Psychiatry - Psychosis/Schizophrenia Flashcards
Schizophrenia?
- Most common form of psychosis
- Lifelong condition
- Acute Vs Chronic: Course can take a chronic form or a form with relapsing and remitting episodes of acute illness
- Affects patients and their family and friends
- Most researched of the psychoses
- Affects about 1 in 100
- Has dramatic and devastating effects
- Untreated it runs a chronic, deteriorating course
- Personal tragedy plus substantial public health burden
Schizophrenia?
Epidemiology?
- Can develop at any age
- Most commonly in adolescence and the early 20s
- In young people aged 10-18 it accounts for 24.5% of all psychiatric admissions, with a marked rise after the age of 15
- Peak age of onset is later in women
- Men are also more likely to have negative symptoms and more serious forms
- More common in migrants and this probably reflects a mixture of environmental and social factors
Schizophrenia?
Aetiology?
- Genetic, environmental and social
- Short-lived illnesses are associated with cocaine, amphetamines and cannabis (similar to paranoid schizophrenia)
- CANNABIS – culprit in both established schizophrenia and in enhancing future risk in those who have not yet developed psychotic symptoms
Risk factors:
- Family history
- Intrauterine and perinatal complications e.g. premature birth, low birth weight
- Intrauterine infection, particularly viral / winter births
- Abnormal early cognitive/neuromuscular development
- Social isolation, migrants
- Abnormal family interactions
Schizophrenia?
Presentation?
Acute symptoms
Hallmark symptoms of psychosis:
- Delusions
- Hallucinations
- Thought disorder
- Lack of insight
Schneider’s First Rank Symptoms
Schizophrenia?
Presentation?
Acute symptoms:
- ‘First rank’ or ‘positive’ symptoms of schizophrenia are rare in other psychotic illnesses
- Presence of only one of the following symptoms is strongly predictive of the diagnosis:
- Delusions
- Delusional perceptions
- Thought insertion, removal or interruption
- Hallucinations – auditory – third person
- Formal thought disorder
- Thought broadcasting
- External control of emotions
- Somatic passivity
- Lack of insight
Schizophrenia?
Presentation?
Chronic symptoms / Negative symptoms:
- Impairment or loss of volition, motivation and spontaneous behaviour
- Loss of awareness of socially inappropriate behaviour and social withdrawal
- Flattening of mood
- Blunting of affect
- Anhedonia
- Poverty of thought and speech
- Self-neglect
Schizophrenia?
ICD-10
At least one of the following:
• Thought echo, insertion, withdrawal, or broadcasting
• Delusions of control, influence, or passivity; clearly referred to body or limb movements or specific thoughts, actions, or sensations; and delusional perception
• Hallucinatory voices giving a running commentary on the patient’s behaviour or discussing him/her between themselves, or other types of hallucinatory voices coming from some part of the body
• Persistent delusions of other kinds that are culturally inappropriate or implausible (e.g. religious/political identity, superhuman powers and ability)
Or, at least two of the following:
• Persistent hallucinations in any modality, when accompanied by fleeting or half-formed delusions without clear affective content, persistent over-valued ideas, or occurring every day for weeks or months on end
• Breaks of interpolations in the train of thought, resulting in incoherence or irrelevant speech or neologisms
• 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
• A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal
Schizophrenia?
Mental State Examination?
Full physical examination - organic psychosis?
Mental State Examination:
- Appearance and behaviour - withdrawal, suspicion, or (rarely) stereotypical behaviours (repetition of purposeless movements) and mannerisms (e.g. saluting)
- Speech - interruptions to the flow of thought (thought blocking), loosening of associations/loss of normal thought structure (knight’s move thinking)
- Mood/affect - flattened, incongruous
- Abnormal beliefs - delusional percepts, delusions concerning thought control or broadcasting, passivity experiences
- Abnormal experiences - hallucinations, especially auditory
- Cognition - attention, concentration, orientation and memory should be assessed (significant impairment suggests delirium or severe dementia)
Schizophrenia?
Differential Diagnosis?
Other psychiatric disorders
Organic disorders:
- Drug-induced psychosis - amphetamine, LSD, cannabis
- Temporal lobe epilepsy
- Encephalitis
- Alcoholic hallucinosis
- Dementia
- Delirium
- Cerebral syphilis
Schizophrenia?
Associated Conditions?
- Depression
- Anxiety
- PTSD
- Personality disorder
- Substance misuse
- Obesity
- DM (type 11 – clozapine and olanzapine)
- Infections
- Cardiovascular disease
- Continuing disability
Schizophrenia?
Investigations?
As for first episode of psychosis
Usually referral to mental health services if presenting with psychosis
Some investigations to do before:
- FBC & LFTs: Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse
- Syphilis testing
- Urine drug screens
Also consider:
- Intoxication - alcohol, cannabis, amphetamines
- Drug overdose - suicidal, or accidental
Schizophrenia?
Management?
Initial management:
- As for psychosis
- Early intervention is important!
- MDT support
- Physical health monitoring and health promotion
- Monitoring for side effects: Glasgow Antipsychotic Side-effect Scale (GASS) and the Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS
Schizophrenia?
Social and Psychological?
Social:
- Homelessness, poverty and economic deprivation
- Social support for help with housing, vocational support, social isolation, employment and financial aid is important
- Recovery Action Plans
Psychological support:
- Support groups
- Carers support
- Specialist ‘family interventions in psychosis’ teams
- Family therapy has been shown to reduce relapse and admission rates.
- Cognitive behavioural therapy is helpful
- NICE: Art therapy (e.g. music, dancing, drama) for the alleviation of negative symptoms in young people
Schizophrenia?
Medication?
- 1st-line: Newer atypical antipsychotics – e.g. risperidone or olanzapine
- Depot formulations – patient preference after acute episode / non-compliance
- Benzodiazepines - rapid tranquilisation
- Aripiprazole is now recommended for patients aged 15 to 17 years who are intolerant of risperidone, where risperidone is contra-indicated, or where risperidone has not proved effective in controlling the schizophrenia
- Clozapine – treatment resistant schizophrenia
Side-effects:
- Extrapyramidal symptoms are less troublesome with the atypical antipsychotics
- Atypical antipsychotics - weight gain
Schizophrenia?
ECT?
SIGN: May be appropriate in patients resistant to pharmacological therapy, particularly if rapid reduction in symptoms is required. It may have an adjunctive effect with antipsychotics
Schizophrenia?
Types?
Paranoid Schizophrenia:
- Delusions and hallucinations
Hebephrenic Schizophrenia:
- Disorganised speech
- Often silly/shallow/flat or inappropriate
Catatonic Schizophrenia:
- Psychomotor disturbance
Undifferentiated Schizophrenia:
- Meets general criteria
- No specific symptom subtype predominates
Post Schizophrenic depression:
- Some residual symptoms
- Depressive picture predominates
Residual Schizophrenia:
- Previous positive symtoms less marked
- Prominent negative symptoms
Simple Schizophrenia:
- No delusions or hallucinations
- A defect state arises without an acute episode
