Delusional Disorders Flashcards
Schizophrenia
Patient suffers from Psychotic Symptoms and Functional Impairment; In
Delusional Disorders, Experiences of Delusions but no evidence of Hallucinations or other Schizophrenia-Characteristic Symptoms
o Schizophrenia has variable course, frequently chronic and relapsing; Care is
considerable burden onto carers including family
o Presents either as Acute or Chronic Syndromes
Schizophrenia: Epidemiology
• 10-20 per 100,000; M>F; In males, 15-35yrs mean, and older in females
• Might be higher in certain Afro Caribbean groups; Prevalence higher in SES deprived,
especially homeless population
Acute Syndrome: Thoughts
Hallucinations, Persecutory Ideas, Delusions of Reference, Social Withdrawal and Impaired Performance at work o Vs Negative Symptoms – Loss of Function seen in Chronic Schizophrenia o Might appear entirely normal; Some might be awkward, preoccupied, odd; Might react spontaneously unpredictably, or appear perplexed
Acute Syndrome: Mood Changes
Depression, Anxiety, Irritability
or Euphoria; Either due to disorder, response to
insight into nature of disease, or SE to
Antipsychotic medication
o Blunting Affect – Reduction in normal
variation of mood
o Incongruity of Affect – Emotion not in keeping with situation
Acute Syndrome: Speech and Thought
Hard to follow; Might be vague and difficult to grasp; Might develop
into definite abnormalities (Formal Thought Disorders)
o Difficult dealing with Abstract ideas (Concrete Thinking)
o Preoccupation with vague Pseudoscientific or Mystical Ideas
o Lack of Connection between Ideas expressed by patient (Loosening of Associations)
o Can progress to becoming totally incoherent (Word Salad); May also be disorders
with Stream of thought (Pressure, Poverty, Blocking)
Acute Syndrome: Delusions
Primary (Without morbid antecedents e.g. not preceded by ideas or events) or Secondary; May be preceded by ‘Delusional Mood’ (Perplexing sense of something being
amiss or changed) or Hallucinations
o Persecutory, Reference, Control, Thought Insertion, Withdrawal or Broadcasting
Acute Syndrome: Auditory Hallucinations
Most frequent; Simple Noises, Complex Voices or Music
o Voices may speak thoughts aloud (Echoing), or give commands etc; Sometimes two
or more voices might discuss the patient in third-person
o Other types of Hallucinations less frequently and seldom without other kinds of
hallucinations; Visual, Tactile, Olfactory, Gustatory and Somatic might occur, and may
be interpreted in a delusional way
Acute Syndrome: Insight
Insight is usually impaired; Most do not accept that experiences are from illness but instead actions of other people; Often accompanied by unwillingness to accept treatment
Chronic Syndrome
Negative Symptoms – Underactivity and
Disorganised Behaviour, Lack of Drive, Social
Withdrawal, Emotional Apathy, Thought
Disorder and Cognitive Impairment
Schizophrenic Defect State
Impaired Volition (Drive and Initiative); Inactive or Engaging in Aimless and Repeated Activity; Impairment of Personal Hygiene, Appearance, Social Encountered, Breaking Social Conventions (e.g. Obscenities, Disinhibition), Hoarding
Movement (Catatonic) Disorders
Stupor and Excitement (Uncontrolled motor activity) o Odd, repetitive movements; =Stereotypies if not goal directed; If goal directed =Mannerisms o Might have disorders of Muscle tone; Might maintain awkward posture without apparent distress (Waxy Flexibility)
Chronic Syndrome: Speech
Speech is often abnormal, reflecting similar Thought Disorders seen in Acute Syndrome
Chronic Syndrome: Affect
Blunted Affect with Incongruous Emotion
Chronic Syndrome: Hallucinations
Hallucinations are common, similar to the forms in Acute Syndrome
Chronic Syndrome: Delusions
May be held with little emotion; May be encapsulated from rest of the patient’s beliefs (E.g. Delusions of persecution only limited to specific beliefs)
Chronic Syndrome: Cognitive Impairments
May be held with little emotion; May be encapsulated from rest of the patient’s beliefs (E.g. Delusions of persecution only limited to specific beliefs)
Chronic Syndrome: Insight
Insight often impaired; Does not recognise illness, not convinced about need for treatment
Age of Onset
Adolescents and Young Adults typically include Thought Disorder, Mood
Disturbance and Disrupted Behaviour; In Older Adults, Paranoid Symptoms are more
common, and Disrupted Behaviour less frequent
Outcomes
• Illness is generally more severe in males
• 20% will have Acute Illness with Complete Recovery; 50% Recurrent Illness with Persistent Deficits; 20% Chronic Illness with Persistent Functional Disability; 10% Suicide
o Suicide Risk if high in younger patients, when insight still present and
understands likely effect of illness
• Overstimulating environment increases positive symptoms and converse
• Family – Relapse more likely if critical, hostile or
Emotional Overinvolvement; Reducing contact
by increasing day care, or Family Therapy
Diagnosis of Schizophrenia Category A
≥1 for 1/12 • Delusions • Hallucinations (Especially if Running Commentary, or Conversing) • Disorganised Speech • Grossly Disorganised or Catatonic Behaviour • Negative Symptoms
Diagnosis of Schizophrenia
Category B
Social and Occupational Dysfunction etc
Diagnosis of Schizophrenia : Category C
Duration – Continuous signs persist for at least 6/12;
Includes 1/12 of Category A; May include Prodromal or
Residual Periods; Negative, or ≥2 Cat A symptoms
Diagnosis of Schizophrenia : Category D
Rule-out Schizoaffective and Mood Disorder (No, or
relatively brief Major Depressive, Manic or Mixed
during active Schizophrenia Symptoms)
Diagnosis of Schizophrenia : Category E
Rule-out Substance Abuse or General Medical
Diagnosis of Schizophrenia : Category F
If there is history of Autism or other Developmental
Disorder, Prominent Delusions or Hallucinations ≥ 1/12
Schneider’s First Rank Symptoms
Auditory Hallucinations (Echoing, Commentary, Third
Person), Somatic Hallucinations, Thought Withdrawal or Insertion, Broadcasting, Delusional
Perception, Delusions of Control
Differential Diagnosis
If Delusions, without other symptoms of Schizophrenia – Persistent Delusional Disorder
Organic Syndromes Mimicking Schizophrenia
o Substance Abuse (E.g. Amphetamine, Cocaine, MDMA, LSD; Cannabis rarely causes Frank Psychosis but may precipitate relapse)
o Iatrogenic Drugs – Especially Steroids and Dopamine Agonists
o Temporal Lobe Epilepsy – If condition is brief and evidence of clouding of
consciousness; In few, Chronic TLE gives rise to persistent state
o Delirium – Might be mistaken from Acute Syndrome, especially if prominent
Hallucinations and Delusions; Clouding of Consciousness not seen in Schizophrenia
o Dementia – Memory Disorder not seen in Schizophrenia
o Diffuse Brain Diseases e.g. Neurosyphilis (General Paralysis of the Insane)
Psychotic Mood Disorder
Degree and Persistence of Mood Disorder, Congruence of Hallucinations or Delusions with Prevailing Mood, Nature of Prominent Symptoms
o If Prominent Affective Symptoms – Schizoaffective Disorder
Personality Disorders
Prolonged observation for First-rank symptoms
Aetiology of Schizophrenia: Genetic
Strong Evidence for Genetic Factors (10-15% risk in Siblings and child of one affected parent,
and 40% if two affected parents, vs Lifetime risk 1%); Heritability 80%
o Genes believed to have effect on Neurodevelopment and Synaptic Functioning
o Also believed to predispose to several mental disorders; Actual disorder depends on
complex interaction between Genetics and Environment
Aetiology of Schizophrenia: Environmental
Environmental – Risk factors include Abnormalities in Pregnancy, Foetal Development
(?Foetal Hypoxia), Low SES, Heavy Cannabis Consumption, Stressful Life Events
o High Emotional Expression – Strongly expressed feelings especially critical comments;
may lead to high relapse rates
Aetiology of Schizophrenia: Biochemical
• Response to Antipsychotic drugs suggests Biochemical basis (D2 receptors); Evidence of
increased Dopaminergic Transmission in Basal Ganglia (Acute) and Diminished in PFC
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• Dopaminergic transmission not believed to be primary problem; Likely due to upstream
alterations in Glutamate Transmission
Aetiology of Schizophrenia: Neurodevelopmental
Schizophrenia as a Neurodevelopmental Disorder
o Reduced Parahippocampal, Temporal, Amygdala and Hippocampal Volumes, and
increased Lateral Ventricular Volumes
o Dermatoglyphic Abnormalities, sometimes associated with CNS Developmental
disorders, and ‘Soft’ Neurological signs
o Gliosis was not found post-mortem in Schizophrenic patients, suggesting that
abnormalities occurred early in life and did not trigger inflammatory reaction
o More likely than controls to have developmental problems in childhood
Current Model of Aetiology
suggest Polygenetic Susceptibility Interacting with Early Environment leading
to abnormal Brain Maturation (Pruning, Myelination, Apoptosis); Leads to Observable
Childhood Abnormalities, and if Environmental Risk Factors are present – Onset
Assessment of Schizophrenia
Majority treated within Specialist Services;
First presentation by primary care; Delayed
treatment associated with poor outcomes
o Need to be familiar with assessment
and rapid referral
Assessment of Schizophrenia: Non Urgent
Non-urgent – Often from relatives/collateral;
Obtain good description of behaviour and
symptoms, assess Functional Impairment (E.g.
Occupational, Relationships), Risk Assessment
o Persuade patient to accept referral to
Specialist Mental Health
o If refused, discuss with Psychiatrist and consider compulsory order
Assessment of Schizophrenia: Acutely Disturbed
Unwise to be alone with such patient until Risk Assessment made
o Attempt should be made to remove physical restraint while ensuring helpers close
o Main task to exclude Acute Organic or Non-Psychotic Disorder; Difficult to distinguish
between Schizophrenia and Mania (although Immediate Management is the same)
o Need for Admission depends upon – Severity, Nature of Psychotic Symptoms and
Risk, Social Support and Insight
o Compulsory powers might be necessary; Alternatives include Intensive Community
Treatment (Home treatment often preferred by patients and relatives)
Management of Schizophrenia : Early Intervention
• Early intervention – Referral to Specialist Services; Antipsychotics not be started in Primary
care for first presentation, unless done with consult with consultant psychiatrist
Management of Schizophrenia : Antipsychotic
Extrapyramidal, Cardiovascular, Hormonal side effects and patient preference
o Record Weight, Waist Circumference, Sats, Fasting Glucose HbA1c, Lipids and
Prolactin; Assessment of Movement Disorders and Nutritional Status
Management of Schizophrenia : Psychological
Psychological Intervention (Family, Individual CBT)
Management of Schizophrenia : Immediate
Drugs for immediate behavioural control e.g. Benzodiazepines might be required
Management of Schizophrenia : Affective Component
If behaviour suggests affective psychosis (E.g. Bipolar, Unipolar Psychotic Depression) – Treat
as Bipolar Disorder or Depressive Disorder
Antipsychotics
D2 and 5-HT2A antagonism; Various other activity on other D, 5HT subtypes,
Alpha Adrenergic, Muscarinic and Histamine Receptors
Examples of Typical Antipsychotics
Haloperidol, Chlorpromazine, Prochlorperazine
SE of Typical Antipsychotics
Tends to produce Extrapyramidal SE (EPS),
which includes Neuroleptic Malignant Syndrome
(Fever, Rigidity, Autonomic Dysfunction, Altered
Mental Status)
Examples of Atypical Antipsychotics
Risperidone, Olanzapine, Quetiapine, Clozapine
SE of Atypical Antipsychotics
Fewer EPS but more metabolic effects e.g.
Weight Gain, Hyperglycaemia
Clozapine is effective for treatment-resistant
Schizophrenia, but risk of Seizures and
Agranulocytosis (<1%)
SE of both Antipsychotics
Sedation,Anticholinergic/Antiadrenergic Effects (Dry Mouth, Constipation, Blurred Vision, Urinary
Retention and Tachycardia); Increased Prolactin leads to Galactorrhoea and Oligomenorrhoea
If fail to respond to two trials of first-line antipsychotics
consider Clozapine
o Cognitive Therapy might also improve drug-resistant hallucinations and delusions by removing pre-occupation with symptoms
After starting Antipsychotics
symptoms of Excitement, Irritability and Insomnia improves within few days; Hallucinations might improve over several weeks
• Patient should not be left un-occupied (which might lead to being absorbed into symptoms) or overstimulated (prolonged acute symptoms); Suitable programme of activity
ECT
ECT is not regularly used; Might be required if severe Depressive symptoms, or rare cases of
Catatonic Stupor which occurs in Chronic Schizophrenia; Rapidly effective in both
o Also, effective in Acute Syndrome but is simpler and as beneficial
o Postpartum Psychosis – ECT indicated as rapid response is particularly important
Associated Depressive Symptoms
Antidepressants or Lithium, especially if Schizoaffective
Management of Aggressive Behaviour
Risk Assessment; Threats should be taken seriously;
Close Observation or Compulsory orders; Calm, Reassuring, Consistent Environment
Prevention of Relapse
Aim to control symptoms with Antipsychotic drugs while making daily arrangements that protects the patients from too many stressors and return as far as possible to ADLs
o Continue Antipsychotics for 6/12 at tolerable dose
o Family Therapy aimed at reducing critical comments, and improving family’s
knowledge of disorder can reduce Relapse
Continued Pharmacotherapy
Intramuscular Depot injections improve adherence
o Long-term Typical Antipsychotics lead to Tardive Dyskinesia in 15% after 4yrs
o Difficult to predict who requires drugs (20% remain well without); Case-by-case
judging benefit of continuing treatment
o Anticholinergic Drugs reduce Parkinsonian SE, but increased likelihood of Dyskinesia
MDT
Systematic Assessment of Medical and Social Needs; MDT involvement and care planning,
involvement of Experienced Community Psychiatric Nursing
o Key coordinator of care, monitoring mental state, Administering Depot injections,
Monitoring Compliance, Arranging/Carrying out Psychotherapies, Psychoeducation
and Liaison with other care workers
Psychosocial Care
Social Skills, Employment Training, Cognitive Remediation
