Psychotic Disorders Flashcards
1
Q
What are Schneider’s 1st rank symptoms?
A
- Delusions
- Passivity (delusions of control)
- Thought disorder:
- Thought insertion - thoughts being placed into my mind
- Thought withdrawal - thoughts being removed from my mind
- Thought broadcasting - everyone knows what you are thinking
- Auditory disorder:
- Thought echo - hearing my thoughts out loud
- 3rd person voice - ‘no one like’s her, she’s useless’
- Running commentary - ‘now he’s falling asleep, and she’s calling a cab’
2
Q
Define schizophrenia.
A
Severe mental illness characterised by disintegration of the process of thinking, contact with reality, and emotional responsiveness.
3
Q
What is the ICD-10 definition of schizophrenia?
A
-
≥1 Schneider’s 1st rank symptoms of a duration ≥1-month
- (1) Delusions (false and fixed beliefs)
- (2) Passivity (delusions of control)
- (3) Thought disorder:
- (4) Auditory disorder:
_______OR_______
-
≥2 of the following; AND
- Paranoid - persistent hallucinations in any modality
- Hebephrenic - incoherent or irrelevant speech (i.e. neologisms, Knight’s move thinking)
- Catatonic - catatonic behaviour – excitement, posturing, waxy flexibility, negativism, mutism, stupor
- Simple - negative symptoms – apathy, paucity of speech, blunted/incongruent emotional response
- Present, most of the time, ≥1 month; AND
- Not caused by substance use or organic disease
4
Q
Define hebephrenic.
A
Incoherent/Disorganised or irrelevant speech
- neologisms
- Knight’s move thinking
5
Q
Describe the clinical pattern of schizophrenia?
A
-
Prodrome/At-Risk Mental State = -ve symptoms dominant
- Teens to early 20s:
- Social withdrawal
- Loss of interest in work and relationships
-
Acute phase = +ve symptoms dominant
- Delusions
- Hallucinations
- Thought interference (insertion, withdrawal, broadcast to public)
- Passivity
-
Chronic phase = -ve symptoms dominant
- Apathy
- Anhedonia
- Loosening of Association
- Blunted affect
- Poverty of thought/speech (devoid of thoughts/speech)
- Social withdrawal
- Loss of motivation
6
Q
What are the sub-types of schizophrenia?
A
- Paranoid - most common
- Hebephrenic/Disorganised
- Catatonia
- Simple
7
Q
What are the key features of paranoid schizophrenia?
A
- Prominent delusions
- Prominent hallucinations
8
Q
What are the key features of hebephrenic schizophrenia?
A
- Disorganised mood and speech
- Neologisms
- Knight’s move thinking
9
Q
What are the key features of catatonic schizophrenia?
A
- Psychomotor disturbance
- Stupor
- Waxy flexibility - retain any shape you put them into
- Automatic obedience
- Forced grasping - shaking a hand when specifically told not to
- Opposition - same as above
10
Q
What are the key features of simple schizophrenia?
A
- Only negative symptoms
- Apathy
- Blunted affect
- Social withdrawal
- Anhedonia
- Poverty of thought
- Loss of motivation
- Loosening of association
11
Q
What is the average age of onset of schizophrenia?
A
- 15-45
- Late 20s for men
- Early 30s for women
12
Q
What is waxy flexibility?
A
A decreased response to stimuli and a tendency to remain in an immobile posture.
13
Q
What are the biological risk factors for schizophrenia?
A
- Genetics - mulitple susceptible genes
- monozygotic twin concordance = 50%
- Obstetric complications
- Prenatal malnutrition
- Prenatal viral infections
- Pre-eclampsia
- LBW
- Emergency C-section
- Substance misuse
- Val allele = +ve symptoms (even more likely hallucination with cannabis)
- Met allele = -ve symptoms
- Neurodevelopmental
- Enlarged ventricles = smaller brains, lower premorbid IQ
- Early brain damage not obvious at first but becomes more obvious as brain matures
14
Q
What are the psychosocial risk factors for schizophrenia?
A
- Social disadvantage
- Urban life and birth - 2x higher
- Migration - 1st and 2nd generation
- Black Caribbean or African - 4-6x higher
- High expressed emotion/highly envolved relatives - increased relapse risk
- Premorbid schizoid
- Adverse life experiences - sexual or physical abuse
- Fear of madness
- Tendency to jump to conclusions
15
Q
Name and breifly describe 3 biological hypothesis of schizophrenia?
A
- DA hypothesis
- +ve symptoms = increased DA in mesolimbic tract
- -ve symptoms = decreased DA in mesocortical tract
- 5-HT hypothesis- overactivity
- Glutamate hypothesis - dysregulation
16
Q
What investigations hsould be done for suspected schizophrenia?
A
- Collateral History
- Physical examination
- Bloods (FBC, U&E, lipids, LFT, VDRL, 5-HIAA)
- Urine (Drugs Screen, MSU)
- MRI - hypofunction in the pre-frontal cortex
- Rating Scale – Brief Psychiatric Rating Scale
- ADL Assessment and Housing and Finance
17
Q
What differences are found in an MRI of schizophrenic patient?
A
Hypofunction in the pre-frontal cortex
18
Q
WHat differentials should be included for suspected schizophrenia?
A
- Organic – substance misuse, dementia, delirium, epilepsy, steroids, tumours, medication withdrawal etc.
- Acute/transient psychotic episodes – psychosis doesn’t mean you are schizophrenic
- Mood disorder – depression and mania; check order of symptoms
- Schizoaffective disorder – schizophrenic and affective symptoms develop together and are balanced
- Persistent delusional disorder – only delusions
- Schizotypal disorder – eccentricity with abnormal thoughts (not full schizophrenia)
19
Q
What is Schizotypal disorder?
A
Eccentricity with abnormal thoughts - not full schizophrenia/milder symptoms
20
Q
What are the indications for admission for schizophrenia?
A
- Suicide/homicide risk
- Severe symptoms (psychotic, depressive or catatonic)
- Lack capacity
- Significant medication changes
- Address comorbid conditions
21
Q
Why is early intervention for psychosis important?
A
- Psychosis is neurotoxic
- The longer a patient is psychotic, the more it will affect them
- Early treatment leads to a better prognosis
- Aim to keep Duration of Untreated Psychosis <3 months
22
Q
What is the biological treatment of schizophrenia?
A
-
1st line (6 weeks): Atypical antipsychotic – “Start low, go slow”:
- Less strong, less side effects = Aripiprazole , Quetiapine
- Stronger, more side effects = Olanzapine, Risperidone
- Start with low-dose aripiprazole/high-dose olanzapine + education and support
- Augmentation
- BDZ (i.e. diazepam) if non-acute anxiety
- Mood stabiliser (lithium, anticonvulsant) if schizoaffective disorder suspected
- Non-compliance = once-monthly IM depot injection (i.e. zuclopenthixol decanoate 200mg depot injection; ‘Clopixol’)
- 2nd line (6 weeks): Typical antipsychotics
-
3rd line/Treatment resistance: Clozapine
- Tx-failure = failure to respond to ≥2 antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
- Clozapine is a dirty drug that is hard to manage so should be avoided if possible
23
Q
What psychological treatments can be used in schizophrenia?
A
-
CBT - offer to all patients, regardless of level of schizophrenia
- At least 16 sessions
- Emphasis on testing reality
- i.e. If the Prime Minister is watching you, how do they find time to run the country?
-
Family therapy - if needed; especially if young
- At least 10 sessions
- To help control the highly expressed emotions of schizophrenia (helps family cope)
24
Q
What social treatments can be used in schizophrenia?
A
25
What has to be risk assessed in a schizophrenic person?
* **To self** = suicide, neglect, social decline
* **To others** = violence hx, substance misuse, non-concordance, specific threats
* **From others** = victim of crime, discrimination
26
What baseline tests should be done before starting an anti-psychotic?
* **Basic obs**: weight, waist circumference, pulse and BP
* **Bloods**: FBC, U&E, LFTs, fasting BM, HbA1c, lipid profile, prolactin, (more frequent if on clozapine)
* **Assessment of any movement disorders**
* **Assessment of nutritional status:** diet and physical activity (incl. CVD assessment)
* **ECG** (if cardiovascular risk factors present or recommended by the chosen medication)
27
When should monitoring for patients on anti-psychotics start following on from initiation?
* 1, 2, 3, 4, 5, 6 weeks = weight, waist
* 12 weeks = weight, waist, HR, BP
* Annually = weight, waist, HR, BP
* Annual monitoring from now on
28
What should be monitored for patients on anti-psychotic medication?
* Response to treatment and side-effects
* Emergence of movement disorders
* Adherence
* Overall physical health
* Basic obs
* Weight and waist circumference (weekly for 6 weeks, at 12 weeks, annual thereafter)
* Pulse and BP (at 12 weeks, annual thereafter)
* Patients on anti-psychotics have a high CVD risk
29
What is the prognosis of schizophrenia?
* **Good prognostic indicators**
* **S**udden, late onset
* Onset following a stressful event
* No FHx
* Higher IQ
* **Bad prognostic indicators**
* Gradual, early onset
* Lack of precipitant
* FHx
* Low IQ
30
Define 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 diagnosis of either schizophrenia or depressive/manic episodes
31
What is manic schizoaffective disorder?
* Both schizophrenic and manic symptoms prominent
* Develop at the _same_ time
* Single episode, or recurrent disorder (majority manic episodes)
32
What is depressive schizoaffective disorder?
* Both schizophrenic and depressive symptoms prominent
* Develop at the same time
* Single episode, or recurrent disorder (majority depressive episodes)
33
What are the defining features of schizoaffective disorder according to DSM-V?
* Psychotic states to persist for ≥2 weeks without concurrent affective symptoms
* Requires 2 episodes of psychosis
* 1 episode lasting \>2w without mood disorder symptoms
* 1 episode requires obvious overlap of mood and psychotic symptoms
34
How is schizoaffective disorder managed?
* Treat as schizophrenia
* Add a mood stabiliser if affective component isn't well controlled
35
Define acute psychosis.
Sudden onset psychosis that resolves in \<3 months.
- Tend to lack insight
36
What are the symptoms of acute psychosis?
* Psychosis/Same as +ve schizophrenia
* Delusions
* Hallucinations
* Thought interference (insertion, withdrawal, broadcast to public)
* Sense of being controlled (passivity)
37
What are differentials should be considered for suspected acute psychosis?
* Organic – dementia or delirium
* Substance misuse (steroids)
* Schizophrenia
* BPAD
* Depression
* Personality disorder
38
What are the biological and psychosocial treatments of acute psychosis?
* Biological:
* Short term antipsychotics/BDZ (acute behavioural disturbance)
* 1st line = low dose aripiprazole
* Antidepressants/mood stabilisers useful to prevent relapse
* Stop offending medication that is causing psychosis
* Psychosocial:
* Specific social issues
* Reality-oriented/adaptive/supportive psychotherapy
39
What is the prognosis of acute psychosis?
* Better prognosis
* Short interval between onset and full-blown symptoms
* Perplexity or confusion
* Good premorbid social and occupational functioning
* Blunted affect
* Relapse common
* Increased risk of suicide
40
What is delusional disorder?
* Persistent/life-long (≥3 months) delusions with few/no hallucinations
* Cannot include:
* Clear auditory hallucinations
* Schizophrenic symptoms (delusions of control, blunting of affect)
* Evidence of organic/brain disease
41
What are the risk factors for delusional disorder?
* Old age
* Social isolation
* Group delusions
* Low socioeconomic status
* Premorbid personality disorder
* Sensory impairment
* Immigration
* FHx
* Head injury
* Substance abuse
42
What onset of delusional disorder has a better prognosis?
Acute or insidious
43
What are the biological causes of delusional disorder?
* Excess DA and ACh activity
* Neurological lesions to temporal lobe, limbic system, GB
* Cortical damage - persecutory delusions
44
What are the psychosocial causes of delusional disorder?
* Freud - delusions serve defensive functions
* Distrustful/Suspicious/Jealous
* Low self-esteem
* Social isolation
* Seeing own defects in others
* Rumination over meaning and motivation
45
What are the signs and symptoms of delusional disorder?
* Appearance and behaviour = Nil
* Speech = Nil
* Emotion = Nil
* Perception (Hallucinations & Delusions)
* Non-bizarre delusions
* Rarely hallucinations
* Thought
* Process unimpaired, content preoccupied, single theme of thoughts
* Erotomaniac (excessive sexual desire, often believe a VIP in love with them)
* “De Clerembault’s syndrome”
* Othello syndrome (believe partner unfaithful)
* Fregoli syndrome (≥2 people are same person changing disguises to deceive)
* Folie → deux (shared delusions/hallucinations between people)
* Factitious disorder (consciously pretending you have a medical illness)
* Insight = Impaired (delusions affect thought and behaviour)
* Cognition = Nil
46
What are the differentials for suspected delusional disorder?
* Substance-induced
* Mood disorder with delusions
* Schizophrenia
* Dementia + Delirium
* Body dysmorphia
* OCD
* Hypochondriasis
* Paranoid (personality disorder)
47
What are the biological and psychosocial treatments of delusional disorder?
* Consider admission - if high risk to self, to others or from others
* Biological (limited evidence)
* Antipsychotics (poor evidence)
* SSRI (cover other potential missed differentials)
* BDZ (for anxiety)
* Psychological
* Individual CBT
* Psychoeducation
* Social
* Social skills training
* Family Therapy
* Psychoeducation
