Schizophrenia Flashcards
What is formal thought disorder?
A pattern of disordered language use that reflects disordered thought form
E.g. loosening of association (derailment), flight of ideas, circumstantial thoughts, tangential thoughts, thought block
What are the positive symptoms?
Delusions
Hallucinations
Thought disorder
Disorganised behaviour
What are the negative symptoms?
Poverty of speech Social withdrawal Reduced attention Avolition Blunted affect
What are Schneiders First Rank Symptoms?
Auditory hallucinations, Broadcasting of thought, Controlled thought (delusions of control), Delusional perception.
What is delusional perception?
The patient who takes a precept and ascribes an delusional idiosyncratic value to it, e.g. “I heard the church bells and knew I would win Wimbledon”
What is made volition?
The patient reports his will to be under the control of an external force.
What is somatic passivity?
Patient reports experiencing sensations on their body and believed being controlled by an external force
What are organic causes of psychosis?
Delirium - is another syndrome and there are many causes of delirium (e.g. sepsis) Medication-induced (e.g. corticosteroids, stimulants, dopamine agonists) Endocrine disorders (e.g. Cushings, hypothyroidism, hyperthyroidism) Neurological disorder (e.g. temporal lobe epilepsy, multiple sclerosis, movement disorders, Wilson's disease, Huntington's disease) Other systemic diseases (e.g porphyria, SLE)
How is schizophrenia diagnosed?
Symptoms present for longer than 28 days (some classification system needs longer duration)
No “organic” cause
First rank symptoms present or persistent hallucinations and delusions
May also have negative and cognitive symptoms
What are other psychiatric disorders?
Schizoaffective disorder (a mixture of first rank symptoms and mood symptoms)
Delusional disorder (the main symptom is non-first rank delusional belief with minimal hallucination)
Schizotypal Disorder
Acute and transient psychotic disorder (symptoms less than 28 days)
Mood disorder (Mania, Severe depression)
Substance misuse - e.g. alcohol withdrawal, intoxication with stimulants, cannabis
What us the epidemiology of schizophrenia?
Lifetime risk roughly one in a hundred M=F Very rare below age 14 Rare 16-18 Peak incidence 23 yrs male 26 yrs female (second peak between 30-40) Urban > rural Lower social class
What is the aetiology of schizophrenia?
Biological:
Genetic - Family history (possible multiple genes)
Obstetric complication - increased risk
Dopamine theory - how antipsychotic medication works
Neurodevelopmental theory
Psychological:
Cognitive errors - jumping to conclusions (especially in delusions and paranoia)
Premorbid personality - schizotypal disorder
Social:
Urban living (x2 to x3 - consistent research finding)
Migration (x3)
Life events (including physical and sexual abuse)
Ethnicity (x4 in Afro-Caribbeans in the UK; higher incidence also in South Asians)
What are the prodrome symptoms in schizophrenia?
on-specific negative symptoms
emotion distress/ agitation without reason
Transient psychotic symptoms
longer the DUP (duration of untreated psychosis) the worst the outcome.
Average DUP is over a year.
What are good prognostic factors in schizophrenia?
Female Married Family history of affective disorder Acute onset Good Premobid personality Early treatment Prominent mood symptoms Good response to treatment
What are poor prognostic factors in schizophrenia?
Family history of schizophrenia High expressed emotion (more later) Substance misuse Prominent negative symptoms Early onset Lack of insight/non-compliance
What are the outcomes in schizophrenia?
20% after first episode never have another episode
30% continuous illness, not free of symptoms
25% improved, but require extensive support network
Risk of premature death due to suicide (10-15%), cardiovascular disease and type 2 diabetes.
What physical investigations are used?
BC, LFT, RFT, TFT, blood glucose, blood lipids, cholesterol;
other blood tests to look for organic causes if indicated
Urine for drug screen
ECG
BMI, neurological (physical)
Others if indicated - brain scan, EEG
Which antipsychotics are used to treat schizophrenia?
Typical: Chlorpromazine Haloperidol Zuclopenthixol Flupentixol Fluphenazine Atypical: Olanzapine Risperidone Quetiapine Aripiprazole Clozapine
What are common reasons for non compliance with treatment?
lack of insight side effects of medication delusions about medication/ prescriber patient feels better when "ill" patient gains remission from symptoms and thinks medication is no longer required Depot injections can be used
Which tests need to be carried out every year to check physical health?
smoking and drinking status
personal/ family history of diabetes/ coronary heart disease
BP, BMI
blood for FBC, RFT, LFT, glucose and lipid
ECG
What is required for diagnosing treatment resistant schizophrenia?
Lack of response to adequate doses of 2 different antipsychotics review diagnosis (is the diagnosis correct?) rule out co-morbid substance misuse ensure dose, duration and compliance with previous treatment
How often do FBCs need to be taken when a patient is on clozapine?
Need weekly full blood counts for 18 weeks, then every 2 weeks for a year, then every 4 weeks.
What psychological treatment is used for schizophrenia?
CBT Family intervention therapy Psychoeducation Concordance therapy Maastrictht interview (voice assessment for voice hearers)
What does expressed emotion refer to?
Carers emotional reaction to the individual with schizophrenia
criticism
hostility
over-involvement
High EE leads to increased risk of relapse
What is thought disorder?
Circumstantial and tangental thinking
Flight of ideas
Derailment- loosening of association
Thought blocking
Neologisms (new words, often combining syllables of other words)
Preservation (initially correct response is repeated)
Echolalia (senselessly repeated words/phrases said by others)
Irrelevant answers
What are the features of catatonia?
Catatonic rigidity - fixed position and resisting being moved
Catatonic posturing - bizarre position and resisting being moved
Catatonic negativism - resistance to all instructions or attempts to be
moved
Catatonic waxy flexibility - can be moulded like wax
Catatonic stupor - akinesia, mutism and extreme unresponsiveness
What is the ICD-10 criteria for schizophrenia?
1 of more of:
Thought disorder - echo, insertion, withdrawal, broadcast
Delusions of control or passivity
Hallucinatory voices giving running commentary discussing the patient amongst
themselves
Bizarre delusions
Or 2 or more of:
Hallucinations occurring every day for weeks or associated with delusions/sustained
overvalued ideas
Thought disorganisation - loosening of association, incoherence, neologism
Catatonic symptoms
Negative symptoms
Change in behaviour - loss of interest, aimlessness, social withdrawal
What can akathisia do?
increase risk of developing impulsive suicidal ideation after a change in antipsychotic medications
What are the schizophrenia subtypes?
Paranoid: delusions nd hallucinations dominate. Better prognosis, late onset
Catatonic: 1 or more catatonic symptoms
Residual: 1 year of predominantly chronic negative symptoms, preceded by one psychotic episode
Hebephrenic (disorganised), thought disorder, disturbed behaviour, inappropriate/flat affect. Delusions and hallucinations are transient. Early onset, poor prognosis
Post schizophrenia depression: follows a schizophrenic episode with few symptoms of schizophrenia
Simple: Insidious onset, signs of residual depression, without preceding psychotic episode, mostly negative symptoms
What are the contributing factors for poor physical health in schizophrenia?
Standardised Mortality Rate is nearly 5x higher in schizophrenia
Poor diet
Reduced physical activity Smoking
Not engaging in physical health monitoring
Increased risk of metabolic syndrome
