Schizophrenia Flashcards
What is schizophrenia?
A common, chronic relapsing condition (~1%)
Often presents in adulthood
With psychotic, disorganisation and negative symptoms
Sometimes cognitive impairment
Major implications for patients, work and families
What are examples of psychotic symptoms?
Hallucinations
Delusions
What are examples of disorganisation symptoms?
Incongruous mood
Abnormal speech and thought
What are examples of negative symptoms?
Apathy Lack of motivation Withdrawal Self-neglect Blunted mood
What is psychosis?
Distorted thinking and perception
E.g. hallucinations and delusions
What are the causes of psychosis?
Affective psychosis (bipolar, depression)
Transient psychotic disorders (usually substance misuse)
Organic psychoses (e.g. brain tumour)
Schizophrenia
Schizophrenia-like non-affective disorders (delusional disorder, brief psychotic disorder, schizophreniform disorder)
What are the symptoms of schizophrenia?
Thought insertion/thought broadcast/thought withdrawal
Delusions (e.g. they are being influenced or controlled by external forced)
Hallucinatory voices (e.g. running commentary/discussing amongst themselves)
Persistent delusions of other kinds that are culturally inappropriate and completely impossible
Persistent hallucinations in other modalities
Breaks or interpolations in train of thought resulting in incoherence or irrelevant speech/knights move thoughts/odd logic/neologisms
Catatonic behaviours (strange, purposeless Behavior) e.g. easy flexibility, echopraxia, negativism, mutism
Negative symptoms resulting in social withdrawal
What is a delusion?
A belief held unshakeably irrespective of counter-argument that is unexpected and out of keeping with the patient’s sultry all background
What is the difference between delusional perception and delusional intuition?
Delusional perceptions form around a real perception given a delusional interpretation
Delusional intuition ‘appears out of the blue’ as a fully formed idea
What is the difference between mood congruent and mood incongruent delusions?
Mood congruent delusions tend to be seen in affective psychoses e.g. nihilistic delusions in depression and grandiose delusions in bipolar
Mood incongruent delusions are not related to mood and seen more in schizophrenia
Give some examples of types of delusions.
Persecution (most common) - being spied on/conspired against with the intention to cause harm - causes a feeling of paranoia
Infestation - e.g. formication - seen in organic illness and cocaine use
Religious
Delusional misidentification - belief that people close to them have been replaced by an exact double/are being impersonated
Jealousy
Love - belief that a high status individual/stranger is in love with them and secretly sending messages or signs
Communicated - psychotic person transmits their beliefs to a close relative, usually subservient who now shares them
Reference - coincidental or innocuous events are interpreted to have great personal significance
What is the diagnostic criteria for schizophrenia?
At least one of (thought possession, delusions, auditory hallucinations) OR
At least 2 of (hallucinations in another modality, knight’s move thoughts, catatonic behaviour, negative symptoms)
Needs to be present for at least 6 months
Symptoms present for most of the time for at least 1 month
Marked impairment in social or occupational functioning
Other causes of psychosis ruled out (CNS tumours, drugs/alcohol, head injury, bipolar)
What are the different subtypes of schizophrenia?
Paranoid (commonest) - hallucinations/delusions more prominent
Hebephrenic - onset 15-25Y, poor prognosis, fluctuating affect prominent, fleeting fragmented delusions and hallucinations
Catatonic - stupor, posturing, waxy flexibility, negativism
Simple and Residual - negative symptoms predominate
What are prodromal life symptoms?
Precede most first episodes of psychosis by up to 18 months, sometimes just a few days
Characterised by a gradual deterioration in functioning
Sometimes conceptualised as ‘altered life trajectory’
Give some examples of prodromal symptoms.
Transient/lower intensity psychotic symptoms Odd thoughts, beliefs and behaviours Concentration problems Altered affect Social withdrawal Reduced interest in daily activities
What are the other ‘schizophrenia disorders’?
Schizoaffective (neither/both a variant of schizophrenia and a mood disorder) - symptoms of both experienced within days and of the same intensity without the presence of another medical disorder/substance abuse - give antipsychotic and mood stabiliser
Schizotypal - personality disorder which may represent a partial expression of schizophrenia - not treated with medication
Schizophreniform - subclinical schizophrenia usually by duration - treated with antipsychotics
What are some of the social risk factors of schizophrenia?
Being brought up in the city
Migrant groups
When should antipsychotics be started in schizophrenia and why?
Very soon after diagnosis
Delaying antipsychotics could worsen negative symptoms
What are the psychosocial interventions for schizophrenia?
Drugs and alcohol services if substance abuse
Working with family/family therapy - address blame, shame etc.
Support groups
Address housing, benefits, social skills training
Supported employment
How is aftercare delivered to a patient with schizophrenia?
Coordinated via an allocated key worker and MDT
Performed though CPA (care programme approach)
What are some good prognostic factors?
Sudden onset No negative symptoms Supportive home Female sex (better social integration) Late onset of illness No CNS ventricular enlargement No family history
What advice and monitoring is needed when starting antipsychotics?
Personal/FH of diabetes, HTN and cardiovascular disease
Advise on diet, weight control and exercise
BP, weight, fasting glucose, lipid profile, FBC
ECG (if on clozapine)
6 monthly monitoring - LFT, U&Es, prolactin, weight, HbA1c
What is the only licensed third generation antipsychotic that’s licensed and why does it have a better side effect profile than first and second generation antipsychotics?
Aripiprazole
It is a partial dopamine agonist
What is the first line treatment for newly diagnosed schizophrenia?
Oral SGAs
Olanzapine, quetiapine, risperidone, amisulpride, zotepine
What is the indication for clozapine?
Treatment-resistant schizophrenia
What can be done about Parkinsonism as a result of antipsychotics?
Decrease dose
Change to SGA
Try procyclidine
How would you treat acute dystonia?
Treat with procyclidine IV/IM
May take up to 30 mins to work
How can akathisia be treated?
Switch to SGA
Use lowest possible dose
Propranolol +/- cyproheptadine
What is the treatment for tardive dyskinesia?
May be irreversible
Try tetrabenazine
What are the main lifestyle issues with taking antipsychotics?
Hunger after taking the medication ~3 hours (consider bedtime dose) Increased thirst (suggests water/sugar-free alternatives) Smoking induces metabolism - quit smoking/higher doses
Which antipsychotics are least likely to cause weight gain? Which ones are most likely to cause it?
Least - Aripiprazole and amisulpride
Most - olanzpine and clozapine
Which antipsychotics particularly increase the risk of diabetes?
Olanzapine and clozapine
When is combination drug therapy used in schizophrenia?
When treatment failure has occurred i.e. multiple drugs trialled at adequate doses and clozapine has been attempted
What is the function of psychological therapies in schizophrenia?
Quick recovery and relapse prevention
Reduce impact of symptoms on the patient’s life
Promote early detection of episodes
Treating residual symptoms at the end of an episode e.g. difficult thoughts, voices and negative symptoms
What a psychological interventions are used in schizophrenia?
CBT - general/targeted to auditory hallucinations
Promoting abstinence - improves prognosis
Family therapy and support groups
Social support - circumstances may alter dopamine levels which increase the chances of relapse - helping with housing, employment, social skills etc can be of benefit
Referral to an early intervention service
What is the aim of an early intervention service?
Reduce duration of untreated psychosis
Provide the most effective care at and early stage to maximise chance of recovery
Increase likelihood of return to education/employment
Prevent loss of life trajectory
