Schizophrenia and other psychoses

Question 1

What is Schizophrenia?

Answer 1

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

Question 2

A pt presents with physcosis, disordered thinking and perception e.g. delusions and hallucinations.

What are some differencials ?

Answer 2

• 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.

Question 3

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/

Answer 3

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/

Question 4

What is the most common psychotic disorder?

Answer 4

Schizophrenia

Question 5

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/

Answer 5

• 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).

Question 6

Using the ICD-10 criteria ‘any 2’ of what features need to be present in Schizophrenia ?

CARD 2/2

Answer 6

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.

Question 7

Causes of psychotic symptoms:
give broad headings

Answer 7

Interactions between:
* genetic
* social
* environmental risk factors

Question 8

Comment on genetic link and psychotic disorders

Answer 8

• heritability - twin studies suggest 85%
• 7.5 fold increased risk of psychotic disorders with a parent with schizophrenia

Question 9

What are some social and environmental risk factors for psychotic disorders?

Answer 9

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

Question 10

What is the prodomal period ?
When does it start?
What are the features?

Answer 10

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).

Question 11

What follows the prodomal period?

Answer 11

acute psychotic episode that includes hallucinations, delusions, and behavioural disturbances, often accompanied by agitation and distress.

Question 12

What are factors associated with a poor prognosis in psychotic disorders?

Answer 12

• 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.

Question 13

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)

Answer 13

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

Question 14

What are subtypes of schizophrenia?

Answer 14

• 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

Question 15

Management for Schizophrenia

Answer 15

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

Question 16

What factors to consider when choosing an anti-psychotic medication ( possible side effects )

Answer 16

• 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). [

Question 17

Before starting an antipyschotic medication what baseline investigations to do?
(more monitoring in depth in medications deck)

Answer 17

• 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

Question 18

How does ICD10 define schizoaffective disorders?

Answer 18

• 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

Question 19

Treatment for schizoaffective disorder

Answer 19

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

Question 20

How do ICD-10 define psychotic depression (F32.3)

Answer 20

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.

Question 21

How to treat psychotic depression?

https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#psychotic-depression

Answer 21

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

Question 22

Poor prognosis indicators for Schizophrenia?

Answer 22

Factors associated with poor prognosis
* strong family history:
* gradual onset
* low IQ
* prodromal phase of social withdrawal
* lack of obvious precipitant

Question 23

Schneider’s first rank symptoms for schizophrenia

Answer 23

Auditory hallucinations
thought disorders
passivity phenomena
delusional perceptions

(TAPP)

Question 24

examples of auditory hallucinations in Schneider’s first rank symptoms

Answer 24

two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour

Question 25

examples of thought disorder in Schneider’s first rank symptoms

Answer 25

thought insertion
thought withdrawal
thought broadcasting

Question 26

explain passivity phenomena in Schneider’s first rank symptoms

Answer 26

bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others

Question 27

examples of delusional perception in Schneider’s first rank symptoms

Answer 27

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’.