Psych Flashcards
(89 cards)
How is a diagnosis of schizophrenia classified
Diagnosis The diagnosis of schizophrenia has to be distinguished from that of just a brief psychotic episode – thus when at least one of the following has been apparent for at least one month we say schizophrenia is present: Auditory hallucinations Thought echo Thought insertion Thought broadcast Thought withdrawal Delusion (primary or persistent) Passivity experiences
OR at least two of the following for more than one month
Persistent hallucinations
Incoherent/irrelevant speech (including neologisms)
Mannerisms
Catatonia
Negative Symptoms
Prevalence schizophrenia
1% of the population will have at some point in life If sibling has condition - 9%
If parent has condition – 13%
If both parents have condition – 45%
Prognosis schizophrenia
20% of patients will make a full recovery with drug and supportive treatments
A further 35% have long periods of remission
35% will have persistent mild positive and negative symptoms, that can be managed in the community
10% have severe schizophrenia that is unresponsive to treatment, and these people will often require institutionalised care.
A small number of patients may require forensic care, due to high risk.
Risk factors are there for schizophrenia
Tendency as a child to be withdrawn, eccentric, and/or clumsy, before developing the disease later in life
For a period (perhaps lasting years) before ‘true symptoms’ develop, the individual may show other symptoms, such as:
Loss of interest
Social withdrawal
Self-neglect
Depression
Anxiety
Brief psychotic episodes
This period is known as the prodromal period. A long prodromal period usually means that the diagnosis is delayed, and in these situations, the prognosis is poor
Periods of increased stress
Periods of intense emotion (both positive and negative) – e.g. losing your job, winning the lottery
Increased levels of criticism from friends and family members
Drugs – particularly hallucinogens, stimulants, including alcohol and cannabis
what sort of hallucinations can occur in schizophrenia? which is most common?
Auditory Hallucinations – the most common symptom, and often the easiest to elicit. These can take several forms:
Third person – talking about the individual who hears them. May be single or multiple voices. These are the most common type of auditory hallucination in schizophrenia. The voices are often critical of the individual. With treatment, these voices may not go away, but they may become quieter, and contain more positive content
Thought echo – the individual hears their thoughts spoken aloud, either simultaneously (as thinking the thought) or just afterwards.
Second person – talking to the individual – can still occur in schizophrenia, but also present in lots of other mental disorders.
NOTE – auditory hallucinations in which the person talks to the voice they hear are most commonly the result of TRAUMA or are fictitious.
what is catatonia?
Catatonia – a state where the person may not respond to stimuli and exhibits strange physical behaviour. The state may involve a particular movement or posture that a patient often performs. Can be associated with any mental health condition. Examples can include
Stupor – the patient is unable to move or speak except for moving their eyes.
Strange postures – that are normally very difficult to hold
Negativism – the patient does the exact opposite of what they are asked
Automatic obedience
Waxy flexibility – the patient has strange muscle tone that allows the doctor to put the patient into physical position that would otherwise be very difficult and/or painful.
What are the negative symptoms of schizophrenia?
Weight change
Sleep problems
Guilt / hopelessness / low self worth
The symptoms can also be attributed to sedative medications
Alogia – this is a general impoverished level of thinking, usually seen in the form of poverty of speech – whereby the patient will give very short answers, and will not voluntarily give any input to a conversation. They are unable to elaborate on their thoughts. The patient feels as though their ‘mind is empty’.
Poverty of content of thoughts – is a less extreme version. The patient is able to answer questions, but their thought process is not properly utilised and they cannot explain their answers.
Blunting of Affect – the person has a lack of emotion
Avolition (loss of volition) – the patient has a general lack of interest in life, self care, social activities and motivation.
Slowness of thought an movement
how can negative symptoms of schizophrenia be distinguished from post-psychotic depression?
Post psychotic depression –this is a prolonged depressive episode that occurs on resolution of the psychosis. This can be distinguished from the negative symptoms of schizophrenia because:
In schizophrenia – negative symptoms increase/decrease in conjunction with the severity of positive symptoms
In post psychotic depression – the depressive type symptoms do not change in concordance with any positive symptoms
This case can be extremely difficult to distinguish from the normal negative symptoms of depression – but it requires different treatment – and so if you suspect it, you should make the extra effort to try and find out. Patients with post psychotic depression are at high risk of suicide, and they have a particular feeling of hopelessness. In post-psychotic depression the patient often has a good degree of insight – because the depression is often in response to their diagnosis. It can also be a result of neuroleptic medication
characteristics of delusional disorder
Delusional disorder – basically, might appear like schizophrenia, but, there are only hallucinations and /or delusions, and no other signs of schizophrenia. We say that delusional disorder exists when an individual has a complex and logical system of beliefs that are based on one or more delusional beliefs. There may also be auditory hallucinations, but there are usually no other schizophrenia-like symptoms. The delusions are usually either persecutory or grandiose. Three particularly common delusions are:
Dysmorphophobia – a delusion that their body is particularly deformed (e.g. they think they have a massive nose when they clearly don’t), to that it is always giving off a particularly foul smell
Morbid Jealousy – a delusion that the patient’s partner is cheating on them, despite very little evidence – e.g. they were late home one night
Erotomania – this is where the patient loves another individual, and believes the other individual also loves them – but that they are unable to show it
Often these patients have a history of paranoid personality, particularly sensitive to criticism, have a very rigid belief system, or a history of sensory depravation or temporal or parietal lobe defects.
Treatment – it can be very difficult to persuade the patient that they need treatment! treatment from the GP is often more accepted than from the mental health practitioner. The first line drug is pimozide – but other neuroleptics can be used. (NB neuroleptic just means antipsychotic). Full recovery is seen in ½ of patients, with a further 33% showing improvement
Which organic conditions can mimic symptoms of schizophrenia
Epilepsy – particularly temporal lobe seizures
Dementia
B12 def
Hypoglycaemia
Trauma/head injury
In trauma and head injury, the patient may hear voices that they can ‘talk to’. In psychiatric disease, this does usually not occur (or if the patient claims it does occur, it is often fictitious)
Which drugs can cause symptoms of schizophrenia?
- The drugs that cause these symptoms can be stimulants or hallucinogens. Examples include: Cannabis Steroids - These two drugs produce symptoms particularly consistent with schizophrenia Cocaine Ecstasy LSD Magic mushrooms (psilocybin) Mescaline Phencyclidine
What are schneider’s first rank symptoms of schizophrenia
Schneider’s First Rank Symptoms of Schizophrenia
These are a ‘sub-class’ of Positive symptoms and basically include:
Delusions – an unshakeable belief that is not in keeping with the person’s social, cultural or educational background, for which there is no logical evidence basis.
Primary delusions – these appear with no apparent precipitating event. The individual may enter a state of being ‘perplexed’ for several days or months, and as the perplexity disappears, the delusion develops.
Persistent delusions – these arise with the period of perplexity. If other symptoms of schizophrenia are present, this can be diagnostic for schizophrenia. If they are not, then it can be diagnostic for delusional disorder.
Secondary delusions – these arise when other symptoms of schizophrenia have been present for a period just before the delusion, and arise from strange experiences the individual has as a result of their schizophrenia.
Thought issues
Thought insertion – the patient believessomebody or something is ‘planting’ thoughts into their mind. This happens against the person’s will.
Thought broadcast – the patient believes their thoughts are ‘broadcast’ to others against their will
Thought withdrawal – the patient believes thoughts are being removed from their mind against their will, and this leaves the mind ‘blank’.
What proportion of the general public experience hallucinations?
5-10%
Which sorts of thought disorder exist
Neologism – this is a phenomenon that may occur with some patients. They may make up a new word, or give an existing word a new meaning that is only apparent to the individual, and does not make sense. They may keep repeating this word. E.g. “I like to sprong”
Word salad – the form of the sentences makes no sense at all. Words are mixed up, in the wrong place.
Flight of thought – this is where the patient moves quickly from one idea to another, often half-way through a sentence, with no apparent association between ideas.
Knight’s move thinking (aka Derailment)- patient moves from one idea to another with strage illogical associations between the ideas.
Pressure of speech – the patient speaks at a rate faster than normal
Circumstantiality – excessive ‘long-windedness’ – the patient takes forever to reach the point when they talk.
Alogia (also poverty of speech) – A poverty of speech, either in amount or content; it can occur as a negative symptom of schizophrenia.[1]
Blocking – An abrupt stop in the middle of a train of thought; the individual may or may not be able to continue the idea.[9] This is a type of formal thought disorder that can be seen in schizophrenia.[1]
Circumstantiality (also circumstantial thinking, or circumstantial speech) – An inability to answer a question without giving excessive, unnecessary detail.[9] This differs from tangential thinking, in that the person does eventually return to the original point.
Clanging or Clang association – Ideas that are related only by similar or rhyming sounds rather than actual meaning.[9] This may be heard as excessive rhyming and/or alliteration. e.g. “Many moldy mushrooms merge out of the mildewy mud on Mondays.” “I heard the bell. Well, hell, then I fell.”
Derailment (also loose association and knight’s move thinking) – Ideas slip off the topic’s track on to another which is obliquely related or unrelated.[9] e.g. “The next day when I’d be going out you know, I took control, like uh, I put bleach on my hair in California.”
Distractible speech – During mid speech, the subject is changed in response to a stimulus. e.g. “Then I left San Francisco and moved to… where did you get that tie?”
Echolalia – Echoing of another’s speech[9] that may only be committed once, or may be continuous in repetition. This may involve repeating only the last few words or last word of the examiner’s sentences. This can be a symptom of Tourette’s Syndrome. e.g. “What would you like for dinner?”, “That’s a good question. That’s a good question. That’s a good question. That’s a good question.”
Evasive interaction – Attempts to express ideas and/or feelings about another individual come out as evasive or in a diluted form, e.g.: “I… er ah… you are uh… I think you have… uh– acceptable erm… uh… hair.”
Flight of ideas – Excessive speech at a rapid rate that involves fragmented or unrelated ideas.[9] It is common in mania.[9]
Illogicality – Conclusions are reached that do not follow logically (non-sequiturs or faulty inferences). e.g. “Do you think this will fit in the box?” draws a reply like “Well duh; it’s brown, isn’t it?”
Incoherence (word salad) – Speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish,[9] e.g. the question “Why do people comb their hair?” elicits a response like “Because it makes a twirl in life, my box is broken help me blue elephant. Isn’t lettuce brave? I like electrons, hello please!”
Loss of goal – Failure to follow a train of thought to a natural conclusion. e.g. “Why does my computer keep crashing?”, “Well, you live in a stucco house, so the pair of scissors needs to be in another drawer.”
Neologisms – New word formations.[9] These may also involve elisions of two words that are similar in meaning or in sound. e.g. “I got so angry I picked up a dish and threw it at the geshinker.”
Perseveration – Persistent repetition of words or ideas even when another person attempts to change the topic.[9] e.g. “It’s great to be here in Nevada, Nevada, Nevada, Nevada, Nevada.” This may also involve repeatedly giving the same answer to different questions. e.g. “Is your name Mary?” “Yes.” “Are you in the hospital?” “Yes.” “Are you a table?” “Yes.” Perseveration can include palilalia and logoclonia, and can be an indication of organic brain disease such as Parkinson’s.
Phonemic paraphasia – Mispronunciation; syllables out of sequence. e.g. “I slipped on the lice and broke my arm.”
Pressure of speech – Unrelenting, rapid speech without pauses.[9] It may be difficult to interrupt the speaker, and the speaker may continue speaking even when a direct question is asked.
Self-reference – Patient repeatedly and inappropriately refers back to self. e.g. “What’s the time?”, “It’s 7 o’clock. That’s my problem.”
Semantic paraphasia – Substitution of inappropriate word. e.g. “I slipped on the coat, on the ice I mean, and broke my book.”
Stilted speech – Speech characterized by the use of words or phrases that are flowery, excessive, and pompous.[9] e.g. “The attorney comported himself indecorously.”
Tangentiality – Wandering from the topic and never returning to it or providing the information requested.[9] e.g. in answer to the question “Where are you from?”, a response “My dog is from England. They have good fish and chips there. Fish breathe through gills.”
Word approximations – Old words used in a new and unconventional way. e.g. “His boss was a seeover.”
what are the classifications of bipolar
Bipolar 1 disorder – there is underlying depression, interspersed with episodes of main (usually depressive and manic episodes occur in the ratio 1:1
Bipolar 2 disorder – the depression is more predominant, and the ratio of depressive to manic episodes is about 5:1. Manic episodes may only be slight, or precipitated by anti-depressant medication
Rapid cycling bipolar – a new classification, where there are >4 episodes/year of mania + depression
epidemiology of bipolar
Prevalence of 1-1.5%
Bipolar 1 more common
More common in women
Usual onset in teenage years
If first incidence is after 45, suspect organic cause
↑ risk in those with a tendenacy to have rapid mood changes (cyclothymia) or unusual periods of elated feelings (hyperthymia)
Precipitating factors of mania
Lack of sleep / early morning waking (e.g. due to shift pattern work)
Positive life events (may precipitate mania)
Negative life events (may precipitate depressive episode, or depression (not bipolar
Treatment bipolar
Acute Manic Episode
First line – Atypical antipsychotic - e.g. clozapine, risperidone, quetiapine, olanzapine
Second line –try Valporate, lamotrigine (anticonvulsants), or Lithium
May require sedation, benzodiazapines
Depressive Episode
AVOID ANTIDEPRESSANTS! – these can cause rapid cycling mood
Clozapine – atypical antipsychotic – this is useful to treat rapid cycling.
Consider atypical antipsychotics, anticonvulsant, and possible lithium adjunct.
In some cases, SSRI may be suitable, but be very careful
General Maintenance
First line – Lithium (mood stabiliser)
In cases of manic or depressive episodes, first add an atypical antipsychotic, and if response is poor, consider anticonvulsants.
How might mania be distinguished from schizophrenia
If the symptoms of psychosis persist after the period of ‘excitement’ has passed, then the diagnosis is more likely to be schizophrenia.
what are the common organic causes of mania?
Drugs Stimulants – cocaine, amphetamines, cannabis, hallucinogens (LSD) Steroids Antidepressants Neurological Disorders MS Epilepsy CVA Brain tumour – particularly one affecting the frontal / subcortical areas. Endocrine Disorders Thyroid Adrenal Pituitary You should particularly consider an organic cause when there is a known organic disorder, and the onset of depression occurs at roughly the same time as the known onset of the organic disorder
how might mania be maintained
Generally, you need to avoid changes in medication regimens, and assess the effectiveness of current treatments over months
Consider a mood diary. As the patient to rate their mood (e.g. out of 10) everyday – it is most effective when part of the bedtime routine. You can then use this to assess the patients mood over a long period – e.g. 12-18 months
Consider education/therapy to encourage a proper diurnal pattern.
Lithium – this is the first line maintenance treatment. You should add mood stabilisers until the required level of maintenance is attained.
Recurrent depression – add atypical antipsychotic or lamotrigine to maintenance
Recurrent mania – add atypical antipsychotic or valproate to maintenance
Clozapine can be used in rapid cycling patients.
prognosis bipolar
It is very unusual for a person to only ever have one manic episode. Therefore if a patient has experienced one, they are very likely to experience others in the future:
Typically 8-10 manic/depressive episodes over lifetime in untreated cases
Following manic episode 90% chance of will further episodes, 50% chance in the next year
80% chance in the next 4 years
Depressive episodes»_space;> manic episodes
No cure but with treatment both intensity and frequency of episodes are reduced
30% will have residual episodes between episodes
Suicide 10%
definition of cyclothymia
Cyclothymia – >2 year history & no episodes reach threshold for depression or hypomania
What are the psychosocial considerations for acute mania?
Use of MHA common
CRHT & possibly Early Intervention of Psychosis Team (EIP)
In-patient to manage risks or behaviour
May require rapid tranquillisation
psychoeducation/support, job/education/finances, social inclusion,
