Flashcards in Psychotic Disorders Deck (33)
What is the epidemiology of schizophrenia ?
1% lifetime risk
Age of onset: male 18-25 female 25-35
Incr prevalence in lower socio economic classes
Genetic risk, monozygotic twins show 50% concordance
What anatomical abnormalities are thought to be associated with schizophrenia?
Reduced brain size
What is the hypothesised pathophysiology of schizophrenia?
Over activity of the mesolimbic dopamine pathway
Based in the effects of conventional antipsychotics which block D2 receptors
Drugs which potentiate the pathway e.g. Amphetamines are known to cause psychotic sx
What are the main psychotic disorders?
Acute + transient psychoses
What can increase relapse risk in schizophrenic patients?
High expressed emotion in family members
Compliance failure: 80%
What is the first line treatment for schizophrenia?
What is treatment resistant schizophrenia?
Lack of satisfactory clinical improvement
Despite sequential use of two antipsychotics (one being an atypical) for 6-8 wks
Start on clozapine asap
How can compliance be improved in schizophrenic patients?
depot IM 2-4 wkly (risperidone)
Increased social support
What is the role of benzodiazepines in the treatment of schizophrenia?
Short term relief of:
Insomnia, aggression, agitation, behaviour disturbance
No antipsychotic effect
What are negative symptoms?
Apathy: anhedonia, flat affect
Poverty of thought + speech
What are the positive symptoms?
What is the role of antidepressants in schizophrenia?
Sometimes used to augment antipsychotics in treatment resistant cases
Especially with significant affective symptoms
Used in schizoaffective disorder + post schizophrenia depression
What is the role of ECT in treatment of schizophrenia?
Indicated only with severe catatonic symptoms
What is the role of CBT in treatment of schizophrenia?
Effective in reducing symptoms as an adjunct to pharmacological treatment
Improves insight and compliance
What is the role of family psychological interventions in treating schizophrenia ?
Can help reduce expressed emotion:
Expressions of hostility and criticism
Reducing relapse and admission rates
How should acute behaviour disturbance be managed?
Environmental + behavioural interventions
Oral - benzo +- atypical antipsychotic or typical antipsychotic
Refusing oral - IM lorazepam 0.5-2mg +- IM haloperidol
What is paranoid schizophrenia?
Schizophrenia dominated by florid positive symptoms
Delusions may be built into a complex conspiracy theory
Paranoid: sense of things occurring around them having special personal significance
What is simple schizophrenia?
Presents only with negative symptoms
What is hebephrenia?
Mix of positive and negative symptoms
Adolescent onset 15-25
Disorganised + chaotic: mood, behaviour and speech
Behaviour seems aimless
What organic causes might you want to rule out in a schizophrenic picture?
Complex partial seizures- temporal lobe epilepsy
Alcoholism, illicit drug use, medications causing hallucinations
What is a hallucination ?
A perception in the absence of stimulus
What is a delusion?
A fixed, false belief held despite rational argument or evidence to the contrary.
That cannot be explained by the patient's cultural, religious or educational background
What are the three stages of schizophrenia?
At risk mental state: prodrome
Acute phase: positive symptoms predominate
Chronic phase: negative symptoms predominate
What are the features of the at risk mental state?
Low grade symptoms of:
Loss of interest in work/study/relationships
No frank psychotic symptoms
What are diagnostically significant hallucinations?
Voices giving running commentary on patient's actions
Voices discussing/arguing about the patient
What are diagnostically significant delusions?
Delusional perception: real stimulus delusional interpretation
Passivity: movement, sensation, emotion or impulse being controlled by an external force
Thought interference: withdrawal/insertion/broadcasting
What symptoms might be expected in the chronic phase of schizophrenia?
Poverty of thought and speech
What is catatonic schizophrenia?
What are Schneider's first rank symptoms?
Delusions of thought interference: insertion, withdrawal, broadcasting
Auditory hallucination: thought echo, third person, running commentary
What is the differential diagnosis in a patient seemingly presenting with schizophrenia?
Organic causes: substance misuse, dementia, delerium, epilepsy esp temporal lobe, medication, brain tumour, stroke, HIV, wilson's, porphyria, neurosyphillis
Acute and transient psychotic episode
Persistent delusional disorder
How would you investigate a patient with apparent schizophrenia?
FBC, TFTs, U&Es, LFTs, CRP, fasting G, ?HIV, ?Syphillis, lipids
Urine drug screen
CT if cerebral pathology suspected, EEG if epilepsy suspected
Symptom rating scale
OT Assessment of activities of daily living
Social work assessment of housing, finances, carers needs
What is DUP?
Duration of untreated psychosis
Time delay from first symptoms to first ever effective treatment
Psychosis is toxic: greater the DUP, the greater the damage to cognitive abilities, insight and social situation
The sooner treatment started the better the prognosis
Hence early intervention services aim to keep DUP