Mental Health: Schizophrenia (1) Flashcards
Risk factors for developing schizophrenia
Risk of developing schizophrenia
- monozygotic twin has schizophrenia = 50%
- parent has schizophrenia = 10-15%
- sibling has schizophrenia = 10%
- no relatives with schizophrenia = 1%
Other selected risk factors for psychotic disorders include:
- Black Caribbean ethnicity - RR 5.4
- Migration - RR 2.9
- Urban environment- RR 2.4
- Cannabis use - RR 1.4
6 Types of schizophrenia (just name them)
ICD-10 lists six key types of schizophrenia:
- Paranoid schizophrenia
- Hebephrenic schizophrenia
- Catatonic schizophrenia
- Undifferentiated schizophrenia
- Residual schizophrenia
- Simple schizophrenia
Epidemiology of schizophrenia
- affects about 1 in 100 people
- affects men and women equally
- usually diagnosed between the ages of 15 and 35
- age of onset tends to be slightly earlier in men (18-25) and later in women (25-35)
- higher incidence of schizophrenia in urban areas and among migrants
- incidence is also higher in lower socioeconomic classes, but this may be a consequence, rather than a cause, of schizophrenia
What’s a delusion?
A fixed unshakeable belief that is not in keeping with patients social, cultural and educational background
Examples:
- Persecution
- Thought insertion, thought withdrawal and thought broadcast
- Control
- Reference (often from the T.V or the radio)
What are hallucinations?
A percept experienced in the absence of an external stimulus to the sense organs but with the same quality as a true percept
Examples:
- Running commentary
- Commonly 2nd person or 3rd person
- Coming from some part of the body
- Somatic hallucinations
Types of catatonic behaviours
Catatonic = motor disturbance:
- Excitement
- Posturing
- Waxy flexibility
- Negativism
- Stupor
What’s a thought disorder?
Disorders of thinking recognised from speech and writing.
“Loosening of associations”
- Thinking is muddled and illogical
- Cannot be clarified by further inquiry
- The more you attempt to clarify, the less you understand
Negative symptoms of schizophrenia
Negative symptoms usually involve a decline in normal functioning; neglect of self or others
- Blunted affect
- Apathy
- Social isolation
- Poverty of speech
- Poor self-care
Positive symptoms of schizophrenia
Positive symptoms tend to represent a change in behaviour or thought
- Thought echo (hearing your own thoughts out loud)*
- Thought insertion or withdrawal*
- Thought broadcasting*
- 3rd person auditory hallucinations*
- Delusional perception *
- Passivity and somatic passivity*
- Odd behaviour
- Thought disorder
- Lack of insight
*These are also referred to as Schneider’s First Rank Symptoms.
Positive vs negative symptoms of schizophrenia
- Positive symptoms → tend to represent a change in behaviour or thought
- Negative symptoms → usually involve a decline in normal functioning
Aetiology of schizophrenia
- Precise cause of schizophrenia is unknown
- it is believed to be a consequence of a combination of psychological, environmental, biological and genetic factors
- people may have a susceptibility to schizophrenia and that emotional life experiences can act as a trigger for developing the illness
Risk factors for schizophrenia
- Family history
- pregnancy: malnutrition, viral infection, pre-eclampsia, emergency CS
- cannabis use (especially when as a teenager)
- psychotic symptoms from amphetamines, LSD, cocaine
- socio-environmental: urban areas, lower economic class, stressful life events, being 1st or 2nd generation migrant
- being a victim of physical or sexual abuse
- Afro-Caribbean ethnicity
Factors associated with poor prognosis in schizophrenia
Factors associated with poor prognosis
- strong family history
- gradual onset
- low IQ
- premorbid history of social withdrawal
- lack of obvious precipitant
Pathophysiology of schizophrenia - neurodevelopmental hypothesis
Neurodevelopmental hypothesis
- hypoxic brain injury at birth or who were exposed to viral infections in-utero are at greater risk of developing schizophrenia
- temporal lobe epilepsy or smoking cannabis while brain is still developing are also at higher risk
This suggests that brain development is implicated in the pathophysiology of schizophrenia.
Imaging has shown changes in the brains of people with schizophrenia, including enlarged ventricles, small amounts of grey matter loss and smaller, lighter brains.
Changes in the brains of patients with schizophrenia
- enlarged ventricles
- small amounts of grey matter loss
- smaller, lighter brains
Pathophysiology of schizophrenia - neurotransmitter hypothesis
Neurotransmitter hypothesis
- excess of dopamine and overactivity in the mesocorticolimbic system is believed to cause the positive symptoms of schizophrenia
- dopamine antagonists are therefore used to treat schizophrenia
- less dopamine activity in the mesocortical tracts, causing the negative symptoms in schizophrenia (this is why dopamine antagonists are more successful at treating positive than negative symptoms)
*Psychotic symptoms are seen in people with Parkinson’s disease if they are overtreated with levodopa as this increases the amount of dopamine in the brain.
*Amphetamines and cocaine also increase dopamine release and lead to psychosis.
Dopamine is not the only neurotransmitter implicated in schizophrenia. There is also an increase in serotonin activity and a decrease in glutamate activity
What to do if a GP patient is suspected to have schizophrenia?
If a patient is suspected to have schizophrenia, they will be referred to the local community mental health team where a psychiatrist or specialist nurse carries out a detailed assessment
Investigations for diagnosis of schizophrenia
According to ICD-101, a diagnosis of schizophrenia requires…
1) A first-rank symptom or persistent delusion present for at least one month:
- Delusional perception
- Passivity
- Delusions of thought interference: thought insertion, thought withdrawal and/or thought broadcasting
- Auditory hallucinations: thought echo, third-person voices and/or running commentary
2) No other cause for psychosis such as drug intoxication or withdrawal, brain disease (including dementia/delirium/epilepsy), or extensive depressive or manic symptoms (unless it is clear that schizophrenic symptoms antedate the affective disturbance).
Investigations used to role out other causes of symptoms of a patient with suspected schizophrenia
Other investigations used to rule out the other causes of confusion/psychotic symptoms:
- MSU → to rule out UTI causing delirium
- Urine drug screen → to rule out drug intoxication
- CT scan → if an organic neurological cause is suspected
- HIV testing if applicable
- Syphilis serology if applicable
- Check lipids → before starting antipsychotics
- Full physical examination
- Bloods including FBC, TFTs, U+Es, LFTs, CRP and a fasting glucose
Teams involved in treatment of patient with schizophrenia
- Early intervention team (initial referral after the first psychotic episode)
- Community mental health team (provide day-to-day support and treatment)
- Crisis resolution team (for patients experience an acute psychotic episode)
What’s Care Programme Approach for a patient with schizophrenia?
Patients with schizophrenia will usually have a care programme approach.
There are four stages to a CPA:
- Assessing health and social needs
- Creating a care plan
- Appointing a key worker to be the first point of contact
- Reviewing treatment
What’s voluntary admission?
- Psychiatrists may sometimes recommend an inpatient stay
- Most patients are admitted voluntarily but occasionally they may be detained under the Mental Health Act
