Clinical Flashcards
Extrapyramidal Sx
- dystonia (continuous spasms and muscle contractions)
- akathisia (motor restlessness)
- parkinsonism (characteristic symptoms such as rigidity, bradykinesia, and tremor)
- dyskinesia (irregular, jerky movements) - e.g. tardive dyskinesia - anticholinergics make this worse (make the other 3 better)
Extrapyramidal symptoms are most commonly caused by typical antipsychotic drugs that antagonize dopamine D2 receptors. The most common typical antipsychotics associated with EPS are haloperidol and fluphenazine.
Tx of EPS
Anticholinergic drugs (benztropine (Cogentin), diphenhydramine (Benadryl), and trihexyphenidyl (Artane)) are used to control neuroleptic-induced EPS, although akathisia may require beta blockers or even benzodiazepines. If the EPS are induced by an antipsychotic, EPS may be reduced by dose titration or by switching to an atypical antipsychotic.
Another common course of treatment includes dopamine agonist agents such as pramipexole.
Types of delusions (5)
- Persecutory (Someone or something is interfering with the person in a malicious/destructive way)
- Grandiose (Being famous, having supernatural power or enormous wealth)
- of reference (Actions of other people, events media etc. are referring to the person or communicating a message)
- Thought insertion/withdrawal/broadcast (Thoughts can be controlled by an outside influence: inserted, withdrawn or broadcast to others)
- Passivity (Actions, feelings or impulses can be controlled or interfered with by outside influence)
Categories of questions relating to suicide (3)
Suicidal thoughts
Do you ever feel that life is so bad you don’t want to live anymore?
Have you ever thought that you might try to harm yourself?
Suicidal plans
Have you ever reached a point where you have thought
how you might harm yourself?
Suicidal intent
Do you think you would actually do this?
(if not) What stops you from acting on your plan?
Good prognostic factors in schizophrenia
FINDING PLANS
Female In relationship, good social support No negative symptoms aDheres to medication Intelligence (more educated) No stress Good premorbid personality
Paranoid subtype Late onset Acute onset No substance misuse Scan (CT/MRI head) normal
5 subtypes of schizophrenia
- Paranoid type: Delusions or auditory hallucinations are present, but thought disorder, disorganized behavior, or affective flattening are not. Delusions are persecutory and/or grandiose, but in addition to these, other themes such as jealousy, religiosity, or somatization may also be present.
- Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought disorder and flat affect are present together.
- Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility.
- Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met.
- Residual type: Where positive symptoms are present at a low intensity only.
Schizophrenia 1st-rank Sx
Third-person auditory hallucinations (discussing/giving
running commentary)
Thought echo (hear own thoughts out loud)
Delusional perception (delusion arises from a real perception, e.g. from ‘a bunch of flowers’ to ‘I therefore knew terrorists were after me’)
Thought insertion/withdrawal/broadcast (thoughts interfered with)
Passivity (actions, feelings or impulses interfered with) and somatic passivity (body controlled by others)
Schizo: groups of Sx
° positive (hallucinations, delusions)
° negative (poverty of speech, flat affect, poor motivation, social withdrawal and lack of concern for social conventions)
° cognitive (poor attention and memory)
Neurochem changes in schizo (3)
Not clearly understood, but the final common pathway appears to involve:
° dopamine excess or overactivity in mesolimbic dopaminergic pathways (stimulant drugs such as amphetamines release dopamine and lead to psychosis; antipsychotics, which block dopamine receptors, treat psychosis successfully)
° increased serotonin activity
° decreased glutamate activity
Schizo: initial assessment (11)
- positive symptoms such as hallucinations and delusions
- negative symptoms such as flat or blunted affect, poverty of thought or thought content, and avolition
- disorganization such as thought disorder, inappropriate
affect, and disorganized behaviour - affective symptoms such as anxiety or depression,
particularly in relation to the psychotic symptoms - suicidal or aggressive thinking and behaviour,
impulsivity, because any risk for suicide or violence has
implications for where the patient should be assessed and
treated - the time of onset or exacerbation of symptoms and the
context and possible precipitating factors - substance use and abuse in relation to the onset and
persistence of psychotic and associated symptoms - the current living situation, including housing, finances,
social supports, ADLs, social activity, school, and work - a mental status examination, including office or bedside
assessment of cognitive function, based on data from all
sources of information, in which positive and negative
findings should be documented, since they may change
over time - a physical examination, including neurologic
examination, and laboratory tests, including screening
toxicology - a general medical history and review of symptoms
Which chromosomal abnormality is assoc with schizo?`
Chromosome 22q11 deletion
Why should brain CT or MRI be done in schizo pts?
Patients with schizophrenia have an increased prevalence
of structural brain abnormalities.
Differences between Schizoid personality disorder, Schizotypal personality disorder, and Schizophrenia
Schizoid personality disorder
Thought form: Organized
Thought content: No psychosis
Relationships: Solitary, NO desire for social relationships
Schizotypal personality disorder
Thought form: Organized, but vague and circumstantial
Thought content: No psychosis, may have ideas of
reference, paranoid ideation, odd beliefs and magical thinking
Relationships: Lacks close relationships, INTERESTED in
relationships but socialy inept
Schizophrenia
Thought form: Disorganized, tangiental, loosening of associatations
Thought content: Psychosis, hallucinations
Relationships: Socially marginalized, but not by choice
Antidepressants with less/no sexual side FX
Mirtazapine, bupropion
Neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) is a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. NMS typically consists of muscle rigidity, fever, autonomic instability, and cognitive changes such as delirium, and is associated with elevated plasma creatine phosphokinase.
The incidence of neuroleptic malignant syndrome has decreased since it was first described, due to changes in prescribing habits, but NMS is still a potential danger to patients being treated with antipsychotic medication.
Because of the unpredictability of NMS, treatment may vary substantially. NMS is a medical emergency, and can lead to death if untreated. The first step is to stop the antipsychotic medication and treat the hyperthermia aggressively, such as with cooling blankets or ice packs to the axillae and groin. Supportive care in an intensive care unit capable of circulatory and ventilatory support is crucial. The best pharmacological treatment is still unclear.
