Schizophrenia and Psychotic Disorders Flashcards
What is schizophrenia?
A disorder characterised in the acute stage by hallucinations and delusions relating to disruption of ego-boundary and in the chronic stage by deficits of affect, motivation and thinking
What is psychosis characterised by?
- Thought-form disorder
- Delusions
- Hallucinations
What is characteristic of psychotic symptoms in schizophrenia?
- Usually bizarre thoughts and experiences
- Often related to a breakdown in the boundary between a patient’s internal personal experience and external reality (ego-boundary)
What are Schneider’s First Rank symptoms?
- Auditory hallucinations
- Delusions of thought alienation/interference
- Delusions of control - somatic passivity, passivity phenomena
- Delusional perceptions
With reference to Schneider’s First Rank symptoms, what specific types of auditory hallucinations are experienced in schizophrenia?
- Thought echo
-
3rd person auditory hallucinations
- Running commentary on their actions
- Voices arguing about them
In terms of Schneider’s First rank symptoms of Schizophrenia, what specific delusions about thought alienation/interference occur?
- Thought withdrawal
- Thought insertion
- Thought broadcasting
In terms of Schneider’s First Rank symptoms, what are passivity phenomena?
Delusions that their thoughts, feelings, or impulses are driven by some external force or person
In terms of Schneider’s First Rank symptoms of SChizophrenia, what are somatic hallucinations?
A delusion that some external force is causing physical sensations (which may be hallucinations) in their body
In terms of Schneider’s First Rank symptoms of schizophrenia, what delusional perceptions occur?
A delusion which arises because of a completely unrelated happening in external reality
e.g. “Three letters, which is the number of the Holy Trinity, came through my letter box, and then I realized I was the son of God”
What is the deifnition of Ego-boundary?
A sense or awareness that there is a distinction between the real and unreal. In some psychoses the person does not have an ego boundary and cannot differentiate his or her personal perceptions and feelings from those of other people.
Besides Schneider’s First Rank symptoms, what are other positive/psychotic symptoms of acute schizophrenia?
- Persecutory or grandiose delusions
- Other bizarre delusions
-
Disorders of thought form
- e.g. “loosening of associations”
Besides Schneider’s First Rank symptoms of Schizophrenia, what are other non-psychotic symptoms of acute schizophrenia?
- Mood Disturbance
- Unusual behaviour
In schizophrenia, what are regarded as “positive” schizophrenic symptoms?
Symptoms of Psychosis/Schneider’s first rank symptoms
What are the negative symptoms of schizophrenia?
Profound interference with daily functioning
- Apathy and lack of motivation
- Poverty of speech (and lack of thoughts)
- “Blunted” or incongruous affect (and lack of emotions)
- Social withdrawal
- Occupational decline
What do negative symptoms of schizophrenia suggest?
Long term illness
What are the cognitive symptoms of Schizophrenia?
- Poor executive function
- Poor abstract reasoning
The deficits are subtle and are usually not evident on basic clinical tests of cognition such as the Mini-Mental State Examination.
What is the definition of executive function?
A set of cognitive processes that are necessary for the cognitive control of behavior: selecting and successfully monitoring behaviors that facilitate the attainment of chosen goals. Executive functions include basic cognitive processes such as attentional control, cognitive inhibition, inhibitory control, working memory, and cognitive flexibility.
What categories are the symptoms of schizophrenia divided into?
- Positive - psychotic
- Negative - apathy, pverty of speech etc
- Cognitive - executive, abstract reasoning
What would be your differential diagnosis for someone presenting with psychotic symptoms?
- Psychotic mania/depression
- Delirium
- Drug induced psychosis/intoxication
- Medication e.g. steroids
- Cerebral causes
- Endocrine disease
- Systemic illness
What neurological problems would be part of your ddx when assessing someone with pschosis?
- Tumour
- Infection
- Infarction
- Epilepsy
What endocrine problems would be part of your differential diagnosis when assessing someone with psychotic symptoms?
- Thyroid
- Chronic hypoglycaemia
- Cushing’s
- Addison’s
What systemic illnesses would be part of your differential diangosis when assessing someone with psychotic symptoms?
- Anaemia
- Carcinoma
- Sarcoid
What is the defintion of psychosis?
A severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality (disrupted ego-boundary)
What is the most implicated neurotransmitter in schizophrenia?
Dopamine
Of the different dopaminergic pathways implicated in schizophrenia, which is most closely associated with positive symptoms?
Meso-Limbic Dopamine pathway - DA overactivity results in positive symptoms
Of the different dopaminergic pathways implicated in schizophrenia, which is most closely associated with negative symptoms?
Meso-cortical Dopamine Pathway - DA underactivity associated with negative symptoms.
Of the different dopaminergic pathways implicated in schizophrenia, blockade of which pathway causes extrapyramidal side effects such as parkinsonism?
Nigro-striatal dopamine pathway - D2 blockade
Of the different dopaminergic pathways involved in schizophrenia, blockade of which pathway would lead to the development of hyperprolactinaemia?
Tuberoinfundibular Dopamine Pathway - D2 blockade
When assessing thought as part of the MSE, what might you notice in someone with an acute schizophrenic episode?
- Delusions
- Thought block
- Thought withdrawal
- Thought insertion
- Passivity
- Derailment
When assessing perceptions as part of the MSE, what might you find in someone with schizophrenia?
Hallucinations
When assessing speech as part of the MSE, what might you find in someone with schizophrenia?
- Neologisms
- Word Salad
When assessing mood as part of the MSE, what might you see in someone with schizophrenia?
- Blunted affect
- Incongruent mood
When assessing cognition and insight as part of the MSE, what might you see in someone with schizophrenia?
- Lack of insight
- Slowing in cognitive function
- Poor executive funtion
- Poor abstract reasoning
When assessing behaviour and appearence as part of the MSE, what might you observe in schizophrenia?
- Social withdrawal
- Self neglect
- Agitation
- Disorganisation
- Distractible
If you suspected schizophrenia, what else would be part of your differential diagnosis?
- Substance induced psychotic disorder
- Dementia/delerium
- Mood disorder with psychotic symptoms
- Medication induced psychosis
- Schizotypal personality disorder
When investigating someone with suspected schizophrenia, what blood tests would you do?
- Routine - U+E’s, LFTs, FBC, Calcium, glucose
- Consider - TFTs, VDRLs, PTH, Cortisol, tumour markers
When investigating someone with suspected schizophrenia, what investigations could you perform on the urine?
- Drugs screen - stimulants and cannabis
- Microscopy and culture
What tests could you perform to investigate schizophrenia?
- Bloods
- Radiology
- Urine
- EEG
- 24 hr Cortisol
What are the common ways for schizophrenic individuals to present?
- Spouse/relative noticing behaviour
- Following deliberate self-harm episode
- Interaction with the law
How would you initially assess acute psychosis?
- Assess risk - themselves and others
- Degree of insight
- Need for urgent treatment
- Physical examination
- Collateral history - if possible
How would you manage and acute psychotic episode?
- Antipsychotic medication
- Sedatives
What are the typical (first generation) antipsychotic medications?
- Haloperidol
- Chlorpromazine
What are the indications for Antipsychotic medications?
- Acute mania
- Acute psychosis
- Chronic schizophrenia
- Sedation in acute confusional states
- Premedication before general anaesthesia
How do antipsychotic medications act?
All are dopamine receptor type 2 antagonists. This is the most likely explanation for their sedative / tranquilizing effect. The antipsychotic effect is probably an adaptive response to the antidopaminergic actions.
The atypical antipsychotic drugs have greater effects on other receptors than the dopamine receptor (including 5HT2 receptor, histamine receptor).
Which class of antipsychotic medications are more at risk of causing extra-pyramidal side effects?
1st generation (typical) antipsychotics - due to their greater action on dopamine receptors
What is important to bear in mind about antipsychotics in terms of side effects?
The greater the sedative level of the drug, the less extrapyramidal or anticholinergic side effects there are
What are the main atypical (second generation) antipsychotic medications?
- Respiradone
- Olanzapine
- Quitiepine
- Aripiprazole
- Clozapine
What side effects are seen with antipsychotic use?
- Extra-pyramidal side effects
- Anti-cholinergic side effects
- Hyperprolactinaemia
- Hyperglycaemia
- Temp regulation interference
- Venous thromboembolism
- Prolonged QT interval
What are extra-pyramidal side effects?
Drug-induced movement disorders that include acute and tardive symptoms:
- Parkinsonian symptoms
- Dystonia (abnormal face and body movements) and dyskinesia
- Akasthisia (restlessness)
- Tardive dyskinesia
What are anti-cholinergic side effects?
- Dry mouth
- Tachycardia
- Blurred vision
- Acute glaucoma
- Poor urinary flow or retention
- Constipation
- Hypotension
- Rare - Ileus, Glaucoma
What is dyskinesia?
https://www.youtube.com/watch?v=IR1K7HW6KZ0
The impairment of voluntary motor activity by superimposed involuntary motor activity
What is akasthisia?
https://www.youtube.com/watch?v=pSXzuCNlI6Q
A subjective sense of uncomfortable desire to move, relieved by movement of the affected part. Often a side effect of neuroleptic drugs
What is tardive dyskinesia?
A movement disorder associated with long-term treatment with neuroleptic drugs. Characterised by abnormal movements, especially of the mouth and tongue such as lip smacking, sucking and puckering. It can also involve other parts of the body with chore-athetoid movements of the finger, toes and writhing movements of the trunk. They tend to increase when the patient is aroused and are typically absent when they are asleep. In some cases it is irreversible.
What are the side effects associated with respiradone?
- Increased risk of EPSE
- Most likely to induce hyperprolactinaemia
- Weight gain
- Sedation
What side effects are associated with Olanzapine?
- Weight gain - can be as much as 30-50lbs
- Hypertriglyceridemia, hypercholesterolemia, hyperglycemia - even without weight gain
- Hyperprolactinemia - less than risperidone
- Abnormal LFT’s - 2% of all patients
What are the side effects of Quitiepine?
- Abnormal LFT’s - 6% of all patients
- Weight gain - though less than seen with olanzapine
- Hypertriglyceridemia, hypercholesterolemia, hyperglycemia - however less than olanzapine
- Orthostatic hypotension
Which antipsychotic is most likely to cause orthostatic hypotension?
Quitiepine
What are the side-effects of clozapine?
- Agranulocytosis
- Increased risk of seizures - especially if combined with lithium
- Sedation
- Weight gain
- Abnormal LFT’s
- Hypertriglyceridemia, hypercholesterolemia, hyperglycemia
- Nonketotic hyperosmolar coma and death
- Neutropenia
- Idiopathic hyperthermia
- Hypersalivation
Which atypical antipsychotic is the most sedative?
Clozapine
Which antipsychotics cause abnormal LFT’s?
- Quitiepine
- Olanzipine
- Clozapine
Which atypical antipsychotics cause weight gain?
All except Aripirazole
What is neuroleptic malignant syndrome?
A rare, but life-threatening, idiosyncratic dose independent medication reaction to neuroleptic or antipsychotic medications.
Characterised by Severe muscle rigidity + Fever, plus 2 or more of:
- Altered mental status
- Autonomic instability
- Elevated WBC
- Tachycardia
- Tremor
- Dysphagia
- Diaphoresis
What is the mechanism of action of benzodiazepines?
Potentiation of GABA neurotransmission
What are examples of benzodiazepines?
- Diazepam
- Lorazepam
- Midazolam
- Temazepam
When are benzodiazepines indicated for use?
- Seizure termination - particularly prolonged/status epilepticus - CHECK SIGN GUIDELINES
- Severe panic disorders if resistant to antidepressants*
- Anxiety disorders - short term use only
- Insomnia - short term use only
- Alcohol withdrawal
- Perioperative sedation
What are the side effects of benzodiazepines?
TOLERANCE/DEPENDENCE - long term use
- Drowsiness
- In-coordination
- Muscle weakness
- Dizziness
- Confusion
What drug can increase the risk of developing the schizophrenia?
Cannabis - more likely to occur if smoke in your teens
What is regarded as treatment failure?
Failure to respond to 2 or more antipsychotic medications given in therapeutic doses for 6 weeks or more
What antipsychotic is used to treat resistant schizophrenia?
Why is this medication kept as a last resort?
Clozapine
Due to awful side effect profile
Why do extra-pyramidal side effects occur?
Occur as a result of D2 receptor blockade in the nigrostriatal pathway and are more likely to be
associated with high potency antipsychotics (70-80% D2 occupation) which have little
anticholinergic action, such as the piperazine phenothiazines and the butyrophenones
How would you manage someone with schizophrenia in the long-term?
Refer to psychiatry
- Antipsychotic medication
- Support in the community - e.g. housing, employment, support worker
- Rehabilitation in dedicated facilities
What is paranoid schizophrenia?
Subtype of schizophrenia characterised by paranoid delusions and auditory hallucinations
What is hebephrenic schizophrenia?
Subtype of schizophrenia characterised by mood changes, unpredictable behaviour, shallow affect and fragmentary hallucinations. The outlook is often poor as negative symptoms may develop rapidly.
What is simple schizophrenia?
Similar to hebephrenic schizophrenia in that it is characterised by negative symptoms. However, in simple schizophrenia, patients have never experienced positive symptoms.
What is Catatonic schizophrenia?
Catatonic schizophrenia is characterised by its 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?
Residual schizophrenia is again characterised by negative symptoms. It usually occurs when the positive symptoms have ‘burnt out’
What are the subtypes of schizophrenia?
- Paranoid
- Hebeprhenic
- Simple
- Catatonic
- Undifferentiated
- Residual
In terms of schneider’s first rank symptoms, what are delusions of control experienced by someone with schizophrenia?
-
Passivity phenomena
- Passivity of affect
- Pssivity of impulse
- Passivity of volition
- Somatic Passivity
What mnemonic could you use to remember the diagnostic criteria for schizophrenia?
DEAD
- Disorders of thought possession (insertion, withdrawal, broadcasting)
- Experiences of passivity (other people are controlling their feelings or impulses – passivity phenomenon)
- Auditory hallucinations (thought echo, running commentary, being constantly referred to in the third person)
- Delusions that persist (culturally inappropriate)
