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Y4 Psychiatry: Conditions > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

What is schizophrenia?

A

Schizophrenia is the most common psychotic condition, characterised by hallucinations, delusions and thought disorders which lead to functional impairment.

It occurs in the absence of organic disease, alcohol or drug-related disorders and is not secondary to elevation or depression of mood.

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2
Q

Briefly describe the pathophysiology/ aetiology of schizophrenia

A

The aetiology of schizophrenia involves both biological and environmental factors.

There is an increased likelihood of schizophrenia in those with a positive family history, and monozygotic twin studies show a 48% concordance rate.

The dopamine hypothesis states that schizophrenia is secondary to over-activity of mesolimbic dopamine pathways in the brain. This is supported by conventional antipsychotics which work by blocking dopamine (D2) receptors, and by drugs that potentiate the pathway (e.g. anti-parkinsonian drugs and amphetamines) causing psychotic symptoms.

Factors that interfere with early neurodevelopment such as obstetric complications, fetal injury and low birth weight lead to abnormalities expressed in the mature brain.

Adverse life events and psychological stress increase the likelihood of developing schizophrenia.

Expressed emotion is the theory that those with relatives that are ‘over’ involved or that make hostile or excessive critical comments are more likely to relapse.

The stress–vulnerability model predicts that schizophrenia occurs due to environmental factors interacting with a genetic predisposition (or brain injury). Patients have different vulnerabilities and so different individuals need to be exposed to different levels of environmental factors to become psychotic.

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3
Q

What are the predisposing factors for schizophrenia?

Note: biological, psychological and social

A

Biological

  • Genetic: monozygotic twin studies – 48% concordance
  • Neurochemical: ↑ dopamine, ↓ glutamate, ↓ serotonin, ↓ GABA
  • Neurodevelopmental: intrauterine infection, premature birth, fetal brain injury and obstetric complications
  • Age 15– 35
  • Extremes of parental age: ≤20 years or ≥35 years

Psychological

  • Family history: the closer the family relationship to an affected relative, the higher the risk
  • Childhood abuse

Social

  • Substance misuse
  • Low socioeconomic status
  • Migrants: higher incidence in migrant populations (e.g. African-Caribbean), but not in offspring born in the new location
  • Living in an urban area- although this could be as a result of urban drift into cities
  • Birth in late winter/early spring season (controversial)
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4
Q

What are the precipitating factors for schizophrenia?

Note: biological, psychological and social

A

Biological

  • Smoking cannabis or using psychostimulants

Psychological

  • Adverse life events
  • Poor coping style

Social

  • Adverse life events
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5
Q

What are the perpetuating factors for schizophrenia?

Note: biological, psychological and social

A

Biological

  • Substance misuse
  • Poor compliance to medication

Psychological

  • Adverse life events

Social

  • ↓ Social support
  • Expressed emotion
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6
Q

How common is schizophrenia worldwide?

A

Schizophrenia affects approximately 24 million people worldwide.

The incidence of schizophrenia is estimated to be 5 per 100 000 people.

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7
Q

What is the peak age of onset for schizophrenia?

A

Peak age of onset is 15-35 years.

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8
Q

Are males or females more likely to have schizophrenia?

A

Males and females are equally affected but a systematic review showed men aged <45 years had twice the rate of schizophrenia as women.

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9
Q

Which is the most common type of schizophrenia?

A

Paranoid schizophrenia.

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10
Q

How long do the symptoms of schizophrenia need to be present for diagnosis?

A

>1 month.

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11
Q

Briefly differentiate between positive and negative symptoms of schizophrenia

A

The symptoms of schizophrenia can be referred to as positive (the acute syndrome) when there is the appearance of hallucinations and delusions. This is in contrast to negative symptoms (the chronic syndrome) which refers to loss of function.

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12
Q

What are the positive symptoms of schizophrenia?

Note: Delusions Held Firmly Think Psychosis

A
  • Delusions
  • Hallucinations
  • Formal thought disorder
  • Thought interference
  • Passivity phenomenon
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13
Q

Whar are delusions?

A

A delusion is a fixed false belief, which is firmly held despite evidence to the contrary and goes against the individual’s normal social and cultural belief system.

Usually persecutory, grandiose, nihilistic or religious in nature.

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14
Q

What are ideas of reference?

A

Ideas of reference are thoughts in which a patient infers that common events refer to them directly (e.g. personal messages from television and newspapers).

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15
Q

What are hallucinations?

A

A hallucination is a perception in the absence of an external stimulus. They are usually third person auditory hallucinations which may be of running commentary nature.

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16
Q

What is a formal thought disorder? And give examples.

A

Abnormalitities of the way thoughts are linked together.

Examples: dertailment of thought, tangential thinking, word salad, circumstantiality, thought blocking and neologism.

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17
Q

What is thought interference?

A

This could either be the feelings that thoughts are being inserted (thought insertion), removed (thought withdrawal) or heard out loud by others (thought broadcast).

18
Q

What is passivity phenomenon?

A

Actions, feelings or emotions being controlled by an external force.

19
Q

What are the negative symptoms of schizophrenia?

Note: the A factor

A
  • Avolition ( ↓ motivation): reduced ability (or inability) to initiate and persist in goal-directed behaviour.
  • Asocial behaviour: loss of drive for any social engagements.
  • Anhedonia: lack of pleasure in activities that were previously enjoyable to the patient.
  • Alogia (poverty of speech): a quantitative and qualitative decrease in speech.
  • Affect blunted: diminished or absent capacity to express feelings.
  • Attention (cognitive) deficits: may experience problems with attention, language, memory and executive function.
20
Q

What is prodrome?

A

The onset of clinical features may be preceded by a prodrome where the patient becomes reserved, anxious, suspicious and irritable with a disturbance in normal everyday functioning.

21
Q

What are Schneider’s first rank symptoms?

A

Schneider’s first-rank symptoms of schizophrenia are symptoms which, if one or more are present, are strongly suggestive of schizophrenia and is an alternative tool to ICD-10 in diagnosing schizophrenia:

  1. Delusional perception: a new delusion that forms in response to a real perception without any logical sense, e.g. ‘the traffic light turned red so I am the chosen one.’
  2. Third person auditory hallucinations: usually a running commentary.
  3. Thought interference: thought insertion, withdrawal or broadcast.
  4. Passivity phenomenon.
22
Q

What are the different classes of schizophrenia?

Note: Paranoid Psychotic Humans Can’t Supply Understandable Reasoning

A
  • Paranoid
  • Postschizophrenic depression
  • Hebephrenic schizophrenia
  • Catatonic
  • Simple
  • Undifferentiated
  • Residual
23
Q

What is paranoid schizophrenia?

A

Most common.

Dominated by the positive symptoms (hallucinations and delusions).

24
Q

What is postschizophrenic depression?

A

Depression predominates with schizophrenic illness in the past 12 months with some schizophrenia symptoms still present.

25
Q

What is hebephrenic schizophrenia?

A

Thought disorganisation predominates. Onset of illness is earlier (15-25) and have poorer prognosis.

26
Q

What is catatonic schizophrenia?

A

Rare form where negative symptoms develop without psychotic symptoms.

27
Q

What is undifferentiated schizophrenia?

A

Meets diagnostic criteria for schizophrenia but does not conform to any of the subtypes.

28
Q

What is residual schizophrenia?

A

1 year of chronic symptoms preceded by a clear-cut psychotic episode.

29
Q

Briefly describe the ICD-10 Criteria for schizophrenia

A
30
Q

Briefly describe the MSE for schizophrenia

A

Appearance: can be normal (positive) or inappropriate with poor self-care (negative).

Behaviour: preoccupied, restless, noisy or suspicious (positive). A few show sudden, unexpected changes in behaviour. Withdrawn, poor eye contact and apathy (negative).

Speech: may reflect understanding thought disorder (loosening of associations, pressured and distractable speech), interruptions to flow of thought (thought blocking) and poverty of speech (negative).

Mood: incongruity of affect or mood changes such as depression, anxiety or irritability. Flattened affect (negative).

Thought: delusions (e.g. persecutory, delusions of control, delusions of reference), thought insertion/withdrawal/broadcast, formal thought disorder (loosening of associations, word salad, concrete thinking, circumstantiality/tangentiality) (all positive).

Perception: hallucinations (especially third person auditory in nature) (positive).

Cognition: normal orientation. Attention and concentration often impaired (positive). May be evidence of premorbid cognitive impairment. Specific cognitive deficits (negative).

Insight: generally poor.

31
Q

What are the investigations for schizophrenia?

A

Blood tests: FBC (anaemia, infection), TFTs (thyroid dysfunction can present with psychosis), glucose or HbA1c (as atypical antipsychotics can cause metabolic syndrome), serum calcium (hypercalcaemia can present with psychosis), U&Es and LFTs (assess renal and liver function before giving antipsychotics), cholesterol (as atypical antipsychotics cause metabolic syndrome), vitamin B 12 and folate (deficiencies can cause psychosis).

Urine drug test: illicit drugs can cause and exacerbate psychosis.

ECG: antipsychotics cause prolonged QT interval.

CT scan: to rule out organic causes such as space-occupying lesions.

EEG: to rule out temporal lobe epilepsy as possible cause of psychosis .

32
Q

What are the poor prognostic factors for schizophrenia?

A

Factors associated with poor prognosis:

  • Strong family history
  • Gradual onset
  • ↓ IQ
  • Premorbid history of social withdrawal
  • No obvious precipitant
33
Q

Briefly describe the bio-psycho-social model for treatig schizophrenia

A

Biological

  • Antipsychotics
  • Adjuvants
  • ECT

Psychological

  • CBT
  • Family intervention
  • Art therapy
  • Social skills training

Social

  • Support groups
  • Peer support
  • Supported employment programmes
34
Q

Briefly describe the use of antipsychotics in schizophrenia

A

Antipsychotics can be broadly divided into typical and atypical.

Atypical antipsychotics are first-line, e.g. risperidone and olanzapine.

Depot formulations should be considered if the patient prefers or there is a problem with non-compliance.

Clozapine is the most effective antipsychotic and used for treatment-resistant schizophrenia (failure to respond to two other antipsychotics).

35
Q

What adjuvants can be used to treat schizophrenia in addition to antipsychotics?

A

Benzodiazepines can provide short term relief of behavioural disturbance, insomnia, aggression and agitation.

Antidepressants and lithium can be used to augment antipsychotics.

36
Q

When is ECT used to treat schizophrenia?

A

May be appropriate in patients who are resistance to pharmacological agents. Effective for catatonic symptoms.

37
Q

What is the role of CBT in treating schizophrenia?

A

CBT is strongly recommended by NICE. Reduces residual symptoms.

38
Q

What is the role of family intervention in treating schizophrenia?

A

Particularly useful for families of patients with schizophrenia who have persisting symptoms.

Psychoeducation helps families reduce high levels of expressed emotion which reduced relapse rates.

39
Q

What is the role of art therapy in schizophrenia?

A

NICE recommends art therapy (e.g. music, dancing and drama) for alleviation of negative symptoms in young people.

40
Q

What is the role of social skills training in schizophrenia?

A

Uses a behavioural approach to help patients improve interpersonal, self-care and coping skills needed in everyday life.

41
Q

Briefly describe the treatment of first-episode schizophrenia

A
42
Q

What differentials should be considered in schizophrenia?

A

Y4 Psychiatry: Conditions (23 decks)

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