Schizophrenia and Psychosis Flashcards
What are the symptoms of schizophrenia?
Acute schizophrenia - positive symptoms
- Hallucination - Delusion - Interference with thinking - Some recover, some progress to…
Chronic symptoms - negative symptoms
- catatonism - Lack of drive - retardation - Social withdrawal
Positive symptoms respond well to anti-psychotic treatments, when progress into chronic makes it harder to treat.
What is hallucination
False perception without an external stimulus
* Auditory: running commentary; voices discussing the person in third person; hearing one's own thoughts aloud (thought echo) * Visual: may suggest an organic brain disease * Olfactory: smelling gas * Gustatory: can taste 'poison' in food * Tactile: insects crawling upon skin, sexual sensations
Tactile - very common in delirium treatments in alcohol intoxication. Sexual sensations can be common if the patient has delusional love affairs etc.
What is delusion?
- A false, fixed belief
- Firmly held belief, despite evidence to the contrary
- Not in keeping with the patient’s socio-cultural background
- Grandiose (‘special gifts’), persecutory and bizarre
- Religious pattern for those who have faith
What is Schneider’s first rank symptoms of schizophrenia, also the ICD 10 criteria for diagnosing schizophrenia?
Proposed this group of symptoms but said they were in no way essential to diagnose schizophrenia.
Perception is real but perceived in a delusional way.
what are the positive symptoms
positive symptoms – any change in behaviour or thoughts, such as hallucinations or delusions.
what are the negative symptoms
negative symptoms – where people appear to withdraw from the world around then, take no interest in everyday social interactions, and often appear emotionless and flat.
About F20.0 paranoid schizophrenia
The most common type.
Negative symptoms can be present but must not dominate the positive symptoms.
About F20.1 hebephrenic schizophrenia
This presentation is getting much more rate in industrialised countries
What is the epidemiology of schizophrenia?
Prevalence around 1% of population, and this is the same anywhere in the world.
Does schizophrenia have a genetic component
There is a very strong relationship with genetics
Prevalence of Schizophrenia
Prevalence around 1% of population, and this is the same anywhere in the world.
Neuroimaging of schizophrenia
Haas been proved that there are some structural changes in the brains of patients with schizophrenia. Interestingly, none of them are specific for schizophrenia however, so they can’t be used as diagnostic criteria.
Neuroimaging can help to exclude other causes - organic causes.
- Enlarged lateral ventricles
- L. Temporal lobe abnormalities
- Broca’s area (responsible for speech light up in fMRI)
in hallucinations (since they are misperceptions of
someones own internal thoughts) - Brain volume reduction 3%
- Significant loss of grey matter , up to 25%
- Parietal, temporal, frontal loss
- Have abnormal brains before starting medication
Illusion VS Hallucination
Illusion - there is a stimuli but you’re not receiving it as it is, its just been changed for you. Hallucination is different as there is no stimuli there in the first place.
What are the psychological factors triggering schizophrenia
-Stereotyping -‘Schizophrenogic mother’- the mothers fault / due to parenting
-Double bind - in period of development, if parents are communicating with the child in a confusing way - calling to a child but sounding like rejection.
-Expressed emotion- such as constant arguments, over engaged family
Predicts relapse
-Life events
What is the social learning theory
Learning behaviour form others e.g. parents, and it is reinforced by the parents continuing to behave in this way
About antipsychotic medication for schizophrenia
Good evidence to treat acute schizophrenia - mainly for positive symptoms
What are the side effects of antipsychotic medication for schizophrenia?
Extra pyramidal side effects - shakes, movement problems, rigidity, involuntary facial movements, eye rolling etc.
Can get so bad that people may have to stop treatment.
Course and outcome of schizophrenia
Roughly half patients have multiple episodes…Static impairment means that it isn’t getting worse.
Duration of untreated psychosis (DUP) is a predictor of outcome- so the longer people go untreated, the worse the outcome.
2 fold increase in standardised mortality ratio
- Higher suicide rate (?up to 7%, usually near onset)
- Physical health- Higher rate of MI, stroke, diabetes
- 80-90% smoke versus 20% general population
What is the difference between neurosis and psychosis?
Neurosis is anything where you feel negative. Psychosis is where you lose touch with reality and you lose insight, which is the critical distinction. You don’t know that you are ill if you are psychotic. This makes it more dangerous as you don’t seek help and you also believe your own delusions.
About drug induced psychosis
If drug induced need to stop the drug. Change the environment to lose the cues.
Family history - has a genetic factor so can make someone predisposed, meaning that any drugs etc can have an ever greater risk than those without this predisposition.
About alcohol withdrawal and psychosis
Of all the drugs, we chose to legalise potentially the worst one because this is the only one which you can die from the withdrawal symptoms (10% mortality in normal individuals, up to 30% if have another comorbidity eg diabetes or a chest infection etc).
Alcohol works on GABA which is to do with inhibition. Higher level functioning parts of the brain (planning, scheduling, attention etc) are inhibited. The remaining active parts of the brain is the brain stem - eg breathing, and also the limbic system which is to do with the emotional response. Therefore you start to display behaviours like fighting, doing inappropriate emotionally driven things as you are still able to react in this way but not reason.
If you drink habitually you constantly suppress the neocortex. You get tolerance (needing higher amounts to get the same effect) and withdrawal. If drinking a lot daily then you are permanently inhibiting brain function. If you suddenly stop drinking then the brain turns back on what you’ve turned on - get massive activation, brain switching on all at once, and this is why you get terrible withdrawal - hallucinations (usually visual), delusions, tremors. If this is untreated there is a high mortality rate. Treated using a drug that inhibits a measure of the same thing, using benzodiazepine (also a GABA inhibitor). If you’re not used to it then it will totally inhibit you and put you to sleep.
When taking these drugs while withdrawing from alcohol your body biologically has what the alcohol was doing so you don’t get the withdrawal symptoms. These drugs are however very addictive so to come off of these we lower the dose daily over around 8-10 days. Any longer than this then it is addiction territory. Must NOT drink whilst on these drugs or will get respiratory depression. However, less likely to drink on this medication as they are not biologically n withdrawal any more anyway.
Takes about 48 hours for withdrawal effects from alcohol to take place.
About psychosis and comorbidity
You can get psychosis with other conditions; psychotic depression for example. There is some overlap with depression which is interesting as there is a neurosis and a psychosis.
Top 3 most common delusions
- Persecution/paranoia
- Grandiosity
- Delusions where you believe you are some key figure eg Christ
Talking to patients about hallucinations
Patients will talk to you about their hallucinations openly. This shows that they truly believe that they are real. They will also frequently ask you to stop the person they can hear talking etc. By them approaching you this show that they clearly lack insight. They can’t realise in the moment how this seems to you who can see/hear the things they can. Their behaviour is also very consistent with the delusions and hallucinations. They are out of touch with our reality but within their own the are very consistent. They behave as though what they believe they are/see/hear is actual reality.
What are the signs and symptoms of psychosis?
- Delusions
- Hallucinations
- Bizarre behaviour or posture
- Disorganised speech
What is the Jaspers (1959) standard model of delusions?
- Jaspers (1959) – The standard model
- False judgements
- Extraordinary conviction
- Impervious to counterargument
- Impossible content
What are themes/ types of delusions?
- Persecutory
- Morbid jealousy
- Love
- Misidentification - Capgras, Fregoli
- Grandiose
- Religious
- Guilt/worthlessness
- Poverty
- Hypochondriacal
- Infestation
- Communicated - la folie a deux
What are primary and secondary delusions?
Primary - ununderstandable e.g., believing everyone in a chamealion
Secondary - understandable given what we know about the patient’s mood, life history etc
What are over-valued ideas?
An acceptable, comprehensible idea which is pursued beyond the bounds of reason
What are hallucinations?
False perception without an external stimulus, such as hearing voices, seeing things, etc
- Auditory: running commentary, voice discussing the person in third person, hearing one's own thoughts aloud (thought echo) - Visual: may suggest an organic brain disease - Olfactory: smelling gas - Gustatory: can taste 'poison' in food - Tactile: insects crawling upon skin, sexual sensations
What are pseudohallucinations?
- Lacking in some quality of hallucinations
- Take place in ‘inner space’
- Patient is aware that they are not real
About bizarre behaviour and posture in psychosis?
- Catatonia
- Grimacing
- Waxy flexibility
- Psychological pillow
presentations of formal thought disorder?
- Acceleration
- Retardation
- Circumstantial
- Derailment
- Fusion
- Perseveration
About passivity in formal though disorder
Control over thoughts- believing that someone in taking your thoughts out of your head
- Withdrawal - Broadcast - Insertion
What is psychosis?
- Categorical vs dimensional approach
- 5-8% of population hear voices
- 10-15% of population delusions
- lack of insight and people loose touch with reality
What is the differential diagnosis of psychosis?
○ Schizophrenia ○ Schizoaffective disorder ○ Brief psychotic episode ○ Substance misuse ○ Mood disorder with psychosis ○ Personality disorder ○ Epilepsy ○ Delirium ○ Dementia ○ Brain tumour ○ Stroke ○ Ganser syndrome ○ Delusional disorder ○ Malingering ○ Delirium tremens
Epidemiology of schizophrenia
- 20 per 100,000 per year
- 0.5-1% population
- Males age onset 28
- Females age onset 32- with a second peak late 50s and early 60s
- occurs in all cultures
Aetiology of psychosis
- Winter births
- Left handed
- Obstetric complications
- Urban birth
- 2nd generation immigration (Africa and Caribbean)
- South Asian
- Cannabis
What is the genetic link between twins in schizophrenia?
48%
What is the biochemistry of schizophrenia?
Dopamine hypothesis
- Amphetamine psychosis - Antipsychotic action
Serotonin
- LSD psychosis
Excitatory amino acids
- PCP
Psychodynamic explanations of schizophrenia
Psychological conflicts usually arise in childhood, result of problems and conflicts between the developing personality (the ID, ego and superego).
Manifest as ‘ego defence mechanism’ eg repression, projection, denial, regression, sublimation, displacement, humour, rationality and intellectualisation.
Family systems theory of schizophrenia
- The psychoanalytical tradition (the influence of the family on abnormal behaviour)
- Systems thinking (idea that things are best understood by looking at the relationships between a set of entities)
- Family set of interacting entities
Neuropsychology of schizophrenia
- Intellectual impairment in negative syndrome
- Some premorbid IQ deficit
- Attention - poorer information processing
- Perception - impairment in picture and face recognition
- Executive function - frontal lobe
Cognitive psychology of schizpphrenia
- Filter theories/internal monitoring - unable to ‘filter out’ irrelevant info, misinterpret as external rather than internal source
- Overinclusive thinking
- Theory of mind
Social learning theory of schizophrenia
- Consequence of faulty learning
- Children who do not receive reinforcement early in their lives will put larger attention into irrelevant environmental cues
- Bizarre behaviour by parents is copied by children
- Parents then reinforce this behaviour and the behaviour
Cognitive behavioural model of schizophrenia
- Breakdown of relationship between information that has already been stored in memory and new, incoming information eg schemas
- Sensory overload and do not know which aspects of a situation to
- Internal thoughts are attributed to external sources
Frith 1992 - schizophrenia
- Unable to distinguish between actions generated externally and those generated internally
- Inability to generate willed actions, to monitor willed action, to monitor beliefs and intentions of others
- Specifically a disconnection between frontal and posterior areas of the brain
- In people with schizophrenia, this differentiation between schemas and new situations does not occur
- There is a confusion between internal events and external stimuli and can result in the experience of hallucinations
What is a neurodevelopmental disorder?
Neurodevelopmental: means that the primary brain insult or pathology occurs during brain development, long before the illness is clinically manifest.
What sit eh neurodevelopmental hypothesis of schizophrenia?
- Brain abnormalities: increased ventircular size and decreased frontal and temporal volume are present at the onset of the disorder
- Evidence of pregnancy and birth complications, season’s of birth effect and inconclusive evidence for viral influences
- Childhood antecedents of schizophrenia
- Neuropathological evidence for neuronal disorganisation
What is evidence for schizophrenia being a neurodevelopment disorder?
Evidence:
- Minor physical abnormalities - Soft neurological signs - Childhood antecedents - Reduced cortical/cerebral volume predating the onset of illness - Abnormalities of cerebral lateralisation
Possible causes:
- Pregnancy and birth complications - Prenatal viral exposure
What investigations are done into schizophrenia?
Rule out organic causes
- CT head - Bloods (infection, metabolic abnormalities) - ?Auto-immune screen - EEG
Baseline before starting treatment
- Glucose - Cholesterol - ECG - Prolactin
What is the course and outcome in schizophrenia?
- Duration of untreated psychosis (DUP) is a predictor of outcome
- 2 fold increase I standardised mortality ratio, conservatively
- Higher suicide rate (?up to 7%, usually near onset)
- Physical health - higher rate of MI, stroke, diabetes
- 80-90% smoke versus 20% general population
What are good prognostic factors in schizophrenia?
- Abrupt onset
- Marked mood component
- Family history mood disorder
- Later onset
What are poor prognostic factors in schizophrenia?
- Male
- Insidious onset
- Negative syndrome
- Cognitive impairment
- Poor premorbid adjustment
- Early onset
Outcomes of schizophrenia treatment
- One episode no impairment 22%
- Several episodes, minimal impairment 35%
- Multiple episodes, static impairment 8%
- Multiple episodes, worsening impairment 35%
