1
Q
psychosis
A
- Acute and severe episode (of mental condition)
- Out of touch with reality (though process, beliefs, perceptions)
2
Q
schizophrenia
A
- Protracted psychosis
- Heterogenous syndrome of disorganised and bizarre thoughts, delusions, hallucinations (textile, visual, auditory, gustatory, olfactory)
3
Q
positive sx
A
- Delusions (paranoid)
- Hallucinations (exhortatory voices)
- Thought disorder – feeling that thoughts are controlled by outside agency
- Abnormal behaviors (stereotypical/ aggressive behaviors)
4
Q
negative sx
A
- Withdrawal from social contacts
- Flattening of emotional responses
5
Q
predisposing causes of schizo
A
- Genetic factors
- Susceptible genes identified in chromosomal regions:
- DISC1, neuregulin-1, dysbindin-1, catechol-O-methyl transferase (COMT)
- Not all schizophrenics share same mutations of susceptible genes
- Environmental factors
- Neurodevelopmental abnormalities
- Maternal viral infection during preg
- Obstetric complications
- Myelination of cortico-cortical pathways
- Onset in late adolescence/e arly adulthood
- Enlarged ventricles, abnormalities in laminar organization of cortical cells
- Neurodevelopmental disorder?
6
Q
struc abnormalities (observable in MRI)
A
incr ventricular size, decr brain size & cortical size, decr hippocampal vol, decr axonal, dendritic comm
7
Q
precipitating factors of schizo
A
- Cerebral tumors or injury
- Drug/ substance induced psychosis
- Alcohol
- Benzodiazepines
- Barbiturates
- Antidep
- Corticosteroids
- CNS stimulants (amphetamines)
- Hallucinogens (LSD, cannabis, volatiles)
- BB (propranolol)
- Dopamine agonist (levodopa, bromocriptine)
- Personal misfortune
- Environ of high expressed emotion
8
Q
perpetuating factors of schizo
A
- 2nd demoralisation
- Social withdrawal
- Lack of support/ poor socio-economic status/ environ
- Poor adherence with antipsychotic meds
9
Q
neurochemical theories
A
1) dopamine theory
* Amphetamine (overactive DA) produce similar sx to acute schizophrenia
* All antipsychotic drugs are D2 antagonists
2) 5HT theory (SGA inhibits)
3) glutamate theory (NMDA antagonist)
10
Q
DSM-5 criteria dx of schizo
A
- =/>2 of following. Persist > 1mnth
* +ve and -ve sx - social/ occupational dysfunction
* work / interpersonal relation/ self care (=/> 1 area below level prior to onset) - duration
* signs of d/o for ≥ 6mnths (remission, prodromal)
* 1mnth of continuous sx - scizoafective/ mood disorders excluded
- not due to medical disorder/ sub abuse
- hx of persuasive developmental disorder present, hallucinations/ delusions
11
Q
schizo sx
DHDDN
A
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganised or catatonic behaviour
- Negative sx (affective flattening, avolition)
other assoc sx
* Cognitive sx: impaired attention, working memory
* Mood sx: depression, dysphoria, hopelessness, demolarisation
12
Q
non pharm management
A
- Individual
- Supportive/ counselling
- Personal therapy
- Social skills therapies
- Vocational sheltered: employment, rehabilitation (social interactions) —– Improve pt adaptive functioning
- Grp cognitive behavioural
- Interactive. Social
- Cognitive behavioural therapy
- Conjunct with meds & fam intervention
- Esp for at risk grp
- Neurostimulation
- Electroconvulsive therapy for tx-resistant schizo
- Repetitive transcranial magnetic stimulation (rTMS) reduce auditory hallucinations
13
Q
pharmacotherapy
main class + adj
A
- suitable APS (FGA/ SGA) not clozapine
- PO, IM
- adequate trial 2-6wks, therapeutic dose range
- adjunct tx
- BZP (agitation)
- antidep
14
Q
pharm tx flowchart
A
check for: adequate resp, tolerable SE, compliance
1) FGA/ SGA
2) another FGA/ SGA
3) clozapine
4) clozapine + FGA/ SGA/ ECT
5) FGA + FGA
FGA + SGA
APS + ECT/ mood stabilisers
15
Q
pharm tx phases
A
- acute stabilisation
- minimise threat to self, others
- reduce acute sx, improve functionings
- stabilisation
- minimise/ prevent relapse
- promote med adherence
- optimise dose, ADR
- stable/ maintenance phase
- monitor for prodromal sx of relapse, ADR
- baseline functioning
16
Q
APS indications
A
- thought organisers
- neuro-leptics, tranquilise w/o impair consciousness, calm disturbed pts
- acute mania (bipolar)
- adjunct w/ antidep (quet, aripip, brexipip)
- antiemetic (palliative care)
- motor tics, tourette’s, intractable hiccup (haloperidol)
- irritability with autistic d/o (risperidone)
17
Q
APS MOA
A
1) mesolimbic tract: APS effect block D2 receptors, less overactivity (+ve sx)
relieve sx of hallucinatiions, delusions, prevent relapse
18
Q
D2 antagonism also has SE
A
- prolactin (tuberoinfundibular): more prolactin
- EPSE (nigrostriatal) : less purposeful movements
- mesocortical: worsen -ve sx
19
Q
maintenace therapy with APS
A
- long term tx after 1st ep to prevent illness from becoming chronic
* most pts require life-long maintenace therapy
* high risk of relapse if APS withdrawn inapp - relapse often delayed (wks): depot reservoir in adipose tissues
20
Q
overcome poor tx adherence
A
- IM LA inj
- comm psychiatric nurse - home visit, inject LAI
- pt and fam, caregiver education
21
Q
pharm tx considerations
A
- med selection is individualised (comor, past responses, pt needs, efficacy, SE)
- compliance to adequate trial
* 2-6 wks
22
Q
clozapine consideration
A
- tx resistant (failed =/> 2 adequate trials of diff APS – one is SGA)
- hamatological monitoring: Agranulocytosis
- tx refractory evaluation: dx, sub abuse, med adherence, psychosocial stressors
- CBT, non pharms, Psychosocial augmentation
23
Q
pop precautions to APS use
A
- CVS!!!!!!
- Parksinson’s: worsen EPSE
- Epilepsy: seizure outbreak
- Depression
- Myasthenia gravis
- Prostatic hypertrophy
- Angle-closure glaucoma
- Severe resp disease
- Hx of jaundice
- Blood dyscrasis (clozapine)
- Elderly with dementia: risk mortality, stroke
24
Q
CVS pop and APS
A
- IV halo, CPZ, zip, ilo, quet, risp
- precautions: HTN, IHD, post-MI, CHF, AF, Brugada syndrome
- QTc prolongation (CI: F >470MS, M > 440MS)
- ECG required esp if
- CVS risk actors
- Personal hx of CVD
- Admitted inpt and naïve to antipsychotics
25
Adjunct for acute agitation
* PO lorazepam 1-2mg
* Oral antipsychotics
* Haloperidol (tab, sol) 2-5mg (need ECG)
* Risperidone (tab, orodispersible) 1-2mg
* Quetiapine (tab, immediate release) 50-100mg
* Olanzapine (tab, orodispersible) 5-10mg
26
Adjunct for uncooperative agitation, remains aggresive
* fast acting IM inj (BZP or APS)
* IM lorazepam 1-2mg
* IM olanzapine (immediate release) 5-10mg [2nd dose =/> 2h
3rd dose =/> 4h]; Not given within 1h of lorazepam (CVS fatality)
* IM arip (immediate relase 9.75mg)
* IM promethazine (anti H1) 25-50mg
* can be combined too
27
adjuncts for catatonia
* very disorganised, frozen in thoughts
*BZP: PO/IM lorazepam
28
adjuncts for depressive sx/ -ve sx of chronic schizo
* antidep for dep sx
* -ve sx: mild-mod can use antiddep (SSRI)
29
therapeutic outcomes
* Monitor effectiveness
* Mental status exam
* Psychiatric rating scales (BPRS 20-40% score reduction, PANSS)
* Monitor ADR --- tx acordingly
* Metabolic parameters: BGL, BMI, BP
* EPSE: presence, severity of any tx emergent EPSE
Drug induced pseudo parkinsonism: Simpson-Angus rating sclae
Akathisia: Barnes Akathisia scale
Tardive dyskinesia: AIMS, DISCUS
* Pt self assessment (freq of mood epi/ schizo sx)
* maintain baseline functioning
30
duration
* Early improvement:
○ 1st wk: less agitation, aggression, hostility
○ 2-4wks: less paranoia, hallucinations, bizaare behaviours, improved org in thinking
* Late improvements
○ 6-12wks: less delusions, neg sx may imrpove
○ 3-6mnths: cognitive sx may improve (w/ SGA)
* adequate trial 2-6wks, therapeutic dose range
31
efficacy
* FGA, SGA: improve +ve sx (D2 antagonism)
* SGA (maybe improve -ve sx)
32
ADR trends
* FGA: more EPSE
* SGA: more metabolic
* except ari, brex, cari, lura, zip
* -ines (cloz, olan, quet): sedating, weight gain
3153 psych
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