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3018 > Schizophrenia Spectrum Disorders > Flashcards

Schizophrenia Spectrum Disorders Flashcards

1
Q

Psychosis

A
  • Refers to loss of contact with external reality characterised by:
  • impaired perceptions
  • thought processes

› Schizophrenia - ‘Split mind’ (Bleuer- 1857-1939)
1. Fragmentation of thoughts
2. Splitting of thoughts from emotions
3. Withdrawal from reality
NOT split personality (classified as Dissociative Identity Disorder

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2
Q

DSM-5: Schizophrenia

A

A. Two or more of following present for a significant
portion of time during a 1-month period (or less if
successfully treated) & at least one must be (1),
(2), or (3) below.
1) Delusions
2) Hallucinations
3) Disorganised Speech
4) Grossly disorganized or catatonic behaviour
5) Negative symptoms

  • One month duration to determine different from other disorders

B. Clinically significant impact to functioning:
- Functioning is below that prior to onset of the disorder
C. Continuous signs of disturbance are present for at
least 6 months
- May include a gradual deterioration in functioning
- Must include at least one-month of psychotic symptoms
D-F. Not better accounted for by other diagnosis: schizoaffective,
substance, autism

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3
Q

Subtypes

A

› Schizotypal (Personality) Disorders, (odd, eccentric nut do not manifest clearly delusional ideation)
› Brief Psychotic Disorder (sudden, 1mth mood disorders)
› Schizoaffective (mood disorder criteria present)
› Substance-induced psychotic
› Psychosis due to a medical condition
› Catatonia & other unspecified (exclude neurodevelopmental or medical condition)
› Schizophrenia

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4
Q

Positive Symptoms

A 
PRESENT & OBSERVABLE
- Hallucinations
- Delusions
- Formal thought disorder
- Behavioural disturbances
- Disorganized, catatonia, odd
movements/behaviours
- Lack of insight (97%) --> don't acknowledge have illness
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5
Q

Negative Symptoms

A

AFFECTIVITY

  • Social withdrawal (poor eye contact)
  • Anhedonia –> inability to experience joy/happiness
  • Emotional blunting (66%)
  • Confusion
  • Amotivational
  • Apathy
  • Self-neglect
  • Poverty of speech
  • Poverty of content

–> Presence of negative symptoms suggest poorer response to treatment

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6
Q

DSM-5: Hallucinations

A

DSM-5 (2013) defines hallucinations as
- Perception-like experiences that occur in absence of any external stimulus
(vivid, clear, & not under voluntary control)
- Occurs in clear sensorium (hypnogogic & hypnopompic not included) –> when falling asleep/waking up

› 75% of patients with schizophrenia report experiencing
hallucinations including:
- Auditory
- Visual (not illusion/misperception)
- Olfactory (smells)
- Gustatory (taste)
- Tactile (insects crawling)
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7
Q

Auditory Hallucinations

A

› 60%-70% report auditory hallucinations
› Hearing voices (Distinct from own thoughts).
- Voices inside head or coming from external sources
- Own thoughts spoken aloud (describing feeling/thinking,
fears or worries)
- Can be comforting
- Derogatory or insulting voices
- Third person commentary
- Commands to perform unacceptable behaviors
› Cross-cultural studies: similar forms across societies
but cultural differences in content & interpretation

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8
Q

Aggression in schizophrenia

A
  • Schizophrenics being aggressive is a myth, reality is Schizophrenics are not more aggressive than general population, just attract attention due to bizarre behaviours & elements of grandiosity

Risk factors for hostility:

  • Younger males (with past history of violence)
  • Non-adherence with medication
  • Substance use
  • Impulsivity
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9
Q

DSM-5: Delusions

A

Delusions are: False firmly beliefs despite what others believe & despite evidence to contrary
- Beliefs are not culturally accepted
› Delusions typically categorised according to content &
bizarreness

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10
Q

Paranoid or Persecutory Delusions

A
  • Most common type
  • Fixed, false belief one is being harmed or persecuted by
    particular person/group
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11
Q

Delusions of Reference

A
  • Neutral event interpreted to have personal meaning for
    individual, e.g., TV newsreader sending messages meant
    specifically for them
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12
Q

Grandiose Delusions

A
  • False belief that one has special powers, abilities, influence, achievements or another identity that typically relates to power, wealth or fame
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13
Q

Nihilistic Delusions

A
  • Belief that one, bodily part, or world does not exist or has been destroyed
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14
Q

Delusions of Guilt

A
  • Personal responsibility for events
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15
Q

Jealousy Delusions

A

(monosymptomatic delusions)

- usually such as partner having an affair

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16
Q

Erotomanic Delusions

A

False belief that patient’s romantic feelings are reciprocated (often by a famous other)

17
Q

Misidentification Delusions

A

Identity of someone they know has been stolen (e.g., imposter has replaced a loved one)

18
Q

Thought Disorder

A

Formal thought disorder: Disturbances in flow &/or form of speech (mess of ideas) –> (as opposed to content as in delusions)

Symptoms categorised into positive & negative manifestations

19
Q

Negative manifestations

A
  • Reduced stream of thoughts & poverty of speech
20
Q

Positive manifestations

A
  • Circumlocution (talking around a point but never getting to it)
  • Derailment (comments slipping from one to next)
  • Tangential (irrelevant responses)
  • Echolalia (acute phase, repeating what someone is saying)
  • Word salad (incomprehensible stream of words)
  • Neologisms (idiosyncratic use of words, meanings: e.g., “Pass me the spoon, moon, I am cacoon”
21
Q

Disorganised Behaviour

A

Grossly disorganized & abnormal motor behaviour: from
child-like silliness to unpredictable agitation
- Catatonic behaviour: (medication reduced prevalence but recent data
found prevalence of 32% (Ungvari et al., 2005)
- Extreme negativism (resistance instructions)
- Immobility (“waxy flexibility”)
- Catatonic excitement : Excessive purposeless physical activity
- Peculiar voluntary movements (posture, repetition, grimacing)
- Mutism; Echolalia; Echopraxia: imitating speech; movement

22
Q

Prevalence

A

Lifetime prevalence of schizophrenia ranges from 1-2%

› Male to Female ratio: 3:2

23
Q

Age of Onset

A

› Typical onset in late adolescence & early adulthood (tends to be later for women)
–> usually person functions very well until onset

› Onset typically preceded by a gradual deterioration in functioning followed by appearance of more acute symptoms
› Onset coincides with an often stressful time of life, further complicated by impact of schizophrenia
› Early onset associated with poorer outcomes

24
Q

Course of Schizophrenia

A

Course highly variable
› One or more episodes with periods of normal (or near normal)
functioning between episodes
- 66% difficulty with at least one daily living activity
› Most remain chronically unwell with a deteriorating course
- 50% classified as unable to work
-

25
Q

Phases of Schizophrenia

A

Course described in separate phases:

  • Prodromal Phase: Median length for symptoms to develop is 2-years but highly variable (Yung et al., 2003)
  • Acute Phase: Typically one year between onset of active symptoms & treatment –> acute phase symptoms become more pronounced, longer they leave before treatment the worse they get
  • Response to treatment related to duration of untreated psychosis
  • Early Recovery Phase
  • Late Recovery Phase: Reintegration
  • 80%-90% relapse within 2-5 years of treatment
26
Q

Affect

A 
› Anxiety & perplexity
- Sufferers is often frightened, perplexed & confused over emerging
symptoms
- Irritability
- 30% of patients attempt suicide
- 5-10% suicide

–> suicide particularly in younger patients

27
Q

Prognostic Factors

A 
Good premorbid functioning
• Acute onset
• Later age of onset (females)
• Precipitating event (e.g., drug
induced psychosis)
• Low substance use
• Brief duration of active phase
• Absence of structural brain
abnormalities
• No family history of
schizophrenia 
Poor premorbid
• Slow insidious onset
• Prominent negative
symptoms
• Duration of untreated
psychosis
• Slower or less complete
recovery
• Lower socioeconomic class
• Migrant status
• Social support network
28
Q

Aetiological Factors

A

Not homogenous, no single cause
Heterogeneous range of disorders with common underlying biological vulnerability

Genetics & Environmental, Social & Psychological –>
Neurodevelopmental Abnormalities –> Neurotransmitter dysregulation –> Schizophrenia

29
Q

Genetic Factors

A

Degree of risk related to degree of genetic relatedness:
Genes determine susceptibility - disorder triggered by other factors
- 7.3% siblings
- 9.4% for children of one affected parent
- 46.3% for children with two affected parents
› Twin studies concordance rates:
- 12.1% for DZ twins
- 44.3% for MZ twins
› Adoption studies have shown that:
- Higher rates among children whose biological parents have schizophrenia (18.8%), compared to children with no biological parents with schizophrenia (10.1%)

30
Q

Biochemical Factors

A

Dopamine hypothesis: Overproduction or oversensitivity of dopamine receptors
1. Excess L-Dopa in Parkinson’s precipitate psychotic episodes
2. Amphetamine (dopamine agonist) psychosis: abnormally large responses to low amphetamine doses
- Suggests over-sensitivity rather than excessive dopamine level
3. Response to anti-dopaminergic medication (e.g. chlorpromazine)
Effective in 60% with more impact on positive symptoms
4. Lack of impact on negative symptoms hints at two separate syndromes
i. Caused by dopamine activity & associated with +ve symptoms
ii. Caused by brain degeneration & associated with –ve
symptoms.

31
Q

Neuroanatomical Factors

A

› Most consistent neuroanatomical finding:
- Enlarged ventricles in schizophrenia (post-mortem; CT scans; MRI studies)
- Relative size more than twice that of normal controls
› Most likely cause is loss of brain tissue; scans indicate chronic schizophrenia is associated with brain abnormalities

Greater brain tissue loss in prefrontal cortex - Linked to negative symptoms (damage to executive functioning
system)
› Recent findings of smaller left hippocampal volume in
those:
- With schizophrenia
- At very high risk of developing schizophrenia
- Without a family history

Structural brain abnormalities appear to predate onset of
psychosis & worsens with progressive illness
› Early neurodevelopmental damage (e.g., from viruses) may play
a key aetiological role

32
Q

Other factors

A

Obstetric complications, viruses, urban birth, nutritional factors & paternal age, seaonal variation
› Birth trauma & maternal viral infections
- Nature & timing of factors obscure but ischaemia/hypoxia & influenza/
viral infections likely
- Nutritional deficiencies may contribute to adverse neurological
development
- Risk for those with birth complications is four times that for noncomplications
- Older fathers age can increase likelihood

  • History of birth complications found in 40%
  • 10 times greater likelihood of complicated caesarean birth

Seasonal variations & place of birth

  • Greater likelihood of winter or spring birth
  • ? Viral illnesses or vitamin D deficiency (brain development)
  • Two-fold increase in risk for urban births
  • -> Little/no evidence socioeconomic status in aetiology
33
Q

Treatment

A

Medication is primary intervention: 60% of clients with positive symptoms respond: Block D2 & D3 dopamine receptors
› 10%-20% do not show symptom improvement in response to medication
› Relapse rates high with 40% relapsing within one year

34
Q

Side Effects of Neuroleptics

A

› Medication non-compliance given common side effects:
- Sedation
- Extrapyramidal side effects:
• Symptoms resembling Parkinson’s Disease
• Tardive dyskinesia (abnormal movements, facial grimacing, lip
smacking)
• Finger tremors, shuffling gait, drooling, chewing, twisted posture
- Side effects often treated with anti-Parkinson drugs
- Weight gain, diabetes, heart disease
- Clozapine additional side effects:
• blood abnormalities; reduced white blood count

35
Q

Psychological Interventions

A

Psychological interventions designed to target specific
deficits or objectives
- Social skills training for interpersonal deficits
- Medication compliance
- Managing delusions/hallucinations
- Reduction of stresses
› CBT potential non-pharmacological treatment

Psychological treatment not pretending delusions are not there, but reduce stress and learn how to deal with them

36
Q

CBT

A

CBT helps patients to:
- Notice early signs of relapse
- Understand relationship between thoughts, feelings & behaviours
- Challenge beliefs about not being able to manage one’s thoughts &
behaviours
- Learn strategies to cope with symptoms & stressors
- Evaluate evidence supporting delusional beliefs versus alternative beliefs (e.g., recognize inner experiences such as ‘thoughts’ can be misattributed to external sources, like ‘voices’)

37
Q

Efficacy of CBT

A

Tarrier et al. (2000) found that CBT showed better outcomes than standard treatment in:
- Reducing relapse, hospitalisation, positive & negative symptoms
- Improving social functioning
- Gains maintained at 2 year follow up
› CBT shown to reduce numbers who go on to develop psychosis in ‘high risk’ groups

38
Q

Family Therapy

A

Family Therapy interventions were developed in response to higher relapse rates for patients from families high in Expressed Emotion (EE)
› Family interventions provide:
- Education about schizophrenia and its treatment
- Realistic goal setting skills
- Communications training (empathic not critical)
- Problem Solving skills
- Promote social support
› Family interventions shown to reduce relapse & enhance family support

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