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54 Cards in this Set

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What are the positive symptoms in schizophrenia?
delusions (fixed false beliefs held with tenacity and not understandable in terms of the sociocultrual context)
hallucinatinos (false perceptions which can occur in any sensory modality, but with auditory hallucinations being most common)
What are the negative symptoms in schizophrenia?
restricted or blunted affect (decreased range of facial expression), paucity of thought content, apathetic social withdrawal
What are the disorganisation symptoms in schizophrenia?
formal thought disorder (disorganised thoughts, manifested by disjointed speech); disorganised behaviour, inappropriate affect (e.g. smiling when discussing a sad event)
What is the aetiology of schizophrenia?
Multifactorial, with genetic and environmental factors interacting.
What is the likely prognosis of schizophrenia?
There is a variable longitudinal course with about 40% having significant long-term disability.
Do all patients present with the same signs and symptoms?
Not all signs and symptoms occur in any one individual at any one time. Different patients show different features and these might change over the course of the illness.
Organic psychoses is a differential diagnosis for schizophrenia. What is it?
Schizophrenia can't be diagnosed if there are clear organic factors causing the symptoms and signs.
Reversible organic causes include brain tumour.
Drug-induced psychosis
How is drug induced psychosis defined?
A clear temporal sequence between drug exposure and onset of symptoms.
A resolution of symptoms on cessation of the drug.
A relatively short duration of symptoms (under one month).
Different to drug-precipitated relapses in people with established schizophrenia. E.g. in drugs such as cannabis.
Schizoaffective disorder is a differential diagnosis for schizophrenia. What is it?
If there are clear affective and psychotic symptoms which occur at different times over the course of the illness, a label of schizoaffective disorder is applied. Vague boundaries.
Delusional disorder is a differential diagnosis for schizophrenia. What is it?
Well-circumscribed delusions in the absence of prominent hallucinations or negative or disorganisation symptoms. Delusional content is understandable, e.g. beliefs about having a disease or having an unfaithful partner.
Pervasive developmental disorders are differential diagnoses for schizophrenia. What are they?
Autism, Asperger's syndrome, etc.
Abnormalities in social interactions and a restricted and stereotyped range of interests and activities, evident from before 3 years of age.
Which comorbidity is common with schizophrenia?
Depression. This needs to be recognised and treated or else it can lead to an extra-burden for the individual.
How can one distinguish depressino from negative symptoms in schizophrenia?
Features that suggest a depressive disorder include: vegetative symptoms (e.g. anorexia, insomnia), functional shift symptoms (e.g. mood worse in morning, early morning wakening), guilty feelings, suicidality.
Compare this with the negative symptoms of schizophrenia: restricted or blunted affect, paucity of thought content, apathetic social withdrawal.
Which anxiety disorders can be a comorbidty in depression?
Panic disorder, generalised anxiety disorder, agoraphobia, social phobia, OCD. OCD is particularly associated with the use of atypical antipsychotics, especially clozapine.
Does post-traumatic stress disorder occur in excess in people with schizophrenia? Yes or no?
Yes. This relates in part to increased rates of child sexual abuse and early disadvantage, the symptoms of psychosis themselves, the trauma associated with the treatment process (e.g. seclusion).
How common is substance abuse in schizophrenia?
40 - 60% of patients with schizophrenia also abuse substances, most commonly alchol and cannabis.
what is the impact of problematic substance use on outcomes in schizophrenia?
1) Mental health: increased psychotic symptoms, greater relapse rates, more hospitalisatios and ED presentations, increased suicidality rate
2) increased violence and crime rate
3) poorer overall physical health
4) financial problems
5) homelessness, increased family conflict
Which cardiovascular risk factors are elevated in schizophrenia?
Obesity, smoking, diabetes, hypertension, hyperlipidaemia. This is due to sedentary lifestyles, poor diet and antispychotic medications (clozapine, olanzapine).
Which cancer mortality rates are higher in people with schizophrenia?
Breast and GIT cancers.
What is the incidence rate of schizophreia?
Between 7 and 14 new cases per 100,000 per year.
What is the risk at birth of developing schizophrenia during one's lifetime?
0.5 - 1.0% risk.
Are males and females equally prone to schizophrenia?
Yes, over a whole lifespan. Males have an earlier onset overall (teens), compared to females (early 20s, then peaks of onset in 40s and 60-70s).
What is the long-term course of schizophrenia?
~ 25% single episode the resolves.
~ 33% episodic course but good intermorbid functioning.
~ 40% poor outcomes
What non-modifiable factors are associated with a poor outcome in schizophrenia?
Factors include:
- male gender
- early onset of illness
- strong family loading for schizophrenia
- insidious onset of illness
- long prodrome
- poor premorbid functioning
- lack of affective symptoms at onset
- prominent negative symptoms at onset
- lack of obvious precipitating symptoms at onset
- neurological soft signs
- significant neurocognitive deficits at onset
- structural brain abnormalities
What modifiable factors are associated with a poor outcome in schizophrenia?
- long duration of untreated psychosis
- suboptimal treatment of psychotic symptoms
- suboptimal treatment of comorbid symptoms
- poor medication adherence
- medication side-effects
- substance abuse
- high family expressed emotion (negative emotion)
Is schizophrenia genetic?
Genetic causality is well established in schizophrenia. There is an increased risk in biological relatives of people with schizophrenia. 10% in siblings, 50% in monozygotic twins, 15% if one parent is affected, 50% if both parents affected.
There is no single schizophrenia gene but there are multiple gens of small effect.
What are the putative 'environmental' causal factors in schizophrenia?
- exposure to type A influenza in second trimester of pregnancy
- maternal starvation during first trimester of pregnancy
- pregnancy and birth complications
- maternal stress during pregnancy
- ubran birth and upbringing
- migration
- ethnic minorities
- substance abuse
- advancing paternal age
None of these factors independently cause schizophrenia and they have only a modest effect on risk.
Are there structural brain abnormalities in people with schizophrenia?
General abnormalities include:
- enlarged lateral ventricle
- enlarged third ventricle
- reduced overall grey matter volume
- widespread cortical and cerebellar atrophy
Site-specific abnormalities include:
- frontal lobe: volume reduction, especially inferior prefrontal cortex
- temporal lobe: volume reduction in amygdala, hippocampus and parahippocampal gyrus, more marked on the left side
There is a great degree of overlap with normals and no signal finding is pathognomonic.
What is the neurodevelopmental model for schizophrenia?
The neurodevelopmental model posits that schizophrenia has its roots in aberrant development of the brain, but positive symptoms only manifest in late teens and early adulthood when the brain develops the capacity to produce such symptoms.
Individuals with schizophrenia are more likely than normal to have physical abonormalities that represent neurodevelopmental devience and are at greater risk of delayed milestones. These abnormalities include high-arched palate, widely spaced eyes, low set ears and unusual finger prints.
What is the dopaminergic hypothesis of schizophrenia?
Dopaminergic agonists can cause positive psychotic symptoms, and drugs that ameliorate these symptoms block dopamine D2 receptors in mesolimbic tracts. However, other NTs are likely implicated.
What is the serotonergic hypothesis of schizophrenia?
Serotonergic mechanisms have also been of interest in schizophrenia because of the serotonergic LSD is a hallucinogen, but also because the atypical antipsychotic agents block serotonin 5HT-2 receptors.
What is the glutamatergic hypothesis of schizophrenia?
Phencyclidine (PCP), and antagonist of the NMDA subtype of the glutamatergic receptor, can produce a clinical picture that looks much like schizophrenia. Also a glutamatergic 2/3 agonist has antipsychotic properties - potential new treatment.
What are the benefits of anyipsychotic medications? What do they do?
rlieve psychotic symptoms of any cause, to some degree.
Reduce the intensity of sensory information and perceptions, gradually improve reality processing, facilitate more appropriate responses to internal and external environment.
What is the mode of action of antipsychotics?
All increase production of nerve growth factors in the brain and may have other useful effects upon neuronal and glial function.
Modulating effects upon dopamine activity in the brain.
In certain types, serotonergic effects postively affect negative features and cognitive function.
What are the adverse effects of antipsychotics?
Antipsychotics can provoke extrapyramidal side effects.
What is the mechanism behind EPS?
Inhibition of dopamine-1 receptors in the substantia nigra and basal ganglia provokes an imbalance of dopaminergic and cholinergic activity. This can produce clinical signs and symptoms usually associated with basal ganglia diseases such as Parkinson's disease.
What are the acute forms of EPS?
tremor (worse at rest)
dystonias (involuntary sustained muscular contractions, inc. laryngeal and occular)
Parkinsonism: mask-lik faical expression, muscle rigidity with tremmor, shuffling gait, retropulstion, reduced spontaneous arm swing
akathisia: subjective uncomfortable restlessness not relieved by movement, patient tries to walk as much as possible
What are the tardive forms of EPS?
Tardive EPS effects are delayed in onset and may take months or years to form. These include:
tardive dyskinesia: chewing movements, lip-smacking, grimacing
tardive dystonia
tardive akathisia
How is acute EPS managed?
Reduce dose of medication if possible.
Anticholinergics such as benzotropin 1 - 2mg (orally/IM) or benzhexol 2 - 5mg orally.
Beta-blockers (propanolol) and benzodiazepines (diazepam) for akathisia.
How is tardive EPS managed?
Benzodiazepines may give some relief.
Change to atypical medication, esp. clozapine.
May resolve spontaneously.
What are second generation antipsychotics also called?
Atypical antipsychotics.
What are the metabolic side-effects of some antipsychotics?
Weight gain.
Hyperlipidaemia (esp. TG)
Diabetes Mellitus II
Metabolic syndrome (weight gain, DMII, HTN, hypercholesterolaemia). These side effects are most prominent with atypicals.
What are the cardiovascular side-effects of antipsychotics?
Postural hypotension (esp. first generation, e.g. chlorpromazine).
Cardiac dysrhythmias, e.g. prolonged QT interval (haloperidol, quetiapine, ziprasidone, sertindole). A QTc interval of < 500 ms is considered reasonable, but for safety < 450 ms is preferable.
What is NMS?
Neurolepic Malignant Syndrome is a very serious, but rare, neurological reaction to antipsychotic medications.
What are the features of NMS?
It is characterised by severe hypertonia, high fever, autonomic instability and delirium. It is idiosyncratic and unpredictable. It develops over hours to days with lead-pipe rigidity an early sign.
Myolysis and myoglobinuria.
Creatine phosphokinase levels rise sharply and can be very high, liver transaminases and neutrophil counts may also rise.
What are the first generation antipsychotics?
chlorpromazine, fluphenazine, pericyazine, trifluoperazine
zuclopenthixol, flupenthixol,
What are the second generation antipsychotics?
clozapine, olanzapine, quetiapine
paliperidone, risperidone
- amisulpride
- aripiprazole
- sertindole
- ziprasidone
Which antipsychotics are avaialble as rapidly disintegrating oral meds?
olanzapine (wafer)
risperidone (tablet)
What antipsychotics are available as depot?
flupenhazine, flupenthixol, zuclopenthixol, haloperidol.
What can sometimes happen when someone taking chlorpromazine is exposed to sunlight?
This can provoke erythema and painful photosensitivity.
Which antipsychotic can cause liver dysfunction?
Any atypical, but especially clozapine.
Which antipsychotic causes the most weight gain?
What should be done if the patient doesn't respond fully to the first prescribed antipsychotic?
Trial another agent from a different class. If that also fails, use clozapine.
What psychological treatments may work in schizophrenia?
Cognitive behvaioural therapy can help patients with delusions and hallucinations that don't respond to medical treatment.