Schizophrenia Flashcards
a perception in the absence of a
stimulus, i.e. hearing, seeing, smelling, touching or
tasting something that isn’t there - is a ?
Hallucination
a fixed, false belief, held despite rational
argument or evidence to the contrary. It cannot be
explained by the patient’s cultural, religious, or educational background - is a ?
Delusion
list obstetric factors that increase the risk of schizophrenia?
why do they increase risk?
Maternal prenatal malnutrition
viral infections
pre-eclampsia,
low birth weight,
emergency Caesarean section
increase risk because these things may be caused by genetic abnormaliities or hypoxic brain damage
list aetiological factors responsible for schizophrenia?
Genetics - 50% MZ concordance. increased risk in 1st degree relatives
Obstetric complications
Subtance misuse - LSD, amphetamines, cocaine (stimulants) cause psychotic symptoms
Social disadvantage - poorer adults, not kids
Urban living and birth
Migration and ethnicity - afro carribeans
Expressed emotion - critical relatives - increases relapse but not causal
Premorbid schizoid
Bad life experiences - abuse
Neurochemical theories
Neurological structural abnormalities - reduced brain sign, EEG changes
how is cannabis linked to schizophrenia?
doesnt cause it but increases risk the risk factors already in place.
Skunk is a particularly dangerous form for those vulnerable to schizophrenia, since it has higher concentrations of tetrahydrocannabinol, the chemical in cannabis most associated with psychosis.
which cannabis users are at highest schizo risk?
people who are Val–Val allele have the highest risk.
The enzyme catechol-O-methyl transferase (COMT) breaks down dopamine.
There are two alleles coding for the COMT gene: Val and Met.
The Val allele increases the risk of schizophrenia in cannabis users: , those who are Met–Met have the
lowest risk, and heterozygotes have intermediate risk.
what are the theories explaining schizophrenia?
A. Neurodevelopmental
1. enlarged ventricles with overall smaller
and lighter brains
- lower premorbid IQs, deficits inlearning memory and executive function
B. Neurotransmiitter theories
1. dopamine hypothesis states that schizophrenia is a
result of dopamine overactivity in certain areas of the brain
- postive symptoms -> DA overactivty -> increased
mesolimbic system
- negative symptoms -> DA underactivity -> decreased
mesocortical system
- serotonergic overactivity and glutamate dysregulation
C. Psychological theories
- defects in thinking i.e jumping to conclusions lead to delusions
what are the positive symptoms of schizophrenia
cause?
hallucinations and
delusions
are thought to result from excess dopamine
in the mesolimbic tracts.
what are the negative symptoms of schizophrenia
cause?
apathy—the opposite of enthusiasm; loss of motivation
• blunted affect—decreased reactivity of mood
• anhedonia—the inability to enjoy interests/activities
• social withdrawal
• poverty of thought and speech.
marked decrease in selfcare,
-> thought block/ paucity of thought
->Ideas don’t connect - loose associatoin
May result from dopamine underactivity in the mesocortical tracts.
what is the at-risk mental state (ARM) ?
consists of low-grade symptoms such as
social withdrawal and loss of interest in work, study, and
relationships, without any frank psychotic symptoms.
Typically, the picture is of someone in their late teens or
early twenties who has dropped out of college or work
after a period of increasing absences. seem distant. may deny psychotic symptoms
MAY lead to schizo. used to be called prodrome
how does the acute phase of schizophrenia present?
PSYCHOTIC and POSITIVE symptoms
The acute phase has the most striking and florid psychotic features:
delusions - any type
hallucinations - auditory
Thinking is disturbed, resulting in muddled speech, and behaviour may be withdrawn, overactive, or bizarre.
Negative symptoms such as a marked decrease in selfcare, social withdrawal, can also present
which are The most diagnostically significant delusions in schizophrenia?
- Delusional perception
- Passivity - being controlled
- Delusional thought interference
Delusional perception - This is a two-stage process
whereby a real perception is then interpreted in a
delusional way, e.g.
– ‘The traffic lights changed to green and I knew I
was Queen of Ireland!’
Passivity - belief that movement, sensation, emotion,
or impulse are controlled by an outside force, e.g.
– ‘He makes my eyes go round and round and I can’t
keep them still.’
DTI - their thoughts are under the control of something
List the type of auditory hallucinations in schizo?
thought echo
third person - discussing about the patient
runnin comentary - of patients life
what is a formal thought disorder?
Formal thought disorder is when thoughts become
disconnected (loosening of associations).
Vagueness may
progress to very disjointed speech that is hard to follow
and apparently senseless.
as part of Delusional thought interference explain Thought withdrawal
Thought withdrawal—thoughts are removed from the
patient’s mind, e.g. ‘The old man uses an invisible
fishing line to pluck the thoughts from my head!’
as part of Delusional thought interference explain thought insertion
– Thought insertion—thoughts are placed directly
into the patient’s mind, e.g. ‘She uses magnets to
push her thoughts in.
as part of Delusional thought interference explain thought broadcasting
– Thought broadcasting: thoughts are broadcast to others
so that people can know what they are thinking,
characterise the chronic phase of schizo?
negative symptoms which may last
indefinitely and be immensely disabling
what are the subtypes of schizophrenia?
how do they present? most common?
Paranoid
- most common. delusions and hallucinations
Catatonic
- psychomotor disturbance; stupor, excitement
- rigidity, automatic obedience
- absent or non prominent delusions and hallucinations
Hebephrenic
prominent sx:
- disorganized and chaotic mood/behaviour/speech
- loosened associations and schizophasia (“word
salad”), and flat or inappropriate affect.
- hebephrenia, named after the Greek term for
“adolescence”
- Ages affected ; adolescnce 15-25
- non prominent: delusions and hallucinations
Simple
- negative sx only
Residual
- negative sx after delusion and hallucinations stop
may overlap
list schneiders first rank symptoms?
Delusional perception
Passivity
Delusions of thought interference
• Thought insertion
• Thought withdrawal
• Thought broadcasting
Auditory hallucinations • Thought echo • ‘Third person’ (voices discussing or arguing about the patient) • Running commentary
importnace of in schneiders first rank symptoms in diagnosing schizo?
they are neither necessary nor sufficient to make
the diagnosis, as they can occur in mania and delirium,
and may be absent in schizophrenia.
sx presnt for 1 month at least.
list ddx for schizophrenia?
- Organic causes - i.e. medications, delirium & dementia
- Acute and transient psychotic episode
- self resolves in months - Mood disorder: psychotic sx indepression+ mania
- Schizoaffective disorder - schizo + affective sx present
- Persistent delusional disorder - no hallucinations
- Schizotypal disorder - abnormal thoughts and personality disorder
what is the importance of the duration of untreated psychosis (DUP)?
the longer the DUP, the greater the damage to the
person’s cognitive abilities, insight, and social situation (e.g. dropping out of school, work, relationships).
what is the rx of schizo?
Antipsychotics
- typical
- atypical
Psychological management
- CBT: should all be offered this (NICE)
- Family therapy ; to reduce EXPRESSED EMOTION -
reduces relapse
- Concordance therapy
Social approaches
- ward admission
- education, housing, training, support foe employment
- social skills development
how to treat drug resistant schixo?
start clozapine
-> is titrated
try depot if concordance problem
define treatment resistant/refractory schizo?
failure to respond to 2 or more antipsychotics
where at least 1 is atypical
at a therapeutic dose for more than 6 weeks
side effects of clozapine therapy?
how to monitor?
Hypersalivation
Excessive sedation
Constipation - they can actually die from this
Weight gain, metabolic syndrome
Irreversible cardiomyopathy - beware of chest pain
Seizures , postural hypotension
Agranulocytosis - severe and dangerous leukopenia most commonly of neutrophils
weekly bloods to spot neutropaenia early -for about 18 weeks or so? if all is well, monthly tests
what is the MOA of antipsychotics?
dopamine agonists
block post synaptic D2 receptors
atypical antipsychotics - also block serotonin 5HT2 receptors
what antipsychotics cause extrapyramidal side effects most?
list the Extrapyramidal side effects?
- in order of onset after taking drug
Typicals
Extrapyramidal side effects;
dystonia - muscles contract uncontrollably
akathisia - inner restlessness, mental distress
parkinsonism - tremor, slow movement etc
tardive dyskinesia - involuntary movements
define tardive dyskinesia?
involuntary, repetitive body movements, which may include grimacing, sticking out the tongue, or smacking the lips.
name a rare but life threeatening side effect of antipsychotics?
what is the presentation and aetiology?
Neuroleptic malignant syndrome
- presentation: muscle stiffness, rigidity, altered consciousness. Fever tachycardia and labile BP
- trigger; dose increase, new antipsychotic drug
- response to dopamine blockade
How does death come about from Neuroleptic malignant syndrome ?
Acute renal failure (you know its acute when baseline bloods were normal but now abnormal) due to;
rhabdomylosis
SO Creatine kinase and WCC will be very high
which antipsychotics gives greatest seizure risk and why?
Clozapine
- reduces seizure threshold
chlopromazine, haloperidol and depots- flupentixol are which type of antipsychotics?
typical
list some atypical antipsychotics?
onlazapine
risperidone
quietiapine
clozapine
when are depots used?
compliance issues - are long acting formulations
which antipsychotics gives weight gain risk and why?
clozapine
onlanzapine
patient with schizophrenia comes in with sexual dysfunction, gyanecomastia, ogalactorrheoa.
what is going on?
which drug most likely cause
hyper prolactinaemia - respiridone use
secondary to antipsychotic meds
patient with schizophrenia comes in with dry mouth, tachycardia, blurred visioin, constipation.
what is going on?
anticholinergic side effects
what should be monitored in patients undergoing treatment for schizo?
BMI, waist circum,
BP
FBC, LFTs, Glucose tolerance test - diabetes risk
ECG - in odler patients - check QTc interval
Prolactin - if on respiridone
what ecg changes may be seen with antipsychotic and antidepressant use ?
prolonged QTc interval
what are the subtypes of acute dystonia?
Acute dystonia - sustained muscle contraction such as torticollis or oculogyric crisis
which drugs to ask patients with schizo about?
weed
lsd
speed/amphetamines
cocaine
characterise the presentation of catatonia?
This is dominated by psychomotor disturbance:
- Stupor—a state of being immobile, mute, and unresponsive, despite appearing to be conscious (eyes are open and will follow people around the room).
- Excitement—periods of extreme and apparently purposeless motor hyperactivity.
• Posturing—assuming and maintaining inappropriate
or bizarre positions.
• Rigidity—holding a rigid posture against efforts to be
moved.
• Waxy flexibility—the patient’s limbs offer minimal
resistance to being placed in odd positions which are
maintained for unusually lengthy periods (cataplexy).
• Automatic obedience—to any instructions.
• Perseveration—inappropriate repetition of words or
movements.
opposition - resist attmepts to move their limb
negativism - resist all attempts to make contact with their body; more intense opposition
aversion - turn away from dr trying to speak to them
define catatonia?
abnormality of movement and behaviour arising from a disturbed mental state (typically schizophrenia).
It may involve repetitive or purposeless overactivity, or catalepsy,
resistance to passive movement, and negativism.
what is commonly confused with catatonia?
extrapyramidal side effects
catatonia - increased muscle tone at rest abo;ished by voluntary activity
define echolalia and describe the difference to perseveration?
echolalia - repeat the words you say (also in catatonic schizophrenia)
perseveration - repeat one word or phrase in response to numerous questions
what are the 3 criteria for confirming delusions?
Certainty (the person is convinced the delusion is real).
Incorrigibility (the person cannot be convinced otherwise or have the belief shaken in any way).
Impossibility - theres no way on earth it can actually be true
define delusions of reference/ ideas of reference
the belief that everything occurring around them is related somehow to them when in fact it isn’t.
an individual experiencing innocuous events or mere coincidences and believing they have strong personal significance.
It is “the notion that everything one perceives in the world relates to one’s own destiny”, usually in a negative and hostile manner
what is a tactile/haptic hallucination?
give an example
the false perception of tactile sensory input
but really its a hallucination
example: formication - the feeling of imaginary insects or spiders on the skin.
in which conditions may you get haptic hallucinations ?
schizophrenia
delirium tremens
cocaine abuse
alcohol abuse
parkinsons
list organic causes of psychosis
drug induced
deliruim
dementia
list differentials for psychosis?
Organic:
drug induced, deliruim, dementia
schizophrenia
delusional disorders
affective disorders;
depressive psychosis
manic psychosis
what is the epidemiology of schizophrenia?
1%
M=F
prognosis of schizophrenia?
rule of thirds
1/3 recover - if good family support and help and understanding
1/3
1/3 relapse and chronic condition
5% suicide rate
what is the difference between schizoaffective disorder vs schizophrenia vs schizotypal disorder?
schizoaffective:
- marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as MAJOR depression or mania : are roughly evenly balanced
- affective sx do not develop b4 schizo ones
schizotypal:
-suspicious, cold, and aloof with rather odd ideas,
without showing definite symptoms of schizophrenia
- personality disorder
what are the types of schizoaffective disorder?
diagnostic criteria?
Manic type
A schizoaffective disorder manic type diagnosis means you have symptoms of schizophrenia and mania at the same time through a period of illness.
Depressive type
have symptoms of schizophrenia and MAJOR depression at the same time through a period of illness.
Mixed type
schizophrenia, depression and mania at same time
Diagnostic:
Requires 2 episodes of psychosis to qualify
1▪ One episode must last > 2 weeks without mood disorder symptoms (unless non-major depression)
2▪ One episode requires obvious overlap of mood and psychotic symptoms
what is the difference between schizoid and schizotypal pd?
schizotypal; have social anxiety Magical thinking or “odd beliefs” Bodily illusions or strange perceptual experiences Being suspicious or paranoid Not expressing emotions
The schizoid individuals simply feel no desire to form relationships, because they see no point in sharing their time with others.
loners - social isolation
DSM5 criteria of schizophrenia?
and icd 10?
The presence of 2 (or more) of the following,
each present for a significant portion of time during a 1-month period (or less if successfully treated),
with at least 1 of them being (1), (2), or (3): (1) delusions, (2) hallucinations, (3) disorganized speech,
(4) grossly disorganized or catatonic behavior, and (5) negative symptoms
ICD10 adds that; there must have been disruption to abnormal functioning for at least 6 months.
what is schizophreniform disorder?
Schizophreniform disorder is a mental disorder diagnosed when symptoms of schizophrenia are present for a significant portion of the time within a one-month period,
but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia.
what are the positive and negative symptoms of psychosis?
+ and -ve sx of schizo:
Postive: adds to the normal function
Delusions, hallucinations, disorganised speech/behaviour (tangentiality etc)
Negative: takes away/ decrease
apathy, lack of motivation, blunted affect, etc
