Schizophrenia

Question 1

What must a pt have to be diagnosed with schizophrenia?

Answer 1

DSM-V - at least two of the following

Delusions
Hallucinations
Disorganised speech
Disorganised or catatonic behaviour
Negative sx

Question 2

Which symptoms must have been present for 6 months, with a 1 month active period for a schizophrenia diagnosis to occur?

Answer 2

delusions

hallucinations

disorganised speech

Question 3

What are the positive symptoms in schizophrenia?

Answer 3

hallucinations

Delusions

impaired insight

disorganised thinking and speech

Question 4

What are the negative symptoms in schizophrenia ?

Answer 4

Lack of motivation

Poor self-care

blunted effect

reduced speech output

social withdrawal

Question 5

What neural pathway is responsible for positive sx in schizophrenia?

Answer 5

mesolimbic pathway

Question 6

What is the role of the mesocrotical pathway in schizophrenia?

Answer 6

deficiency in this pathways causes negative and cognitive symptoms

Question 7

What is the role of the tuberfundicular and nigrostriatal pathway in schizophrenia?

Answer 7

tuberfun = inhibition of prolactin release with dopamine

nigrostriatal = movement

Question 8

What is the difference between 1st gen and 2nd gen antipsychotics?

Answer 8

1st gen = inc risk of EPSE such as tardive dyskinesia
- potent D2 block, work on +ve sx mainly

2nd = reduced risk of EPSE
- greater 5HT versus D2 block, fast dissociation

Question 9

Will second gen antipsychotics cause EPSE?

Answer 9

yes - At high doses or when multiple are used together

Question 10

What are the goals behind treating acute psychosis?

Answer 10

Reduce risk of harm to self and others, verbal de-escalation

Immediate objective - sedate (benzos)
- Diazepam 5 - 10 mg - oral OR
- lorazepam 1 to 2 mg injected

Question 11

What are the first line therapies for tx of first psychosis episode?

Answer 11

Amisulpride 100mg

Aripiprazole 10 mg

Quetiapine 50 mg (immediate release) OR 150 mg (XR)

Risperidone 1 mg

Ziprasidone 40 mg

Question 12

Which first line antipsychotic therapy is ineffective in pt under 18 y/o?

Answer 12

Ziprasidone

Question 13

Which antipsychotic, due to its severe metabolic ADRs should not be used as first line therapy in first psychosis episode?

Answer 13

olanzapine (3rd line)

Question 14

What are some second line therapies for the first episode of psychosis?

Answer 14

Asenapine

brexpiprazole

Lurasidone

paliperidone

Question 15

What is a shared and potentially serious cardiac ADR of antipsychotics?

Answer 15

Prolonging QT interval

Question 16

List the four cardinal EPSEs

Answer 16

Dystonias

Akathisia

Parkinsonism

Tardive dyskinesia

Question 17

What is dystonia? What age group is effected? When is it seen with antipsychotic use?

Answer 17

Sx = spasms (carpopedal, perioral), trismus, torticollis, laryngeal spasms

Common in children & young adults

Likely in high dose, 24 - 48 hours after starting tx/inc dose

Question 18

How can dystonia be treated/imporved?

Answer 18

Anticholinergics improve sx

Question 19

What is akathisia? When is it seen with antipsychotic use?

Answer 19

Motor restlessness

Occurs 2-3 days (up to several weeks) after starting treatment

Question 20

How do you differentiate between akathisia associated with psychosis compared to medication induced?

Answer 20

Dose dec = improve akathisia, worsen agitation (?disease)

Dose inc = worsen akathisia, improve agitation (?meds)

Question 21

What is parkinsonism? When is it seen with antipsychotic use?

Answer 21

Tremor, rigidity, bradykinesia

Develops after weeks/months of tx

Question 22

Can antipsychotic associated parkinsonism be reversed?

Answer 22

Yes - short term use of anticholinergics may help

Reduce antipsychotic dose or switching agent

Question 23

What is akathisia? When is it seen with antipsychotic use?

Answer 23

1/3 of people treated for 10 yrs w/ older antipsychotics - low incidence with clozapine
- may appear after medium/long-term antipsychotic tx or when stopping

Involuntary movement of face, mouth, or tongue (can be head, neck, trunk, limbs)

Question 24

Who is at increased risk of tardive dyskinesia with antipsychotic use?

Answer 24

smokers

elderly

diabetic pt

Question 25

What is neuroleptic malignant syndrome? How is it treated/improved?

Answer 25

Rare but serious ADR - rapid drop in dopamine levels (too much antipsychotic too rapidly) Remove antipsychotics + review need for drug - slow improvement Can re-challenge drug after min 5 days w/small dose and monitoring

Question 26

What are the sx of neuroleptic malignant syndrome?

Answer 26

Hyperthermia muscle rigidity altered consciousness autonomic instability raised creatinine kinase

Question 27

Which antipsychotics are associated with metabolic ADRs (inc BG, weight, dyslipidaemia)?

Answer 27

Clozapine olanzapine quetiapine

Question 28

When is clozapine used in psychosis?

Answer 28

Psychosis unresponsive/intolerant to at least 2 antipsychotics ADRs = agranulocytosis, neutropenia, eosinophilia, myocarditis Monitor serum neutrophils and drug concentration

Question 29

How is smoking treated in schizophrenia?

Answer 29

NRT preferred tx Buprioprion and varenicline - can cause psychosis/worsen

Question 30

What are the long-acting antipsychotic depot injections?

Answer 30

Aripiprazole Flupenthixol Fluphenazine Haloperidol, olanzapine Paliperidone risperidone zuclopenthixol

Question 31

What is the time-lime of sx improvement with antipsychotics?

Answer 31

Agitation & aggression = 1-3 days Improved socialisation, self-care habits, mood = 1-2 weeks Improved thought, conversations, dec delusions, hallucinations = 3-6 weeks

Question 32

How long do positive and negative sx take to improve w/ tx?

Answer 32

+ve sx = several weeks to response -ve sx = less responsive, cause of sig long-term disability