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
Non-psychotic features associated with psychosis?
agitation/aggression
neurocognitive impairment (e.g. in memory, attention or executive function)
depression
thoughts of self-harm
Examples of conditions in which psychotic symptoms may occur?
schizophrenia: the most common psychotic disorder
depression (psychotic depression, a subtype more common in elderly patients)
bipolar disorder
puerperal psychosis
brief psychotic disorder: where symptoms last less than a month
neurological conditions e.g. Parkinson’s disease, Huntington’s disease
prescribed drugs e.g. corticosteroids
certain illicit drugs e.g. cannabis, phencyclidine
The peak age of first-episode psychosis is when?
Around 15-30 years of age
What is circumstantiality and how does it differ from tangentiality?
Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail.
However, this differs from tangentiality in that the person does eventually return to the original point.
What is tangentiality
Tangentiality refers to wandering from a topic without returning to it.
What are neologisms?
Neologisms are new word formations, which might include the combining of two words.
What are clang associations?
Clang associations are when ideas are related to each other only by the fact they sound similar or rhyme.
What is word salad?
Word salad describes completely incoherent speech where real words are strung together into nonsense sentences.
What is Knight’s move?
Knight’s move thinking is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.
What is flight of ideas?
Flight of ideas, a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them.
What is Perseveration?
Perseveration is the repetition of ideas or words despite an attempt to change the topic.
What is echolalia?
Echolalia is the repetition of someone else’s speech, including the question that was asked.
What is derailment?
The conversation moves randomly from one topic to another.
What is poverty of speech?
A lack of spontaneous speech.
What is thought blocking and how can it be explored?
Thought blocking involves sudden cessation of thought, typically mid-sentence, with the patient being unable to recover what was previously said.
Questions which may be useful to explore thought blocking include:
“Do you feel able to think clearly?”
“Do you ever experience your thoughts suddenly stopping as though there were no thoughts left?”
“What is it like? How do you explain it?”
What is meant by formal thought disorder?
Formal thought disorder refers to disorganised thinking as evidenced in speech. They are especially associated with schizophrenia and psychosis.
Specific thought disorders?
Circumstantiality
Derailment
Poverty of speech
Perseveration
Thought blocking
Clang associations
Word salad
Flight of ideas
Tangentiality
Knight’s move
Echolalia
Neologisms
Thought withdrawal
Thought insertion
Thought broadcasting
What is meant by the term hallucination?
A hallucination is a perception in the absence of an external stimulus that has qualities of real perception.
Types of hallucination?
Auditory hallucination
Somatic hallucinations
Visual
Olfactory
Tactile
Elementary vs complex hallucinations
Elementary e.g. flashes of light, noises
Complex e.g. faces, scenes, music
What is a somatic hallucination
A perception of being touched in the absence of a sensory stimulus is termed a somatic hallucination. This may result in hallucinations of being touched, assaulted or that insects are beneath the skin.
What is thought withdrawal and how can it be explored?
Thought withdrawal refers to a patient’s belief that thoughts can be removed from their mind by others.
Questions which may be useful to explore thought withdrawal include:
“Is there anything like hypnosis or telepathy going on?”
“Is there anyone or anything taking thoughts out of your head?”
What is though insertion and how can it be explored?
Thought insertion refers to a patient’s belief that thoughts can be inserted into their mind by others.
Questions which may be useful to explore thought insertion include:
“Are your thoughts your own?”
“Is there anyone/anything putting thoughts into your head that you know are not your own?”
“How do you know they aren’t yours? Where do they come from?”
What is thought broadcasting and how can it be explored?
Thought broadcasting refers to a patient’s belief that others can hear their thoughts.
Questions which may be useful to explore thought broadcasting include:
“Can anyone hear your thoughts? For example, can I hear what you are thinking right now?”
“Do you ever hear your own thoughts echoed or repeated?”
What are delusions, and how can you explore them?
Delusions are firm, fixed beliefs based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms. These may include persecutory delusions, in which the patient erroneously believes another individual or group is trying to harm them or ideas of reference, in which the individual incorrectly believes specific events relate to them.
Questions which may be useful to explore delusional perception include:
“Do you sometimes have thoughts that others tell you are false?”
“Do you have any beliefs that aren’t shared by others you know?”
“Do you ever feel that people are out to do you harm?”
“Do you ever feel that specific events in the world are related to you in some way?”
“When you watch the television/listen to the radio/hear something, do you feel that the stories are referring to you or something that you have done?”
What is meant by passivity and how can it be explored?
People who experience passivity do not feel in control of their actions, thoughts and perceptions, believing them to influenced by an external agent.
Questions which may be useful to explore passivity include:
“Do you ever feel as though you are being controlled by someone or something?”
“Do you ever think that someone or somebody is controlling you?”
“Are your thoughts/mood/actions under your control or is someone forcing you to behave in this way?”
What is meant by first rank symptoms?
Certain symptoms as being characteristic of schizophrenia and therefore exhibiting a “first-rank” status in the hierarchy of potentially diagnostic symptoms.
However first rank symptoms can occur in other disorders such as mania or delirium which is why their isolated presence is not sufficient for a diagnosis of schizophrenia.
First rank symptoms
Delusional perception
Passivity
Delusions of thought interference
Auditory hallucinations
What are delusions?
Delusions can be defined as a belief that is held in spite of superior evidence to the contrary. They are seen in a number of psychiatric conditions, such as schizophrenia, bipolar disorder and psychotic depression.
Delusions may be bizarre, non-bizarre and mood congruent or mood-neutral.
Types of delusions
Nihilistic delusions
Delusions of grandeur/grandiose delusions
Delusions of control
Persecutory delusions
What are nihilistic delusions?
Negative delusions that are typically mood-congruent and see in depressed patients.
What are delusions of grandeur/grandiose delusions ?
Delusions with a strong positive affect where patients believe they have highly positive traits e.g “I’m rich” “I’m the Prime Minister”. Associated with mania.
What are delusions of control?
To a sensation that an external party is controlling an individuals thoughts or actions. Seen in psychosis.
What are persecutory delusions?
A set of delusional conditions in which the patient believes they are being persecuted. May be seen in psychosis.
What is Cotard syndrome and what might it be associated with?
Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent.
This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.
Cotard syndrome is associated with severe depression and psychotic disorders.
It can also appear as a result of parietal lobe lesions.
What is De Clerambault’s syndrome?
De Clerambault’s syndrome, also known as erotomania, is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
What is delusional parasitosis
Delusional parasitosis is a relatively rare condition where a patient has a fixed, false belief (delusion) that they are infested by ‘bugs’ e.g. worms, parasites, mites, bacteria, fungus. This may occur in conjunction with other psychiatric conditions or may present by itself, with patients often otherwise quite functional despite the delusion.
What is a psuedohallucination?
A pseudohallucination is a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.
An example of a pseudohallucination is a hypnagogic hallucination which occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone. These are pseudohallucinations as the affected person is able to determine that the hallucination was not real.
The relevance of pseudohallucinations in practice is that patients may need reassurance that these experiences are normal and do not mean that they will develop a mental illness.
Pseudohallucinations commonly occur in people who are grieving.
What is Logoclonia
A patient repeats the last syllable of a word or phrase.
What is pressure of speech
Increased quantity and speed of speech. Common in mania.
What is Monomania
A preoccupation with a single subject to a pathological degree.
What is othello syndrome?
Othello syndrome is a strong delusional belief that their spouse or partner is unfaithful with little or any proof to back up their claim.
It is associated with alcohol abuse, psychosis and right frontal lobe damage.
What is Ekbom’s syndrome
Ekbom’s syndrome is a delusional belief where a patient feels that they are infested with parasites.
They often complain of feeling “crawling” in the skin. It can appear as part of a psychotic illness or a secondary organic disease such as B12 deficiency, hypothyroidism and neurological disorders.
What is Capgras delusion
Capgras delusion refers to a delusion that either oneself or another person has been replaced by an exact clone. It may be part of a psychotic illness or as a result of trauma to the brain.
What is meant by psychosis?
mental disorder in which thought and emotions are so impaired that contact is lost with external reality
‘out of touch with reality’- the person is experiencing a reality that is not true
lack of insight
What are the 4 key features of psychosis?
Hallucinations
Delusions
Formal thought disorder
Passivity phenomena
Hallucination vs imagery
Hallucination: outside space, clear boundaries, vivid colour, exists independentof pt, 3D - rotate, light
Imagery: Inside, blurred, grey, only when pt imagines it,’flat’
2nd vs 3rd person hallucinations
2nd person hallucination - associated with affective disorders
3rd person hallucination, including commands - associated with schizophrenia
Olfactory hallucinations may indicate a problem with where?
Frontal lobe
Visual hallucinations should prompt investigation for what
Organic causes e.g. delirium
Auditory hallucinations may incicate what non-psychiatric causes?
May be normal
Temporal lobe problem
Primary vs secondary delusions
Primary (true delusions)
Secondary delusions (associated with some other experiences - i.e. belief someone is going to kill them secondary to an auditory hallucination saying someone is going to kill them)
General management of a psychotic episode
Where should the patient most safely be managed? RISK?
Rule out organic (medical) causes e.g. delerium
Considering sectioning if neded
Consider drug misuse (stimulants)
Treatment - follow biopsychosocial method
Antipsychotics, psychological support, social and drug issues
Schizophrenia vs schizoaffective disorder
In both schizoaffective disorder and schizophrenia, hallucinations and delusions tend to occur
Psychotic symptoms in schizophrenia tend to be persistent, while a person with schizoaffective disorder will generally have briefer episodes of psychotic symptoms that come and go
A person who has schizophrenia can become depressed or manic, but these mood disorder symptoms are not generally a prominent or persistent part of their condition.4 Conversely, a person with schizoaffective disorder will experience chronic and persistent mood symptoms.
A diagnosis of schizophrenia is more likely if the individual experiences at least two of the following symptoms:
Confused thinking or speech
Delusions
Hallucinations
Negative symptoms, such as lack of expression
Unusual body movements
What is Othello Syndrome?
Othello’s syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.
What is catatonia
Stopping of voluntary movement or staying still in an unusual position
Symptoms of hypomania in primary care
Routine refferal to CMHT
What symptoms would it be important to assess for/ask about when assessing someone who may be psychotic?
Delusions – fixed false beliefs – e.g. Persecutory delusions/paranoia, Delusions of control/passivity phenomena (thoughts, actions or sensations).
Hallucinations – tend to be auditory hallucinations (third person or running commentary) in Paranoid Schizophrenia.
Thought echo, insertion, withdrawal or broadcast.
Negative symptoms including apathy, paucity of speech and blunted affect.
Catatonic symptoms.
Mood symptoms e.g symptoms of depression or mania.
Aside from continuing medication, what other interventions might be considered following discharge to ensure a patient is best supported following a psychotic episode?
Referral to a CPN/Early Intervention Psychosis team for support and monitoring in the community.
Psychology referral, for example, for CBT or family therapy.
Occupational groups or support groups locally.
Education about lifestyle factors, e.g. recreational drug use, cardiometabolic health, smoking.
Support with finances e.g. benefits or employment support.
What is brief psychotic disorder?
This is a short-term disturbance that involves the sudden onset of at least 1 positive psychotic symptom. Positive symptoms include delusions, hallucinations, disorganised speech, and grossly disorganised or catatonic behaviour.
Brief psychotic disorder often resolves with a return to baseline functioning
Treatment of steroid induced mania
• Treat as for any other mania – usually antipsychotic first-line
• Liaise with oncology team, patient and family re risk/benefit of continuing steroid and whether to gradually reduce
• May or may not require MHA assessment and inpatient psychiatric care
• Long term psychiatric follow up in outpatients, gradual reduction of antipsychotic.
• Psychoeducation re. relapse indicators of future mood episodes for both patient and family
Schizophrenia first rank symptoms - auditory hallucinations specific types
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour
Delusional perception vs ideas of reference
While a person experiencing an idea of reference will change his or her mind when evidence dictates he/she must, a person experiencing a delusion will believe something refers back to him or her even in the face of strong evidence to the contrary.
What is Palilalia
Palilalia is the automatic repetition of one’s own words, phrases or sentences.
Differentiating between Knight’s move and flight of ideas
Knight’s move thinking there are illogical leaps from one idea to another, flight of ideas there are discernible links between ideas
What are Pareidolic illusions
Pareidolic illusions are vivid illusions that occur from indistinct stimuli, like seeing a face in burn marks. They occur as a result of fantasy and vivid visual imagery and can occur without conscious effort, although they often intensify if the person concentrates. They are not related to affect (state of mind).
