Psychosis

Question 0

Incidence of schizophrenia

Answer 0

Life time incidence: 1%, typical onset 15-45 (18-25 commonly)
Overall risk is even for men and women, but men are affected earlier and more severely

Question 1

Schizophrenia

Answer 1

A psychotic illness where there is a loss of contact with reality (hallucinations and delusions) and a disordering of thought

Question 2

Aetiology of schizophrenia

Answer 2

Genetic
Obstetric factors
Substance misuse
Lifestyle factors

Question 3

Genetic factors in schizophrenia

Answer 3

10x increased for 1st degree relatives, 48% risk if both parents have schiz
MZ twin concordance is 40-50%, DZ twin 10-20%
Rarely single genes may cause (DISC1/2)
Likely multiple risk genes overlapping with other mental illnesses

Question 4

Obstetric factors in schizophrenia

Answer 4

Maternal malnutrition and illness during pregnancy, particularly 2nd trimester increase risk -> viral infections, pre-eclampsia, low birth weight, emergency C section
Schiz is more likely in people born in winter months

Question 5

Substance misuse in schiz

Answer 5

LSD, amphetamines, cocaine and cannabis all produce psychotic states
Cannabis increases risk in people with the valine allele of the COMT enzyme
Greatest vulnerability is as a teenager, and it shows a doses response with amount/strength smoked

Question 6

Socioeconomic factors in schizophrenia risk

Answer 6

Higher prevalence of schiz in lower SES adults which isn’t true for status at birth, indicating downward social drift
Prevalence is also twice as high in urban areas for similar reasons

Question 7

Migration and ethnicity factors in schizophrenia risk

Answer 7

1st and 2nd generation immigrants show a 3x higher risk of schiz compared to natives.
This varies with populations with black Caribbean and African populations showing the highest rates (4-6x risk compared to white British) –> not understood why

Question 8

Adverse life experiences in schiz risk

Answer 8

Sexual or physical abuse increases the risk of schizophrenia (Read et al 2005)
Psychological treatment for this may be an important part of the management

Question 9

Premorbid personality in schizophrenia

Answer 9

1/4 patients with schiz will have had premorbid schizoid personality preceding development of schizophrenia
Schizotypal disorder is also commonly associated, possibly due to a shared genetic basis

Question 10

Theories of schizophrenia

Answer 10

Neuro-developmental theories
Neuro-transmitter theories
Psychological theories

Question 11

Neurodevelopmental theories of schizophrenia

Answer 11

Schiz pts have enlarged ventricles and smaller, lighter brains –> but no gliosis indicated it is not degenerative
Premorbid low IQ and learning, memory and executive function.
This may then interact with factors during development to lead to overt schizophrenic symptoms

Question 12

Neurotransmitter theories of schizophrenia

Answer 12

The dopamine hypothesis argues that mesolimbic DA over-activity is responsible for positive symptoms and negative symptoms are due to mesocortical DA under-activity
All antipsychotics are D2 antagonists, and work best on positive symptoms - DA agonists also produce psychosis

Question 13

Psychological theories of schizophrenia

Answer 13

These argue that deficits in thinking producing a tendency to jump to conclusions and form overly valued ideas is the source of delusions.
Delusions may also develop out of the desire to rationalise hallucinations –> aberrant salience hypothesis

Question 14

High expressed emotion

Answer 14

This is a type of familial relationship where relatives are highyl critical or overly involved in the persons life
Kavanagh 1992 showed that this was an important factor in schizophrenic relapse, but did not cause schizophrenia.

Question 15

Progression of schizophrenia

Answer 15

At risk mental state / prodrome
Acute phase –> characterised by positive symptoms
Chronic phase –> negative symptoms are more obvious
It is now known that this is not a fixed chronological progression and negative symptoms may predate positive

Question 16

Prodromal state/at risk state

Answer 16

This indicates people at high risk of developing schizophrenia, but it is not inevitable
Low grade negative symptoms –> lack frank psychosis
May deny vague positive symptoms for fear of their significance

Question 17

Positive symptoms of schizophrenia

Answer 17

Hallucinations
Delusions
Thought disorder

Question 18

Negative symptoms of schizophrenia

Answer 18

Apathy or avolition 
Flattened or blunted affect
Anhedonia
Poverty of movement, thought and speech
Social withdrawal

Question 19

Hallucinations

Answer 19

A percept without a stimulus, as opposed to an illusion which is a mis-interpretation of stimulus.
As all perception is interpretation this distinction is of limited use
Can be of any modality but most commonly auditory 2nd/3rd person –> may be arguing, commentary, to you or thought echo

Question 20

Delusions

Answer 20

A fixed, usually false over-valued idea or belief which is not culturally explicable
May be delusional perception, passivity phenomena or thought interference

Question 21

Delusional perception

Answer 21

A real perception is used to reach an entirely delusional conclusion
The sky was red so my wife is cheating on me

Question 22

Passivity phenomena

Answer 22

Can be of thought, affect, impulse, sensation or movement
‘I’m angry but its not my thoughts’
‘They are making my arms move’

Question 23

Thought interference

Answer 23

The patient believes that their thoughts are being controlled:
Withdrawal–> ‘people keep plucking the thoughts from my head’
Insertion–> ‘the aliens are putting thoughts in my head’
Broadcast–> ‘people are listening to my thoughts’

Question 24

Formal thought disorder

Answer 24

The form and organisation of thoughts is disrupted There is loosing of associations and vagueness may progress to full 'word salad' This may progress to poverty of thought where few thoughts are had at all

Question 25

Acute phase of schizophrenia

Answer 25

Striking and florid psychosis Hallucinations and delusions, patient may appear manic, distracted or paranoid --> thoughts may be very disordered Negative symptoms can also be present but are less visible

Question 26

Thought echo

Answer 26

An auditory hallucination where the patient hears a voice echoing all there thoughts

Question 27

2nd person auditory hallucinations

Answer 27

Where a voice is talking to you Almost always distressing and ego-dystonic (against the patient) May tell them to do something This may underly much of the crime committed by schizophrenics

Question 28

3rd person auditory hallucinations

Answer 28

Often a conversation between two people about you May also be a commentary --> major risk of suicide Generally unpleasant and ego-dystonic

Question 29

Pseudohallucinations

Answer 29

These are voices heard by the patient, but within their own mind, and usually the voices of people they know (eg parents or partner) Usually not schizophrenic but may be due to anxiety disorders

Question 30

Chronic phase

Answer 30

After acute psychotic episodes some patients do not recover but remain ill in a 'burnt out' state where negative symptoms are much more prominent This is easy to confuse with post-psychosis depression, schizoaffective disorder or side effects from medication

Question 31

Paranoid schizophrenia

Answer 31

Most common type with hallucinations and delusions which will have a paranoid/persecutory element, such that there is a complex and absurd set of beliefs about who and why people want to hurt them Can lead to violence

Question 32

Catatonic schizophrenia

Answer 32

``` Dominated by psychomotor disturbances: Stupor/general catatonia Excitement/motor hyperactivity Posturing, rigidity and waxy flexibility Preservation and obedience ```

Question 33

Waxy flexibility

Answer 33

A type of psychomotor disturbance: The patient is offers no resistance to positioning, and will hold uncomfortable positions for hours (cataplexy) It may co-occur with rigidity (holding a posture rigidly against pressure) or posturing (assuming & maintaining bizarre positions)

Question 34

Hebephrenic schizophrenia

Answer 34

Early onset between 15-25 Lacking prominent hallucinations or delusions but significantly disorganised and chaotic mood, behaviour and speech Affect is labile, inappropriate and superficial The patients behaviour may seem aimless

Question 35

Simple schizophrenia

Answer 35

Negative symptoms only without ever having had positive psychosis

Question 36

Residual schizophrenia

Answer 36

The prominent negative symptoms that remain after positive symptoms subside

Question 37

First rank symptoms of schizophrenia

Answer 37

First described by Schneider Auditory hallucinations --> 3rd person conversation, running commentary, or Thought echo Delusions--> delusional perception, passivity or thought interference

Question 38

Differential diagnosis for schizophrenia

Answer 38

``` Organic causes of psychosis Acute/transient psychotic episode Mood disorders Or Schizoaffective disorder Persistent delusional disorder Schizotypal personality disorder ```

Question 39

Organic causes of psychosis

Answer 39

In the elderly dementia or delirium Temporal lobe epilepsy Substance misuse/withdrawal (alcohol, amphetamine, LSD, ecstasy, ketamine or PCP) or (steroids, DA agonists) Brain tumour, stroke, HIV, Wilson's disease, neurosyphillis

Question 40

Acute and transient psychotic episode

Answer 40

Presents identically to schizophrenia but resolves within a few months

Question 41

Mood disorders

Answer 41

Both depression and mania, when severe enough can cause psychosis Schizophrenia should not be diagnosed unless it preceded the affective symptoms

Question 42

Schizoaffective disorder

Answer 42

Occurs when schizophrenic and affective symptoms occur to a roughly equal level at roughly equal time. A questionable diagnosis as each set of symptoms can lead to the other secondarily and the two syndromes can co-occur

Question 43

Persistent delusional disorder

Answer 43

A syndrome where the patient suffers from persistent delusions but few if any hallucinations

Question 44

Schizotypal personality disorder

Answer 44

A cluster A personality disorder A lifelong state of eccentricity with abnormal thoughts and affect May be cold, aloof and suspicious Do not show definite symptoms of schizophrenia but may develop it later

Question 45

Schizoid personality disorder

Answer 45

A type A personality disorder It presents as people who are anhedonic, limited emotional range, socially isolated but this doesn't concern them. Little interest in sexual or close relationships Usually have extensive fantasy world

Question 46

Antipsychotic medications

Answer 46

All have D2 receptor antagonism --> linked to efficacy of positive symptom block Extra pyramidal side effects are inevitable with higher levels of DA block but are rarer with atypical antipsychotics --> each drug has other side effects based on actions at other receptors

Question 47

'Typical' antipsychotics

Answer 47

Old drugs such as --> chlorpromazine, haloperidol and flupentixol Cause significant EPSEs Widely used because they are cheap and can be given as depot doses

Question 48

'Atypical' antipsychotics

Answer 48

Newer drugs which lacks the EPSEs and don't tend to raise prolactin levels but still have significant side effects Still block D2 receptors but also block 5HT2 receptors Olapzepine, amisulpride, risperidone, quetiapine, aripiprazole, clozepine

Question 49

Atypical antipsychotics are generally used for

Answer 49

First line treatment for new onset psychosis If there are unacceptable side effects from typical APs or if the patient tends to relapse when on typical APs Risperidone can be given as a depot injection

Question 50

Antipsychotic side effects

Answer 50

Extrapyramidal & anticholinergic side effects or NMS Hyperprolatinaemia (mainly in typical antipsychotics) Weight gain (esp. Olanzepine & clozapine) and hyperlipidaemia Sedation and increased diabetes risk Arrhythmias and seizures (clozapine)

Question 51

NMS (Neuroleptic malignant syndrome)

Answer 51

A rare and serious response to DA block causing dystonia, altered consciousness and autonomic disregulation Raised creatine kinase and WCC --> may die from AKI or rhabomyolyisis Require stop of AP and ICU treatment

Question 52

Extra pyramidal side effects

Answer 52

Dystonia --> an involuntary, painful muscle spasm Akathisia --> an unpleasant feeling of internal restlessness Parkinsonism--> resting tremor, rigidity and bradykinesia Tardive dyskinesia--> involuntary, rhythmic movements of limbs or face including grimaces or sucking movements

Question 53

How do you treat EPSEs?

Answer 53

Earliest onset side effects,dystonia, treat with anti-Ach (procyclidine) --> Later onset akathisia (Tx with B-blocker or benzos) or Parkinsonism (anti-Ach procyclidine) or both by lowering or changing AP, this can also work for tardive dyskinesia but anti-Ach make worse and may be irreversible

Question 54

Types of dystonia

Answer 54

Torticollis --> neck is twisted to one side Oculogyric--> eyes twist up so patient cannot look down Other rarer types may occur

Question 55

If a patient is on anti-psychotic what should you monitor?

Answer 55

Generally: BP, FBC, U+E, lipids and diabetic screens BMI and waist size for olanzepine or clozapine Prolactin levels in typical AP or risperidone ECG to monitor QTc interval in patients who are elderly or middle aged or on clozapine/high doses

Question 56

Clozapine

Answer 56

An atypical antipsychotic It is used as a drug treatment for treatment resistant schizophrenia It can work when everything else has failed but has a 0.7% risk of agranulocytosis, must be monitored and 3% must stop clozapine

Question 57

Treatment resistance

Answer 57

Failure to respond to 2 or more antipsychotics, at least 1 of which must be atypical, each given at therapeutic dose for at least 6 weeks

Question 58

Psychological management for schizophrenia

Answer 58

CBT --> should be offered, with an emphasis on reality testing Family therapy --> reduces relapse rates, useful for reducing high expressed emotion in families Concordance therapy --> pt is encouraged to think and make choices about their management

Question 59

Suicide risk in schizophrenia

Answer 59

10% lifetime Risk is highest in intelligent young men with good premorbid functioning, after the first episode and in the presence of depressive symptoms Also at risk of self harm, neglect, social decline and exploitation

Question 60

Risk of violence in schizophrenia

Answer 60

Only a problem in a subgroup of patients <10% of violent crimes in Britain are committed by a mentally ill person Risk factors: Hx of violence, drug use, acute psychosis, non-compliance, specific threats to victim, access to weapon, PD

Question 61

Risk from others to schizophrenic patients

Answer 61

Patients with schizophrenia are 14 times more likely to be victims of a violent crime than be arrested for one