Schizophrenia and Psychoses Flashcards
A sensory experience vivid enough to be a hallucination but recognised by the subject not to be real.
Pseudohallucination
The subject hears voices which talk to them directly (e.g. “You’re going to die, you’re going to die”)
2nd person auditory hallucination
The subject hears voices talking about them but not to them, or commentating on their actions. (e.g. “he’s having a drink, now he’s going to the bathroom”)
3rd person auditory hallucination
False perception of a real stimulus. Three types: affect, completion and pareidolia.
Illusion
A perception which occurs in the absence of a stimulus. To the person this has the impact of a real perception and is indistinguishable. It occurs externally (not in the mind).
Hallucination
What is the difference between “illusion” and “hallucination”?
An illusion is based on a real sensory stimulus that is interpreted incorrectly whereas a hallucination is created by the mind without any stimulus.
What are the three types of illusion?
Pareidolia
Completion
Affect
What is a pareidolia illusion?
Seeing shapes in inanimate objects
What is a completion illusion?
The mind completes partial images
What is an affect illusion?
Based on the subject’s current affect
Seeing faces in clouds would be an example of which type of illusion?
Pareidolia illusion
Seeing a monster in the corner of the room when you are scared would be what type of illusion?
Affect illusion
A cluster of symptoms that often occur in chronic schizophrenia including poverty of speech, flat affect, poor motivation, poor attention and neglect.
Negative symptoms
A cluster of psychotic symptoms including hallucinations and delusions.
Positive symptoms
To the subject the external world appears unreal or artificial. They’re aware this is abnormal.
Derealisation
A change in awareness of self, in which the individual feels they’re not real and are detached from the world. They are aware this is abnormal.
Depersonalisation
A fixed firmly held belief that is held with unshakeable conviction despite evidence to the contrary and cannot be explained by the subject’s cultural or religious background.
Delusion
Extremely negative delusions of being dead or part of the body decaying.
Nihilistic delusions
Loss of structured thinking. The subject seems muddled and doesn’t become clearer with further questioning, things often seem more confusing the more you ask them.
Loosening of associations
Rapid flow of thought, manifested by accelerated speech with abrupt changes from topic to topic. There is often some form of link between topics. Often seen in mania.
Flight of ideas
Delusion of having of a higher status or significance, special powers or a secret mission.
Grandiose delusions
The subject receives a normal perception but it’s interpreted with delusional meaning and has immense significance (e.g. I know I’m the king as I saw the traffic light turn green)
Delusional perception
The subject believes their thoughts, feelings and/or actions are not their own but are being imposed/controlled by an outside force.
Delusion of control/passivity
Thoughts which are not believed to be the subject’s own infiltrate their mind. They often have bizarre explanations of how it’s happened.
Though insertion
The subject believes their thoughts are being shared with others (e.g. being broadcast on the radio)
Thought broadcast
The subject believes their thoughts have been removed from their mind by an external agency.
Thought withdrawal
The belief that innocuous events have direct personal significance to the subject (e.g. believing something on the TV is a direct message to them).
Ideas of reference
What is the difference between “thought broadcast” and “ideas of reference”?
In thought broadcast they believe their thoughts are being broadcast for others to receive. With ideas of reference they take special meanings from inoculous stimuli.
The repetition of a particular response (phrase, word, or gesture) despite the absence or cessation of the stimulus. Often seen in organic brain disorders.
Perseveration
The subject experiences his own thoughts as if they were being spoken aloud.
The repetition may not be a simple echo but subtly or grossly changed in quality.
Thought echo
A new word that has no real meaning.
Neologism
The three clusters of psychotic symptoms
- Hallucinations
- Delusions
- Thought disorder
What is a delusion?
A false, unshakable belief held with intense conviction and despite evidence to the contrary; but not explained by culture or religious background.
What is thought disorder?
An abnormality in the mechanism of thinking.
To the observer their speech doesn’t make sense.
True or false: psychosis is not a psychiatric diagnosis.
True. It is an umbrella term for a number of symptoms that involve a disconnection with reality.
In which gender is schizophrenia more common?
Males
What is the average age of onset of schizophrenia in men and women?
Men tend to develop symptoms earlier (~20-28yo).
Female average onset ~26-32yo.
What are the rates of incidence and prevalence of schizophrenia?
Incidence 0.1%
Prevalence 1%
What are some of the aetiological factors for schizophrenia?
Genetics
Cannabis (4x risk if regular use before age 15)
Living in urban area
Children of migrants
Economic adversity/social exclusion
Childhood trauma and/or abuse
Winter birth or if perinatal viral infection or trauma
Which neurotransmitter is most implicated in schizophrenia?
Dopamine
What are the main dopamine pathways in the brain?
Dopamine is produced in the midbrain and taken to different active sites via 4 pathways:
- Mesocortical: midbrain to frontal cortex
Cognition and executive function
Low levels of DA here cause schizophrenia negative symptoms.
- Mesolimbic: midbrain to limbic system
Motivation, emotion, reward (assigns emotional importance to experiences)
High DA levels create schizophrenia positive symptoms.
- Nigrostriatal: basal ganglia.
Stimulation of movement.
Normal levels in schizophrenia, but this pathway explains the extrapyramidal side effects of some antipsychotics.
- Tuberoinfundibular pathway: pituitary gland.
Normal levels of DA here in schizophrenia. But, DA functions as a prolactin inhibitor. Therefore, antipsychotics may reduce DA levels and increase prolactin = sexual dysfunction, dysmenorrhea, gynaecomastia.
__A__ of schizophrenia include delusion, __B__ and hallucinations. These are psychotic symptoms and are the focus of medical treatments. The presence of these symptoms offers a __C__ prognosis.
A) Positive symptoms
B) thought disorder
C) better
Lack of motivation, __A__, poverty of speech and __B__ affect are examples of __C__ sometimes seen in schizophrenia.
These are part of the continuum of normal traits and often present __D__ in the course of the disease. They are __E__ to treatment.
A) anhedonia B) blunt C) negative symptoms D) later E) less responsive
Define the ICD-10 classification of schizophrenia
For at least one month and without an organic cause or substance abuse:
One or more of:
- Delusion
- Delusional perception
- 3rd person hallucination
- Thought insertion/echo/withdrawal/broadcast
- Delusion of control/passivity
Two or more of:
- Any other hallucination
- Negative symptoms
- Loosening of associations
- Catatonia
What is catatonic schizophrenia?
A state of immobile stupor with cardinal features such as posturing and waxy flexibility.
What is paranoid schizophrenia?
Paranoid delusions usually with auditory hallucinations. The most common type.
What is simple schizophrenia?
Profound negative symptoms without any delusions or hallucinations.
What subtype of schizophrenia is being described?
Prominent affect changes with shallow and inappropriate mood. Irresponsible and unpredictable behaviour.
Fleeting delusions and hallucinations. Rapid development of negative symptoms.
Hebephrenic
What is the prognosis for a subject with schizophrenia?
Following 1st psychotic episode:
Third recover, third relapse/remit with good function between, third have chronic schizophrenia.
Taking an antipsychotic reduces risk of schizophrenia relapse by __A__. Stopping an antipsychotic within six months increases the risk of relapse by __B__.
A) a third
B) four times
Which of the following is a good prognostic factor for schizophrenia?
A) Single
B) Older age of onset
C) Insidious onset
D) Male
B) Older age of onset
Interestingly, older age of onset is a better prognostic factor than early age of onset.
What is acute psychotic disorder?
Patient has psychotic symptoms lasting less than 28 days.
If symptoms persist beyond 28 days then they will later be given the diagnosis of schizophrenia
What is schizoaffective disorder?
Schizophrenia can’t be diagnosed in the presence of extensive affective symptoms (mania or depression).
Therefore, a patient is diagnosed with schizoaffective disorder if he displays both psychotic and affective symptoms are simultaneously present and equally prominent.
What are delusional disorders?
Mental illness in which delusions are the most prominent feature.
They are typically well formed and long standing (they can be life-long!) and very difficult to treat. Patients usually retain delusion but are less preoccupied with it.
Hallucinations aren’t present or are only fleeting
Delusions of control/passivity experiences aren’t compatible with this diagnosis.
They believe their partner is cheating on them. Risk to the partner and the other individual of violence and stalking.
Othello syndrome (delusion disorder)
A nihilistic delusion without other psychotic symptoms. They believe they are dead, rotting or have lost body parts.
Cotard’s syndrome (delusion disorder)
They believe that someone from a higher social standing is in love with them and sends them secret messages to convey their love.
De Clerambault’s syndrome (sometimes known as ‘erotomania’; a delusion disorder)
They believe they are infested with parasites despite no evidence of this. Risk of self harm through excoriation or trying to get the parasites out.
Ekbom’s syndrome (delusion disorder)
The dominant partner has a delusional belief and then the dependent partner develops the same belief.
The dominant partner requires treatment but the dependent partner recovers upon separation.
Folie a Deux
sometimes known as ‘induced delusional disorder’; a delusion disorder
They believe multiple people are actually one individual in disguise who is persecuting them.
Fregoli’s syndrome (delusion disorder)
They believe someone has been replaced by an imposter
Capgras syndrome (delusion disorder)
What class of drugs are used in the management of schizophrenia and other psychotic-related disorders?
Antipsychotics
The indications for use of antipsychotics include:
- Psychotic disorders (e.g. schizophrenia)
- Affective disorders (e.g. mood-stabiliser for bipolar)
- Sedative (e.g. palliative care to ease agitation)
How quickly do you see the effects antipsychotics have?
Sedative - within hours
Side-effects - hours to days
Antipsychotic effects - days to weeks
How are antipsychotics classified?
Typical/First Generation:
- Haloperidol, zuclopenthixol, flupentixol
Atypical/ Second Generation:
- Olanzapine, risperidone, quetiapine, aripiprazole, clozapine
Which is the most effective of the common antipsychotics?
Clozapine.
It also has some high-risk side effects which mean it should never be a first line treatment.
- agranulocytosis in 1%, myocarditis, reduced seizure threshold.
Clozapine should only be started after two other antipsychotics have failed, including at least one 2nd gen (atypical).
What preparations are available for antipsychotic medication?
Oral (acute management and maintenance therapy)
IM (acute agitation where unable to give oral medication)
Depot (often preferred for longer term, or may use if poor compliance)
What investigations should be performed prior to commencing antipsychotics?
Observations:
- BP and BMI (2nd gen can cause metabolic side-effects)
- Heart rate (some increase QTc)
Blood:
- FBC, U&E, LFT, TFT
- Prolactin (can be raised due to DA inhibition)
- HbA1c and lipids (2nd gen can cause metabolic side-effects)
ECG:
- Many can cause prolonged QTc
What are the extrapyramidal side effects of some antipsychotics?
EPSE’s are particularly prominent in typical (1st gen).
Acute:
- Acute dystonia (spasms, torticollis; managed with anticholinergics)
- Parkinsonism (tremor, rigidity, bradykinesia; managed with anticholinergics)
- Akathisia (restlessness; managed with sedatives or medication change)
Chronic:
- Tardive dyskinesia (choreoathetoid movements, lipsmacking, pinching and other pointless repetitive movements; manage by changing drug or reducing dose, anticholinergics worsen TD symptoms)
True or false: Metabolic side effects are more common in antipsychotics like haloperidol.
False. Haloperidol is a typical (1st gen) antipsychotic. Metabolic side-effects are more common in 2nd gen (atypical) antipsychotics.
Include: weight gain, diabetes, dyslipidaemia.
True or false: Extrapyramidal side effects are more common with typical antipsychotics than atypicals?
True. First gen (typical) antipsychotics such as haloperidol are more likely to give EPSEs than second gen’s like olanzapine and risperidone.
What psychosocial interventions are available for psychoses and schizophrenia?
Family therapy
CBT
Art therapy (rec. for those with negative symptoms)
What conditions may cause psychosis?
Schizophrenia
Schizoaffective disorder
Affective disorders (depression, bipolar)
Organic diseases (dementia, delirium, encephalitis, metabolic disturbance)
Illicit substance use/withdrawal
Alcohol (intoxication, delirium tremens, withdrawal)
Sleep deprivation
Bereavement/grief
