Week 8 - Schizophrenia & Prelude to Substance Use Disorders

What is psychosis?

Primarily associated with delusions, hallucinations and disordered thinking

Management for Psychosis

- Inpatient hospitalization for patients at risk of self-harm or harm to others

- Additional hospitalizations may be required for people with the inability to secure basic needs or protect oneself form harm

What is a 5150?

An 72 hour involuntary psychiatric hold at an inpatient hospital

What is a 5250?

after a person is detained for 72 hours, he/she may be certified for up to 14-day extension of the hold

What is DTS?

danger to self

What is DTO?

danger to others

What is GD?

Gravely disabled - person must be unable to provide their own food, clothing or shelter due to a mental health issue

Wha is Schizophrenia?

A psychiatric disorder associated with difficulty thinking, related to other people, and regulating emotions

Who is affected more by schizophrenia?

Men 18-25 y.o.

What neurotransmitter is schizophrenia related to?

Dopamine

What is the cause of schizophrenia in adolescence?

Cannabis and Stimulant Use

What is the cause of schizophrenia in prenatals?

Paternal age >50 yrs at birth

When are individuals with schizophrenia more likely to be born?

Late winter and spring

What are the clinical manifestations of schizophrenia?

- Insidious Onset

- Prodrome on negative symptoms (social withdrawal, change in affect, cognitive impairment)

- Hallucinations (M/C auditory)

- disorganized thinking

- Blunted/flat affect

DSM-V criteria for dx'ing Schizophrenia?

- Active psychotic symptoms present for past month

- 6 months for total duration of illness

Mangement for Schizophrenia

- Hospitalization

- Antipsychotic drugs (2nd gen preferred)

- Physical restraints are ALWAYS last resort

What are side effects of first gen antipsychotic drugs?

- Produce more extrapyramidal symptoms (EPS) and tardive dyskinesia

What are the side effects of second gen antipsychotic drugs?

Metabolic side effects

What drugs are in 1st gen antipsychotic class?

- Haloperidol

- Chlorpromazine

- Thorazine

What drugs are in the 2nd gen antipsychotic class?

- Risperidone

- Olanzapine

- Quetiapine

- Ziprasidone

What are EPS symptoms?

Parkinson like features (tremors, unstable gait, bradykinesia, etc.)

What is Akathisia?

motor restlessness

What is tardive dyskinesia?

Choreform movements of the tongue, facial grimacing, lateral jaw movement, sucking or smacking of lips

What is Metabolic Syndrome?

Weight gain, insulin resistance, dyslipidemia

Why are second gen antipsychotics preferred over first gen?

Due to side effect profile

How long should schizophrenic pharm interventions be tried before switching to a new agent?

4-6 weeks

When is it appropriate to switch to Clozapine for treatment of a schizophrenic pt?

If two adequate trials are not successful, then switch to clozapine

What is the box warning for Clozapine? What must be monitored?

- Box warning for agranulocytosis

- Regular CBC monitoring

What is neuroleptic malignant syndrome (NMS)?

Its a rare life threatening side effect of antipsychotic meds characterized by hypothermia, rigidity, mental status changes and autonomic instability + elevated CK levels

What is serotonin syndrome?

Any drug that affects serotonin receptors that presents with tremors, akathisia, myoclonus and GI symptoms

What is the treatment for brief psychotic disorder?

Antipsychotic drugs - usually respond quickly and completely resolve symptoms; if response is positive, tx should be continued for 1-3 months

What is schizophreniform disorder?

Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months

Tx for schizophreniform disorder?

Second Gen Antipsychotic therapy - mainstay

What is schizoaffective disorder?

- Chronic psychotic disorder with prominent mood symptoms (mania or depression)

- Psychotic symptoms from Criteria A must occur for AT LEAST 2 weeks independent of a mood episode

Management for Schizoaffective disorder?

Address both the mood and psychotic symptoms (e.g. antipsychotics)

What is delusional disorder?

Persistent, fixed delusions w/o psychotic features

Clinical Manifestations of delusional disorders

-Non-bizarre delusions that may be far-fetched (Ex. J Lo wanting to marry you)

How long does it take to dx delusional disorders?

1 month

Management for delusion disorder

Second gen antipsychotics however pts generally resist tx as they are convinced their delusions are real

Clinical Manifestations of Cannabis Intoxication

- Conjunctival injection WITHOUT pupillary change

- Euphoria

- Increased appetite (munchies)

- Panic attacks

- Paranoia

What is the time period for diagnosing a substance use disorder?

12 month

What are the clinical manifestations of cannabis use disorder

- Chronic mood changes

- Increased risk of psychosis and schizophrenia for chronic cannabis use beginning in adolescence

What are the clinical manifestations/timeline for cannabis withdrawal

Usually occurs w/i 1 week of suddenly stopping heavy prolonged cannabis use w/ most symptoms beginning 24-72 hrs after stopping

Clinical Manifestations of Tobacco-related disorder intoxication

- Elevated HR and BP

- Suppressed Appetite

- Restlessness

When does tobacco disorder withdrawal usually peak?

First 72 hrs

Management for Tobacco Cessation

- Bupropion (Zyban)

- Varenicline (Chantix)