Schizophrenia Flashcards
Define Schizophrenia
Disintegration of the process of thinking, contact with reality, and emotional responsiveness
Characterised by positive and negative symptoms
Describe the paranoid subtype of schizophrenia
Most common
Prominent delusions
Prominent hallucinations
Describe the hebephrenic/disorganised subtype of schizophrenia
Mainly focused on speech/thought
Disorganised mood and speech
Neologisms, Knights move thinking
Inappropriate affect (laughing at something sad)
Describe the simple subtype of schizophrenia
Negative symptoms only
Apathy
Social withdrawal
Describe the catatonic subtype of schizophrenia
Psychomotor disturbance
Stupor, waxy flexibility
Automatic obedience
Forced grasping, opposition
Give examples of hypotheses behind the aetiology of schizophrenia
Dopamine hypothesis
Serotonin (5-HT) overactivity
Glutamate dysregulation
Stress: people with a vulnerability encounter stressful influences
Neurodevelopmental: enlarged ventricle
What are the risk factors for schizophrenia
Family history
Social disadvantage
Urban life
First/second gen immigrants
Black Caribbean/African
Expressed emotion from relaitives
Premorbid personality
Adverse life experiences
Fear of madness
Cognitive behaviour - jumping to conclusions
Cannabis use
Birth in the Winter months
What are the gender differences in schizophrenia presentation
Males at a greater risk than females
Females present later than males
What is the UK/worldwide prevalence of schizophrenia
1%
What is required for an ICD-10 diagnosis of schizophrenia
(A) ≥1 Schneider’s 1st rank symptoms
(B) ≥1 other symptoms (paranoid, hebephrenic, catatonic, simple)
(C) Present for most of the time, ≥1month
(D) Not caused by substance use or organic disease
What are Schneider’s first rank symptoms
(1) Thought disorder (delusions):
- Thought insertion thoughts being placed into my mind
- Thought withdrawal thoughts being removed from my mind
- Thought broadcasting everyone knows what you are thinking
(2) Auditory disorder (hallucination):
- Thought echo hearing my thoughts out loud (delusion)
- 3rd person voice ‘no one like’s her, she’s useless’
- Running commentary ‘now he’s falling asleep, and she’s calling a cab’
(3) Passivity (delusions of control - their thoughts/actions are controlled by external forces)
(4) Delusions (false and fixed beliefs)
What are the negative symptoms of schizophrenia
Alogia (poverty of speech)
Anhedonia (loss of pleasure)
Avolition (lack of motivation)
Apathy (lack of concern, interest)
Blunting of affect
Catatonia
Poverty of ideation
Social withdrawal
Describe the progression of schizophrenia
At risk mental state (ARMS) -ve symptoms dominant - from teens to early 20s
* Social withdrawal
* Loss of interest in work and relationships
* Mild or brief psychotic symptoms
2. Acute phase: +ve symptoms dominant
3. Chronic phase (-ve symptoms dominant)
What % of patients with an at risk mental state will go on to develop psychosis and schizophrenia
20-30% will develop psychosis, half of whom meet criteria for schizophrenia
What is residual schizophrenia
previous schizophrenia (+ve & -ve S/S) → just -ve symptoms
Give some differentials for schizophrenia
Substance misuse: cannabinoids, cocain, amphetamine
Delirium
Functional disorders: BPAD, schizoaffective disorder, acute and transient psychotic disorder
Medicine: steroids, anticholinergics, dopaminergics
Infection: encephalitis, meningitis
Neurological: CVA, SOL, Alzheimer’s, Parkinsons
What investigations are done for schizophrenia
bedside: urine toxicology, urine MSU, ECG (prior to starting treatment)
Bloods: FBC, U&Es, TFTs, CRP/ESR, anti-NMDA/anti-VGKC, lipid
Other: MRI/CT, EEG, lumbar puncture
What is the management for an acute episode of psychosis
Urgent emergency: Crisis resolution team and home treatment team
Non-urgent emergency: Early intervention in Psychosis (EIP) team
Bio: Medication - antipsychotics, anxiolytics, sedatives
Psycho: psychoeducation, talking therapies (CBT, family therapy)
Social: education/employment, housing/finance, career
What factors would necessitate admission for schizophrenia
Suicide/homicide risk
Lack capacity
Significant medication changes
Severe symptoms (Psychotic, depressive, catatonic)
Failure of OPD treatment
Address comorbid conditions
What is the biological approach to schizophrenia management
First line: Atypical antipsychotic for 6 weeks
1. Aripiprazole, quetiapine
2. Olanzapine, risperidone
Second line: typical antipsychotics e.g. chlorpromazine
Treatment resistance: Clozapine
± lithium for schizoaffective, diazepam for anxiety
What defines treatment resistance in schizophrenia
failure to respond to >2 antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
What is the psychological approach to schizophrenia management
Individualised CBT for psychosis
* >16 sessions
* Emphasis on testing reality
* Establishing links between thoughts, feelings and actions and their symptoms
Family therapy
Cognitive remediation therapy (CRT)
* Good for negative symptoms
* Aims to improve neurocognitive skills e.g. concentration, memory, problem-solving
What is the social approach to schizophrenia management
Social skills training e.g. budgeting, cooking, role-play for interpersonal skills
Education, training, employment
Benefits
Housing (supported)
Carer support
MDT: social workers, benefits advisors, occupational therapists
What can you do if the patient is non-compliant with antipsychotics
IM depot injection, usually every 4 weeks
e.g. zuclopenthixol decanoate
What are the complications of schizophrenia
Suicidal tendencies
Substance abuse
Tobacco abuse/dependence
Tardive dyskinesia
Depression
What is the prognosis for schizophrenia
Life expectancy is shortened by 11-15 years
Rule of quarters:
1/4 will not have another episode
1/4 continue to have episodes but are able to function
1/4 continue to have episodes but are unable to function, but can stay out of hospital
1/4 will be in and out of hospital
Early detection and treatment can reduce the duration of psychosis and can predict more favourable outcomes
What are the bad prognostic factors for schizophrenia
Gradual onset
Early onset
Lack of precipitant stressful event
Family history
Low preceding IQ
Negative symptoms
Longer duration of untreated psychosis (DUP)
What is the management for catatonia
IM lorazepam
