Schizophrenia Flashcards
Definition
Mental health condition in which a persons perceptions, thoughts, mood and behaviour are significantly altered.
Form of psychosis that can be chronic or relapsing and remitting
Epidemiology
- Fhx
- Intrauterine: poor maternal nutrition, intrauterine growth restriction
- Childhood adversity e.g. bullying
- Stressor e.g. bereavement, jobless
- SA or black community: black carribean particularly high risk (RR 5.4)
- Substance abuse
- Migration
Pathophysiology
Complex interplay between genetics, environmental stressors, and neurological dysfunction.
- Neuroanatomical alterations identified:
= global reduction in brain
volume by 5-10% +
= decreased amygdala, hippocampal and prefrontal cortex volume
- Imbalances in neurotransmitters such as dopamine, serotonin and glutamine
- Hyperdopaminergic theory hypothesis = overactivation of dopaminergic neurons in reward pathway (mesolimbic tract) leads to positive symptoms
- Reduced dopaminergic transmission in the prefrontal cortex (mesocortical tract) for negative Sx
Schneider’s first rank symptoms
Auditory hallucinations:
- Third-person commentary discussing the Px
- Voices commenting on patients behaviour
- Thought echo
Formal thought disorder
- Thought insertion
- Thought withdrawal
- Thought broadcasting
Delusional perceptions
- A normal perception followed by suddenly by a seemingly unrelated, intense delusional insight into the object e.g. The sun is shining therefore I am God.
Passivity
- The belief that the Px is being controlled by an external force
- The external force may control the Px thoughts, feelings or actions
Negative Symptoms
Alogia
Anhedonia
Incongruity/blunting of affect
Avolition
Neologism
Diagnostic criteria
ICD criteria:
- Over a period of ≥ 1 month , patients must have one first rank symptom OR at least two other symptoms such as:
= Persistent hallucinations in any form: e.g. non-auditory hallucinations, accompanied by fleeting or half-formed delusions without clear affective content, or with overvalued ideas
= Disorganised thinking or speech: neologisms, word salad, perseveration, echolalia, clang association, interruption in train of thought
= Negative symptoms: blunting of affect, anhedonia, decreased speech, poor motivation; must be clear that symptoms are not due to depression or medication
= Catatonic behaviour: positive, e.g. strange and sudden rigid movements, excitement, posturing, or negative, e.g. mutism or stupor
= A change in overall quality of some aspects of personal behaviour : manifests as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal
Diagnosis
Clinical diagnosis
Consider:
- Urine drug screen: rule out a substance-induced psychotic disorder
- Infectious cause: syphilis or HIV testing
- CT or MRI brain: rule out intracranial pathology, such as a space-occupying lesion
- Endocrine screen: high cortisol can result in psychosis
Treatment
FIRST LINE:
- Oral anti-psychotic (atypical) AND psychological interventions: CBT, art therapy, family interventions
SECOND LINE:
- Alternative oral anti-psychotic
THIRD LINE:
- CLOZAPINE = offered if Px not responded to two sequential anti-psychotics for at least 6 weeks each
Atypical antipsychotics
Risperidone
Quetiapine
Aripiprazole
Olanzapine
Clozapine
Typical
Haloperidol
Chlorpromazine
Complications
- Drug-related side-effects
= Extrapyramidal symptoms and QT prolongation : typical antipsychotics
= Metabolic syndrome: atypical anti-psychotics
= Neuroleptic malignant syndrome: caused by any antipsychotic
= Agranulocytosis: clozapine, an atypical agent, can cause agranulocytosis - Self-harm and suicide: 5% lifetime risk of suicide.
- Substance misuse: up to 1 in 3 individuals with schizophrenia use drugs
- Depression
Prognosis (rule of quarters)
25% never have another episode
25% improve substantially on treatment
25% have some improvement
25% are resistant to treatment
