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)
