2 - Psychosis and Schizophrenia Flashcards
What is the definition of psychosis?
‘Lost touch with reality’
Someone who is perceiving, believing or interpreting a different reality to the rest of us
What are some causes of psychosis?
- Schizophrenia (Most common, non affective)
- Affective (Bipolar and Depression)
- Drug induced (Transient)
- Head injury
- Brain tumour
- Puerperal
How can we prevent psychosis?
Referral to specialist services in patients who are distressed with declining social function and:
- Transient or attenuated psychotic symptoms or
- Other experiences or behaviour suggestive of possible psychosis or
- A first-degree relative with psychosis or schizophrenia
Trained in CBT, family interventions and can treat any anxiety and depression
What are some symptoms of psychosis?
- Hallucinations
- Delusions
- Thought and Speech disorder
- Disorders of the self (Jed changing shape)
- Lack of insight!!!!!
What is Schizophrenia?
Chronic relapsing condition that is a form of psychosis with distortion to thinking and perception and inappropriate or blunted affect
Psychotic Symptoms and Negative Symptoms
Usually acute episodes of psychosis and presents in early life (age 15-35)
What is the incidence and prevalence of Schizophrenia?
Incidence: 14.5 per 1000 people/year
Prevalence: 0.5-1% background risk
Same prevalence in men and women but women present later!
What are people with Schizophrenia at an increased risk of?
- Cardiovascular disease
- Suicide
What are some changes in the brain anatomy of a person with schizophrenia?
- Increased size of ventricles
- Decreased brain volume
- Increased activity of dopamine in the mesolimbic region (psychosis)
What are some risk factors associated with Schizophrenia?
- Family history
- Cannabis use (especially in childhood)
- Illicit substances
- Traumatic events in childhood (e.g. poor maternal affection and bonding, poverty, exposure to natural disasters)
- Maternal poor health (including malnutrition and infections such as rubella and cytomegalovirus)
- Birth trauma (hypoxia and blood loss in particular)
- Living in the city
- Living in/emigrating to more developed countries
What are some symptoms of schizophrenia?
- Hallucinations
- Delusions
- Thought insertion/withdrawal/broadcast
- Catatonic behaviour
- Negative symptoms (apathy, blunting)
What are some prodromal symptoms for schizophrenia?
Usually occur up to 18 months before first episode of psychosis
Gradual deterioration in function
Changes: Transient psychotic symptoms, odd thoughts/beliefs/behaviours, concentration problems, altered affect, social withdrawal, reduced interest in daily activities
What is the ICD-10 diagnostic criteria for Schizophrenia?
Psychotic episode lasting for at least one month, schizophrenia may be diagnosed if one (or more) of the following is present:
- Thought echo, insertion, withdrawal, or thought broadcasting.
- Delusions that thoughts, feelings, impulses or actions are being controlled by external forces
- Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves
- Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather).
Or psychotic episode lasting for at least one month if two (or more) of the following are present:
- Persistent hallucinations in any modality, when occurring every day for at least one month
- Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech (Knight’s move thoughts)
- Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
- “Negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses
The episode should not be attributable to organic brain conditions (e.g. encephalitis), or to substance misuse, intoxication, dependence or withdrawal
What are the first rank symptoms of Schizophrenia?
(Schneider’s) First rank symptoms
• Auditory hallucinations
o Thought echo – hearing thoughts aloud o Running commentary o Third person – multiple voices talking about the
patient
• Passivity experiences
o Belief that an action or feeling is caused by
external force
• Thought withdrawal, broadcast or insertion
o Thought withdrawal – belief thoughts are being
taken out of the mind o Thought broadcast – belief that everyone knows
what patient is thinking o Thought insertion – belief that thoughts are being
implanted by others
• Delusional perceptions
o Attribution of a new meaning to a normally
perceived object
• Somatic hallucinations
o E.g. the sense of being touched when no one is
there
What are some examples of negative symptoms in Schizophrenia?
- Alogia (poverty of speech)
- Anhedonia (inability to derive pleasure)
- Incongruity/blunting of affect
- Avolition (poor motivation)
What are the different subtypes of schizophrenia?
- Paranoid: most common, hallucinations and/or delusions are prominent. Usually no abnormal affect or catatonia
- Hebephrenic: Onset 15-25 years, poor prognosis, affective symptoms are prominent with abnormal behaviour. Negative symptoms are significant and social isolation may result
- Catatonic schizophrenia: Predominant symptoms are those of psychomotor disturbance e.g stupor, posturing, waxy flexibility
- Undifferentiated schizophrenia: Those that meet the diagnostic threshold but do not fit into one of the above categories
- Simple and Residual: negative symptoms predominate
What is the definition of the following:
- Schizoaffective disorder
- Schizotypal disorder
- Schizophreniform
- Schizoaffective disorder: When patient has both symptoms of a mood disorder (mania or depression) and schizophrenia at the same time and of the same intensity. Need to give anti-psychotic and mood stabiliser
- Schizotypal disorder: Personality disorder which has partial expression of schizophrenia, treated without medication
- Schizophreniform: Disorders that fail to meet threshold for schizophrenia (usually duration of psychosis) but still have symptoms and deterioration in functioning. Treated with antipsychotics
What investigations should you do if you suspect Schizophrenia?
Need to rule out other causes e.g infections, metabolic abnormalities and organic brain disease
Bedside
- Blood sugar
- Urine dipstick (+/- MSU)
- ECG (evaluate for long QT if considering antipsychotics)
Bloods
- FBC
- LFT
- Thyroid function tests
- Syphilis serology
- Bloodborne virus screen
- Autoimmune screen (e.g. ANA, anti-DS DNA for Lupus)
Illicit drugs and alcohol screen
Those presenting with acute psychosis of unknown cause
Additional investigations
CT, MRI head or EEG may be ordered. Serum markers of autoimmune encephalitis (anti-NMDA receptors) can be sent as well as lumbar puncture and CSF sampling if indicated
What are some differentials for Schizophrenia?
- Substance induced psychosis (commonly drugs of abuse, but can be iatrogenic e.g. steroids)
- Organic psychosis: infection, brain injury, Wilson’s disease
- Metabolic disorder: hyperthyroidism and hyperparathyroidism
- Dementia and depression can also co-occur with psychosis
What are the different types of antipsychotics, give a few examples of each and what is their mechanism of action?
Typical (First-Generation)
- D2 Antagonists
- Haloperidol, Chlorpromazine
Atypical antipsychotics (Second generation)
- D2 and Serotonin (5HT2A) antagonist
- Clozapine, Olanazpine, Quetiapine, Risperidone, Zotepine
Third Generation
- D2 partial agonist
- Aripiprazole
What are some general side effects of typical and atypical antipsychotics?
Typical
- Extrapyramidal side effects e.g dystonia and tremor
- Tardive dyskinesia (uncontrollable repetitive movements)
- Bone marrow suppression
- Agranulocytosis
Atypical
- Weight gain
- Insuline resistance
- Dyslipidaemia
- Bone marrow suppression
- Agranulocytosis
What are some specific side effects with atypical antipsychotics?
- Hyperprolactinaemia: usually olanzapine
- Sexual Dysfunction: ED, low libido, anorgasmia, retrograde ejaculation (risperidone)
- Weight gain
- Diabetes
- Long QT, Fatal Myocarditis, Cardiomyopathy: clozapine
- Daytime drowsiness: clozapine
- Seizure threshold: lowered
Psychological Interventions are a key part of the care plan in Psychosis as well as antipsychotics. What are the different interventions that can be used to promote a quick recovery and prevent relapse?
- CBT: general or targeted on auditory hallucinations. 16 one to one sessions starting in acute phase
- Family Sessions: all families who live near or are in close contact. 10 sessions over 3 months to 1 year. Can help address carer issues like embarrassment, self blame and shame
- Referral to Early Intervention Service
What are some predictors of a better prognosis in Schizophrenia?
- Sudden onset
- No negative symptoms/Positive symptoms predominant
- Supportive home
- Female sex
- Later onset of illness
- No family history
- High IQ/Education
What is the typical prognosis with Schizophrenia?
Chronic Disease
Rule of quarters: 25% never have another episode, 25% improve substantially on treatment, 25% have some improvement and 25% are resistant to treatment
-Following treatment significant improvement in positive symptoms but negative difficult to treat
-The majority of patients will have further acute psychotic episodes, though treatment can reduce the frequency
-Around 10-15% have persistent psychotic features following on from an acute episode.
What hallucinations are most common in psychosis?
AUDITORY (2ND OR 3RD PERSON)
‘I’m hearing voices in my head’ is Pseudohallucination. The noises are perceived as out in the external world if a real hallucination
There are lots of organic causes of psychosis e.g drug induced. What are the functional causes?
- Schizophrenia
- Manic
- Depressive
What model should you use for treatment of Schizophrenia?
Biopsychosocial Model
Bio: Rule out organic causes
Psycho: MSE and Collateral Hx
Social: Social assessment
