Schizophrenia -Clinical aspects Flashcards
What is the difference between neurosis and psychosis?
Neurosis occurs in anxiety depressive disorders, OCD, adjustment disorders and somatisation disorders. Not caused by organic disease, no loss of touch with reality
Psychosis is an organic symptom, occurs in schizophrenia, bipolar and depressive psychosis. An illness characterised by a loss of boundaries with reality and loss of insight, with primary features of delusions and hallucinations
What is a psychotic episode?
1 week duration of psychosis at significant severity
What are delusions?
What types exist?
Ideas briefly and FIRMLY held on inadequate grounds. Not countered by rational argument or evidence to the contrary. Not shared by someone of similar age, educational, cultural, religious or social background
Types of delusions:
- Primary (delusional perception): out of the blue
- Secondary: to psychosis
- Persecutory
- Grandiose
- Of Guilt
- Nihilistic (I can’t eat because my insides are dead)
- Of Passivity
What causes delusions?
Dopamine plays a role in motivation and reward, with excessive dopamine in these pathways –> world seems pregnant with significance
-Content usually has particular relevance e.g. religious, persecution by government, controlled by implant, responsibility for world tragedy, seagulls
What are hallucinations?
A perception experienced in the absence of an external stimulus.
- In any sensory modality but auditory in psychosis
- Due to internal perception attribution erroe
Outline the history of schizophrenia
Esquirol (1838)
- Described as course and prognosis of insanity and seperated it from melancholia which had a better outcome
Kraepelin (1898)
- Defined ‘dementia praecox’ with onset in adolescence of progressive, irreversible decline in mental function. Inability to plan ahead.
- Distinguished from man depressive illness
Bleuler (1911)
- “Schizophrenia”: splitting of the mine
- fundamental symptoms include abnormal associations, autism, abnormal affect, ambivalence (dont care)
Schneider (1946)
-FIRST RANK SYMPTOMS pathognomic of schizophrenia
2017- Identification that we need better diagnostic criteria and staging model
Outline Schneider’s First Rank Symptoms (1946)
In the absence of organic disease signify schizophrenia
- Auditory hallucinations: thoughts spoken aloud, third person hallucinations, running commentary
- Somatic hallucinations
- Thought insertion, withdrawal or broadcast
- Passivity phenomena. Made to do acts/impulses
- Delusional perception
Affective psychosis is a differential diagnosis for schizophrenia. Give examples
Bipolar disorder
Depressive psychosis
Schizoaffective disorder
Organic psychosis is a differential diagnosis for schizophrenia. Give examples
Epilepsy (temporal lobe)
Infections: encephalitis, subacute sclerosing panencephalitis, neurosyphilis, HIV
Cerebral trauma
CV Disease
Demyelination: multiple sclerosis
Neurodevelopmental disorders: Velocardiofacial syndrome
Endocrine: thyroid disorders (hyper and hypo), Cushing’s syndrome
Metabolic: SLE
Acute drug intoxication e.g. ketamine, cannabis, LSD, PCP, Amphetamine, MDMA
Toxins- lead
Dementias
Personality disorder is a differential diagnosis for schizophrenia.
What are its signs?
Side effects of medication?
Self-neglect, perplexity, inappropriate clothing, posturing, social disturbance including unprovoked violent acts
Side effects of medication:
- Parkinsonian symptoms: tremor, rigidity, bradykinesia
- Tardive dyskinesias including orofacial, athetosis and dystonias
- Skin discoloration
- Severe weight gain
How is schizophrenia diagnosed?
Schneiders first rank symptoms- not inclusive for all subjects
- no objective pathognomonic signs
- A clinical interview is required
- no lab tests/ predictive imagine
ALL LEADS TO STIGMA
Consider acute syndrome (positive symptoms/ Type 1)
What can be said about:
- Appearance
- Mood
- Disorder of thinking
- Delusions
- Hallucinations
- Insight
- Cognition
Appearance: Preoccupied and withdrawn- restless and unpredictable
Mood: Blunting of mood, disinhibition, perplexed, anxious
Disorder of thinking: Vague, formal thought disorder (loosening of associations), thought block
Delusions: Primary and secondary
Hallucinations: Auditory, visual, tactile (somatic), olfactory, gustatory
Insight: Impaired
Cognition: Normal orientation and memory initially
Consider chronic syndrome (negative symptoms/ Type 1)
What can be said about:
- Appearance
- Movement abnormalities
- Mood
- Delusions
- Hallucinations
- Insight
- Cognition
Appearance: Lack of drive and activity. Social withdrawal. Self-neglect
Movement abnormalities: Stupor, Catatonia, abnormal movements and tone
Mood: Blunting of mood, depression
Delusions: Primary and secondary
Hallucinations: Auditory, visual, tactile (somatic), olfactory, gustatory
Insight: Impaired
Cognition: Normal orientation but cognitive decline
Explain the epidemiology of schizophrenia
Consider prevalence, incidence, geography, sex, onset and social class
Prevalence : 0.2-0.7%
Incidence: 2/10k per annum, Increasing in S London
Geography:
- Incidence up to 5x variation worldwide
- Increased rate in migrants (particularly A/C as culturually isolated in europe)
- More prevalent in urban than rural areas. ‘Urban drift”- high incidence the larger the town and longer lived there
Sex: Men have earlier onset and more negative symptoms
Onset: Men 21-26/ Female 25-32
Social class: Lower, social drift hypothesis
Outline the course of schizophrenia
Function begins to decline steadily = at-risk mental state
Define psychosis threshold
Followed by period of untreated psychosis, DUP
Treatment, Rx
Followed by wavelike course
What is the prognosis of schizophrenia?
Better in 3rd world countries andintroduction of early intervention service
-20% completely recover, 25% persistent symptoms, >50% have a relapsing-remitting illness with some functional impairment
Recurrent episodes may lead to progressive deterioration
Functional recovery lags behind symptom recovery
Suicide in 5-10% OF MEN
In terms of substance-induced harm there is a positive correlation between dependence of certain drugs and physical harm.
Starting from least, state a few drugs
Alkyl nitrites Anabolic steroids, solvents, ecstasy, GHB Methylphenicate, LSD, Cannabis 4-MTA Tobacco Ketamine, Amphetamine, Alcohol, Benzodiazepines Barbituates Cocaine Heroin
What are the effects of cannabis on schizophrenia?
Increases vulnerability to psychosis
Impact of cannabis on developing brain is more potent
Schizophrenia patients more sensitive to cannabis
Familial liability for psychosis is expressed as differential sensitivity to cannabis
Chronic use sensitizes to effect and increases vulnerability to psychosis
Describe a patient with schizophrenia likely to have a good prognosis
Female Married Familial history of affective disorder Good premorbid function Acute onset Life event at onset Early treatment Affective symptoms Good treatment response
Describe a patient with schizophrenia likely to have a poor prognosis
Male Single Familial history of schizophrenia Premorbidity schizoid Slow onset Long duration untreated Negative symptoms Obsessions High expressed emotion in the family Substance misuse
What is an illusion?
Perceive a stimulus as something it is not
Give examples of negative symptoms
Low mood, flattened emotional response
Poverty of speech
Lack of motivation/ initiative
Social withdrawal
