Schizophrenia and other psychoses Flashcards
What is Schizophrenia?
A common chronic relapsing condition often presenting in early adulthood with:
- psychotic symptoms (incongourous mood, abnormal speech and thought)
- Negative symptoms (apathy, decreased motivation, withdrawal, self neglect, blunted mood
- sometimes: cognitive impairment
A pt presents with physcosis, disordered thinking and perception e.g. delusions and hallucinations.
What are some differencials ?
- Affective psychoses (depression, biploar disorder)
- Transient psychotic disorders (e.g. substance misuse)
- Psychosis due to a medical disorder (e.g. brain tumour)
- Schizophrenia-like non affective disorders (brief psychotic disorder, persistnt delusional disorder, schizophreniform disorder)
- Schizoaffective disorder — where symptoms of schizophrenia and a mood disorder (depressed or manic) are equally prominent.
NICE: The term ‘psychosis’ encompasses a number of symptoms associated with significant alternations to a person’s perception, thoughts, mood, and behaviour.
List symptoms a pt may have (divided into positive and negative) :
https://cks.nice.org.uk/topics/psychosis-schizophrenia/background-information/definition/
Positive symptoms
* Hallucinations (perceptions in the absence of stimulus) - auditory (most common) e.g. running commentary / command / echo
* Hallucinations- visual, smell, taste, or tactile (less common).
* Delusions (fixed or falsely-held beliefs) e.g. delusions of reference, delusions of control. Includes thought insertion, thought withdrawal, and thought broadcasting. Delusions of persecution
* Disorganised behaviour, speech, and/or thoughts (thought disturbance).
Negative symptoms
* Emotional blunting.
* Reduced speech.
* Loss of motivation.
* Self-neglect.
* Social withdrawal.
https://cks.nice.org.uk/topics/psychosis-schizophrenia/background-information/definition/
What is the most common psychotic disorder?
Schizophrenia
Using the ICD-10 criteria what ‘1 or more features’ needs need to be present in Schizophrenia ?
(Later card: ‘any 2’ features to save space as nice divides based on ICD10)
CARD 1/2
https://cks.nice.org.uk/topics/psychosis-schizophrenia/background-information/definition/
- Hallucinatory voices - a running commentary on the person’s behaviour, or discussing the person among themselves, or other types of hallucinatory voices coming from some part of the body.
- Thought echo, thought insertion or withdrawal, and thought broadcasting.
- Delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations.
- Persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (for example being able to control the weather, or being in communication with aliens from another world).
Using the ICD-10 criteria ‘any 2’ of what features need to be present in Schizophrenia ?
CARD 2/2
Persistent hallucinations
* in any form, fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas (similar to preoccupations), or when occurring every day for weeks or months on end.
Breaks or interpolations in the train of thought
* incoherence or irrelevant speech, or neologisms (invented words).
Catatonic behaviour
* excitement, posturing, or waxy flexibility; negativism; mutism; and stupor.
Negative symptoms
* apathy, reduced speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance
* make sure not due to depression or to antipsychotic medication.
Significant / consistent change in personal behaviour
* manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.
Causes of psychotic symptoms:
give broad headings
Interactions between:
* genetic
* social
* environmental risk factors
Comment on genetic link and psychotic disorders
- heritability - twin studies suggest 85%
- 7.5 fold increased risk of psychotic disorders with a parent with schizophrenia
What are some social and environmental risk factors for psychotic disorders?
Stressful life events
* bereavement, job loss, eviction, and relationship breakdown
Childhood adversity
* abuse, bullying, parental loss or separation
Family heritage
* 2 to 5-fold increased risk in south-Asian and black populations compared with the white population
Migration
* (especially from a developing country) — associated with a 3-fold increased risk of schizophrenia. Increased risk also demonstrated in children of migrants (second generation effect).
- Urban living
Cannabis use
* 40% increased risk, worse with heavier use, starting in adolescence, compounds with a high tetrahydrocannabinol content
Other substance use
* amphetamines, cocaine, ketamine, LSD, or inhaled substances such as toluene and certain types of glue
Medication use
* high-dose corticosteroid use can precipitate psychosis.
Early life factors
* in utero exposure to medication, maternal stress, nutritional deficiency, and infection; intrauterine growth restriction, birth and postnatal trauma.
Parental age
* paternal age of > 40 years and parental age of < 20 years
Exposure to the protozoan parasite Toxoplasma gondii
What is the prodomal period ?
When does it start?
What are the features?
What?
* prodomal perido can precede psychosis
When?
* can preced first episode by up to 18 months, sometimes a few days
Features:
* emotional and behavioural changes leading to a deterioration in personal functioning and social withdrawal
* Reduced interest in daily activities — may manifest as poor personal hygiene and/or reduced performance at school or work.
* Problems with mood, sleep, memory, concentration, communication, affect, and motivation.
* Anxiety, irritability, or depressive features.
* Incoherent or illogical speech — suggestive of thought disturbance.
* Transient, low-intensity psychotic symptoms — self-limiting episodes, typically lasting < 1 week. e.g hallucinations / unusual thoughts (including new preoccupation with mystical or religious themes, concerns about being under surveillance, etc).
What follows the prodomal period?
acute psychotic episode that includes hallucinations, delusions, and behavioural disturbances, often accompanied by agitation and distress.
What are factors associated with a poor prognosis in psychotic disorders?
- Longer duration of untreated psychosis.
- Early or insidious onset of schizophrenia.
- Male sex.
- Negative symptoms.
- Family history of schizophrenia.
- Low IQ, low socioeconomic status, or social isolation.
- Significant psychiatric history.
- Continued substance misuse.
If you think someone is in the prodomal period of psychosis, what medical tests / investigations could you do to rule out an alternative underlying cause to their pyschosis (other than schizophrenia)
Review pt Hx :
- prescribed drugs that can cause psychosis e.g. anticonvulsants, high-dose corticosteroids, levodopa and dopamine agonists, or opioids.
- urine drug screen
Amphetamines , cocaine use - HIV and/or syphilis screen
use clinical judgement - both infections can cause psychiatric symptoms. - FBC count
if anaemia is a potential cause of negative symptoms. - neurological condition such as temporal lobe epilepsy or cerebrovascular disease, SOL
What are subtypes of schizophrenia?
- Paranoid: commonest - delusions and/or hallucinations are prominent
- Hebenephric : 15-25yrs age of onset, fluctuating affect with fleeting and fragmented delusions and hallucinations
- Catatonic: stupor, posturing, waxy flexibility and negativism.
- Simple : negative symptoms predominate
- Residual : negative symptoms predominate
Management for Schizophrenia
Bio:
oral antipsychotic medication e.g. aripiprazole
* 10–15 mg once daily; usual dose 15 mg once daily (max. per dose 30 mg once daily.
Psyh:
* psychological interventions - family intervention (see NICE) and individual CBT
* psychoeducation for patients and family
Social
* Referal to Community mental health team - appoint key worker to monitor regularly post discharge as well as consultant led outpatient clincis
* All first epsiodes of psychosis should be referred to early intervention psychosis team
* Support groups in the community
https://www.nice.org.uk/guidance/cg178/chapter/recommendations#how-to-use-antipsychotic-medication
also used tutorial information
What factors to consider when choosing an anti-psychotic medication ( possible side effects )
- metabolic (including weight gain and diabetes)
- extrapyramidal (including akathisia, dyskinesia and dystonia)
- cardiovascular (including prolonging the QT interval)
- hormonal (including increasing plasma prolactin)
- other (including unpleasant subjective experiences). [
Before starting an antipyschotic medication what baseline investigations to do?
(more monitoring in depth in medications deck)
- weight (plotted on a chart)
- waist circumference
- pulse and blood pressure
- fasting blood glucose or glycosylated haemoglobin (HbA1c)
- blood lipid profile and prolactin levels
- assessment of any movement disorders
- assessment of nutritional status, diet and level of physical activity
- ECG / CVD exam
How does ICD10 define schizoaffective disorders?
- Episodic disorders in which both affective and schizophrenic symptoms are prominent but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes.
Royal college of psychiatrists :
* experience ‘pyschotic’ and ‘bipolar’ symptoms
* must be present for most of the time over at least 2 weeks
* Schizoaffective disorder depressive type
* Schizoaffective disorder manic type
* Schizoaffective disorder mixed type
https://www.rcpsych.ac.uk/mental-health/problems-disorders/schizoaffective-disorder
Treatment for schizoaffective disorder
Schizoaffective disorder depressive type
* Atypical antipyschotic e.g. Risperidone
* SSRI e.g. sertraline
Schizoaffective disorder manic type
* Atypical antipyschotic e.g. Risperidone
* mood stabilisers e.g. lithium / sodium valporate
Psych:
* CBT
* Family meetings
Social:
* art therapy
* self help groups
* Community mental health team - psychiatric nursing, social services, OT, support in managing financial affiars
See link below for more details of community services
https://www.rcpsych.ac.uk/mental-health/problems-disorders/schizoaffective-disorder
How do ICD-10 define psychotic depression (F32.3)
An episode of depression (described in a different section)
WITH:
* hallucinations
* delusions
* psychomotor retardation, or stupor so severe that ordinary social activities are impossible
* * there may be danger to life from suicide, dehydration, or starvation. The hallucinations and delusions may or may not be mood-congruent.
How to treat psychotic depression?
https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#psychotic-depression
Bio:
* Antipsychotic (NICE: olanzapine or quetiapine)
* SSRI e.g. sertraline
Psych:
* CBT - 1 on 1
* psychoeducation for patient and family
Social:
* CMHT referal
* Early intervention for psychosis team
* Support groups in the community
Poor prognosis indicators for Schizophrenia?
Factors associated with poor prognosis
* strong family history:
* gradual onset
* low IQ
* prodromal phase of social withdrawal
* lack of obvious precipitant
Schneider’s first rank symptoms for schizophrenia
Auditory hallucinations
thought disorders
passivity phenomena
delusional perceptions
(TAPP)
examples of auditory hallucinations in Schneider’s first rank symptoms
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour
examples of thought disorder in Schneider’s first rank symptoms
thought insertion
thought withdrawal
thought broadcasting
explain passivity phenomena in Schneider’s first rank symptoms
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
examples of delusional perception in Schneider’s first rank symptoms
a two stage process
1. where first a normal object is perceived
2. then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
