Schizophrenia & Psychosis Flashcards
How is Schizophrenia managed?
1st line: Antipsychotic (Olanzapine)- response 3-4weeks treated for at least 1year
Alternative: Depot monthly
Clozapine: Tx resistant
Antidepressants
Lithium
psychotherapy: CBT, family interventions, art therapy, relapse signature, reduce expressed emotion
Catatonic: ECT
How is a first episode of psychosis managed in GP?
Urgent referral to secondary care
Early assessment: Stage & severity, Crisis team, inpatient care
What are the indications of antipsychotics? How quickly do they work?
Psychotic disorders Other: Affective, neurotic, organic illness SE: Hours-days Work: Days-weeks Tranquilizing: Hours
What is the MOA of antipsychotics?
Bind to and block post-synaptic dopamine receptors
What areas of the brain in the dopamine pathways are associated with the different symptoms?
Inc dopamine pathway mainly involved in pathophysiology
+ve symptoms: Mesolimbic (arousal, memory, behaviour)
-ve symptoms: Mesocortical (cognition, socialisation)
EPSE: Nigrostriatal (Modulation of EPS, voluntary movements)
Tuberoinfundibular: Regulation of prolactin
What is ‘Depot’?
IM slow release antipsychotic Good in chaotic & poor compliance Initial dose then 14days then monthly Oral meds required until steady state Weeks-months to see effect of starting/stopping RISPERIDONE/OLANZAPINE/PALIPERIDONE
What are the risk factors for relapse of illness?
Presence of persistent symptoms Low socioeconomic status Exposure to high level of expressed emotion Lack of insight Substance use Poor adherence to Tx regimen
What are the chances of Schizophrenia relapse whilst on treatment?
On continuous antipsychotic meds= 1/3
Stopping antipsychotics esp abruptly increases risk of relapse in short-medium term
In Schizophrenia what are the good prognostic factors?
Female, married Older age of onset Good pre-morbid intelligence & personality Fhx of affective disorder Acute onset, affective symptoms Rapid & effective response to Tx
In Schizophrenia what are the bad prognostic factors?
Male, single Early age of onset Abnormal pre-morbid personality (Schizoid) Fhx of Schizophrenia Delay in Tx Substance abuse Insidious onset, negative symptoms
In what disorders is psychosis present?
Organic states (Delirium, Dementia, metabolic disorders)
Psychoactive substance misuse (intoxication & withdrawal states, Delirium Tremens)
Schizophrenia
Affective disorders (Depression, mania)
Sleep/sensory deprivation
Bereavement
What are the symptoms of Schizophrenia?
\+ve: Hallucinations (esp auditory) Delusions Thought disorder -ve: Avolition (lack of motivation) Anhedonia (unable to experience pleasure) Alogia (poverty of speech) Asociality (lack of desire for relationships) Affect blunt Part of continuum of normal traits
What are the psychopathological phenomena seen in Schizophrenia?
Diagnosis made if symptoms >1/12m Thought echo Thought insertion/withdrawal Thought broadcasting Delusional perceptions Delusions of control/influence/passivity Hallucinations Thought disorder Negative symptoms
What is schizoaffective disorder?
Schizophrenic & affective symptoms are prominent at the same time
AKA: Patient meets the criteria for Schizophrenia & mood disorder at the same time
What are the different types of Schizophrenia?
Paranoid Simple Hebephrenic Undifferentiated Catatonic
What are the signs & symptoms of Hebephrenic Schizophrenia?
Early age of onset- POOR PROGNOSIS Rapid development of -ve symptoms (flattening of affect & loss of volition) Speech: Incoherent Incongruent affect Delusions& Hallucinations Fleeting & fragmentary Behaviour irresponsible & unpredictable Mannerisms common Mood: Shallow & inappropriate Thought disorder Tendency to social isolation
What are the signs & symptoms of paranoid Schizophrenia?
Most common subtype Relatively stable Often paranoid delusions usually accompanied by hallucinations (auditory) Perceptual disturbances Inc suicide risk
What are Schneider’s first rank symptoms of Schizophrenia?
HIGHLY suggestive of Schizophrenia in absence of organic disease
-Delusional perception & Somatic passivity- body influences
- Auditory hallucinations: 3rd person, running commentary, thoughts spoken aloud, present in all settings
-Thought alienation: Echo, withdrawal, broadcast, insertion
-Influences: Made acts, impulses, emotions
CAVIAT: Absent in 20% schizophrenics, present in other psych disorders (depression, mania)
What are the ‘causes’ of Schizophrenia?
Genetics: Thought to be multiple genes involved
Environmental: Winter births, viral infection, CNS pathology (Neurosyphilis, encephalitis, temporal lobe epilepsy)
Life events: Social exclusion, childhood trauma, migration, urban living, negative attitude
Substance misuse: Cannabis, amphetamines
Peri-natal trauma: Hypoxia, maternal stress
What are the types of delusional disorders? Describe them
- Persecutory
- Othello Syndrome: Morbid jealousy, partner having affair- no evidence, risk of stalking/violence, associated w/OH- or sexual dysfunction
- De Clerambault’s Syndrome: Erotomania, belief another is in love with them, can’t declare love so communicate by signs
- Capgras Syndrome: Misidentification, relative/spouse/friend replaced by identical imposter
- Fregoli’s Syndrome: Different people are a single person who changes appearance/disguise, persecuted by that person
- Cotards Syndrome: Dead, dying, non-existent, lost body parts, associated w/depression
- Ekboms Syndrome: Parasitosis- infested w/parasites- no evidence, associated w/formication, risk of self-harm
- Folie à deux: Induced, psychosis shared by 2 people
What is a delusional disorder?
Long-standing delusions
Single or multiple related usually persistent
What factors are not compatible with a diagnosis of delusional disorder?
Clear & persistent auditory hallucinations
Marked blunting of affect
Delusions of control
Definite evidence of brain disease
What is Catatonic Schizophrenia?
Prominent psychomotor disturbances
Alter between extremes: Hyperkinesis & stupor
signs: Excitement, posturing, negativism, rigidity, wavy flexibility, perseveration of words, mutism
Episodes of violent excitment
Dream-like state w/vivid scenic hallucinations
What is Simple Schizophrenia?
Insidious development fo -ve symptoms
Progressive development of oddities of conduct & decline in total performance
Inability ro meet demands of society
Characteristic negative features develop without any overt psychotic symptoms
What is undifferentiated Schizophrenia?
Psychotic conditions meeting general diagnostic criteria
Not conforming to any subtypes
What is somatic passivity?
Patient feels they are receiving bodily sensations from an outside agency (e.g alien twisting their intestine)
What are the signs & symptoms of schizotypal disorder?
Type of personality disorder: Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent
What are the different types of personality disorders?
Avoidant Antisocial Borderline Dependent Histrionic Narcissistic Obsessive-compulsive Paranoid Schizoid Schizotypal
How is a dissociative disorder characterised?
Loss of normally integrated concepts:
Self-identity
Memories
Awareness of the present
Control of bodily movements
MUST: Be some form of traumatic/interpersonal stress
AND: Absence of preexisting physical/psychiatric illness
What is the theory of MOA of Schizophrenia?
Symptoms caused in part by central dopaminergic hyperactivity in mesolithic-mesocortical system.
What is a sign associated with psychotic depression?
Nihilistic delusion- delusion that part of the patients body s rotting away (severe depression)
Describe someone with a Schizoid type personality?
Prefer own company
Lack emotional expression (can be perceived as cold & disinterested)
Little interest in forming sexual/confiding relationships
May not gain pleasure from many activities
What are the social theories related to Schizophrenia?
Lower socioeconomic group
Drift hypothesis
Life events
Cannabis use in adolescents
What are the positive symptoms?
Mesolimbic system affected Delusions Hallucinations Bizarre behaviour Formal thought disorder
What are the criteria in ICD-10 to diagnose schizophrenia?
> 1: First rank symptoms
OR
2
Duration: >1months
What are the causes of acute & transient psychotic disorders?
Duration: <1month
Acute schizophrenia
Drug induced psychosis
Acute polymorphic psychotic disorder (changing hourly)
PTSD
Personality disorder
Organic: Infection, Parkinson’s, temporal lobe epilepsy, hyperthyroidism, B12 deficiency
What are the causes of Enduring psychotic disorders?
Duration: >1month Schizophrenia Schizoaffective disorder Persistent delusional disorder Non-organic psychotic disorder Psychosis associated w/mood disorder
