Schizophrenia and psychotic disorders

Question 1

What is a modern use of the word psychosis?

Answer 1

• Represents an inability to distinguish between symptoms of delusion, hallucination and disordered thinking from reality.

Occurring in the most severe forms of mental illness.

There is also often a lack of insight, such as into having an illness, needing treatment etc. (can’t determine what is and is not real)

Question 2

In what ways does psychosis present clinically?

Answer 2

• Hallucinations
  
  • Have full force and clarity of true perception
  • Always located in external space (percieved)
  • No external stimulus
  • Not willed or control
• 5 special senses
  
  • auditory (most common) or visual (more in brain pathology)
  • tactile
  • olfactory and gustatory

Question 3

Please explain the characteristics of hallucinations:

Answer 3

• Have the full force and clarity of true perception
• located in external space
• no external stimulus
• not willed or controlled

Question 4

What is the definition of a delusional belief?

Answer 4

•“ a delusion is an unshakeable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction.”

Question 5

What are some examples of delusional beliefs?

Answer 5

• grandiose
• paranoid (correctly persecutory)
• hypochondriacal
• self referential - such as believe they are a tv show character etc.

Question 6

Which illnesses present with psychotic symptoms?

Answer 6

• Schizophrenia
• Delirium
• Severe affective disorder
  
  • Depressive episode with psychotic symptoms
  • Manic episode with psychotic symptoms

Question 7

What is the most common cause of psychosis?

Answer 7

Schizophrenia

• 1 per 100 population
• Males and females equally
• Age of onset 15-35 yrs

Question 8

What are the positive (prognosis is slightly better, more obvious symptoms) symptoms of schizophrenia?

Answer 8

Positive means - “dramatic, more obvious)”)

• Hallucinations
• Delusions
• Disordered thinking

Question 9

What are the negative symptoms of schizophrenia?

Answer 9

• Apathy
• Lack of interest
• Lack of emotions

These are harder to notice than positive symptoms.

Question 10

What is the ICD-10 classification of schizophrenia? (its LONG)

Answer 10

• For more then a month in absence of organic (dementia etc) or affective disorder:
• At least one of the following:
  
  • a) Alienation of thought as thought echo, thought insertion or withdrawal, or thought broadcasting.
  • b) Delusions of control, influence or passivity, clearly referred to body or limb movements actions, or sensations; delusional perception.
  • c) Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body.
  • d) Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. beingable to control the weather).
• Or at least two of the following:
  
  • e) Persistent hallucinations in any modality, when occurring every day for at least one month.
  • f) Neologisms (making up on new works), breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech.
  • g) Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
  • h) “Negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses.

Question 11

What are the considerations for aetiology of schizophrenia?

Answer 11

Biological factors
Psychological factors
Social factors
Evolutionary Theories

• Each of the above can be considered as
  
  • Possible predisposing factor
  • Precipitating factor
  • Perpetuating factor

Question 12

What are the biological factors?

Answer 12

• Genetics
  
  • Cf Acknowledged heritability from twin/family studies
  • Neuregulin
  • Dysbindin
  • Di George Syndrome
• Neurochemistry
  
  • “Dopamine hypothesis” - think that schizo is related to wrong dopamine release
  • Glutamate
  • GABA
  • Serotoninergic transmission

[there is no simple one thing]

• Obstetric complications
• Maternal influenza
• Malnutrition and famine
• Winter birth
• Substance misuse - such as cannabis consumption

Question 13

Psychological theory: Jung’s concept - please explain

Answer 13

WTF

something about storing memories

Question 14

Psychological theory: Conrad - please explain

Answer 14

• a state of fear
• the delusional idea appears
• an effort to make sense of the experience by altering one’s view of the world
• final breakdown, as thought disorder and behavioural symptoms emerge

Question 15

What is the link between psychosis and familes?

Answer 15

Mothers:

Concept of a “schizophrenogenic mother” (Fromm-Reichmann 1948) not upheld

Hasn’t really been brought out in any studies

•BUT Expressed Critical Emotion “High EE Families”

important concept and basis for family work

Question 16

What social and psychosocial factors could be at play?

Answer 16

• Occupation and social class but be aware of “drift hypothesis”
• Migration
• Recent meta-analysis of 18 studies confirms the risk in schizophrenia (Cantor-Grae et al BJPsych 2005).
• Social Isolation
• Life Events as Precipitants
• Cultural factors NOT IMPLICATED
• Families - critcal / “dramatic”

Question 17

What are the differentials for schizo?

Answer 17

• Delirium (or acute organic brain syndrome)
  
  • due to brain or systemic disease
  • prominent visual experience: hallucinations and illusions
  • Affect of terror
  • Delusions are persecutory
  • They fluctuate, worse at night: any psychotic disorder worse at night - be worried
• Depressive episode with psychotic symptoms
  
  • delusions of guilt, worthlessness and persecution
  • Derogatory auditory hallucinations
• Manic episode with psychotic symptoms
  
  • Delusions of grandeur; special powers or messianic roles
  • Gross overactivity, irritability and behavioural disturbance: Manic excitement

Question 18

Which sign guidance explains how to manage schizo?

Answer 18

Sign 131

Question 19

For management of schizophrenia see psychopharmarcology lecture.

Question 20

What is the general prognosis and recovery in schizo?

Answer 20

• Scottish Recovery Network defines recovery as “being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms”. - means that some patients can still be experiencing symptoms but feel that they can go on with life and are content
• 80% for recovery after a first episode of psychosis
• Early intervention and more effective treatment mean that the outlook is not as bleak as it once was.
• Up to 50% have a moderate recovery
• Small group with chronic symptoms and little recovery

Question 21

What are good prognostic factors?

Answer 21

• Absence of family history
• Good premorbid function - stable personality, stable relationships
• Clear precipitant
• Acute onset
• Mood disturbance
• Prompt treatment
• Maintenance of initiative, motivation

Question 22

What indicate a poor prognosis?

Answer 22

• Slow, insidious onset and prominent negative symptoms are associated with a worse outcome.
• Mortality is 1.6 times higher than the general population.
• Shorter life expectancy is linked to cardiovascular disease, respiratory disease and cancer.
• Suicide risk is 9 times higher.
• Death from violent incidents is twice as high.
• 36% of patients have a substance misuse problem and there are high rates of cigarette smoking.
• Poorer if starts in childhood

Question 23

What are the effects of schizophrenia on cognition?

Answer 23

• Chronic schizophrenic patients show poorer cognition than first onset patients
• But there is no decline in cognition in follow-up studies of first onset psychosis
• The findings in chronic patients are an artefact of selective loss of subjects – those who recover are not studied

Question 24

What are the take home messages regarding psychosis?

Answer 24

• Psychosis is a confusing term but is destined to stay.
• Understanding concepts of hallucination and delusion are critical
• Delirium, schizophrenia and the affective psychoses are the principal illnesses.