Schizophrenia - Manaia Health PHO
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Transcript Schizophrenia - Manaia Health PHO
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Schizophrenia
Presentation for PHO
Dr Verity Humberstone
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Overview
Why prioritize schizophrenia?
Diagnosing Schizophrenia
Treatment of schizophrenia
Atypical Antipsychotic – metabolic monitoring
Clozapine
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Questions
Which is the most common diagnosis in acute and forensic hospitals?
Which is the most common diagnosis for people requiring residential
support?
Are people with schizophrenia at a greater risk of victimisation?
Are people with schizophrenia at a greater risk of perpetrating violence?
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Maori and Schizophrenia
The psychiatric report 1986 – Maori 10-12% population 67%
special patient admissions
Te Puni Kokiri - 1996 rates of admission for schizophrenia 2-3
times greater for Maori than Non Maori / Pacific. Greater first
presentations and readmissions.
Hauora: Maori standards of Health IV has identified that
between 2003 and 2005 Maori were over 3.5 times more
likely to be hospitalized for schizophrenia than non Maori.
Maori men had a hospitalization rate for schizophrenia of
416.7 per 100,000 compared with 222.4 for Maori women,
119.7 for non-Maori men and 62.3 per 100,000 for non- Maori
women
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Prevalence Schizophrenia Kake et al
Maori Men
1.27%
Maori Women
0.7%
Non Maori men
0.41%
Non Maori Women
0.24%
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Diagnosing schizophrenia
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Bleuler
“Contrary to the general opinion, the concept of
schizophrenia is as precise as is possible for any fact found in
nature. There is no room for it to be confused with any other
mental disorder”
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Review of Clinical features Prodrome
Sleep
disturbance
Depressed
Social
Drop
withdrawal
off in function e.g. work / study
Irritable
Odd
mood
/ Oversensitive
beliefs / Odd Behavior
Suicidal
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Positive Symptoms of Schizophrenia
Delusions
Hallucinations
Formal Thought Disorder
Bizarre Behavior
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Delusions
Bizarre
Grandiose
delusions
Non
Delusions
of control
Bizarre
Delusions
of reference
Religious
delusions
Delusions
of mind reading
Nihilistic
delusions
Jealous
delusions
Persecutory
delusions
Somatic
delusions
Erotomanic
delusions
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Negative Symptoms of Schizophrenia
Attention
Alogia
Avolition - Apathy
Anhedonia
Asociality
Affective Disturbance
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Cognitive Symptoms of Schizophrenia
Verbal memory and learning
Executive function
Attention
Spatial memory
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Classification
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Types of schizophrenia
Delusional disorder
Paranoid schizophrenia
Undifferentiated schizophrenia
Disorganized schizophrenia
Catatonic schizophrenia
Schizotypal personality
Schizoaffective disorder (controversial)
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Clarify Diagnosis
If
people have delusions, thought disorder
and hallucinations with a euthymic or
normal mood the diagnosis is schizophrenia
rather than a mood disorder
Look
Look
at longitudinal history
for medical conditions / drug and
alcohol
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Diagnostic Confusion
Where
schizophrenia is diagnosed as bipolar
affective disorder
Where
schizophrenia is diagnosed as a
personality disorder
Where
schizophrenia is diagnosed as a
substance induced psychosis
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Schizophrenia diagnosed as Bipolar
Affective Disorder
Grandiose
delusions, sleep disturbance
and elevated mood are often attributed to a
manic episode from cross sectional rather
than longitudinal analysis
Key
distinguishing factor is in
schizophrenia the arousal and mood
disturbance resolve more quickly than
hallucinations, delusions or thought
disorder
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Schizophrenia diagnosed as Bipolar
Affective Disorder
Key
features relate to affect and function
Analysing
cases all have combinations of
mood stabilisers and antipsychotics
inevitably stabilised on clozapine –
controversial usefulness of mood stabilisers
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Mood changes
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Schizophrenia treated as depression
Mood changes are very common in schizophrenia and
particularly a dysphoric, tormented, anxious mood with
sleep disturbance
If there are hallucinations and delusions or any other
psychotic symptom treat with antipsychotic medication
SSRIs will be useless
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Schizophrenia Diagnosed as Substance
induced psychosis
Significant
substance abuse is common – ending
up with recurrent psychotic mental health
admissions is very uncommon
Psychosis
with substances does not explain
disturbances in affect, persistent disorganisation or
cognitive dysfunction
Controversy
regarding severe prolonged
amphetamine use and paranoid schizophrenia
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Marijuana
Heavy marijuana use prior to age 18 years in prospective
studies increases risk of developing schizophrenia by 6-7
times.
NZ Dunedin study 10.3% those using marijuana at age 15
years had schizophrenia by 26 years cf 3% controls
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Schizophrenia diagnosed as personality
disorder
A totally normal social history is not compatible with the diagnosis of
personality disorder
Schizophrenia typically has a pattern of a deteriorating social history
although this can be complex with early onset schizophrenia
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Schizophrenia diagnosed as Borderline
Disorder
Distracted
by extreme behaviours that evoke
powerful emotions within staff
Often
an underlying hostility and wish to reject
the patient
Behavioural
disturbances are a direct
manifestation of the psychotic process often the
underlying exploration of the causes of behaviour
are inadequate and the patient’s explanation is
accepted at face value
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Schizophrenia diagnosed as Borderline
Disorder
Often
recurrent self harm is equated with
borderline disorder when it can be part of a
psychotic manifestation either directly in
response to undisclosed schizophrenia or as
a coping strategy in people with a limited
degree of psychological maturity or
propensity to externalising behaviours
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Schizophrenia diagnosed as Antisocial
Personality Disorder
Schizophrenia
can present through contact with
the criminal justice system
Behavioural
disturbance in the forms of violence
or law breaking can be directly attributable to
psychotic symptoms or a secondary manifestation
e.g. paranoia and disorganisation leading to
homelessness and trespass / burglary
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Schizophrenia diagnosed as Antisocial
Personality Disorder
Two important patterns to distinguish
1.
Absence of conduct disorder and sudden
change to criminality and convictions
later in life
2.
Premorbid conduct disorder then change
in escalating pattern of offending or
nature of offending
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Schizophrenia diagnosed as Antisocial
Personality Disorder
Key
feature is a careful analysis of causes of
offending or violent behaviour
Does
What
What
it make sense?
are the motivations?
are the observations of staff within
the criminal justice system?
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Interviewing Issues
Look
and Observe
Understand
the different language that
people have for perceptual experiences –
look for dimensionality and affective
investment
“Do
you hear voices inside / outside head”
– limiting and simplistic
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Interviewing Issues
For
guarded patient use other strategies e.g.
proverb analysis with cognitive assessment
“People
Assess
Be
in glass houses should not throw stones”
negative and cognitive features
aware of the tendency to normalise psychosis
like completion illusions
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Being guarded
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Functional Issues
Developmental
Housing
arrest
history
Employment
pattern – however factor in
socioeconomic deprivation
Relationships
Change
– shrinking network
in habitual behaviour
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Functional impact
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Family Interview
Changes
Times
Did
in sleep, motivation, self care
that they did not make sense
you ever hear them talk to themselves
and what did they say about it
Anger
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Management
1. Engagement
2. Safety
3. Clarify the Diagnosis
4. Biological Management
5. Psychological Management
6. Social and Family
7. Rehabilitation
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Safety
Assess
risk of killing or harming themselves
Assess
risk of killing or harming others
Assess
sexual risk towards others or of being
exploited / abused / pregnant
Assess
risk from coexistent medical condition
Assess
risk of homelessness
Assess
risk of financially exploited
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Safety
Assess
risk of very poor self care e.g. ability to
obtain food, manage money
Assess
risk from comorbid substance abuse
Assess
risk of treatment disengagement
Assess
risk from certain symptoms: Command
Hallucinations, Delusions of control, Jealous
delusions, Persecutory delusions
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Question
Which
features of the mental
state are important when assessing
risk?
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Biological Management
Atypical Antipsychotics vs typical
First line treatment can include risperidone, aripiprazole,
amisulpride, ziprasidone, quetiapine, olanzapine
Olanzapine has a higher risk of weight gain and metabolic
syndrome than the other first line agents and should be only
used after prior treatment intolerance and with caution
Clozapine only effective treatment for treatment resistant
schizophrenia
Depot antipsychotics require- three months to steady state
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Antipsychotic prescribing
Antipsychotic
Dose range
Risperidone
2-6mg
Aripiprazole
10-30mg
Olanzapine
10-30mg
Quetiapine
300mg – 900mg
Ziprasidone
Amisulpride
40mg bd – 80mg bd
200mg – 800mg
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Risperidone
Risperidone – generally first line, can have akathisea, EPSE,
or high prolactin.
Available in depot form two weekly (paliperidone monthly)
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Aripiprazole
No weight gain
Can be activating, can have akathisea
1.5 : 1 potency to olanzapine
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Olanzapine
Risks weight gain
Metabolic syndrome
Recent depot preparation – post injection syndrome
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Quetiapine
Frequently used low dose range off label conditions
Doses required for antipsychotic effect may be too sedating
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Ziprasidone
Needs to be taken twice daily
Needs to be taken with food
Low metabolic effects
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Amisulpride
Low does beneficial effects negative symptoms
Higher doses sedating, EPSE
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Clozapine
Clozapine
has revolutionized the
treatment of schizophrenia and
is simply more effective than
other antipsychotic medication
for persistent and severe
psychotic illness.
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Clozapine
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Treatment resistant schizophrenia
Two
different antipsychotic agents taken at
right doses for sufficient time still not
associated with improvement in positive
psychotic symptoms
Repeated
admissions, suicide attempts,
assaults, homelessness, imprisonment,
severe coexisting substance abuse
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Clozapine outcomes
33%
significant improvement in six
week, 70% one year
Reduction
in hospitalization, suicide,
imprisonment, increased housing
stability, drug use
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Clozapine side effects
Constipation
Hypersalivation
Reflux
Sedation
Weight gain / metabolic effects
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Clozapine – Serious but rare
Neutropenia – agranulocytosis – requires weekly FBC for first
18 weeks and after every 28 days
Myocarditis
Cardiomyopathy
Lowering seizure threshold – myoclonic jerks
Toxic megacolon
Death with high alcohol consumption
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Clozapine initiation
Gradual dose titration – cross tapering
Fortnightly BP Temp Pulse
Wide dose range
Levels useful for adherence but not for therapeutic window
Clozapine re titration after missing three days
Clozapine and alcohol
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Common side effects of atypical
antipsychotic medication
Insulin resistance
Weight gain
Dyslipidemia
Elevation in prolactin
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Differing risk profiles
Medication Weight
gain
Diabetes
risk
Poor Lipid
profile
Elevated
prolactin
Olanzapine
++++
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0
(temporary)
Clozapine
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+
0
Risperidone ++
D
D
++
Quetiapine
D
D
0
0/+
0
++
Aripiprazole 0/+
0/+
/
ZiprasidoneD = discrepant results
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Insulin resistance
Antipsychotic medication causes changes in glucose
homeostasis
Other risk factors
Aging
Family history of diabetes
Ethnicity – Maori
Cigarette smoking
Physical inactivity
Diagnosis of schizophrenia itself
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Weight Gain with antipsychotic
medication
Combination of
Decreased physical activity – sedation, negative symptoms,
poverty, demoralization
Alteration of the hunger / satiety centers mediated by hormone
leptin
Blocking of certain receptors
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Dyslipidemia
Generally consistent with gain in weight
Other risks family history
Diet
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Prolactin levels
Antipsychotics especially risperidone and first generation
antipsychotics (e.g. haloperidol, clopixol) can be associated
with increased prolactin
Dopamine inhibits prolactin increase so antipsychotics
blocking dopamine lead to increase prolactin
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Side effects of increased prolactin
In Females
Galactorrhoea
Irregular or no menstruation
Infertility
Sexual dysfunction
In Males
Galactorrhoea
Gynaecomastia
Impotence, reduced libido, erectile dysfunction
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Side effects of increased prolactin
In both men and women long term increase in prolactin leads
to risk of osteoporosis from effects on sex steroid production
Be aware of other causes of increased prolactin such as a
brain tumor
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Monitoring Program
Now core practice in all DHBs in New Zealand with National
guidelines
Role of all mental health workers to be aware and participate
All doctors and key workers are expected to be able to
record height, weight, waist circumference where
appropriate and calculate a BMI
If antipsychotics are changed the monitoring program should
start again
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Baseline Monitoring
At start of antipsychotic prescribing – or as close as possible
Document personal and family history of dyslipidemia,
hypertension, smoking, heart disease, history of syncope or QT
abnormalities
Sudden death in relative under 40 years
Galactorrhoea, menstrual problems, sexual dysfunction,
Gynaecomastia
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Baseline monitoring
Height and weight to calculate BMI
HbA1C
Fasting lipids
Full bloods count
Electrolyte and creatinine
Liver function
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Monthly for first three months
Weight calculate BMI
Waist circumference
BP
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Three months after starting
antipsychotic medication
Repeat blood tests
HbA1C
Fasting lipids
Liver function tests
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Annually
Height and weight to calculate BMI
HbA1C
Fasting lipids
Full bloods count
Electrolyte and creatinine
Liver function
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ECGs
It is good practice to have an ECG before prescribing any
antipsychotic
This is indicated for
Known heart disease
History of syncope
Family history of sudden death under 40 years
Congenital long QT
Co administration of any QT prolonging medication
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ECG
For patients on polypharmacy of antipsychotic medication or
high doses of antipsychotic medication an ECG should be
performed 6 monthly
Clozapine clients require a yearly ECG
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Information for consumers
Prior to starting antipsychotic medication (or when over
acute phase) discuss with consumer and family the possible
side effects and need for awareness of diet and exercise
Written information and assistance with practical support
such as Green prescription , local lifestyle groups should be
given
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Prevention better than weight loss
It is easier to prevent weight gain than deal with needing to
loose weight.
Where possible use antipsychotic medication that has a
lower risk of weight gain – remember clozapine is the only
antipsychotic that is more effective than the others at
reducing psychosis
Most of the weight gain is in the first three months – critical
time for follow up
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Triggers for Intervention
Measure
Trigger
Interventions
BMI
Waist circumference
>25
Women >88cm
Men > 102cm
Discuss risks, explore
diet and exercise
program
Look at changing
antipsychotic
Offer smoking
cessation help
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Triggers for Intervention
Measure
Trigger
Intervention
HbA1c
>40 and less than 50
Repeat three months
HbA1C
>50 two readings
means diabetes
Consult GP
Diet and exercise
program
Consider
antipsychotic switch
Offer help with
smoking cessation
Fasting lipids
Triglycerides >2
Total cholesterol :
HDL > 4.5
Consult GP
Diet and exercise
program
Consider
antipsychotic switch
Offer help smoking
cessation
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Psychological Management
Therapeutic
Alliance and Recovery focus
Psychoeducation
Early
Warning Signs
Triggers
and Stress
Substance
Cognitive
Abuse
Behavioral therapy for persistent
symptoms of schizophrenia
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Rehabilitation
Assessment must involve an understanding of:
Impairment - symptoms
Disability - functional life domains
Handicap - social roles
Skill retrieval, Skill development, Community Integration