Psychiatry - Schizophrenia and psychosis

Question 1

Symptoms of psychosis

Answer 1

1) Delusions
2) Hallucinations
3) Passivity phenomena

These tend to be episodic

Question 2

Delusions

Answer 2

= false belief that is held unshakably despite evidence to the contrary. It is not culturally appropriate

Delusions are abnormal thoughts

Question 3

Hallucinations

Answer 3

= perception which arises in the absence of any external stimulus

Auditory hallucinations are the most common

Question 4

Passivity phenomena

Answer 4

= patient feels that he/she is being controlled externally. This may affect their thought processes (e.g. thought insertion, thought withdrawal, made feelings, made impulses etc)

Question 5

Are all hallucinations pathological?

Answer 5

No.

Hallucinations can occur in special situations such as those associated with sleep (hypnagogic and hypnopompic). These are non pathological and it is usual for the patient to retain insight and recognise these are not true or real experiences. This is not the case in psychosis

Question 6

What are the 4 non affective (mood related) or primary psychoses?

Answer 6

1) Schizophrenia
2) Schizoaffective disorder
3) Persistent delusional disorder
4) Acute and transient psychosis

Diagnosis may change over time - e.g. presentation with acute and transient psychosis may progress to symptoms of schizophrenia

Question 7

What is thought insertion and withdrawal?

Answer 7

Caused by passivity phenomena
Thought insertion - thoughts originate elsewhere and are put into the patients head

Thought withdrawal - the experience of thoughts being removed from one’s mind

Question 8

Characteristics of schizophrenia

Answer 8

Chronic illness characterised by repeated episodes of psychosis, particularly Schneider’s first rank symptoms

Patients may also experience negative symptoms that are not episodic - usually remain and worsen

Question 9

What are Schneider’s first rank symptoms?

Answer 9

Symptoms of psychosis which if present are considered to be suggestive of schizophrenia (can occur in 8% of patients with bipolar)

1) Third person auditory hallucinations - discussing/ running commentary
2) Thought echo (hear own thoughts out loud)
3) Delusional perception (delusion arises from a real perception
4) Passivity phenomena
- Thought insertion/ withdrawal/ broadcast (thoughts interfered with)
- Passivity and somatic passivity

Question 10

Negative symptoms of schizophrenia

Answer 10

Symptoms that develop gradually and progressively unlike the episodic symptoms of acute psychosis

• impaired motivation
• lack of drive
• social withdrawal
• reduced reactivity
• poverty of speech
• self neglect

Question 11

Schizoaffective disorder

Answer 11

= Simultaneous presence of both typical symptoms of schizophrenia and affective disorder, neither being predominant

Question 12

Persistent delusional disorder

Answer 12

= At least 3 months duration of one or more delusions

Other psychotic symptoms and negative symptoms of schizophrenia are absent

Question 13

Acute and transient psychosis

Answer 13

= Sudden onset of rapidly changing symptoms of florid psychosis - strong mood element is common (that does not precede the psychosis)

Episode often precipitated by some stressful event. Usually lasts no longer than 3 months

Question 14

Physical causes of psychosis

Answer 14

1) Any cause of delirium
2) Head injury/ intracranial pathology
3) Degenerating dementias
4) Epilepsy
5) Acute intermittent porphyria
6) Hyperthyroidism

Question 15

What drugs can cause psychosis?

Answer 15

• L-DOPA
• Steroid hormones
• Disulfiram
• Anticonvulsants

Question 16

Why does drug or alcohol abuse lead to psychotic symptoms?

Answer 16

2 reasons:
1) Intoxication with some drugs (e.g. amphetamines) can cause psychosis - psychosis usually resolves once the drug has been cleared

2) Drug misuse can precipitate psychosis in patients who have mental illness (e.g. schizophrenia) - psychosis may persist after patient has stopped drug abuse

Question 17

Diagnostic work up in a patient to rule out organic cause of psychosis

Answer 17

• Physical examination
• FBC, U&E, LFTs, TFTs
• MRI of head should be considered in all first presentations of psychosis to rule out an underlying disorder (e.g. epilepsy, head trauma, encephalitis)

Question 18

What drugs are associated with acute florid psychosis?

Answer 18

Amphetamines

Visual hallucinations suggest psychosis due to drug intoxication - urine sample may be required

Question 19

What differentiates a manic episode from acute and transient psychosis?

Answer 19

Mania should be a differential for acute psychosis
Mania/ affective disorders with psychotic symptoms has a prolonged period of deteriorating mood prior to the onset of psychosis which is normally precipitated by stressful event

Question 20

How long should anti-psychotic medication be maintained in a patient with acute psychosis?

Answer 20

Continuation antipsychotic treatment for at least 1 year to prevent relapse

Question 21

What is the prognosis for a patient with an acute psychotic episode?

Answer 21

• Short term prognosis is good - psychosis will not usually last for more than 2/3 months
• Patients are more likely to experience further episodes
• Recurrence is less likely with maintenance antipsychotics

Question 22

Typical presentation of low mood and symptoms of psychosis

Answer 22

• Psychosis can result from affective disorders (e.g. depression or bipolar)
• Normally, clear period of low mood PRECEDING the onset of psychosis
• Psychotic symptoms are normally mood congruent - i.e. in keeping with the affective disorder, so with depression negative/ insulting hallucinations, pessimistic ideas/ delusions, feelings of guilt

Question 23

Prognosis in depressive episodes with psychosis

Answer 23

• Short term prognosis is good - response to treatment is usual
• Depression is relapsing so likely to have further episodes in the future
• Recurrence is reduced by maintenance antidepressant treatment

Question 24

Diagnostic criteria for schizophrenia

Answer 24

First rank symptoms or persistent delusion + present for at least 1 month (ICD-10) + no drug intoxication, withdrawal, organic brain disease or prominent affective symptoms

Question 25

What are formal thought disorders?

Answer 25

These are features of a patients speech that suggests abnormalities in their thought process, some are common in schizophrenia - Loosening of associations - no discernible link between statements - Neologisms - made up words e.g. "headshoe" meaning hat - Word salad - Concrete thinking (inability to deal with abstract ideas)

Question 26

What type of delusions are common in schizophrenia?

Answer 26

1. ) Persecutory = someone or something is interfering with a person maliciously 2. ) of reference = actions of other people, media etc are referring to the person or communicating a message

Question 27

Genetic factors in schizophrenia

Answer 27

Schizophrenia and affective psychoses are more prevalent in relatives of people with schizophrenia. Risk is - 50% monozygotic twin - 15% dizygotic twins Genes affecting brain development probably contribute Increased paternal age is a risk factor - increased risk of chromosomal abnormalities

Question 28

What is the neurodevelopmental hypothesis of schizophrenia?

Answer 28

Factors that interfere with early brain development lead to an increased risk of schizophrenia as an adult - winter births (increased risk of influenza) - obstetric complications, low birth weight - developmental delay - temporal lobe epilepsy - smoking cannabis in adolescence

Question 29

Social factors in schizophrenia

Answer 29

Schizophrenia is associated with: - low SES - living in urban areas - excess of live events in the 3 weeks before the onset of acute symptoms Incidence of all psychoses is higher in Black African and African-Caribbean populations Schizophrenic patients with high expressed emotional relatives (those that get too involved) are at greater risk of relapse

Question 30

How do genetic, social and neurodevelopmental factors result in schizophrenia?

Answer 30

Unknown. Final common pathway appears to involve: - dopamine excess in mesolimbic dopaminergic pathways (antipsychotics block these) - Increased serotonin activity - Decreased glutamate

Question 31

What is the most common form of schizophrenia?

Answer 31

Paranoid schizophrenia | Evident delusions and auditory hallucinations

Question 32

Can a patient have schizophrenia without positive symptoms?

Answer 32

Yes - undifferentiated (simple) schizophrenia This is a rare form where negative symptoms occur without preceding psychotic symptoms

Question 33

What is the lifetime risk of developing schizophrenia?

Answer 33

0.7% - risk is greater in men (1.4:1) Peak incidence is in late teens or early adulthood

Question 34

How should an acute episode of psychosis be managed?

Answer 34

Early detection and intervention are important: - Longer period between symptom onset and effective treatment (duration of untreated psychosis) the worse the average outcome - First few years after onset can be distressing, with high suicide risk Antipsychotics: - Lowest effective dose - Treat in the community wherever possible - Monitor side effects Psychological therapy: - Self help to come to terms with symptoms/ illness Social support: - Focus on engagement, hope and to reduce stigma - Include family and carers

Question 35

Which antipsychotics are better at treating positive symptoms?

Answer 35

Both atypical and typical antipsychotics are equally effective in treating positive symptoms but have different side effects: - Atypical antipsychotics cause fewer motor side effects, but cause more metabolic problems Using 2 antipsychotics at the same time should be avoided

Question 36

Clozapine

Answer 36

This is the only antipsychotic that has shown to be effective in treating psychosis that does not respond to treatment with at least 2 other antipsychotics Blood monitoring is required because of potentially dangerous side effects (agranulocytosis)

Question 37

What steps can be taken to help reduce the risk of relapse after an acute psychotic episode?

Answer 37

Maintenance treatment of antipsychotics is important - relapse rates are reduced if patients continue meds for > 1-2 years after acute episode Family therapy helps to reduce over expressed emotions Social support to reduce substance abuse and misuse which increase relapse rates

Question 38

What psychological treatment can be used to promote long term recovery in psychosis?

Answer 38

NICE guidelines state that all patients with schizophrenia should be offered CBT and their families should be offered family interventions if they are in close and regular contact CBT can help patients with persistent delusions and hallucinations, but the aim is to alleviate stress and disability NOT necessarily to eliminate symptoms: - learning to challenge or think differently about a voice - strategies to cope with hearing voices - encouraging patients to challenge delusional beiefs

Question 39

Prognosis in schizophrenia

Answer 39

70% of people experience a first psychotic episode will be well within a year .....but 80% will have a further episode within 5 years 75% of patients will discontinue their medication within the first 18 months which increases relapse risk by 5 times Lifetime suicide risk is 10%

Question 40

What factors are associated with a better prognosis in schizophrenia?

Answer 40

"FINDING PLANS" - Female - In relationship, good social support - No negative symptoms - aDheres to medication - Intelligence (more educated) - No stress - Good premorbid personality - Paranoid subtype - Late onset - No substance misuse - Scan (CT/MRI) normal