Psychoses Flashcards
What is Schizophrenia? How can it be defined - how may it present?
Schizophrenia is a severe mental disorder where thought and emotions are so impaired that contact with external reality is lost
Characterised by presence of delusions (fixed, false beliefs held despite evidence on the contrary) and hallucinations (perception in the absence of a stimulus) + LOSS OF INSIGHT
ICD-10 Definition
(A)
1 or more of Schneider’s 1st Rank Sx:
-> Delusions (+delusional perception)
-> Passivity (delusions of control)
-> Thought disorder (insertion, withdrawal and broadcasting)
-> Auditory disorder/Hallucinations (thought echo/hearing thoughts aloud, 3rd person voice, running commentary)
OR
(B)
2 or more of the following:
-> Paranoid - persistent hallucinations in any modality
-> Hebephrenic - incoherent or irrelevant speech (knight’s move, neologisms)
-> Catatonic - catatonic behaviour (excitement, posturing, mutism, stupor)
-> Simple (or residual) - negative symptoms only (apathy, blunted or incongruent emotional response, paucity of speech)
(C) Present for most of the time for at least 1 month (DSM 5 says Sx must be present for 6m with 1 month of TWO active sx)
(D) Not caused by substance use or organic disease
What is the general clinical progression of schizophrenia? Which age is most commonly affected?
Age of onset is around 18-25 in men and 25-35 in females
- Prodrome/At risk mental state (-ve symptoms dominant)
- From teens to early 20s
- Social withdrawal
- Loss of interest in work and relationships - Acute phase (+ve symptoms dominant)
- Delusions
- Hallucinations
- Thought interference - Chronic phase (-ve symptoms dominant)
- Apathy
- Blunted affect
- Social withdrawal
- Anhedonia
- Poverty of thought/speech
What are the positive and negative symptoms caused by pathophysiologically?
POSITIVE Sx - i.e. delusions, hallucinations, thought disorder
-> Due to EXCESS dopamine in the mesolimbic tracts
NEGATIVE Sx - i.e. apathy, blunted affect, poverty of speech
-> Due to REDUCED dopamine in the mesocortiyal tracts
What are the subtypes of schizophrenia?
- Paranoid
- most common
- prominent delusions (persecutory) and hallucinations - Hebephrenic/Disorganised
- mainly focussed on speech/thought
- DISORGANISED mood and speech
- neologisms, knights move speech
- inappropriate affect (i.e. laughing at sad things) - Catatonia
- psychomotor disturbance
- stupor, waxy flexibility (retain any shape you put them into), opposition, automatic obedience - Simple
- negative sx only
- residual schizophrenia also has negative symptoms only but initially had both before
What is the prevalence pf schizophrenia and some epidemiology facts?
0.7% prevalence with lifetime risk of 1.5%
Men > Women (+ women have later onset)
9x higher in Afro-Caribbean ethnicity individuals, 5x black africans and 1.4x in south asians
Peaks in late adolescence/early adulthood
What are some causes and RF for schizophrenia?
Biological:
- Genetics - STRONG link, especially with 1st degree relatives, monozygote twin risk =50%
- Obstetric complications - infections, winter births, LBW, maternal drug use, pre-eclampsia
- Cannabis - particularly in developing brain
- Low IQ
- Paternal age
Psychosocial:
- Social disadvantage
- Migration and Ethnicity
- Adverse life experiences
- Urban life and birth (2x higher)
- Cognitive behaviour and premorbid personality being schizoid
What are some other DDx for schizophrenia?
DDx:
- Affective psychosis - congruent affect either elated/depressed, check ORDER of symptoms
- Drug-induced psychosis
- Delirium
- Personality disorder
- Organic brain pathology/physical conditions e.g. porphyria, TLE, Dementia, stroke, steroid use
- Persistent delusional disorder (only delusions)
What Ix would you do in suspected schizophrenia?
Ix:
- Collateral Hx
- MSE and Physical exam
- Urine drug screen
- Bloods (FBC, U&Es, HbA1c, lipids, endocrine tests, LFTs)
- MRI/CT for possible organic causes if suspected
- EEG for TLE or post-octal symptoms
- ADL assessment and housing and finance
How would you manage Schizophrenia? (emergency/acute, chronic)
Mx:
Urgent emergency - crisis resolution team and home treatment team (or admission if:)
- Suicide/homicide risk
- Lack capacity
- Severe sx (psychotic, depressive or catatonic)
- Failure of OPD treatment
- Address co-morbid conditions
- Significant medication changes
Non-urgent emergency - refer to early intervention (EIP) team (>14yo)
- > Aims to keep duration of untreated psychosis <3m
- > Tx with antipsychotics and psychosocial interventions
Rapid tranquillisation [if required]
- > 1st line = oral -> IM Haloperidol
- > 2nd line = 5mg Haloperidol + 1mg Lorazepam
BIOLOGICAL:
[Long-term:]
-> 1st line = atypical antipsychotic for 6w = usually low-dose Aripiprazole OR high-dose Olanzapine + education and support [Quetiapine in MedEd]
note: LESS strong + fewer SE = Aripiprazole (initial akasthia), Quetiapine (sedation, weight gain)
STRONGER + more SE = Olanzapine (weight gain, metabolic syndrome), Risperidone (hyperprolactinaemia, EPSEs, sedation)
-> Augment with BDZ (e.g. diazepam) if non-acute anxiety or mood stabiliser (Li, lamotrigine) is schizoaffective disorder suspected
IF non compliant then once-monthly depot injection (zuclopenthol decanoate 200mg)
-> 2nd line = 6w of typical antipsychotic (Haloperidol, Chlorpromazine) or different atypical - SE = EPSE, hyperprolactinaemia, dystonias
- > 3rd line (Tx resistant) = Clozapine
- ‘Dirty’ drug which is hard to manage
- Risk of agranulocytosis so requires frequent monitoring
PSYCHOLOGICAL:
- > CBT - to all patients, at least 16 sessions and emphasis on testing reality
- > Family therapy - if needed, especially if young, at least 10 sessions and help control emotions and family to cope
SOCIAL:
- Social skills training
- Education
- Benefits, housing
- MDT support - psych nurse, care coordinators, organisations, OT/PT
+ MONITORING
Why is monitoring important in schizophrenia and what is monitored?
Monitoring - can continue with GP/CMHT in community
Baseline measurements before starting antipsychotics
- > weight, waist, pulse and BP, bloods - FBC, U&Es, LFTs, lipids, HbA1c, fasting BM, prolactin
- > Assessment of any movement disorders, nutritional status/diet/physical activity
- > ECG if CV risk factors or recommended by chosen medication
Continued monitoring:
- Response to Tx and side effects
- Adherence (can be low, and this is associated with high relapse rate)
- Overal physical health
- Movement disorders
- start at 1,2,3,4,5,6, 12w to annual monitoring (obs, weight and waist)
What are some good and bad prognostic factors for schizophrenia?
Good - sudden onset, late, stressful event, no FHx, higher IQ
Bad - gradual onset, early, lack of precipitant, FHx, low IQ
What is the definition of schizoaffective disorder?
A group of disorders in which both affective and schizophrenic (psychotic symptoms) are prominent equally (50:50) but do not justify a full Dx of either schizophrenia or depressive/manic episodes
How may patients with schizoaffective disorder present? How long must Sx be present?
Manic type:
- both schizophrenic and manic symptoms prominent
- may be single episode or recurrent disorder (w majority manic episodes)
- develop at same time
Depressive type:
- both schizophrenic and depressive symptoms prominent
- may be a single episode or recurrent disorder (majority depressive episodes)
- develop at same time
How would you Ix schizoaffective disorder?
Ix:
- [same as schizophrenia]
- Full/Collateral Hx
- MSE and physical exam
- Urine drug screen
- Bloods - FBC, TFTs, HIV/Syphilis tests
- CT/MRI/EEG if required
How would you manage schizoaffective disorder? (acute vs chronic)
Mx [Same as schizophrenia if the affective component is not being controlled]
note: if BPAD = fluoxetine and olanzapine, 2nd line = lamotrigine
Urgent emergency - crisis resolution team/home treatment team (or admission if:)
- Suicide/homicide risk
- Lack capacity
- Severe sx (psychotic, depressive or catatonic)
- Failure of OPD treatment
- Address co-morbid conditions
- Significant medication changes
Non-urgent emergency - refer to early intervention (EIP) team (>14yo)
- > Aims to keep duration of untreated psychosis <3m
- > Tx with antipsychotics and psychosocial interventions
Rapid tranquillisation
- > 1st line = oral -> IM Haloperidol
- > 2nd line = 5mg Haloperidol + 1mg Lorazepam
BIOLOGICAL:
[Long-term:]
-> 1st line = atypical antipsychotic for 6w = usually low-dose Aripiprazole OR high-dose Olanzapine + education and support
note: LESS strong + fewer SE = Aripiprazole (initial akasthia), Quetiapine (sedation, weight gain)
STRONGER + more SE = Olanzapine (weight gain), Risperidone (hyperprolactinaemia, EPSEs, sedation)
-> +++ Augment with mood stabiliser (Li, lamotrigine)
IF non compliant then once-monthly depot injection (zuclopenthol decanoate 200mg)
-> 2nd line = 6w of typical antipsychotic (Haloperidol, Chlorpromazine) or different atypical - SE = EPSE, hyperprolactinaemia, dystonias
- > 3rd line (Tx resistant) = Clozapine
- ‘Dirty’ drug which is hard to manage
- Risk of agranulocytosis so requires frequent monitoring
PSYCHOLOGICAL:
- > CBT - to all patients, at least 16 sessions and emphasis on testing reality
- > Family therapy - if needed, especially if young, at least 10 sessions and help control emotions and family to cope
SOCIAL:
- Social skills training
- Education
- Benefits, housing
- MDT support - psych nurse, care coordinators, organisations, OT/PT
+ MONITORING
