • Clozapine
  • Zuclopenthixol
49
Q

which antipsychotics cause low BP and what do they interact with

A

chlorpromazine, clozapine, risperidone
- antihypertensives
- TCAs
- alcohol

50
Q

which antipsychotics cause seizures and what do they interact with

A

clozapine, chlorpromazine
- TCAs
- sudden benzo withdrawal

51
Q

which metabolic changes cause sedation and what do they interact with

A

chlorpromazine, clozapine, olanzapine
- lithium
- mirtazapine
- TCAs
- valproate

52
Q

which antipsychotics are metabolised by CYP

A
  • Clozapine
  • Olanzapine
  • Aripiprazole
  • Chlorpromazine
  • Haloperidol
  • Risperidone
  • Zuclopenthixol
  • Quetiapine
53
Q

what are some CYP inhibitors

A
  • Caffeine
  • Cimetidine
  • Ciprofloxacin
  • Amiodarone
  • Duloxetine
  • Fluoxetine
  • Paroxetine
  • Sertraline
  • Diltiazem
  • Clarith/erythromycin
  • Verapamil
54
Q

what are some CYP inducers

A
  • Phenytoin
  • Barbiturates
  • Tobacco smoke
  • Rifampicin
  • Carbamazepine
55
Q

what effect does tobacco smoke have on antipsychotics

A

reduces plasma clozapine levels by 50%
reduces olanzapine levels by 50%

56
Q

what effect does caffeine have on antipsychotics

A
  • Increase in clozapine levels by up to 60%

year three exam 2 (38 decks)

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