Schizophrenia Flashcards

1
Q

What is Psychosis?

A
  • loss of boundaries with reality and loss of insight
  • delusions, hallucinations and conceptual disorganization is a primary feature in this illness also
  • a psychotic episode is deemed to be a 1 week duration of either of these symptoms at a significant severity
    • often associated with some behavioural disturbance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are delusions?

A
  • Belief held firmly but on inadequate grounds, not affected by rational argument or evidence to the contrary, and not shared by someone of similar age, educational, cultural, religious or social background.
  • Types of delusion include:
    • primary (delusional perception), secondary, persecutory, -of reference, grandiose, -of guilt, nihilistic, -of passivity etc.
  • maybe due to error of salience of attribution
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are hallucinations?

A
  • A perception experienced in the absence of an external stimulus.
    • In any sensory modality but auditory hallucinations is the most common in psychosis
  • maybe due to internal perception attribution error
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is Conceptual disorganization?

A
  • confused, disorganized and disconnected thought processes: demonstrated through speech
  • aka Loosening of associations | Knight’s Move | Schizophrenic thought disorder | Disorder of form of thought | Formal thought disorder
  • This should be rated on the basis of integration of the verbal products of the patient and not on the patients own subjective impression their level of function
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are Schneider First Rank Symptoms for Schizophrenia? (1946)

A
  • Auditory Hallucinations:
    • Thoughts spoken aloud
    • Third person hallucinations
    • Running commentary
  • Somatic hallucinations
  • Thought insertion, withdrawal or broadcast
  • Passivity phenomena. Made acts/ impulses/ affect
  • Delusional perception
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the ICD 10 Diagnosis of Schizophrenia?

A

needs to have a minimum of a-d or two of e-h for at least 1 month al in the absence of an organic disorder

  • a Thought echo, insertion, withdrawal or broadcast
  • b Delusion of passivity or delusional perception
  • c Running commentary hallucination or 2 voices discussing the patient
  • d Persistent delusions of other kinds
  • e Persistent hallucinations in any modality with accompanying brief delusions
  • f Breaks in thought resulting in abnormal speech (eg. incoherent, neologisms)
  • g Catatonic behaviour eg. Excitement, posturing, waxy flexibility, negativism
  • h Negative symptoms not due to depression or medication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are potential Differential Diagnose instead of Schizophrenia

A
  • Affective psychosis:
    • Bipolar disorder
    • Depressive psychosis
    • Schizoaffective disorder
  • Organic psychosis: (loads)
    • Epilepsy (temporal lobe)
    • Infections: encephalitis, SSP, neurosyphilis, HIV
    • Cerebral trauma/ Cerebrovascular disease
    • Dementias
    • Acute drug intoxication
    • Endocrine disorders/ Metabolic disorders
  • Personality disorder
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Signs of Schizophrenia

A
  • Bizzare appearance or behaviour
    • ‘talking to themselves’
    • self-neglect, clothing
    • social disturbance, posturing, perplexity
  • symptoms from schizophrenia medication

non are specific to schizophrenia, no predictive tests or imaging, genetics only tract to identify a vulnerability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the side effects of Schizophrenia medication?

A
  • Parkinsonian symptoms: tremor, rigidity, bradykinesia
  • Tardive dyskinesias including orofacial, athetosis, dystonias
  • Skin discolouration
  • Severe weight gain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What would a mental state examination find in an individual who had positive symptoms of Schizophrenia

  • Appearance
  • Mood
  • Thinking/ perception
  • Insight
  • Cognition
A
  • Appearance: Preoccupied and withdrawn to restless and unpredictable
  • Mood: Blunting of mood, disinhibition, perplexed, anxious
  • Thinking/ Perception:
    • Disorder of thinking: Vague, Formal thought disorder (loosening of associations) Disorders of stream (thought block)
    • Delusions: Primary, secondary
    • Hallucinations: Auditory, visual, tactile (somatic), olfactory, gustatory
  • Insight: Impaired
  • Cognition: Normal orientation and memory (initially)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What would a mental state examination find in an individual who had chronic syndrome Schizophrenia (negative symptoms)

  • Appearance
  • Movement
  • Mood
  • Thinking/ perception
  • Insight
  • Cognition
A
  • Appearance and behaviour: Lack of drive and activity, Social withdrawal, Self-neglect
  • Movement: Stupor, Catatonia, abnormal movements and tone
  • Mood: Blunting of mood, Depression
  • Thinking/ Perception:
    • Delusions and Hallucinations as in acute syndrome but maybe less evident
  • Insight: Impaired as in acute syndrome
  • Cognition: Normal orientation. Disturbed attention. Later cognitive decline
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Go over the epidemiology and aetiology of Schizophrenia

A
  • prevalence 0.2-0.7% of population
  • increasing incidence in S London - 2/10000 a year
    • incidence up to 5x variation worldwide
    • more prevalent in urban areas and in lower social classes (social drift)
  • earlier onset in men with more negative symptoms
    • male peak onset: 21-26
    • female peak onset 25:32
  • there is an additive/ interactive effect between the multiple susceptibility genes and environmental factors
    • genes involved overlap with autism and other neurodevelopment syndromes but activation at different ages presents different neuropathy
    • increased likelihood if ScZ in the family
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the prognosis of Schizophrenia?

A
  • 20% have a complete recovery and stop treatment LIne a
  • 25% have persistent symptoms after first episode or what was originally described as ‘dementia praecox’. Line b
  • >50% have a relapsing-remitting illness with some functional impairment between episodes. Line c
  • progressive episodes may lead to progressive decoration
  • functional recovery lags behind symptom recovery
  • suicide in 5-10% particularly in men within 3 years of onset
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What would indicate a good Schizophrenia prognosis?

A
  • Female
  • Married
  • Family history of affective disorder
  • Good premorbid function
  • Acute onset
  • Life event at onset
  • Early treatment
  • Affective symptoms
  • Good treatment response
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What would indicate a poor Schizophrenia prognosis?

A
  • Male
  • Single
  • Family history of schizophrenia
  • Premorbidly schizoid: (looner, cold, aloof)
  • Slow onset
  • Long duration untreated
  • Negative symptoms
  • Obsessions
  • High Expressed Emotion in the family
  • Substance misuse
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the role of Cannabis in Schizophrenia?

A
  • schizophrenia patients are more sensitive to cannabis
  • familial liability for psychosis is expressed as differential sensitivity to cannabis
  • chronic use sensitises to effect and increases vulnerability to psychosis
    • most likely the current social determined of transition to psychosis from a genetic vulnerability
17
Q

What are the neuropathological changes seen in Schizophrenia?

A
  • Ventricular enlargement
  • reduced brain volume (less grey matter)
    • temporal lobes, frontal lobes, subcortical structures reduced
  • Cytoarchitectural differences in cortex and hippocampus (different cell structures)
  • Reduction in length of the Paracingulate sulcus
    • associated with hallucinations
18
Q

What does the neurodevelopmental model of schizophrenia suggest?

A
  • during adolescence, grey matter is lost which may speed up in early-onset schizophrenia
    • age of the first admission is just after adolescence
  • Grey matter loss occurs in the parietal, frontal and temporal lobe
  • could be due to synaptic pruning or increase myelination
19
Q

The Wisconsin Card Sorting Task

  • what does it show?
A
  • when carrying out the task there is an increase in the dlPFC activity in healthy individuals, whereas this is absent
  • shows that brain damage/ lesions in the frontal cortex impaired the planning, decision making and behavioural inhibition that is supposed to be carried out
  • hence the behavioural changes in those with schizophrenia
20
Q

Explain the role of Pruning and Cell development it’s a role in explaining the neurodevelopmental model of schizophrenia

A
  • pruning is thought to be when weak synapses are removed only leaving strong ones: potentially also increased pruning of excitatory synapses
    • increase in inhibitory synaptic strength vs excitatory
  • however, in schizophrenia, there is aberrant synaptic pruning, which also attacks stronger synapses as well
    • hence the early presentation of schizophrenia
  • Lewis theory for later development of schizophrenia
    • , chandelier cells (GABAergic cortical interneurons) fail to cultivate pyramidal cells during childhood or early adolescence.
    • organised neural traffic is not formed therefore PFC cannot create the usual level of coordinated firing or gamma synchrony that generates working memory
  • this is more evident when synapses are pruned in adolescence and the brain cannot consistently organize its electrical activity and also it;s thoughts- (schizophrenic symptoms)
21
Q

What neurophysiological changes are seen in the brain in Schizophrenia?

A
  • Auditory cortex activation during hallucinations (fMRI)
  • High-frequency oscillations and synchrony emerge during the transition from adolescence to adulthood.
    • in ScZ patients, there is less activation in the neural oscillations and synchrony
  • Hypofrontaility
  • Hyper-excitbale sensory cortex
22
Q

Explain the DA psychopharmacology behind ScZ

A
  • the DA system specifically in the midbrain and it’s projections into the forebrain play a significant role in the management of ScZ
    • D2R antagonists are used to preventing positive symptoms of ScZ
      • Atypical antipsychotic drugs (e.g Clozipine) are used now as they have fewer side effects:
        • no Parkinsonian-like symptoms, or Tardive dyskinesia
23
Q

Clozapine

A

an Atypical antipsychotic drug:

  • oral daily medication, taken with regular blood neutrophil monitoring
    • causes neutropenia
  • activity mainly at D4 receptors (also binds D3, D1, D2, D5) 5HT receptors
  • improves positive and negative symptoms
  • Side effects: weight gain, sedation, hypersalivation, tachycardia, hypotension, neutropenia (needs to be watched - blood tests)
24
Q

Explain the Glutamate psychopharmacology behind ScZ

A
  • PCP (phencyclidine, angel dust)
    • Causes many positive, negative and cognitive symptoms of schizophrenia
    • NMDA receptor antagonist
      • N-methyl-D-aspartate receptors (NMDARs) are a subclass of glutamate receptors
  • reduced NMDA receptor activity results in schizophrenic-like behaviour as seen in genetically modified mice with fewer NMDA receptors
    • NMDA antagonism in PFC - less glutamatergic firing to VTA GABA neurons
    • Less GABAergic inhibition of VTA-NAcc DA neurons –> Greater DA release in NAcc
    • Less activation of VTA-PFC DA neurons - less Glu - hypofrontality
25
Q

What are the neurocognitive deficits seen in ScZ

A
  • Lower IQ
  • Attentional deficits (e.g. Stroop Test)
  • Working memory (e.g. Wisconsin Card Sorting Test)
  • Planning and information processing deficits

typical antipsychotics have no effect of these symptoms whilst atypical ones have some improvement (increase in verbal fluency)

26
Q

Which drugs are associated with psychosis influence via the DA, 5-HT, Glutamate

A
  • L-Dopa
  • Amphetamine
  • LSD
  • Cannabis
  • Cocaine
  • Ketamine
  • MDMA
  • PCP
27
Q

What are the Environmental/ Biological factors that increase risk of ScZ

A
  • Obstetric complications ↑risk:
    • Premature birth
    • Low birth weight
    • Perinatal hypoxia
  • Intrauterine infection 1st/2nd trimester (winter births)
  • Antepartum bleeding
  • Immune activation (colds)
28
Q

What are the 3 main DA pathways in the brain?

A
29
Q

What are the adverse affects of blocking the following receptors/

  • D2, 5-HT2, Alpha-1 (Norepinephrine), H1 (Histamine) , M1 (cholinergic)
A
  • D2: Parkinsonism. Tardive dyskinesia. Raised prolactin
  • 5-HT2: Positive effect to offset Parkinsonism
  • alpha-1 Norepinephrine: Postural hypotension
  • H1 Histamine: Sedation Weight gain
  • M1 Cholinergic:
    • Antagonism: Constipation, Urinary retention, Blurred vision, Confusion etc
    • Agonism (clozapine only): Saliva overproduction
30
Q

Atypical antipsychotics overall effects and side effects

A
  • Increase DA activity in the PFC
  • Decrease DA in NAcc

Side effects

  • Sedation: (olanzapine, clozapine, quetiapine) (least for aripiprazole)
  • Metabolic: weight gain, glucose intolerance, ↑triglycerides (olanzapine / clozapine more than others; least for aripiprazole)
  • Raised prolactin: galactorrhoea, ↓sexual fn, osteoporosis (risperidone, amisulpride)
  • Cardiac: Hypotension (quetiapine) Arrhythmias (less than typicals)
  • Neutropaenia with clozapine in 1% hence requires regular blood monitoring
31
Q

Give examples of Atypical Antipsychotic drugs

A
  • AMISULPRIDE
  • ARIPIPRAZOLE
    • can be long injecting
  • CLOZAPINE
  • RISPERIDONE
  • OLANZAPINE
    • can be long injecting
  • QUETIAPINE
  • LURASIDONE
  • DEPIXOL
  • CLOPIXOL
  • PIPORTIL
  • PALOPERIDONE (RESPERIDONE)