Schizophrenia and Psychotic Disorders Flashcards
The 3 principle psychotic disorders
Delirium
Schizophrenia
Affective psychosis
Definition of psychosis
Represents an inability to distinguish between symptoms of delusion, hallucination and disordered thinking from reality
Main symptom of schizophrenia
lack of insight
What does a predisposing factor mean?
putting you at risk
What does a precipitating factor mean?
something that starts it
What does a perpetuating factor mean?
keeping it going
Presentation of psychosis
Hallucinations - full force and clarity of true perception - located in external space - no external stimulus - not willed or controlled Delusional beliefs - grandiose - paranoid (correctly persecutory) - hypochondrial - self referential Lacks insight
5 special senses of hallucinations
Auditory Visual Tactile (touching you) Olfactory Gustatory (Taste)
Definition of delusion
An unshakable idea or belief which is out of keeping with the persons social or cultural background; it is held with extraordinary conviction
Illnesses that have psychotic symptoms
Schizophrenia
Delerium
Severe affective disorder
What is severe affective disorder?
Either
- depressive episode with psychotic symptoms
OR
- manic episode with psychotic symptoms
Differential diagnosis of psychosis
Delerium Acute organic brain syndrome Depressive episodes with psychotic symptoms Manic episodes with psychotic symptoms Schizophrenia Making it up e.g. in a police case
Features of psychosis caused by delirium or acute organic brain syndrome
Prominent visual experience, hallucinations and illusions
Affect of terror
Delusions are persecutory and evanescent (quickly disappear)
Fluctuating worse at night
Definition of an illusion
Abnormal perception of a real thing
Features of psychosis caused by depressive episode with psychotic symptoms
Delusions of guilt, worthlessness and persecution
Derogatory and auditory hallucinations
Features of psychosis caused by a manic episode with psychotic symptoms
Delusions of grandeur; special powers or messianic roles
Gross overactivity, irritability and behavioural disturbance
Manic excitement
Treatment of psychosis
Early intervention - family and psychological
Community treatment
Antipsychotics
Treatment to prevent relapse during remission
CBT
Cognitive remediation
Social skills training
Definition of schizophrenia
A severe mental illness affecting thinking, emotion and behaviour
What is the most common cause of psychosis?
Schizophrenia
Who gets schizophrenia?
M = F
onset 15-35 years
Possible biological causes of schizophrenia
genetics neurochemistry (glutamate, GABA) obstetric complications maternal influenza malnutrition and famine winter birth substance misuse e.g. cannabis
Symptoms of schizophrenia
Positive - hallucinations - delusions - disordered thinking Negative - apathy - lack of interest - lack of emotions - alogia - disturbed attention
What is a “positive” symptom?
A dramatic, more obvious symptom
ICD-10 Criteria for schizophrenia
> 1 month in the absence of organic or affective disorder
At least 1 of the following
- alteration of thought; echo, thought insertion, thought withdrawal, thought broadcasting
- delusions of control, influence or passivity (other people controlling you), clearly referred to body or limb movements - actions or sensations
- hallucinatory voices giving a running commentary on patients behaviour, or discussing him between themselves or other voices coming from somewhere in the body
- persistent delusions that are culturally inappropriate and completely impossible (e.g. controlling weather)
And OR at least two of the following
- persistent hallucinations of any modality, when occurring every day for at least 1 month
- Neologisms, breaks or interpolations in train of thought, resulting in incoherence or irrelevant speech
- Catatonic behaviour, such as excitement, posturing or wavy flexibility, negativism, mutism and stupor
Good prognostic factors for schizophrenia
Absence of FH Good premorbid function Clear precipitant Acute onset Mood disturbance Prompt treatment Maintenance of initiative, motivation
Poor prognostic factors for schizophrenia
Slow, insidious, early onset Prominent negative symptoms Starts in childhood Male Unmarried Non paranoid type Negative / catatonic symptoms Absence of affective symptoms FH
5 criteria for detention under the Mental Health Act
Mental illness Risk Treatment SIDMA - severely impaired decision making Least restrictive option/necessary
Once detained under the mental health act, what happens?
Investigations to rule out organic cause
May need 24 hour observation by e.g. nurse
Start antipsychotic
What type of symptoms do patients experience when they have their 1st presentation?
+ve symptoms
What is the most common symptom of schizophrenia?
Auditory hallucinations
Definition of alogia
Poverty of speech
Can treatment for schizophrenia be given under the mental health act?
Yes
Complications of schizophrenia
Suicide (4 - 10%)
Social and occupational decline
What is the drug most associated with schizophrenia?
Cannabis
When do men present in comparison to women?
Men present on average 5 years earlier
What can trigger a presentation of acute schizophrenia?
Big life stress
Differentials for psychosis
Schizotypical, schizoaffective and other delusional disorders
Mania
Delerium
Drug abuse / medications
Cerebral tumour / infarct / TLE / infection
Endocrine disease (thyroid, chronic hypoglycaemia, cushings, addisons)
Anaemia / carcinoma / sarcoid
Type of hallucinations, delirium vs schizophrenia
Delerium - visual
Schizophrenia - auditory
What % of people with schizophrenia have 1 episode only?
20%
Types of schizophrenia
Paranoid Hebephrenic (disorganised) Catatonic (motor) Simple Residual Post schizo depression Not otherwise specified
What is the most common type of schizophrenia?
Paranoid
What happens in paranoid schizophrenia?
Systemised delusions and hallucinations
What happens in hebenephric schizophrenia?
Delusions, thought form disorder, disturbed affect
What is the treatment for catatonic schizophrenia?
Lorazepam
What happens in residual schizophrenia?
Predominately -ve symptoms
What happens in simple schizophrenia?
Only -ve symptoms
What are 1st rank symptoms strongly suggestive of?
Schizophrenia
Where can 1st rank symptoms be seen?
Schizophrenia
Organic disorders
Mood disorders
Types of delusions
Paranoid / persecutory
Grandeur
Nilhilistic
Reference
What is an over valued idea?
Less than a delusion as not fully convicted
Definition of a pseudohallucination
Persons thoughts become alienated from them inside their head etc in trauma. They often know it is their own thoughts causing this
What is circumstantiality?
The inability to answer a question without giving excessive, unnecessary detail
What are clang associations?
Describes speech in which topics are related to each other only by sounding something similar
What are flight of ideas?
Describes speech in which there is rapid changing of subjects, unrelated to one another
What is preservation?
Describes repetition of speech on the same subject, despite attempting to change the subject
What is tangentiality?
Describes speech that wanders from a topic, without returning to it
What are neologisms?
New word formations, which might include the combining of two words
What is word salad?
Completely incoherent speech where real words are strung together into nonsense sentences
What is knights move?
Severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another
What is knights move a feature of?
Schizophrenia
What is flight of ideas a feature of usually?
Mania
What is echolalia?
A repetition of someone elses speech, including the question that was asked
What may antipsychotics cause?
Akathisia
What is akathisia?
Severe restlessness
Which atypical antipsychotic has the most tolerance S/E profile, particularly for prolactin elevation?
Aripriprazole
What treatment is now first line for schizophrenic patients?
Atypical antipsychotics
What is the main advantage of atypical agents?
They have a significant reduction in extrapyramidal S/Es
S/Es of atypical antipsychotics
Weight gain
Clozapine - agranulocytosis
Hyperprolactinaemia
What risks are there for using antipsychotics in the elderly population?
Increased risk of
- stroke
- VTE
Examples of atypical antipsychotics
Clozapine Olanzapine Risperidone Quetiapine Amisulpride Arirpiprazole
S/Es of clozapine
Agranulocytosis (1%) and neutropenia (3%)
Reduced seizure threshold (can induce seizures in up to 3% of patients)
Constipation
Myocarditis (ECG before starting Tx)
Hypersalviation
Due to clozapines S/Es, what does this mean in terms of treatment?
Only used in patients who are resistant to other antipsychotic medication
When may the dose of clozapine have to be adjusted?
If smoking is stopped or started during the treatment
Patients with poor oral compliance of anti-psychotics can be switched to what?
Once monthly IM antipsychotic depot injections
What is used to assess the severity of schizophrenia?
Positive and negative syndrome scale (PANSS)
What does tardive dyskinesia present as a S/E of and how does it present?
Due to late onset abnormal involuntary choreoathethoid movements in patients on conventional antipsychotics Can present as - chewing - jaw pouting - excessive blinking
What is it important to do if a patient is on clozapine and develops an infection?
FBC - as need to exclude neutropenia due to clozapine
