Schizophrenia - Manaia Health PHO

Report
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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
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4. Biological Management
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5. Psychological Management
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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
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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
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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
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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
+++
+
+
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
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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

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