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Year 4 Mental Health CBL 1

Schizophrenia

Session learning outcomes

• To be aware of the epidemiology and aetiology of schizophrenia

• To describe the diagnostic classification, clinical features and different types of schizophrenia

• To describe the differential diagnoses of schizophrenia and other causes of psychosis

• To understand the different treatment options (pharmacological and non- pharmacological) and any associated side effects and monitoring

• To be aware of the outcome and prognosis of schizophrenia (including the impact on the patient and their family)

Case 1

A 45 year old man lives in a sheltered accommodation. He hears the voice of ‘the Creator’ and Britney Spears talking to him on a daily basis telling him ‘why are you just sitting, benefit the world, go get up and do that’. He believes he has special powers of dancing given by the Creator by which he can benefit the world. In his experience the Creator is ‘some entity very different from God, and he believes in the Creator with absolute certainty. While talking about the voices he suddenly shifts to talking about what he calls ‘Quantum mechanics’ which is about ‘being modest and ethical’. He uses 1 gram of amphetamines (as powder) three to four times a week as

‘recreational’ use and believes that it enhances his connection with Britney Spears and the Creator. He does not believe that he has any mental disorder or need for treatment. He receives treatment with zuclopentixol decanoate depot injection under a Community Treatment Order.

Questions:

1) What is the most likely diagnosis? Why? Identify all the psychopathology in the case.

Differential diagnosis would be:

- relapse of schizophrenia

- manic relapse of bipolar affective disorder with psychotic symptoms

- amphetamine-induced psychotic episode

- psychotic episode due to acute intoxication with amphetamines

- organic psychotic episode (e.g. due to a UTI or acute amphetamine

withdrawal)

This gentleman displays evidence of psychotic symptoms on a background of regular use of amphetamines. However, there is also possibly an affective (mood) component to his presentation.

This gentleman displays the following psychopathology:

- Second person auditory hallucinations

- Grandiose delusional beliefs

- Formal thought disorder (Knight’s move thinking)

- Lack of insight

2) How do amphetamines influence the neurotransmitters system?

Amphetamines are a psychostimulant (a CNS stimulant). They increase the concentrations of dopamine, serotonin and noradrenaline in the brain.

3) What is the mechanism of action of Zuclopentixol?

Zuclopenthixol decanoate (Clopixol) is a typical antipsychotic depot. It is a D1 and D2

receptor antagonist, α1-adrenergic and 5-HT2 antagonist.

4) What is a Community Treatment Order?

A Community Treatment Order (CTO) is a piece of mental health law legislation that allows a patient with a mental disorder(s) to be closely monitored in the community. It is used for those patients with a mental disorder(s) who are historically poorly engaging with community mental health services, and / or non-concordant with their prescribed psychotropic medication in the community, and / or who have a chronic poor level of insight into their diagnosis and into the need for ongoing treatment of their mental disorder(s).

Under a CTO, a patient will have certain conditions attached - typically, that he / she must agree to take his / her prescribed psychotropic medication in the community; he

/ she must agree to engage regularly with his / her Care Co-ordinator in the community and that he / she must make him- / herself available for medical review by his / her community Responsible Clinician (RC) as, and when, required. If the patient fails to adhere to any of the conditions and his / her mental state deteriorates, he / she may be recalled to hospital for a period of up to 72 hours. Following recall, the patient may have his / her CTO revoked and the Section 3 re-activated, or be discharged from hospital, or agree to remain in hospital on a voluntary basis. A Section 5(2) cannot be used for any patient who is on a CTO.

Case 2

A 35 year old woman believes that she can hear ‘telepathic messages’ put in her head from a radio presenter in Blackpool by which she ‘knows that they should have a relationship’. She leaves a plaque of cardboard with her name and address on it and leaves it at the reception of his workplace. An advert on TV confirms her beliefs because it referred directly to her situation. She feels very depressed and sometimes has thoughts of ending her life because she can’t have this relationship. She also believes that her previous medication (risperidone) had ‘rotted her brain’. She now receives treatment with oral olanzapine and is worried about weight gain. She usually spends time watching TV, likes to have curry and pizza from the nearest takeaway and also acknowledges later that she has 4-6 cans of beer every other day. She brings a letter to the clinic which states the following:

‘Hi doctor. Good man. Not good. I am a genius. Injection makes me kind of soft. I have no personality...ha ha....like a squirrel. I am not allowed to make mistakes in life’.

Questions:

1) Identify all the psychopathology in the case.

This woman displays evidence of erotomanic delusions (i.e. delusion of love) and formal thought disorder. There is evidence of delusions of reference from the T.V. She also presents with auditory hallucinations and possible thought insertion. There is evidence of a paranoid persecutory delusional belief about her previously

prescribed Risperidone. She is very low in mood. There are suicidal thoughts caused by her perception that she cannot have a relationship with the radio presenter from Blackpool.

2) When is clozapine treatment indicated according to NICE guidelines on

Schizophrenia?

Clozapine is indicated and licensed for use in treatment-resistant schizophrenia, i.e. schizophrenia that has failed to be optimally treated following an adequate trial of at least two antipsychotics, at least one of which much be an atypical (or second generation) antipsychotic (Olanzapine, Risperidone, Quetiapine, Amisulpride or Aripiprazole).

3) Discuss metabolic side effects associated with antipsychotics. What are the investigations for monitoring them?

The metabolic side effects associated with antipsychotics are: truncal obesity (increased waist circumference); impaired glucose tolerance (leading to the development of type II diabetes mellitus); dyslipidaemia and essential hypertension.

Essential hypertension is monitored by measuring and recording the blood pressure (B.P). If the B.P remains persistently elevated, the patient should be commenced on an anti-hypertensive (if the patient is < 55 and / or Caucasian, consider an ACE inhibitor; if the patient is > 55 and / or black, consider a calcium channel blocker). Dyslipidaemia is monitored by measuring the serum total cholesterol level and lipid profile and then calculating the patient’s QRISK3 score. If the QRISK3 score is >

10%, initiation of a statin is indicated (typically Atorvastatin 20 mg nocte). Impaired glucose tolerance monitoring is achieved through measuring the patient’s HbA1c level (not fasting plasma glucose level). The HbA1c level will provide an indication of the patient’s level of glycaemic control over the preceding three months. If the HbA1c level is between 41 and 48 mmol/mol, this indicates “pre-diabetes” range. If the HbA1c level is > 48 mmol/mol, this indicates type II diabetes mellitus and initiation of Metformin should be indicated. Truncal obesity is monitored by measuring the patient’s waist circumference. The patient’s body mass index (BMI) may also be measured.

4) What advice would you give her with regards to the weight gain?

This patient should be provided with lifestyle advice on the importance of adhering to a healthy diet and of engaging in regular strenuous physical exercise. She should be advised to reduce her alcohol intake, particularly as beer is rich in calories. She should be encouraged to limit her takeaways as these are very fatty. She could be referred to a community dietician if this option is available. The patient should be encouraged to join a local gym and may be entitled to a free gym pass because of her having a severe and enduring mental illness. This patient should be advised that weight gain is a significant risk factor for heart disease, stroke, type II diabetes mellitus, cancer and joint problems.

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