Schizophrenia Flashcards
CLINICAL FEATURES
Positive symptoms
- Delusions
- Hallucinations
- Formal thought disorder
CLINICAL FEATURES
Delusions
- Commonly persecutory, thought interference or passivity delusions
CLINICAL FEATURES
Hallucinations
- Usually auditory commenting on subject or refering to them in third person
CLINICAL FEATURES
Formal thought disorders
- Loss of normal flow of thinking usually shown in subjects speech or writing
CLINICAL FEATURES
Negative symptoms
- Impairment or loss of volition, motivation and spontaneous behaviour
- Loss of awareness of socially appropriate behaviour and social withdrawal
- Flattening of mood, blunting of affect and anhedonia
- Poverty of thought and speech
DIAGNOSTIC CRITERIA
- At least one of
- Thought echo, insertion, withdrawal or broadcasting
- Delusions of control, influence or passivity
- Hallucinatory voices giving running commentary
- Persistent delusions of other kinds that are culturally inappropriate or implausible
- Or two of
- Persistent hallucinations in any modality
- Breaks in train of thought causing incoherence or irrelevant speech
- Catatonic behaviour
- Negative symptoms
Duration of >= 1 month
Categories of schizophrenia
- Paranoid schizophrenia
- Hebephrenic schizophrenia
- Catatonic schizophrenia
- Undifferentiated schizophrenia
- Post-schizophrenic depression
- Residual schizophrenia
- Simple schizophrenia
Paranoid schizophrenia - key symptoms
- Delusions and hallucinations
Hebephrenic schizophrenia - key symptoms
- Disorganised speech behaviour and flat affect
Catatonic schizophrenia - key symptoms
- Psychomotor disturbance
Undifferentiated schizophrenia - key symptoms
- Meeting general criteria but no specific symptom subtype predominates
Post-schizophrenic depression - key symptoms
- Some residual symptoms, but depressive picture dominates
Residual schizophrenia - key symptoms
- Previous positive symptoms less marked, prominent negative symptoms
Simple schizophrenia - key symptoms
- No delusions or hallucinations - a defect state (negative symptoms)
DIFFERENTIALS
- Substance induced psychotic disorder
- Psychotic disorder due to general medical conditions
- Mood disorders with psychotic features
- Acute/transient psychotic disorder
- Sleep related disorders
- Delusional disorder
- Dementia and delirium
- Body dysmorphic disorder
- Pervasive development disorder
- OCD
- Hypochondriasis
- Paranoid personality disorder
- Schizotypical personality disorder
- Misidentification syndromes
- Anxiety disorder
- Factitious disorder
Examples of substance induced psychotic disorder
- Alcohol
- Stimulants
- Hallucinogens
- Steroids
- Antihistamines
- Sympathomimetic
AETIOLOGY
Hypothesis
- Neurochemical abnormality hypothesis
- Neurodevelopmental hypothesis
- Disconnection hypothesis
AETIOLOGY
Neurochemical abnormality hypothesis
- Dopaminergic overactivity
- Glutaminergic hypoactivity
- Serotonergic (5-HT) overactivity
- a-adrenergic overactivity
- GABA hypoactivity
AETIOLOGY
Disconnection hypothesis
- Frontal-temporal/parietal connectivity may be final common pathway for the development of schizophrenia
EPIDEMIOLOGY
Incidence (x/100000)
15/100,000
EPIDEMIOLOGY
M:F
1:1
EPIDEMIOLOGY
Prevalence - lifetime risk (x/100,000)
15-19/100,000
PROGNOSIS
Reduction in life expectancy
20% reduction
PROGNOSIS
Most common cause of death
Suicide (10-38% all deaths)
AETIOLOGY
Genes
- Neuregulin - NRG1
- Dysbindin - DTNBP1
- DISC1
- Catecholamine O-methyl transferase (COMT)
AETIOLOGY
Environmental factors
- Complication of pregnancy, delivery and neonatal period
- Delayed walking and neurodevelopmental difficulties
- Early social services contact and distored childhood behaviour
- Severe maternal malnutrition
- Maternal influenza in pregnancy and winter births
- Degree or urbanisation at birth
- Use of cannabis
CLINICAL FEATURES
Key features in systematic review
- Neurological
- Headache, head injury, abnormal mvements of mouth or tongue, diplopia, hearing or visual impairment, fits/faints, altered consciousness or memory problems, stroke, coordination problems, marked tremor or muscle stiffness
- Resp
- Dyspnoea, orthopnoea
- CVS
- Chest pain, palpitations
- GI
- Constipation, nausea, vomiting
- Genitourinary
- Urinary hesitancy, sexual problems
CLINICAL FEATURES
Physical examination
- Full neurological most important
- Gait inspection, weakness/altered sensation, hand-eye coordination, cranial nerves
INVESTIGATIONS
- Blood tests
- U&Es, LFT, calcium, glucose
- Radiological
- CT or MRI with neurological abnormality
- CXR where examination suggests resp/CVS condition
- Urine
- Urinary drug screen
- Microscopy and culture
- EEG if seizure
- 24 hour collection for cortisol if Cushings disease suggested
- 24 hour catechlamine collection if phaeochromocytoma/carcinoid syndrome suggested
MANAGEMENT
Issues affecting initial management decisions
- Risk to themselves and others
- Risk of violence
- Insight
- Hospital admission required
- Urgent treatment required
- Current social circumstances
MANAGEMENT
Need for hospital admission
- High risk suicide or homicide
- Behaviour endangers relationships, reputation or assets
- Severe psychotic, catatonic or depressive symptoms
- Lack of capacity to cooperate with treatment
- Lack of psychosocial supports
- Failure of outpatient treatment
- Non-compliance with treatment plan for patients detained under MHA
- Need to address comorbidities
MANAGEMENT
Treatment plan for acute psychosis
- Emergency treatment of behaviour disturbance
- Antipsychotic treatment
MANAGEMENT
Acute - antipsychotic options
- Option 1
- Commence on atypical antipsychotic
- Long acting BDZ to control anxiety/behaviour disturbance
- Option 2
- Low potency typical antipsychotic
- Increase dose if needed over time
MANAGEMENT
Example of low potency typical antipsychotic
Chlorpromazine
MANAGEMENT
Choices of atypical antipsychotic for acute management
- Olanzepine
- Amisulpride
- Risperidone
- Quetiapine
MANAGEMENT
Examples extra-pyramidal SE
- Dystonias
- Parkinsonism
- Akathisia
MANAGEMENT
Which class of antipsychotics are extra-pyramidal SE more common
Typical, less likely with atypical
MANAGEMENT
Prescribe for extra-pyramidal SE
Procyclidine
MANAGEMENT
Maintanence phase - general plan
- With emergence of stability establish simplication of medicine regime and minimal effective dose
- Minimise side effects
- Rehabillitation
- Possible need to manage depression
- Address comorbid substance misuse
MANAGEMENT
Discharge planning principles
- Medication
- Psychological - family therapy and psychoeducation reduce relapse
- Social - social work and housing involvement, community psychiatric nurses
PROGNOSIS
Poor prognostic factors
- Poor premorbid adjustment
- Insidious onset
- Onset in childhood or adolescene
- Cognitive impairment
- Enlarged ventricles
PROGNOSIS
Good prognostic factors
- Marked mood disturbance, especially elation, during initial presentation
- Family history of affective disorder
- Female sex
- Living in developing country
MANAGEMENT
Acute psychosis first episode treatment algorithm
- 1st - ensure safety patient and self
- Adjunct oral benzodiazepine
- Adjunct rapid tranquillisation
- Plus referal to specialist to start antipsychotic
MANAGEMENT
Acute psychosis relapse known schizophrenia algorithm
- 1st - ensure safety of patient and self
- Adjunct oral benzodiazepine
- Adjunct rapid transquillisation
- Plus refer to specialist for review of antipsychotic medication
MANAGEMENT
Long term treatment algorithm
- 1st - continue oral non-clozapine antipsychotic
- Plus psychosocial intervention
- Plus monitor physical health
- 2nd - switch to alternative non-clozapine antipsychotic
- Plus psychosocial intervention
- Plus monitor physical health
- 3rd - clozapine
- Plus psychosocial intervention
- Plus monitor physical health
