Psychiatry - Schizophrenia and psychosis Flashcards
Symptoms of psychosis
1) Delusions
2) Hallucinations
3) Passivity phenomena
These tend to be episodic
Delusions
= false belief that is held unshakably despite evidence to the contrary. It is not culturally appropriate
Delusions are abnormal thoughts
Hallucinations
= perception which arises in the absence of any external stimulus
Auditory hallucinations are the most common
Passivity phenomena
= patient feels that he/she is being controlled externally. This may affect their thought processes (e.g. thought insertion, thought withdrawal, made feelings, made impulses etc)
Are all hallucinations pathological?
No.
Hallucinations can occur in special situations such as those associated with sleep (hypnagogic and hypnopompic). These are non pathological and it is usual for the patient to retain insight and recognise these are not true or real experiences. This is not the case in psychosis
What are the 4 non affective (mood related) or primary psychoses?
1) Schizophrenia
2) Schizoaffective disorder
3) Persistent delusional disorder
4) Acute and transient psychosis
Diagnosis may change over time - e.g. presentation with acute and transient psychosis may progress to symptoms of schizophrenia
What is thought insertion and withdrawal?
Caused by passivity phenomena
Thought insertion - thoughts originate elsewhere and are put into the patients head
Thought withdrawal - the experience of thoughts being removed from one’s mind
Characteristics of schizophrenia
Chronic illness characterised by repeated episodes of psychosis, particularly Schneider’s first rank symptoms
Patients may also experience negative symptoms that are not episodic - usually remain and worsen
What are Schneider’s first rank symptoms?
Symptoms of psychosis which if present are considered to be suggestive of schizophrenia (can occur in 8% of patients with bipolar)
1) Third person auditory hallucinations - discussing/ running commentary
2) Thought echo (hear own thoughts out loud)
3) Delusional perception (delusion arises from a real perception
4) Passivity phenomena
- Thought insertion/ withdrawal/ broadcast (thoughts interfered with)
- Passivity and somatic passivity
Negative symptoms of schizophrenia
Symptoms that develop gradually and progressively unlike the episodic symptoms of acute psychosis
- impaired motivation
- lack of drive
- social withdrawal
- reduced reactivity
- poverty of speech
- self neglect
Schizoaffective disorder
= Simultaneous presence of both typical symptoms of schizophrenia and affective disorder, neither being predominant
Persistent delusional disorder
= At least 3 months duration of one or more delusions
Other psychotic symptoms and negative symptoms of schizophrenia are absent
Acute and transient psychosis
= Sudden onset of rapidly changing symptoms of florid psychosis - strong mood element is common (that does not precede the psychosis)
Episode often precipitated by some stressful event. Usually lasts no longer than 3 months
Physical causes of psychosis
1) Any cause of delirium
2) Head injury/ intracranial pathology
3) Degenerating dementias
4) Epilepsy
5) Acute intermittent porphyria
6) Hyperthyroidism
What drugs can cause psychosis?
- L-DOPA
- Steroid hormones
- Disulfiram
- Anticonvulsants
Why does drug or alcohol abuse lead to psychotic symptoms?
2 reasons:
1) Intoxication with some drugs (e.g. amphetamines) can cause psychosis - psychosis usually resolves once the drug has been cleared
2) Drug misuse can precipitate psychosis in patients who have mental illness (e.g. schizophrenia) - psychosis may persist after patient has stopped drug abuse
Diagnostic work up in a patient to rule out organic cause of psychosis
- Physical examination
- FBC, U&E, LFTs, TFTs
- MRI of head should be considered in all first presentations of psychosis to rule out an underlying disorder (e.g. epilepsy, head trauma, encephalitis)
What drugs are associated with acute florid psychosis?
Amphetamines
Visual hallucinations suggest psychosis due to drug intoxication - urine sample may be required
What differentiates a manic episode from acute and transient psychosis?
Mania should be a differential for acute psychosis
Mania/ affective disorders with psychotic symptoms has a prolonged period of deteriorating mood prior to the onset of psychosis which is normally precipitated by stressful event
How long should anti-psychotic medication be maintained in a patient with acute psychosis?
Continuation antipsychotic treatment for at least 1 year to prevent relapse
What is the prognosis for a patient with an acute psychotic episode?
- Short term prognosis is good - psychosis will not usually last for more than 2/3 months
- Patients are more likely to experience further episodes
- Recurrence is less likely with maintenance antipsychotics
Typical presentation of low mood and symptoms of psychosis
- Psychosis can result from affective disorders (e.g. depression or bipolar)
- Normally, clear period of low mood PRECEDING the onset of psychosis
- Psychotic symptoms are normally mood congruent - i.e. in keeping with the affective disorder, so with depression negative/ insulting hallucinations, pessimistic ideas/ delusions, feelings of guilt
Prognosis in depressive episodes with psychosis
- Short term prognosis is good - response to treatment is usual
- Depression is relapsing so likely to have further episodes in the future
- Recurrence is reduced by maintenance antidepressant treatment
Diagnostic criteria for schizophrenia
First rank symptoms or persistent delusion + present for at least 1 month (ICD-10) + no drug intoxication, withdrawal, organic brain disease or prominent affective symptoms
What are formal thought disorders?
These are features of a patients speech that suggests abnormalities in their thought process, some are common in schizophrenia
- Loosening of associations - no discernible link between statements
- Neologisms - made up words e.g. “headshoe” meaning hat
- Word salad
- Concrete thinking (inability to deal with abstract ideas)
What type of delusions are common in schizophrenia?
- ) Persecutory = someone or something is interfering with a person maliciously
- ) of reference = actions of other people, media etc are referring to the person or communicating a message
Genetic factors in schizophrenia
Schizophrenia and affective psychoses are more prevalent in relatives of people with schizophrenia. Risk is
- 50% monozygotic twin
- 15% dizygotic twins
Genes affecting brain development probably contribute
Increased paternal age is a risk factor - increased risk of chromosomal abnormalities
What is the neurodevelopmental hypothesis of schizophrenia?
Factors that interfere with early brain development lead to an increased risk of schizophrenia as an adult
- winter births (increased risk of influenza)
- obstetric complications, low birth weight
- developmental delay
- temporal lobe epilepsy
- smoking cannabis in adolescence
Social factors in schizophrenia
Schizophrenia is associated with:
- low SES
- living in urban areas
- excess of live events in the 3 weeks before the onset of acute symptoms
Incidence of all psychoses is higher in Black African and African-Caribbean populations
Schizophrenic patients with high expressed emotional relatives (those that get too involved) are at greater risk of relapse
How do genetic, social and neurodevelopmental factors result in schizophrenia?
Unknown.
Final common pathway appears to involve:
- dopamine excess in mesolimbic dopaminergic pathways (antipsychotics block these)
- Increased serotonin activity
- Decreased glutamate
What is the most common form of schizophrenia?
Paranoid schizophrenia
Evident delusions and auditory hallucinations
Can a patient have schizophrenia without positive symptoms?
Yes - undifferentiated (simple) schizophrenia
This is a rare form where negative symptoms occur without preceding psychotic symptoms
What is the lifetime risk of developing schizophrenia?
0.7% - risk is greater in men (1.4:1)
Peak incidence is in late teens or early adulthood
How should an acute episode of psychosis be managed?
Early detection and intervention are important:
- Longer period between symptom onset and effective treatment (duration of untreated psychosis) the worse the average outcome
- First few years after onset can be distressing, with high suicide risk
Antipsychotics:
- Lowest effective dose
- Treat in the community wherever possible
- Monitor side effects
Psychological therapy:
- Self help to come to terms with symptoms/ illness
Social support:
- Focus on engagement, hope and to reduce stigma
- Include family and carers
Which antipsychotics are better at treating positive symptoms?
Both atypical and typical antipsychotics are equally effective in treating positive symptoms but have different side effects:
- Atypical antipsychotics cause fewer motor side effects, but cause more metabolic problems
Using 2 antipsychotics at the same time should be avoided
Clozapine
This is the only antipsychotic that has shown to be effective in treating psychosis that does not respond to treatment with at least 2 other antipsychotics
Blood monitoring is required because of potentially dangerous side effects (agranulocytosis)
What steps can be taken to help reduce the risk of relapse after an acute psychotic episode?
Maintenance treatment of antipsychotics is important - relapse rates are reduced if patients continue meds for > 1-2 years after acute episode
Family therapy helps to reduce over expressed emotions
Social support to reduce substance abuse and misuse which increase relapse rates
What psychological treatment can be used to promote long term recovery in psychosis?
NICE guidelines state that all patients with schizophrenia should be offered CBT and their families should be offered family interventions if they are in close and regular contact
CBT can help patients with persistent delusions and hallucinations, but the aim is to alleviate stress and disability NOT necessarily to eliminate symptoms:
- learning to challenge or think differently about a voice
- strategies to cope with hearing voices
- encouraging patients to challenge delusional beiefs
Prognosis in schizophrenia
70% of people experience a first psychotic episode will be well within a year
…..but 80% will have a further episode within 5 years
75% of patients will discontinue their medication within the first 18 months which increases relapse risk by 5 times
Lifetime suicide risk is 10%
What factors are associated with a better prognosis in schizophrenia?
“FINDING PLANS”
- Female
- In relationship, good social support
- No negative symptoms
- aDheres to medication
- Intelligence (more educated)
- No stress
- Good premorbid personality
- Paranoid subtype
- Late onset
- No substance misuse
- Scan (CT/MRI) normal
