Schizophrenia Flashcards
Give some risk factors for the development of schizophrenia (5-7)
• Genetics
• Obstetric Complications
o Maternal prenatal malnutrition, Viral infections, Pre-eclampsia
• Substance Misuse
o Cannabis, amphetamines, cocaine and LSD can cause psychotic symptoms
o Cannabis, in particular, increases the risk of developing schizophrenia (particularly skunk)
• Social Disadvantage
o Higher rates in lower socioeconomic classes
• Urban Life and Birth
o Twice as high in urban areas
• Migration and Ethnicity
o First- and second-generations immigrants are at increased risk compared to the indigenous population
o Afro-Caribbean populations show the highest rates
• Expressed Emotion
o Close contact with highly critical or over-involved relatives doubles the risk of relapse
Outline 3 theories for the aetiology of schizophrenia (3)
• Neurodevelopmental Theories
o Initial brain abnormalities (either genetic in origin or due to early brain damage) may lead to schizophrenia
o Maturation of the brain along with other risk factors can lead to functional and connectivity abnormalities
• Neurotransmitter Theories
o Dopamine Hypothesis: schizophrenia is a result of dopamine overactivity in certain areas of the brain
o Evidence
• All known antipsychotics are dopamine antagonists
• Antipsychotics work better against positive symptoms
• Dopaminergic agents (e.g. amphetamine, cocaine, L-dopa) can all induce psychosis
• Psychological Theories
o Subtle defects in thinking (e.g. tendency to jump to conclusions without adequate evidence) predisposes to delusions
What are the 3 clinical stages of schizophrenia?
Prodrome: at-risk mental state (ARM) before onset of schizophrenia (social withdrawal, loss of interest)
Acute Phase: positive symptoms (hallucinations and delusions)
Chronic Phase: negative symptoms reflecting things that are lost in schizophrenia (e.g. apathy - loss of motivation, anhedonia
Give some commons delusions seen in schizophrenia
Delusional Perception
• A real perception is interrupted in a delusional way
• E.g. ‘the traffic lights changed to green and I knew I was the king of India’
Passivity
• Belief that movement, sensation, emotion or impulse are controlled by an outside form
Thought Interference: the patient believes their thoughts are under the control of something else
• Thought Withdrawal: thoughts are removed from the patient’s mind
• Thought Insertion: thoughts are placed directly into the patient’s mind
• Thought broadcasting: thoughts are broadcast to others so that people can know what they are thinking
Formal Thought Disorder
• When thoughts become disconnected (loosening of associations)
• Disjointed speech, poverty of thought, thought blocking, word salad (very disconnected, incomprehensible sentences)
Give 5 subtypes of schizophrenia
Paranoid (most common)
- Symptoms are mainly delusions and hallucinations
Catatonic (psychomotor disturbance - seen less commonly due to use of antipsychotics)
- Stupor (immobile, mute, unresponsive)
- Perseveration (inappropriate repetition of words or movements)
Hebephrenic
- Disorganised and chaotic mood, behaviour and speech
- Described as ‘child-like’ behaviour
Simple
- NEGATIVE features only
Residual
- Prominent negative symptoms are all that remains after delusions and hallucinations subside
What are the Schneider first rank symptoms of schizophrenia? (4)
• Delusional perception • Passivity • Delusions of thought interference o Thought insertion, withdrawal, broadcasting • Auditory hallucinations o Thought echo o Third person voices o Running commentary
Give some differential diagnoses for schizophrenia
• Organic
o Substance misuse
o Dementia, Delirium (especially elderly)
o Epilepsy (especially temporal lobe epilepsy)
o Medication side-effect (e.g. steroids, dopamine agonists)
• Acute and Transient Psychotic Episode
o Resolves completely within a few months but can look identical to schizophrenia
o Can be stress-related
• Mood Disorder
o Severe depression or mania can produce psychotic symptoms
o Schizophrenia should NOT be diagnosed in the presence of striking mood disturbance unless the schizophrenic symptoms came first
• Schizoaffective Disorder
o Both schizophrenic and affective symptoms develop together and are roughly evenly balanced
• Persistent Delusional Disorder
o Delusions with few or no hallucinations
• Schizotypal Disorder: personality disorder
o Lifelong state of eccentricity with abnormal thoughts and affect which is regarded as a personality disorder
What investigations would you do for schizophrenia?
- Full physical examination and investigations to exclude organic causes
- Bloods (FBC, TFTs, U&Es, LFTs, CRP, fasting blood glucose): lipids to be checked before starting antipsychotics
- MSU, urine drug screen
- EEG (if epilepsy suspected)
- Social work assessment (e.g housing, finances, carer’s needs)
- Collateral history
What is the significance of EIS (early intervention service) for schizophrenia?
o Psychosis is toxic, the longer a patient is psychotic, the more it will affect their cognitive abilities, insight and social situation
o The sooner effective treatment can be started the better the prognosis
o The Early Intervention Service aims to engage patients with very early symptoms
o Patients are offered antipsychotics and psychosocial interventions with the aim of keeping the duration of untreated psychosis (DUP) under 3 months
What is the MOA of antipsychotics and what is their main side effect?
MOA: dopamine antagonists (block D2 receptor)
Main side effect is extrapyramidal (EPSE), as well as hyperprolactinaemia
Differentiate between the main two classes of antipsychotics
Typical antipsychotics (e.g chlorpromazine, haloperidol, flupentixol decanoate)
- Effective, cheap, and depot options (flupentixol)
- Cause EPSEs more often, even at normal treatment doses
Atypical antipsychotics (e.g risperidone, olanzapine, clozapine, aripiprazole)
- Also block serotonin 5-HT2 receptors
- Less EPSEs
- Risperidone available as depot
What must you avoid when prescribing antipsychotics?
Don’t use more than 1 antipsychotic (multiple drugs increase side effect profile)
Describe the EPSE and their treatments (4)
• Dystonia
Onset: early
Symptoms: involuntary, painful muscle spasms
Treatment: anticholinergic (e.g procyclidine)
• Akathisia
Onset: hours-weeks
Symptoms: unpleasant subjective feeling of restlessness (e.g pts may have to pace to cope with it)
Treatment: decrease dose/change antipsychotic, propranol
• Parkinsonism
Onset: days to week
Symptoms (triad): resting tremor, rigidity, bradykinesia
Treatment: decrease dose/change antipsychotic, try anticholinergic (review frequently)
• Tardive dyskinesia
Onset: months-years
Symptoms: rhythmic involuntary movements of the mouth, face, limbs, trunk
Treatment: stop antipsychotic or reduce dose, avoid anticholinergics, switch to an atypical or clozapine. Can be irreversible
Give some other side effects of antipsychotics
o Hyperprolactinaemia o Weight gain (especially olanzapine and clozapine) o Sedation o Increased risk of diabetes o Dyslipidaemia o Anticholinergic side-effects (dry mouth, blurred vision, constipation, urinary retention, tachycardia) o Arrhythmias o Seizures (reduces seizure threshold) o Neuroleptic malignant syndrome
What is neuroleptic malignant syndrome and what is the treatment for it?
• Rare but life-threatening side-effect of antipsychotics
o Muscle stiffness and rigidity
o Altered consciousness
o Disturbance of autonomic nervous system (fever, tachycardia and labile BP)
• Raised CK and WCC
Treatment
o Stop antipsychotics immediately
o Get urgent medical treatment (usually ITU)
• Death may occur due to several causes (e.g. rhabdomyolysis leading to renal failure)
What needs to be monitored with patients on antipsychotics
Regular review and monitoring:
• BMI and waist circumference
• Blood pressure
• FBC, LFTs, U&Es, glucose tolerance test (or fasting glucose/HbA1c) and lipids
Prolactin levels (if hyperprolactinaemia suspected) ECGs (monitor QTc interval)
Clozapine: outline when it is usually used and a potential lethal side effect of its use
First line for treatment resistant schizophrenia (failure to respond to two or more antipsychotics, at least one of which is an atypical, each given at a therapeutic dose for at least 6 weeks)
Risk of agranulocytosis
- Therefore requires weekly blood tests to check for neutropenia
Outline some psychological therapies for schizophrenia
• CBT
o Particular emphasis on reality testing
o The therapist aims to gently challenge the patient’s beliefs, aiding awareness of illogical thinking
o CBT can also help patients cope with troublesome hallucinations and delusions
• Family Therapy
o Effects of high expressed emotion (discussed earlier) can be ameliorated through communication skills, education about schizophrenia, problem-solving and helping patients expand their social network
• Concordance Therapy
o Collaborative approach where the patient is encouraged to consider the pros and cons of the management
Outline some social measures used to treat schizophrenia
- Provide help with practical needs like benefits, housing, training and education
- Social skills training can help improve interpersonal skills
• Needs to address
o Education, training and employment
o Skills (e.g. budgeting, cooking)
o Housing (e.g. supported accommodation, independent flats)
o Accessing social activities
o Developing personal skills (e.g. creative writing)
What needs to be considered in a risk assessment, and give some factors that may increase risk
Risk to self (suicide, self-neglect, social decline)
Risk to others, factors that increase are:
- Past history
- Substance misuse
- Non-concordance with treatment
- Co-morbid personality disorder (dissocial, emotionally unstable, paranoid)
Risk from others
