Psychosis/ Schizophrenia Flashcards
What is psychosis?
- An umbrella term. Just because you’ve experienced it doesn’t mean you have a mental illness
- Remember psychosis isn’t a diagnosis in its own right – you cant just label someone with it, it needs a cause
- The experience of being out of touch with reality, struggling to distinguish what is real from what is not. Not confined to mental disorder. Describes the experience of hallucinations, delusions and/or thought disorder
What can cause psychosis?
schizophrenia, depression, drug induced e.g. steroids/illicit, temporal lobe epilepsy, delirium, dementia, endocrine disorders, mania, sleep deprivation, sensory deprivation, bereavement, withdrawal states, temporal lobe epilepsy
What must you do if a patient has a first episode of psychosis?
must exclude organic causes. May ask for CT scan etc
What is the epidemiology of Schizophrenia?
- Prevalence of 1 %
- More common on males than females
- Peak onset in 20s for both genders, another peak post menopause in females
- Higher prevalence in immigrants
What is the genetic component in Schizophrenia?
o Identified genes which increase risk dysbindin (chrom 6p), neuregulin 1 (8p_ and G72 (13q)
o Moszygotic twins = 50 % risk
What is the dopamine hypothesis in schizophrenia?
o Says that increased dopamine can lead to psychosis
o This means that dopamine agonists such as L-dopa and amphetamines can cause schizophrenia like symptoms
o Thus treatment = dopamine antagonists - anti psychotics
What are the environmental factors in schizophrenia?
o Developmental factors - obstetric complications, head injury, encephalitis, winter/spring births
o Adverse life events - abuse, tense relationships, isolation, discrimination, poor housing
o Expressed motion - critical, hostile or emotional involved over involved attitudes directed to the schizophrenia sufferer by their relatives/carers
o Cannabis and other drug use, cannabis smoking under age of 15 shown to increase risk of schizophrenia 6x (amphetamines, ecstasy and cocaine also associated)
What are schneiders first rank Sx?
- Auditory Hallucinations
a. Third person = voices discuss or argue about the patient.
b. Running commentary = voices comment on the patients thoughts and behaviour.
c. Gedankenlautwerden and thought echo = the patients thoughts are heard as formed(Gedankenlautwerden) or shortly after they are formulated (echo). - Thought interference
a. Thought insertion = alien thoughts are put into the patients mind by an external agency.
b. Thought withdrawal = thoughts are removed form the patients mind by an external agency.
c. Though broadcasting = the patients thoughts are overheard by, or otherwise accessible to, others. - Delusions of control/ passivity
a. Passivity or affect, volition and impulses = the patients affect, impulses and volition are under the control of an external agency.
b. Somatic passivity = the patients bodily sensations are under the control of an external agency. - Delusional Perception = the patient attributes delusional significance to normal percepts.
What is the ICD 10 criteria for schizophrenia?
A minimum of one very clear symptoms (two or more if not clear cut) from groups (a – d) or symptoms from at least two of the groups (e-h).
• These symptoms should have been present for most of the time during a period of one month or more (if present for less than one month = acute schizophrenia like psychotic disorder).
• A) Thought echo, insertion, withdrawal or broadcasting.
• B) Delusions of control, influence, passivity, delusional perception.
• C) Hallucinatory voices of running commentary, 3rd person discussion or other types of voices coming from some part of the body.
• D) Persistent delusions of other kinds.
• E) Persistent hallucinations in any modality if accompanied by fleeting or half formed delusions that are not affective delusions or overvalued ideas or occurring every day for months,
• F) Breaks in train of thought, resulting in incoherence, irrelevant speech or neologisms.
• G) Catatonic behaviour excitement, posturing, waxy flexibility, negativisim, mutism, stupor.
• H) ‘Negative symptoms’ Apathy, paucity of speech, blunting or incongruity of emotional responses, social withdrawal not due to depression or neuroleptic medication.
I) Significant and consistent change in overall quality of some aspects of personal behaviour manifest as loss of interest, aimlessness, idleness, a self absorbed attitude and social withdrawal
When should schizophrenia not be diagnosed?
Schizophrenia should not be diagnosed in the presence of extensive depressive or manic symptoms, unless schizophrenic symptoms clearly pre-date the affective disturbance. If both schizophrenic and affective symptoms develop together and are evenly balanced, the diagnosis of schizoaffective disorder (F25.-) should be made – even if the schizophrenic symptoms by themselves would have justified the diagnosis of schizophrenia.
Schizophrenia should not be diagnosed in the presence of overt brain disease (including epilepsy) or during states of drug intoxication, use of psychoactive substances or withdrawal.
What are the positive Sx in Schizophrenia?
Hallucinations
Delusions
Thought disorder
What are the negative symptoms in schizophrenia?
6 As
Avolition = lack of motivation
Anhedonia = unable to experience pleasure
Alogia = poverty of speech
Asociality = lack of desire for relationships
Affect blunting = don’t express emotion
Apathy
Which are better - positive or negative Sx?
- Negative symptoms are less noticeable but indicate a worse prognosis
- Positive symptoms respond better to treatment
What is a typical MSE of a schizophrenic patient?
• Appearance and Behaviour
This can be completely normal but classical presentations inc. perplexity, social awkwardness, withdrawal and odd behaviours such as smiling in response to no apparent stimuli.
o Impulsivity along with over aroused behaviours can occur as can aggression, but this is less common than a pattern of withdrawal.
• Speech
o In the acutely ill patient this can be difficult to follow reflecting thought disorder.
o Just as common is poverty of speech (not just in relation to quantity but also poverty of ideas and vocabulary).
o Classically described are neologisms (made up words – sometimes a condensation of more than one word)
• Mood
o Mood changes are common.
o There are three main types that occur.
o Blunting of affect where emotional responsiveness is flattened or absent leading to the patient appearing indifferent to events.
o Mood changes such as depression (relatively common in the acute phase) and euphoria/elation.
o Incongruous mood where the emotional response is not in keeping with the trigger (e.g. smiling when describing sad or upsetting events)
• Thought Form
o The train of the patients thoughts may be difficult to follow, the ideas expressed may be ‘concrete’ reflecting impaired abstract thought or the links between ideas expressed may be tenuous or incomprehensible (loosening of associations).
o Other observed abnormalities may include thought block where the patient suddenly stops speaking mid sentence and has the subjective experience of their thought coming to an abrupt halt.
• Thought Content
o Delusions are common.
o Although primary delusions are classical they are not common.
o Much more frequently seen are secondary delusions.
o These are commonly persecutory but may be grandiose, delusions of reference (where external events have a direct and special meaning for them), delusions of external control (may be called passivity phenomena) or delusions of thought alienation.
o The latter covers thought broadcasting, thought withdrawal and thought insertion.
• Perceptions
o The most common hallucinations are auditory.
o Hallucinations can occur in any sensory modality.
o Delusional interpretation of hallucinations is common.
What investigations should you do in schizophrenia?
- Full history and MSE (in particular identify delusions, hallucinations, thought disorder)
- Check for clouding of consciousness ?delirium
- Full physical (inc. neurological) examination.
- Serum/urine drug screen.
- FBC, U&Es, LFTs, TFTs, HbA1c, Lipids.
- Brain imaging/EEG if organic causes suspected.
- Social assessment: housing, work etc.
