Schizophrenia And Other Psychoses Flashcards
What is schizophrenia
Long term mental health problem affecting thinking, perception and affect
Schizophrenia in men vs women
Affects men and women equally
Onset in women around 25-35, onset in men 18-25
What factors are believed to lead to schizophrenia
A combination of psychological, environmental, biological and genetic factors
Schizophrenia is believed to develop because of physical changes to the brain and to changes in neurotransmitters.
What is the neurodevelopmental hypothesis?
It is suggested that brain development is implicated in the pathophysiology of schizophrenia:
People who experienced hypoxic brain injury at birth or who were exposed to viral infections in-utero are at greater risk of developing schizophrenia.
Temporal lobe epilepsy and cannabis use while the brain is still developing are at high er risk
Imaging has shown changes in the brains of people with schizophrenia, including enlarged ventricles, small amounts of grey matter loss and smaller, lighter brains.
Schizophrenia is believed to develop because of physical changes to the brain and to changes in neurotransmitters.
What is the neurotransmitter hypothesis?
An excess of dopamine and overactivity in the mesocorticolimbic system is believed to cause the positive symptoms of schizophrenia. Dopamine antagonists are therefore used to treat schizophrenia.
There is also thought to be less dopamine activity in the mesocortical tracts, causing the negative symptoms in schizophrenia. This explains why dopamine antagonists are more successful at treating positive than negative symptoms.
Psychotic symptoms are seen in people with Parkinson’s disease if they are overtreated with levodopa as this increases the amount of dopamine in the brain. Amphetamines and cocaine also increase dopamine release and lead to psychosis.
Dopamine is not the only neurotransmitter implicated in schizophrenia. There is also an increase in serotonin activity and a decrease in glutamate activity
Which neurotransmitters are implicated in schizophrenia
Dopamine (excess)
Serotonin (increase in activity )
Glutamate (decrease in activity)
What are the types of schizophrenia
Paranoid - hallucinations, delusions, thought disorders
Hebephrenic - affective symtpoms
Catatonic - movement and behavioural disorders
Undifferentiated
Residual
Simple - chronic, negative
What is the most common subtype of schizophrenia?
Paranoid schizophrenia
How is paranoid schizophrenia characterised?
Paranoid delusions
Auditory hallucinations
How is hebephrenic schizophrenia characterised?
Mood changes
Unpredictable behaviour
Shallow affect
Fragmentary hallucinations
In which patients is hebephrenic schizophrenia diagnosed?
Adolescents and young adults
Why is the outlook for hebephrenic schizophrenia often poor?
Negative symptoms may develop rapidly
Simple schizophrenia vs hebephrenic schizophrenia
Both characterised by negative symptoms
In simple schizophrenia patients have never experienced positive symptoms
How is catatonic schizophrenia characterised?
Psychomotor features, such as posturing, rigidity and stupor.
What is undifferentiated schizophrenia
Patients are designated as having undifferentiated schizophrenia when their symptoms do not fit neatly into one of the other categories of schizophrenia.
What is residual schizophrenia
Characterised by negative symptoms.
It usually occurs when the positive symptoms have ‘burnt
out’
How is the risk of developing schizophrenia influenced by family history and genetics
Monozygotic twin affected - 50% chance
Chance if both parents affected around 50%
Increased risk with paternal age over 55
What pregnancy related issues can increase risk of schizophrenia later in the newborns life?
Malnutrition
Viral infection
Pre-eclampsia
Emergency c section
What drug abuse is associated with increased risk of schizophrenia?
Using cannabis is known to increase the risk of developing schizophrenia, particularly when used as a teenager.
Many other drugs can also cause psychotic symptoms, including amphetamines, cocaine and LSD
Social and environmental risk factors for schizophrenia
Lower socioeconomic class
Living in urban area
Stressful life experiences
Psychical or sexual abuse
Childhood adversity
Migration
Which ethnicity is most affected by schizophrenia (in the UK)
Afro Caribbean (men)
Positive symptoms of schizophrenia
Tend to represent a change in behaviour or thought:
Thought echo
Thought insertion or withdrawal
Thought broadcasting
3rd person auditory hallucinations
Delusional perception
Passivity and somatic passivity
Odd behaviour
Thought disorder
Lack of insight
Negative symptoms in schizophrenia
Usually involve a decline in normal functioning:
Amotivation
Autism (social isolation)
Ambivalence
Alogia/poverty of speech
Affect is blunted
Apathy/poor self care
ICD-10 diagnostic criteria of schizophrenia
- A FIRST RANK SYMPTOM OR PERSISTENT DELUSION PRESENT FOR AT LEAST A MONTH:
Delusional perception
Passivity
Delusions of thought interference
Auditory hallucinations
- NO OTHER CAUSE FOR PSYCHOSIS such as drug intoxication or withdrawal, brain disease (including dementia, delirium, epilepsy) or EXTENSIVE DEPRESSIVE OR MANIC SYMPTOMS (unless it is clear that the schizophrenic symptoms preceedthe affective disturbance)
The management of schizophrenia may involve several multidisciplinary teams including who?
Early intervention team (initial referral after the first psychotic episode)
Community mental health team (provide day-to-day support and treatment)
Crisis resolution team (for patients experience an acute psychotic episode)
What are the four stages to a care program approach?
Assessing health and social needs
Creating a care plan
Appointing a key worker to be the first point of contact
Reviewing treatment
What classes of drugs are used to treat schizophrenia
D2 (dopamine) receptor antagonists - they can be divided into typical and atypical antipsychotics
Examples of typical antipsychotics
Haloperidol
Chlorpromazine
Fluoentixol deconate (depot injection)
Atypical antipsychotics
Olanzapine
Risperidone (depot injection)
Clozapine
Amisulpride
Quetiapine
Aripiprazole
Psychological therapies used to manage schizophrenia
CBT
Family therapy
Complications of schizophrenia
As well as the side effects from antipsychotic medications, complications of schizophrenia may include:4
Suicide: the lifetime risk of suicide is approximately 5%
Cardiovascular disease: there is an increased risk of premature death due to cardiovascular disease, in addition, patients with schizophrenia are more likely to smoke
Cancer: delayed diagnosis and late presentation of cancer
Substance abuse: up to one-third of patients with schizophrenia use drugs
Social isolation
When might clozapine be used to treat schizophrenia?
Clozapine is often used when both typical and atypical antipsychotics have been ineffective.
Examples of negative symptoms
incongruity/blunting of affect
anhedonia (inability to derive pleasure)
alogia (poverty of speech)
avolition (poor motivation)
Factors associated with poor prognosis in schizophrenia
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
What are delusional perceptions
2 stage process
Normal object is perceived and secondary there is a delusional insight into its meaning
What is passivity phenomena
Sense of external influence controlling the thoughts or actions of a person
ie. thoughts and feelings have been ‘put there’ by someone else, patient is not producing them
Thought disorder manifestations examples
Thought broadcasting
Thought insertion
Thought withdrawal
Auditory hallucinations manifestation examples
Third person commentary
Command hallucinations
Thought echo
Good prognostic factors in schizophrenia
High IQ
Good support network
Sudden onset
Obvious precipitating factor
Mainly positive symtpoms
Prognosis of schizophrenia rule of quarters
25% never have another episode
25% improve substantially on treatment
25% have some improvement on treatment
25% treatment resistant
Differentials of schizophrenia
Substance induced psychotic disorder
Organic psychosis caused by infection, brain injury and CNS diseases
such as Wilson’s disease
Metabolic disorder such as hyperthyroidism and hyperparathyroidism
Dementia and depression can also co-occur with psychosis
Pharmacological management of schizophrenia
Paranoid schizophrenia, as with any psychotic disorder, is treated first-line with atypical antipsychotics
such as Risperidone. These are preferred to typical antipsychotics such as Haloperidol, due to the
reduced risk of extra-pyramidal symptoms.
Sedative drugs such as Lorazepam may be used if there is acute behavioural disturbance in the
presentation of paranoid schizophrenia, but this is not the first-line treatment and will not improve
psychotic symptoms.
NICE recommends Clozapine for children and young people whose schizophrenia has not responded to adequate doses of at least two different antipsychotics used sequentially for 6-8 weeks
Examples of psychotic features?
hallucinations (e.g. auditory)
delusions
thought disorganisation
alogia: little information conveyed by speech
tangentiality: answers diverge from topic
clanging
word salad: linking real words incoherently → nonsensical content