Schizophrenia Flashcards
What is the difference between an affective and non-affective psychosis?
What are examples of each? [6]
Non-affective psychosis:
- major disturbance of mood (inherent part of disease)
- E.g. schizophrenia
- Delusional disorder (not many other pyschotic symptoms present apart from delusions)
- Acute and transient pyschotic episodees
- Drug induced pyschosis
Affective psychosis
- Bipolar disorder
- Schizoaffective disorder (have dx criteria for mania/depression and schizo)
- Depression with psychoitc symptoms
Define what is meant by schizophrenia [1]
Schizophrenia is a severe, long-term mental health disorder characterised by psychosis. It most often presents between ages 15 and 30 and earlier in men than women. The symptoms must be present for at least six months before schizophrenia is diagnosed.
- Schizoaffective disorder combines the symptoms of schizophrenia with bipolar disorder. Patients have psychosis and symptoms of depression and mania.
Chronic psychotic illness (e.g. schizophrenia) often associated with pro-drome.
What would this prodrome look like? [+]
- Reduced social interaction, withdrawal, apathy
- Cognitive deficits (poor memory, attention, concentration)
- Mood changes (anxiety, depression, anger, suicidal ideation)
- Sleep disturbance
- Obsessive-compulsive phenomena
- Dissociative symptoms
TOM TIP: You might have to explain schizophrenia simply to a relative in your OSCEs. A helpful example may be…
“Schizophrenia is a condition that affects how the brain processes information.
Normally, the brain is very good at understanding reality, deciding what is important and what is not, and organising thoughts in a structured way.
With schizophrenia, the brain struggles to understand the world, makes mistakes in deciding what information is important and organises thoughts in a confused way.
This can lead to strong beliefs that do not fit with reality, called delusions.
They may also experience voices that are not there, called hallucinations.
The disorganised thoughts can lead to unusual speech and behaviours, which is called thought disorder. When these symptoms occur, it is called psychosis.”
What is the cause of schizophrenia? [+]
Schizophrenia is considered to be the result of genetic and environmental factors. Specific genes that increase the risk of schizophrenia have been identified. Having an affected family member is a risk factor.
- Social adversity such as childhood trauma or neglect can contribute to the onset of schizophrenia by altering stress response systems.
- Cannabis use, particularly during adolescence, is a significant environmental risk factor.
- Prenatal complications such as maternal infections, malnutrition, hypoxia, or stress during pregnancy may increase schizophrenia risk by disrupting normal brain development.
- Several susceptibility genes have been identified through genome-wide association studies (GWAS) and candidate gene studies. Notably, variants in DRD2, COMT, DAT1, and NRG1 are associated with schizophrenia.
NB: now thought that person who has genetic predisposition to psychosis, who then experiences maternal infection, who then stress trauma, who then has dopamine excess in brain
Describe the different classifcations of schziophrenia [+]
What are the positive symptoms of schizophrenia? [+]
Psychosis is the central feature of schizophrenia. The key features of psychosis, called positive symptoms, are:
* Delusions (beliefs that are strongly held and clearly untrue)
* Hallucinations (typically auditory; perceiving things that are not real)
* Thought disorder (disorganised thoughts causing abnormal speech and behaviour)
Other key positive features are:
* Somatic passivity (believing that an external entity is controlling their sensations and actions)
* Thought insertion or thought withdrawal (believing that an external entity is inserting or removing their thoughts)
* Thought broadcasting (believing that others are overhearing their thoughts)
* Persecutory delusions (a false belief that a person or group is going to harm them)
* Ideas of reference (a false belief that unconnected events or details in the world directly relate to them)
* Delusional perceptions
Lack of insight is an important feature of psychosis. They lack awareness that the delusions and hallucinations are not based in reality.
Describe the specific types of audiotory hallucinations experienced in schizophrenia [3]
Auditory hallucinations of a specific type:
* two or more voices discussing the patient in the third person
* thought echo
* voices commenting on the patient’s behaviour
Describe what is meant by passivity phenomena [2]
Passivity phenomena:
* bodily sensations being controlled by external influence
* actions/impulses/feelings - experiences which are imposed on the individual or influenced by other
Describe what is thought disorder [1]
Loss of healthy flow of thought - not a rationable way of having a conversation
What are Schneider’s First rank symptoms of schizophrenia? [5]
Auditory hallucinations:
- Hearing thoughts spoken outloud
- Hearing voices referring to themselves from third person
- Auditory hallucinations in form of commentary
Thought withdrawal
Thought broadcasting
Somatic hallucinations
- E.g. feeling of something crawling on skin
Delusional perception
- See a real stimulus, but interpret this in a wrong way (e.g. see a green car and think this means someone is going to kill them)
Passivity phenomena
Describe what is meant by a delusional perception [1]
Delusional perceptions
* (a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
What are the negative symptoms of schziphrenia? [+]
Negative symptoms of schizophrenia include the four As:
* Affective flattening (minimal emotional reaction to emotive subjects or events)
* Alogia (“poverty of speech” – reduced speech)
* Anhedonia (lack of interest in activities)
* Avolition (lack of motivation in working towards goals or completing tasks)
AND
Cognitive impairment
- one of most important determinents of prognossi
Schizophrenia may involve different patterns of symptoms. When observed over time (e.g., over at least one year), the active-phase symptoms of psychosis may be [3]
Continuous
Episodic (relapsing and remitting)
A single episode only
What are the first rank symptoms of schizophrenia? [4]
The first rank features of schizophrenia can be divided into auditory hallucination, thought disorders, delusional perceptions and passivity phenomena.
A specialist will make the diagnosis based on the DSM-5 criteria.
How long will symptoms needed o have gone on for? [1]
Which symptoms must be present for a dx? [3]
The symptoms (including the prodrome phase) must have been present for at least six months, with symptoms of the active phase (delusions, hallucinations, and thought disorder) present for at least one month (or less if treatment is successful).
Both schizophrenia and bipolar disorder can present with psychotic symptoms.
How would you distinguish between them? [3]
Both schizophrenia and bipolar disorder can present with psychotic symptoms.
- However, in bipolar disorder, these are typically mood-congruent (i.e., consistent with the individual’s current mood state) and occur during episodes of mania or depression.
- The presence of clear manic or hypomanic episodes is a key distinguishing feature favouring a diagnosis of bipolar disorder. These may be characterised by an elevated or irritable mood, increased energy levels, reduced need for sleep, grandiosity, pressured speech and distractibility.
- Cognitive impairment in bipolar disorder is usually episodic and associated with acute phases. In contrast to the persistent cognitive deficits seen in schizophrenia.
How can you distinguish schizophrenia from Major Depressive Disorder (MDD) with Psychotic Features? [2]
The absence of a history of psychotic symptoms in the absence of depressive episodes is a key distinguishing feature favouring MDD with psychotic features over schizophrenia
- Unlike schizophrenia, cognitive impairment in MDD is usually not as severe and tends to improve significantly with remission of the depressive episode.
Describe the management of schizophrenia
Key points:
* oral atypical antipsychotics are first-line
* cognitive behavioural therapy should be offered to all patients
* close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
How can you categorise antipyschotic medications? [1]
Antipsychotic drugs can be classified as typical or atypical, or as first or second-generation. Neither classification is particularly useful, as they relate more to when they were introduced rather than their mechanism or effects.
Antipsychotic medication work by inhibiting [] receptors, specifically [] receptors.
Many second-generation antipsychotics also have high affinity for [] receptors.
- How do they work? [1].
Antipsychotic medication work by inhibiting dopamine receptors, specifically D2 receptors.
Many second-generation antipsychotics also have high affinity for serotonin 5-HT2A receptors.
- They act as antagonists on these receptors, reducing serotonin activity which indirectly increases dopamine release in certain parts of the brain. Some also act as partial agonists at 5-HT1A receptors, further modulating serotonin activity.
What are contraindications for antipyschotics? [4]
Known hypersensitivity:
- Antipsychotics should not be administered to patients with a known hypersensitivity to the drug or any of its components.
Comatose state or CNS depression:
- Antipsychotics are contraindicated in patients suffering from a comatose state or severe central nervous system depression.
Blood dyscrasias:
- Certain antipsychotic medications, such as clozapine, are contraindicated in individuals with blood dyscrasias due to the risk of agranulocytosis.
Pheochromocytoma and untreated narrow-angle glaucoma:
- These conditions can worsen with the use of certain antipsychotics like thioridazine.
When should you use antipyschotics with caution? [5]
Elderly patients with dementia-related psychosis:
- There is an increased risk of cerebrovascular adverse events and mortality in this population. Use of antipsychotics should be carefully evaluated against potential risks.
- In particular, atypical antipsychotics have been associated with an elevated risk of stroke and transient ischemic attack in elderly patients.
Parkinson’s disease and Lewy body dementia:
- Patients may exhibit sensitivity to the extrapyramidal side effects of antipsychotics.
- This includes symptoms such as acute dystonic reactions, parkinsonism, akathisia, and tardive dyskinesia.
Epilepsy:
- Antipsychotics may lower seizure threshold; caution should be exercised with patients with a history of seizures or EEG abnormalities.
Cardiovascular disease:
- Antipsychotics, especially atypical ones, may cause QT prolongation and postural hypotension. Regular monitoring of ECG is recommended in patients with cardiovascular disease.
Liver and renal impairment:
- Dose adjustments may be necessary due to altered drug metabolism and elimination.
What is the prognosis of schizophrenia? [1]
Reduced life expectancy 10-25 years
- Importance of duration of untreated psychosis
Which factors associated with poor prognosis of schizophrenia? [4]
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
Lecture content
Describe the changes on the following dopamine pathways in schizophrenia (and what this means with regards to symptoms) [4]
- mesolimbic
- mesocortical
- nigrastriatal
- tempero-infundibular
mesolimbic
- overactive in pyschosis - causes positive symptoms
mesocortical
- UNDERACTIVE in psychosis
–> Negative symptoms
nigrastriatal
- causes movement
Tempero-infundibular
- Connects hypothalamus to anterior pituitary. Antagnosim –> raised prolactin
Which drugs are 1st generation anti-pyschotics? [3]
What is their MoA? [1]
- Haloperidol
- Zuclopenthixol (Clopixol)
- Flupenthixol (Depixol)
Prominent D2 antagonism
What are the key side effects of 1st generational anti-pyschotics?
Extrapyramidal side effects (EPSEs) (1-4):
1. Parkinsonism
* Tremor
* Bradykinesia
* Rigidity
* Shuffling gait
2. Akathisia
* Motor restlessness
3. Tardive dyskinesia
* Involuntary motor movements of lower face and limbs
4. Dystonias: muscle spasms/contractions
* Neck, jaw, back, limbs, eyes, throat and tongue
Hyperprolactinaemia
- Men: Gynaecomastia, Erectile dysfunction, inorgasmia, Ejaculatory failure
- Women: Amenorrhoea
2nd generation anti-pyschotics have lower risk of hyperprolactinaemia
Except some, e.g. [2]
Lower risk of hyperprolactinaemia
Except some, e.g. risperidone, amisulpride
