Schizophrenia and psychotic disorders

Question 1

Define Psychosis

Answer 1

Inability to distinguish between symptoms of delusion, hallucination and disordered thinking from reality (constellation of symptoms not a diagnosis)

Question 2

Clinical Presentation of Psychosis

Answer 2

Hallucinations: They have the full force and clarity of true perception, Located in external space, no external stimulus, not willed or controlled (5 special senses = auditory or visual, tactile, olfactory and gustatory)
Delusional beliefs = an unshakeable idea or belief which is out of keeping with the person’s social and cultural background – held with extraordinary conviction

Question 3

what illnesses may have psychotic symptoms?

Answer 3

Schizophrenia, Delirium, Severe affective disorder: Depressive episode with psychotic symptoms, Manic episode with psychotic symptoms

Question 4

Define Psychotic…

Answer 4

Lack of insight – no insight into distinguishing between symptoms and reality

Question 5

What is Schizophrenia

Answer 5

Severe mental illness affecting: Thinking, Emotion, Behaviour
Most common cause of psychosis: Affects 1/100 population, Males and females equally, Age of onset = 15-35 years

Question 6

sy/sx

Answer 6

Positive vs negative symptoms – not thought of as good or bad symptoms but more negative symptoms = a worse prognosis. Positive Symptoms are the more dramatic psychotic symptoms. Positive symptoms: Hallucinations, Delusions, Disordered thinking
Negative symptoms: Apathy, Lack of interest, Lack of emotions

Question 7

what are Schneiders first rank sy?

Answer 7

though withdrawl, thought broadcastinng, delusional perception

Question 8

how is it clinically diagnosed?

Answer 8

For more than a month in absence of organic or affective disorder – at least one of the following: (Schneider’s first rank symptoms)
• Alienation of thought as thought echo, thought insertion or withdrawal, or thought broadcasting
• Delusions of control, influence or passivity, clearly referred to body or limb movements actions, or sensations = delusional perception (percivity delusion)
• Hallucinatory voices - coming from outside the patient
• Persistent delusions
Or at least two of the following: Persistent hallucinations, Breaks or interpolations in the train of thought – resulting in incoherence or irrelevant speech, Catatonic behaviour, ‘Negative’ symptoms = marked apathy, paucity of speech and blunting or incongruity of emotional responses

Question 9

Aeitology

Answer 9

• Considerations: Biological factors, Genetics, Neurochemistry, Obstetric complications, Maternal influenza, Malnutrition and famine, Winter birth, Substance misuse
Psychological factors/ Social factors/ Evolutionary theories
Each of the above can be considered as: Possible predisposing factors/ Precipitating factor/ Perpetuating factor

Question 10

The dysfunction of several neurotransmitter systems have been considered to play a part in schizophrenia.

Answer 10

Hyperdopminergic Theory, NMDA receptor hypofunction, Impairment of GABA signaling, Serotonin Theory

Question 11

Ddx for Psychosis

Answer 11

Delerium or organic brain syndrome (Prominent visual experience, hallucinations and illusions, Affect of terror, Delusions are persecutory and evanescent, Fluctuating, worse at night – schizophrenia is the same throughout the day), affective psychoses (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), Schizophrenia.

Question 12

Mx

Answer 12

Antipsychotics, Psycholoical interventions - CBT, adress substance abuse abstinence, housing, benefits, social skills.

Question 13

Give common Typical Antipsychotics

Answer 13

Examples = chlorpromazine, haloperidol. Side effects: Weight gain, Sexual dysfunction, Sedation, Extra-pyramidal side effects (EPSE), Anti-cholinergic

Question 14

Give common Atypical Antipsychotics

Answer 14

Examples = Risperidone, Olanzapine, Clozapine, aripiprazole. Have similar but less side effects, Has to be IM but needs oral medication trial first – may be difficult in poor cooperation, Clozapine is used for treatment resistant disease, Only used after 2x8 week trials of different drugs, se: Weight Gain and Obesity, Diabetes, Metabolic Syndrome (Syndrome of Obesity, Hypertension, Dyslipidaemia and Abnormal Glucose Metabolism).

Question 15

Prognosis…

Answer 15

Good Prognostic Factors - Absence of family history, Good premorbid function – stable personality, stable relationships, Clear precipitant, Acute onset, Mood disturbance, Prompt treatment, Maintenance of initiative, motivation.
Poor Prognostic Factors - 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 16

TUTORIAL

Answer 16

.

Question 17

Sy/Sx

Answer 17

sy - unkept, restlless, akashasia, delusion of being hunted and recruited by the MI5, paranoia, delusional elaboration, ideo of reference (cameras, people seeing him), suspicious, hallucinaitons (auditory in the 3rd person), thought blocking, 6month hx, ideas of granduioure

Question 18

relevant points from hx

Answer 18

previous drug use, lack of insight, previous admission to cornhill with schizophrenia, mother has depression, uncle was schizophrenic,

Question 19

MSE

Answer 19

appearance: poor hygiene, unkept, Behaviour - anxious agitated, suspicious, Speech - normal form, no thought blocking, Mood - uthimic, agitated, annoyed, reactive, Thoughts - delusions, (paranoia, grandeur), Hallucinations (auditory 3rd person), Cognition - alert, orientated, Insight - poor, lacking, Suicide/homocide - low risk, no ideation.

Question 20

Ix

Answer 20

FBC (lfts, thyroid, renal, lipid profile, blood glucose baseline), CXR, CT scan,

Question 21

Mx

Answer 21

consider dangerous behaviour (e..g train tracks)