Schizophrenia Flashcards
Define schizophrenia and it’s epidemiology
Schizophrenia is an illness characterised by primary psychosis, meaning patient’s lose touch with reality, experiencing hallucinationsand delusions.
The lifetime risk of developing schizophrenia is around 1%. Onset is typically from ages 15-45 with men affected earlier and more severely than women. Overall men and women have an equal incidence.
What is the mono and dizygotic concordance for schizophrenia?
Mono - 46%
Di - 14%
What are the stages of schizophrenia?
There are three stages of schizophrenia:
- At risk mental state (ARM) - used to be called prodrome. Consists of low-grade symptoms such as social withdrawal loss of interest in work, study, and relationships, without any frank psychotic symptoms. Difficult to distinguish from depression, substance misuse, or normal teenage behaviour.
- Acute phase - characterised by florid positive symptomsof delusions and hallucinations, which often mask negative and cognitive symptoms.
- Chronic phase - characterised by more prominent negative symptoms.
What are the groups of symptoms for schizophrenia?
- Positive symptoms
- Negative symptoms
- Cognitive symptoms
- Depressive symptoms
- Impaired social cognition
What are the positive symptoms of Schizophrenia?
These include:
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Hallucinations - can be of all modalities, but often auditory. Of particular diagnostic significance are:
- Voices discussing or arguing about the patient
- Voices giving a running commentary on the patient’s actions
- Thought echo - voices are saying the patient’s own thoughts aloud.
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Delusions can also be of any kind, but are often persecutory. The most diagnostically significant are:
- Delusions of reference - such as the TV is directly talking to them.
- Delusions of control (passivity) - the belief that movement, sensation, emotion and impulse are controlled by an outside force.
- Delusions of thought interferenceusually thought withdrawal, thought insertion and thought broadcasting.
- Thought disorder - formal thought disorder is when thoughts become disconnected (loosening of associations)
Patients often lose insight in the acute phase. Poor insight is associated with poor treatment outcomes.
What are the negative symptoms of schizophrenia?
These classically include the 4 A’s:
- Alogia - decrease in verbal output or verbal expressiveness.
- Anhedonia - inability to experience pleasure from positive stimuli
- Avolition - Subjective reduction in interests, desires and goals, and a behavioural reduction of self-initiated and purposeful acts
- Affective flattening - Diminished facial emotional expression, poor eye contact, decreased spontaneous movement, lack of spontaneity.
Describe the cognitive symptoms of schizophrenia
Schizophrenia causes significant neurocognitive impairment in 75% of patients who have stable disease. This impairment is evident in all phases of the disease including premorbid phase. These issues include:
- Global intellectual decline (IQ)
- Memory impairment - both working and verbal memory
- Executive function impairment - affecting ability to set goals, make decisions, and co-ordinate activities.
- Attention deficits - problems with sustained and selective attention.
Describe the depressive symptoms of schizophrenia
Depressive symptoms commonly occur in Schizophrenia in any phase of the illness. If affective disturbance is as prominent as psychotic features, patients may have schizoaffective disorder instead.
What are the subtypes of schizophrenia?
Schizophrenia presentations can be divided into subtypes based on the most prominent symptoms. However, these patterns may overlap or change over time.
- Paranoid schizophrenia is the most common type, with the main symptoms being delusions and hallucinations.
- Catatonic schizophrenia is dominated by psychomotor disturbance, such as stupor, excitement, posturing, rigidity, waxy flexibility, preservation (inappropriate repetition of words or movements). Catatonia is now rare in developed countries due to the availability of antipsychotics an active rehabilitation programmes.
- Hebephrenic schizophrenia - onset is between the ages of 15 and 25 years. The predominant features aredisorganised and chaotic mood, behaviour and speech.
- Simple schizophrenia presents with only negative features, without ever having had positive psychotic symptoms.
- Residual schizophrenia presents with prominent negative symptomsthat remain after delusions and hallucinations subside.
What is the ICD-10 criteria for schizophrenia?
The ICD-10 criteria requires at least 1 major OR at least 2 minor symptoms lasting for at least 1 month. Major symptoms include:
- Delusions of thought interference such as thought insertion, withdrawal.
- Delusions of control, influence or passivity
- Hallucinatory voices giving running commentary, discussing the patient, or coming from some part of the body.
- Persistent delusions of other kinds such as delusional perceptions.
Minor symptoms include:
- Persistent delusions in any modality when accompanied by fleeting or half-formed delusions.
- Thought block, interpolations, resulting in incoherent or irrelevant speech or neologisms
- Catatonic behaviour
- Negative symptoms such as apathy, alogia, anhedonia and avolition.
- A significant and consistent change in personal and social behaviour.
How long do symptoms of schizophrenia have to last for an ICD-10 diagnosis?
1 month
What are the Schneider’s first rank symptoms
- Hearing thoughts spoken aloud
- Third-person hallucinations
- Auditory hallucinations in the form of a ‘running commentary’
- Somatic (bodily, tactile) hallucinations
- Thought withdrawal or insertion
- Thought broadcasting
- Delusional perception
- Feelings or actions experienced as made or influenced by external agents (passivity)
What are the investigations for schizophrenia?
A full physical examination and investigations are important in excluding an organic cause and in making a general assessment of physical health before starting medical treatment.
- Blood tests, including FBC, TFTs, U7Es, LFTs, CRP, etc. Lipids should be checked before starting long-term antipsychotics.
- MSU
- Urine drug screen
- CT scan - only to rule out any organic pathology if suspected
A symptom rating scale may help in assessing severity and response to treatment.
A risk assessment is very important in schizophrenia:
- Risk to self - lifetime risk of suicide is 10%. Intelligent young men with good premorbid functioning are especially vulnerable.
- Risk to others - less than 10% of violent crimes are committed by patients with schizophrenia
- Risk from others - patients are 14x more likely to be a victim of violent crims than to be a victim of one.
An occupational therapy (OT) assessment of activities of daily living should be performed to see if patients can be assisted in any way.
Social worker assessment of housing, finances, and carers’ needs.
Also important to take a collateral.
What is the differential diagnoses for Schizophrenia?
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Organic: physical causes of psychosis must be excluded, including:
- Substance misuse - since people are usually young at first presentation, substance misuse is the most practical first differential to be excluded. Drug intoxication and alcohol withdrawal can produce psychotic symptoms. Common drugs include amphetamine, cocaine, LSD, Ecstasy, ketamine, and phencyclidine.
- Dementia- especially in elderly patients
- Delirium - especially in elderly patients
- Epilepsy - especially temporal lobe epilepsy
- Medication side-effects such as steroids, dopamine agonists
- Other - brain tumour, stroke, HIV, Wilson’s disease, porphyria, neurosyphilis.
- Acute and transient psychotic episode can appear identical to schizophrenia, but resolves completely within a few months. It can be stress related.
- Mood disorder - both depression and mania, if severe enough, produce psychotic symptoms.
Describe the management for schizophrenia
For acute management of psychosis, see Psychosis notes. Essentially:
- For first episode psychosis: assess risk and refer to early intervention service (EIS). Depending on risk, this may need to a be a same-day referral, and the patient may need to be admitted.
- For relapse of psychosis: assess risk and follow care plan. If the patient does not have a care plan refer to crisis resolution and home treatment team (CRHTT) and the patient may need admission.
The long-term management of schizophrenia requires a bio-psycho-social approach:
- Biological therapies are mainly drug treatment with antipsychotics. Second generation antipsychotics are preferred due to side-effect profile. These include olanzapine, risperidone, quetiapine, clozapineetc. Drug therapy needs to be continued for at least two yearsor longer if due to relapse. Patients who struggle with compliance may benefit from a depot injection - risperidone is often administered via depot.
- Psychological therapies mainly involve CBT and family therapy. In CBT the therapist aims to gently challenge the patient’s illogical beliefs, aiding awareness of illogical thinking, and to consider an alternative explanation. As well as improving self-esteem and problem solving, CBT may help patients to cope with troublesome hallucinations and delusions.
- Social approaches involves a social needs review and assessment by occupational therapist and social worker. The OT assesses the patient’s ability to perform activities of daily living, and the social worker assessment is important to address housing, finances and carers’ needs.
It is important that the patient has a care plan. The UK takes a Care Programme Approach (CPA) to formalise the care plan. This involves:
- A systematic assessment of health and social needs
- A treatment planagreed by staff, the patient and relatives
- A key worker assigned to maintain contact with patients, monitor their progress, and ensure that the treatment programme is being delivered.
