Case 8 - Schizophrenia

Question 1

1. What are the 3 criteria for detention under the MHA?
2. What is the definition of a mental disorder? Where is it found in the act?

Answer 1

1. Individual must be suffering from a mental disorder, Disorder must warrant their detention in hospital, Person needs to be detained in the interest of their health or safety to protect others
2. Disroder or disability of the mind, not including a learning disability. Found in s1

Question 2

1. What does s1(3) say?
2. What does s2 allow for?
3. How many days can they be held?
4. How many registered medical practitioners are required?

Answer 2

1. Dependence on alcohol or drugs is not a disorder unless accompanied by mental health disorder
2. Detention for assesment, in the interests of their health and safety
3. 28 days
4. 2

Question 3

1. What does s3 allow for?
2. What are the requirements?
3. How many medical practioners are required?

Answer 3

1. admission for treatment, for their health and safety
2. They need to be detained in order to administer the treatment, and the treatment is available
3. 2

Question 4

1. What does s4 allow for?
2. Who can make the request?
3. How long can they be detained for?
4. Who can extend the time?

Answer 4

1. Admission for assesment in an emergency
2. Approved mental health professional or nearest relative of patient
3. 72 hours
4. A 2nd medical recommendation within the 72hrs

Question 5

1. What does s5 allow for?
2. Who can apply using s5(2)?
3. How long can they be held?
4. Who can apply using s5(4)?
5. How long can they be held?

Answer 5

1. Application to be made for admission for a patient already in hospital
2. Consultant
3. 72 hrs until assesment
4. Nurse
5. 6hrs until assesment

Question 6

What are the 4 factors relevant for assesing capacity?

Answer 6

• Understanding the information relevant to the decision
• Retaining that information
• Use or weigh the information as part of decision making
• Communicating their decision

Question 7

1. What happens when a patient is voluntarily admitted to a mental health facility?

Answer 7

1. Locked doors, property and personal searches.
   
   1. They are expected to remain on the ward until seen by a doctor (at least for 24hrs) and inform staff when they are leaving

Question 8

1. What is compliance?
2. How is it quantified?
3. What is deemed most important for adherence?

Answer 8

1. the extent to which a persons behaviour coincides with the medical advice they have recieved.
2. Adhering to >70% of prescribed medication during the last week
3. Insight (Whether they think they are ill and need treatment)

Question 9

1. What is the recovery model of care?
2. What is the chronic care model of care?

Answer 9

1. People should be supported in the settings of their own choosing, to enable recovery in their own way
2. Patients have a chronic condition which must be managed

Question 10

1. What is the ICD 10 definition of schizophrenia?
2. What is a positive symptom?
3. What are some examples of positive symptoms?
4. What is a negative symptom?
5. What are some examples of negative symptoms?

Answer 10

1. Mental disorder with fundamental distortions of thinking and perception
2. Abnormal thoughts/perceptions
3. Delusions, Hallucinations, disorganised speech
4. Absence of responses that are normally present
5. Alogia, Reduced emotion, Anhedonia, and memory impairment

Question 11

Define these terms:

• Delusion
• Hallucination
• Alogia
• Anhedonia
• Avolition
• Asociality

Answer 11

• Distortions of beliefs
• Distortions of perceptions, in absence of external stimulus
• Lack of speech
• Inability to experience pleasure
• Lack of motivation
• Lack of desire to be sociable

Question 12

1. What are the 4 different types of delusions?
2. What is the link between substance misuse and schizophrenia?
3. What is the effect of untreated psychosis?

Answer 12

1. Reference (Radio talking about them), Persecution (Theyre in danger), Control (physical body not under their control), and Grandiosity
2. Starting using drugs at an earlier age, and heavy usage increases the risk of Sz more - become ill younger than non users
3. The longer the duration of untreated psychosis the more severe the symptoms of Sz

Question 13

1. What is the ICD 10 requirement to diagnose a person with Sz? (2)
2. What are the 1st rank symptoms?
3. What are the 2nd rank symptoms?
4. What is the incidence of Sz in the UK?
5. What is the median onset for men and women?
6. Do males get it more than females?

Answer 13

1. 1 first rank symptom for at least 1 month OR 2 second rank symptoms in the last month
2. Auditory hallucinations, delusions of control, persistent delusions
3. Persistent hallucinations of other modalities, thought disorder, catatonic behaviour, negative symptoms
4. 10-20 per 100,000 adult population
5. 26 for males, and 29 for females
6. Females get it more 1.4 to 1

Question 14

1. How do genetics and environment play a role in Sz?
2. What is the chance of having the disorder if a identical twin has it?
3. What do the genes affect?
4. What are some of the environmental factors for Sz?
5. What are the physical changes in the brain of a person with Sz?

Answer 14

1. Genes make people more vulnerable to the environmental factors which cause Sz
2. 45%
3. Synaptic transmission, or growth of synapses, GABA DA or glutamate NT function
4. Cannabis use, abuse, urban living
5. Enlarged ventricles, reduced cortical thickness

Question 15

1. What are the 4 major projections of the DA system?
2. Where does the Nigrostriatal pathway originate?
3. What are the 2 parts of the Nigrostriatal pathway? What is each responsible for?
4. What is the function of the mesolimbic pathway?
5. What is the function of the mesocortical pathway?
6. What is the function of the tuberoinfundibular pathway?

Answer 15

1. Nigrostriatal pathway, Mesolimbic pathway, Mesocortical pathway, and Tuberoinfundibular pathway
2. Striatum (Substantia Nigra Pars Compacta)
3. Sensorimotor striatum (Involuntary motor control) & Associative (Mid) Striatum (Emotion, cognition)
4. Reward, motivation, affect and memory
5. Cognitive function, motivation and emotional response
6. Prolactin release regulation

Question 16

Identify the following pathways:

• Mesolimbic pathway
• Mesocortical pathway
• Nigrostriatal pathway
• Tuberoinfundibular pathway
• Striatum
• Ventral tegmental area
• Dorsolateral prefrontal cortex (DLPFC)
• Hypothalamus
• Pituitary gland

Answer 16

Question 17

1. Which dopamine receptors are in the D1 receptor family?
2. Which receptors are in the D2 receptor family?

Answer 17

1. D1 & D5
2. D2 & D3 & D4

Question 18

1. Where are the D1 receptors found?
2. Where are the D2 receptors found?

Answer 18

1. Motor, Associative, and ventral striatum & cerebral cortex
2. Motor, Associative and Ventral Striatum

Question 19

1. Where are the D3 receptors found?
2. Where are the D4 receptors found?
3. Where are the D5 receptors found?

Answer 19

1. Ventral, Associative striatum & Hippocampus & Amygdala
2. Frontal cortex & Medulla & Midbrain & Amygdala
3. Hippocampus & Hypothalamus

Question 20

1. What NT is abnormal in Sz?
2. Where is this NT abnormal? Which pathway?
3. What does inaqueate DA in the frontal cortex lead to?
4. What is thought to be the primary abnormality in Sz?
5. What is the overall picture in: What symptoms are they associated with?

• Mesocortical pathway
• Associative striatum
• Ventral striatum

Answer 20

1. DA
2. Associative Striatum (Nigrostriatal pathway)
3. Cognitive deficits
4. GABA or glutamate system dysfunction
5. • Decreased DA in the DLPFC — Cognitive impairment
   • Increased DA in the associative striatum — Psychosis
   • Normal to decreased DA — Negative symptoms

Question 21

1. Which receptor is dysfunctional in the DLPFC?
2. Why is there a decrease of DA in the DLPFC?
3. What does this do to DA?
4. What is the knock on effect in the midbrain?
5. Is this a positive or negative cycle?

Answer 21

1. NMDA receptor
2. Hypofunctional (Low function) glutamate NMDA receptor, leading to excessive glutamate release
3. Knocks down DA function
4. Stimulates more DA production in the striatum
5. Positive cycle

Question 22

1. What are the 4 glutamate receptors?
2. What is the glutamate hypothesis?
3. What drugs mimicked Sz and lead to this hypothesis?

Answer 22

1. NMDA, AMPA, Kainate, mGluR(1-8)
2. Decreased NMDA function leads to excessive glutamate release which causes excitotoxicity leading to disease progression
3. PCP & Ketamine

Question 23

1. What are conventional Sz drugs effects?
2. What is the threshold efficacy for these drugs?
3. Which 2 drugs have receptor occupancy sustained over 24hrs?
4. Which 2 drugs have receptor occupancy that declines more rapidly?
5. Are the drugs selective only for D2 receptors?

Answer 23

1. They are D2 receptor antagonists, reducing positive symptoms of Sz by blocking DA production
2. >65% D2 receptor occupancy
3. Risperidone & Olanzapine
4. Clozapine & Quetiapine
5. No

Question 24

1. Which other receptors are affected?
2. What happens when an M1 antagonist is used?
3. what happens when A-adrenergic antagonists are used?
4. What happens when 5-HT antagonists are used

Answer 24

1. M1 (Muscarinic), A-adrenergic anatognists, H1 antagonism, 5-HT receptors antagonism
2. Dry mouth, sore throat, tachycardia
3. Hypotension, small pupils, sedation, and delayed cardiac conduction
4. Weight gain

Question 25

1. What are the possible side effects of antipsychotics? 2. How much occupancy leads to these effects? 3. What does it cause in the tuberoinfundinbular pathway? 4. What are the manifestations of the this? 5. What is the effect on the enteric nervous system?

Answer 25

1. Extra-pyramidal effects due to reduced DA in nigrostriatal motor pathway 2. \>78% D2 receptor occupancy 3. DA acts as off signal for production of Prolactin, so the drugs lead to Hyperprolactinemia (Increased prolactin) 4. Sexual dysfunction, hypogonadism, breast pathology 5. Blockage of D2 receptors leads to constipation

Question 26

1. When is Clozapine used? 2. What is a rare side effect of this drug? 3. What is required before it is dispensed?

Answer 26

1. If 2 antipsychotics fail or cant be tolerated at full dose 2. Agranulocytosis (Bone marrow stops working) 3. Blood monitoring required, cant be dispensed without clear FBC

Question 27

1. What is risperidone? 2. What are the side effects? 3. What receptors does it work on? 4. What is the effect on from the 5H-T receptors? 5. What is the effect on the DA receptors?

Answer 27

1. Antipsychotic drug to treat Sz, Bipolar disorder, and irritability 2. Movement disorders, sleepiness, weight gain 3. 5-HT receptors (Antagonist), and D1 & D2 receptor family 4. Lowers extrapyramidal effects of the drug 5. Antagonist so blocks the DA pathways, and can induce extra-pyramidal side effects

Question 28

1. What is the aim of psychosocial treatment? 2. what is the aim of family therapy? 3. what is its efficacy?

Answer 28

1. To contain behaviour and emotion safely providing support for people 2. Therapist works with family to identify problematic behaviour and discuss ways of dealing with it 3. Similar efficacy to medication in those spending over 35h per week

Question 29

1. What is the effect of correlation on a patients prognosis? (Community v Institutionalised)

Answer 29

1. Patients who are institutionalised do worse than those who are treated in the community

Question 30

1. What is the aim of CBT? 2. What is the early intervention service?

Answer 30

1. To engage with the patient to determine different appraoches for them 2. Aim is to intervene in a non-stigmatising way