Psychosis & Schizophrenia Flashcards
What is psychosis?
Psychosis is a phenomenon where a person experiences a loss of perception or reality
What may features of psychosis look like?
Delusions
Disorganised Thoughts
Hallucinations
What manifestation of psychosis is expressed in speech by patient?
Delusions
NOTE: Expressed in speech by patient (content of the speech)
Types of delusions seen in psychosis
What is cotard delusion?
rare condition marked by the false belief that you or your body parts are dead, dying, or don’t exist.
Example of a persecutory delusion
Thinking someone is trying to kill you
Example of a somatic delusion
Thinking there are cockroaches on you
Example of a grandoise delusion
Thinking you are the prime minister
Example of a delusion of reference
Thinking someone/something is talking to you/is a sign meant for you
Example of an erotomaniac delusion
Thinking a celebrity is in love with yu
Example of a delusion of control
Thinking your body is in control by someone else
What manifestation of psychosis is shown by the pattern of the speech rather than the content?
Disorganised thoughts
Types of disorganised thoughts seen in psychosis
Alogia = poverty of speech (speak less)
Thought-blocking = sudden, abrupt stop while talking (say something then stop mid-sentence)
Loosening of association = jump from one idea to another
Tangentiality = diverging from one topic to another, usually there is a link e.g. how I feel, how the weather makes me feel, the weather yesterday
Clanging = use words that rhyme “The cow said wow”
Word salad = incoherence words that make no sense, might use neologisms
Perseveration = repeat words that don’t need to be repeated
Circumstantial speech = long, round-about answers to question, you will see that during rotation
What are the two most common types of disorganised thoughts?
Loosening of association and circumstantial speech
Alogia (disorganised thought seen in psychosis)
poverty of speech (speak less)
Thought-block (disorganised thought seen in psychosis)
sudden, abrupt stop while talking (say something then stop mid-sentence)
Loosening of association (disorganised thought seen in psychosis)
jump from one idea to another
Tangentiality (disorganised thought seen in psychosis)
diverging from one topic to another, usually there is a link e.g. how I feel, how the weather makes me feel, the weather yesterday
Clanging (disorganised thought seen in psychosis)
use words that rhyme “The cow said wow”
Word salad (disorganised thought seen in psychosis)
incoherence words that make no sense, might use neologisms
Perseveration (disorganised thought seen in psychosis)
repeat words that don’t need to be repeated
Circumstantial speech (disorganised thought seen in psychosis)
long, round-about answers to question
What are hallucinations?
Sensory perceptions without external stimuli
What psych condition are visual hallucinations often seen in?
Delirium
What psych condition are auditory hallucinations often seen in?
Schizophrenia
What psych condition are olfactory (smell) hallucinations often seen in?
Aura in temporal lobe epilepsy
What psych condition are Gustatory (taste) hallucinations often seen in?
None, they are rare.
NOTE: They are sometimes seen in people with epilepsy
What psych conditions are tactile (touch) hallucinations often seen in?
Alcohol withdrawal
Stimulant use
Relationship between psychosis and schizophrenia
Schizophrenia =/= psychosis. Psychosis is a phenomenon where a person loses touch with reality, such as in Schizophrenia, but can also occur due to drug-use, acute stress, extreme fatigue and a range of other conditions.
What are the 3 core features of schizophrenia?
Cognitive dysfunction
Positive symptoms i.e. psychosis
Negative symptoms
First-Rank symptoms of schizophrenia
Thought insertion, withdrawal and broadcasting
Delusional perceptions (and passivity phenomena)
Auditory hallucinations (3rd person, thought echo, running commentary)
What auditory hallucinations are seen in schizophrenia?
2nd person = talk to you
3rd person = talking about you
Running commentary = narrating your actions
Thought echo = hearing your thoughts being said out loud
How does cognitive dysfunction in schizophrenia present?
Reduced ability to understand or make plans
Diminished memory
Inattention
Examples of negative symptoms of schizophrenia
Blunted affect (objective) or incongruity (inappropriate emotions)
Alogia (objective decrease in speech) 🡪 paucity of speech
Avolition: no motivation or energy
Anhedonia: unable to enjoy things they used to
Asociality: lack of want for social interaction
Who does schizophrenia affect more?
Male
Lifetime prevalence of schizophrenia globally
1%
Suicide risk in schizophrenia
High risk of suicide: 5% of schizophrenic commit suicide, 10% of suicide are done by schizophrenic patients
What are delusions?
Persistent, false, fixed beliefs which cannot be explained by a cultural phenomenon normal for the patient
What delusions are seen in schizophrenia?
Delusions of thought interference: insertion, broadcasting, or withdrawal
Delusions of control/passivity: believing that thoughts, feeling or impulses are externally controlled
Types of delusions of thought interference
insertion, broadcasting, or withdrawal
What are delusions of control/passivity?
believing that thoughts, feeling or impulses are externally controlled
What is a common olfactory hallucination in schizophrenia?
burnt rubber
Examples of associated hallucinations seen in schizophrenia
olfactory (common, classically burnt rubber), somatic – (interference with their organs), elementary (hearing or seeing e.g. whistles, flashes, shadows), formication (feeling of insects crawling from cocaine) or visual (more common in organic psychoses)
How is cognition affected in schizophrenia?
reduced attention, processing speed, memory, executive function, social cognition.
What type of behaviour may be seen in severe schizophrenia? what is it?
Catatonic behaviour: strange or purposeless movement
How can schizophrenia be classified?
Paranoid
Hebephrenic
Catatonic
Undifferentiated
Post-schizophrenic depression
Residual schizophrenia
Simple schizophrenia
What type of schizophrenia is Dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations (particularly auditory) and perceptual disturbances?
Paranoid
What type of schizophrenia has affective changes which are prominent, and has a shallow and inappropriate mood? Who should it be diagnosed in?
Hebephrenic
Should only be diagnosed in adolescent or young adults
What type of schizophrenia is dominated by prominent psychomotor disturbances?
Catatonic schizophrenia
What type of schizophrenia has psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes (i.e. not showing a clear predominance for a particular set of characteristics)?
Undifferentiated
What type of schizophrenia presents with a depressive episode arising in the aftermath of a schizophrenic illness? What are they at iincreased risk of?
Post-schizophrenic depression, increased suicide risk
NOTE: Some schizophrenic symptoms may still be present, but they do NOT dominate the clinical picture. If there are no schizophrenic symptoms, a depressive episode can be diagnosed
What type of schizophrenia presents with long-term negative symptoms?
Residual
What type of schizophrenia presents with long-term negative symptoms without a psychotic symptom prodrome, and has progressive development of oddities of conduct?
Simple schizophrenia
NOTE: Insidious but progressive development of oddities of conduct, inability to meet the demands of society and a decline in total performance
Characteristic negative features of residual schizophrenia (e.g. blunted affect, loss of volition) develop without being preceded by overt psychotic symptoms
Investigations for schizophrenia
History and physical examination:
Prescribed drugs causing psychosis: anticonvulsants; high-dose corticosteroids; levodopa and dopamine agonists; opioids or illicit substances.
Neurological examination.
Beside:
ECG
Urine studies: drug screen, MSU (UTI delirium), STD
Bloods
FBC, U&Es, LFTs, CRP, Vitamin B12 + folate, TFTs
Screen for STDs
Plasma drug level monitoring: if already on these, to check concordance or within therapeutic range
Anti-NMDA blood test: rare autoantibody encephalitis causing psychosis and seizures
CT head: for first episode psychosis, to rule out an organic cause
EEG: Temporal lobe epilepsy
What prescribed drugs can cause psychosis?
anticonvulsants; high-dose corticosteroids; levodopa and dopamine agonists; opioids or illicit substances.
What bloods must be done when investigating schizophrenia?
FBC, U&Es, LFTs, CRP, Vitamin B12 + folate, TFTs
Screen for STDs
Plasma drug level monitoring: if already on these, to check concordance or within therapeutic range
Anti-NMDA blood test: rare autoantibody encephalitis causing psychosis and seizures
CT head: for first episode psychosis, to rule out an organic cause
Why do a CT head in schizophrenia?
for first episode psychosis, to rule out an organic cause
Why do an EEG in schizophrenia?
Temporal lobe epilepsy –> can cause hallucinations
Why do an anti-NMDA blood test in schizophrenia?
rare autoantibody encephalitis causing psychosis and seizures
What is the 1st thing to determine in management of schizophrenia?
Determine if inpatient or outpatient admission for safety
Biological management of schizophrenia if 1st episode
Distress, agitation, or anxiety: PO/IM Haloperidol or Lorazepam
PO atypical antipsychotic: olanzapine, risperidone, quetiapine, aripiprazole
Strong PMH/FH of DM, HTN, CVD: typical antipsychotics (reduced risk of metabolic SEs)
What to give if 1st presentation of distress, agitation or anxiety in schizo?
PO/IM Haloperidol or Lorazepam
What to give in 1st presentation of schizophrenia without distress, agitation or anxiety?
PO atypical antipsychotic: olanzapine, risperidone, quetiapine, aripiprazole
Examples of atypical antipsychotis
olanzapine, risperidone, quetiapine, aripiprazole
What to give in 1st presentation of schizophrenia with a strong PMH/FH of DM, HTN, CVD?
typical antipsychotics (reduced risk of metabolic SEs)
Management of schizophrenic patients who have deteriorated but have a prior diagnoses
Review current dose
Consider switching to depot – common in post-TBI psychosis
Pros: known compliance, predictable bioavailability, steady plasma levels, regular contact for monitoring
Cons: inflexible administration, longer duration if SEs, patient acceptability, injection site complications
PACES Pros and Cons of depot medication for schizophrenia that has deteriorated
Pros: known compliance, predictable bioavailability, steady plasma levels, regular contact for monitoring
Cons: inflexible administration, longer duration if SEs, patient acceptability, injection site complications
What is treatment resistance schizophrenia? What to give?
If symptoms not controlled on 2x atypical antipsychotics switch to Clozapine
When is Clozapine given in schizophrenia?
Treatment resistant schizophrenia, If symptoms not controlled on 2x atypical antipsychotics switch to Clozapine
PACES: Psychological support for schizophrenia
CBT: general or targeted - early use is beneficial in limiting impact & relapses and promotes early identification of an episode
Family support: education, counselling and therapy to improve communication within family, medication adherence and patient wellbeing
PACES: Social support for schizophrenia
Education
Early Intervention Service (after 1st episode), key worker allocation and MDT
CMHT support
Smoking cessation and substance misuse services
Employment services and benefits schemes
Group therapy: social skills training and cognitive rehabilitation for social functioning
Lifestyle: advice on exercise and diet
Who should be involved after the 1st episode of psychosis/schizophrenia?
Early intervention service, key worker allocation and MDT
How long do symptoms need to be present for in order to diagnose schizophrenia?
12 months
Examples of schizoprenia-like conditions
Schizophreniform disorder
Milder form of schizophrenia
Less than 6 months
Brief psychotic disorder:
Milder than schizophreniform disorder
Less than 1 month
Women > Men, following stressful life events e.g. death in the family, job loss
Delusional disorder:
One or more delusions, one month or longer but no other abnormal behavior
Folie a deux: close friends share delusion
What is schizophreniform disorder? How long does it last for?
Milder form of schizophrenia
Less than 6 months
What is a brief psychotic disorder? How long does it last for? Who does it affect most?
Milder than schizophreniform disorder
Less than 1 month
Women > Men, following stressful life events e.g. death in the family, job loss
What is a delusional disorder? How long does it last?
One or more delusions, one month or longer but no other abnormal behaviour
NOTE: Folie a deux: close friends share delusion
Schizophrenia that has lasted less than 6 months
Schizophreniform disoder
NOTE: if less than 1 months –> brief psycotic disorder
One or more delusions, for on emonth or longer with no other abnormal behaviour
Delusional disorder
