Schizophrenia Flashcards
Define
Schizophrenia = severe mental illness characterised by disintegration of the process of thinking, of contact with reality, and of emotional responsiveness
- Hallucination – a perception in the absence of a stimulus
- Delusion – a fixed, false belief, held despite evidence to the contrary (not explained by patient’s background)
Most important psychopathological phenomena:
1. Thought echo
2. Thought insertion or withdrawal
3. Thought broadcasting
4. Delusional perception and delusions of control
5. Influence or passivity
6. Hallucinatory voices commenting or discussing the patient in third person
7. Thought disorders and negative symptoms
Schizophrenia is the MOST COMMON form of psychosis
It is a lifelong condition which can take a chronic or relapsing and remitting form with acute episodes
Epidemiology
Most common psychotic disorder
Lifetime risk is 1%, prevalence is 1%
Men affected earlier than women and more likely to have negative symptoms
Aetiology/ Risk factors
Complex multifactorial aetiology
Multiple factors involved e.g. genetic, environmental, social
Genetics
- Family history – STRONGEST risk factor
- Lifetime incidence increases from 1% to 10% for 1st degree relatives of those with schizophrenia
- 48% if a child whose parents are both affected, 50% for MZ twins
- Multiple susceptibility genes probably interact
Obstetric complications
- Maternal malnutrition, viral infections
- Pre-eclampsia, LBW, emergency CS
- Genetic abnormalities, hypoxic brain damage
Relevant obstetric events:
* Early rupture of membranes
* < 37 weeks gestation
* Incubator use
* Winter births
Substance misuse
- Substance use- cannabis, amphetamines, cocaine, LSD can produce psychotic symptoms
- Cannabis does NOT cause schizophrenia but increases the overall risk and contributes to development in those susceptible
Social disadvantage
- Urban life and birth, migration and ethnicity
- Black Caribbean / African
Expressed emotion
- Over-involvement or high expressed emotion in families can increase relapse
- Premorbid personality- schizoid, schizotypal personality disorder
Adverse life events
Cognitive behaviour
- ways of thinking such as jumping to conclusions or fear of madness
Neurodevelopmental theories, neurotransmitter theories
- enlarged ventricles -> smaller brains, lower premorbid IQ, early brain damage not obvious at first but becomes more obvious as brain matures
- DA hypothesis – DA symptoms:
+ve symptoms (hallucinations/delusions) from increase DA in mesolimbic tract
-ve symptoms (apathy, withdrawal) from decrease DA in mesocortical tract
- 5-HT hypothesis – overactivity
- Glutamate hypothesis - dysregulation
Psychological theories
NOTE: The course of schizophrenia can be continuous or episodic with progressive or stable deficit, or there can be ≥ 1 episodes with complete or incomplete remission
Signs/ symptoms
ICD 10 diagnostic criteria
(A) ≥1 Schneider’s 1st rank symptoms, ≥1-month duration
(1) Delusions (false and fixed beliefs) see definitions…
(2) Passivity (delusions of control)
(3) Thought disorder:
- Thought insertion thoughts being placed into my mind
- Thought withdrawal thoughts being removed from my mind
- Thought broadcasting everyone knows what you are thinking
(4) Auditory disorder:
- Thought echo hearing my thoughts out loud
- 3rd person voice ‘no one like’s her, she’s useless’
- Running commentary ‘now he’s falling asleep, and she’s calling a cab’
_______OR_______
(B) ≥2 of the following; AND
Paranoid - Persistent hallucinations in any form (somatic, visual, tactile) when accompanied by delusions or persistent over-valued ideas
- Most common
- Relatively stable
Hebephrenic - Neologisms, breaks or interpolations in the train of thought, resulting in incoherent or irrelevant speech
- Age of onset: 15-25 years
- Also known as ‘disorganised’
- Behaviour is irresponsible and unpredictable, mannerisms common
- Rapid development of ‘negative’ symptoms (particularly fattening of affect, loss of volition)
- Poor prognosis
Catatonic behaviour- strange and purposeless behaviour, e.g. excitement, posturing, waxy flexibility, negativism, mutism, stupor, rigidity, automatic obedience to any instruction, perserveration
- Example: stopping of voluntary movement or staying still in an unusual position (known as waxy flexibility)
- Negativism- patients do exactly the opposite of what they are asked to do
- Stupor - a state of being immobile, mute, and unresponsive, despite appearing to be conscious (eyes are open and will follow people around the room).
- Excitement—periods of extreme and apparently purposeless motor hyperactivity.
- Posturing—assuming and maintaining inappropriate or bizarre positions.
- Perseveration—inappropriate repetition of words or movements
Simple - negative symp only (e.g. marked apathy, reduced, speech, blunting or incongruity of emotional responses) usually resulting in social withdrawal and lowering of social performance
(C) Present, most of the time, ≥1 month; AND
(D) Not caused by substance use or organic disease
Progression and clinical pattern
THREE stages:
- At-risk mental state (prodrome)- can last from few days to 18 months
- Acute phase/ psychosis
- Chronic phase- negative symptoms reflect things that are lost in schizophrenia
Prodrome
- -ve symp dominant
- Characterised by emotional and behaviour changes leading to deterioration in personal functioning and social withdrawal:
- Reduced interest in daily activities
- Problems with sleep, memory, concentration, affect and motivation
- Transient, low-intensity psychotic symptoms- intermittent, self-limiting episodes, typically lasting < week, may include hallucinations or unusual thoughts
Acute psychotic episode
- +ve symptoms dominant
- Delusions
- Hallucinations
- Often auditory e.g.,
1st voice: ‘No-one likes her.’
2nd voice: ‘Yeah . . . It’s because she’s ugly.’
- Voices giving a running commentary on the patient’s actions, e.g.
– ‘He’s going into the bedroom now. He’s taking off his shoes . . .’ - Thought disorder
- Thought insertion- thoughts placed directly into the patient’s mind
- Thought withdrawal- thoughts are taken directly out of the patient’s mind
- Thought broadcasting- delusions that others can hear one’s thoughts
- Thought interruption
- Thought echo - voices saying the patients thoughts out loud e.g., I am hungry when the pt is hungry
- Passivity- emotions or impulses are controlled by an outside force
- Lack of insight
Chronic phase
- -ve symp dominant
- Underactivity
- Apathy (low motivation)
- Blunted affect - decreased reactivity of mood
- Social withdrawal
- Emotional flattening
- Anhedonia
- Self-neglect
- Poverty of thought and speech
Subtypes
Paranoid
* Most common
* Prominent delusions
* Prominent hallucinations
Hebephrenic / Disorganised
- Mainly focussed on speech/thought
- Disorganised mood and speech
- Neologisms
- Knight’s move thinking
- Inappropriate affect (laugh at something sad)
Catatonia
Psychomotor Disturbance:
- Stupor, waxy flexibilit
- Automatic obedienc
- Forced grasping, opposition
Simple
- Negative symptoms only
- Apathy
- Social withdrawal
Investigations
Collateral history
Brief Psychiatric Rating Scale (BPRS) - https://www.smchealth.org/sites/main/files/file-attachments/bprsform.pdf?1497977629
- Severity of various psych symp
Positive and Negative Syndrome Scale (PANSS)- used for assessing severity of schizophrenia
MMSE
Physical examination
Basic observations
Urine drug screen
Bloods- abnormal LFTs and macrocytosis on FBC suggests alcohol abuse
Serological tests for syphilis, HIV- ruling out organic causes
Imaging if indicated
- MRI - hypofunction in the prefrontal cortex
- EEG - if epilepsy or another organic cause suspected
Differentials of schizophrenia
- Organic – porphyria, dementia, delirium, epilepsy, steroids, tumours, stroke, systemic infection (syphilis, HIV), hyperthyroidism/hypothyroidism, Huntington’s etc.
- Acute/transient psychotic episodes – can have psychosis (doesn’t mean you are schizophrenic)
- Mood disorder – depression and mania can cause psychotic symptoms; check order of symptoms
- Schizoaffective disorder – schizophrenic and affective symptoms develop together and are balanced
- Delirium
- Persistent delusional disorder – only delusions
- Drug-induced psychosis - cannabis, ketamine can induce paranoia and thought disorder (rarely produces -ve symp)
- Schizotypal disorder – eccentricity with abnormal thoughts (not full schizophrenia)
Management of emergency psychotic episode
RISK ASSESSMENT!
If urgent emergency -> crisis resolution team and home treatment team
If non-urgent emergency -> Early Intervention in Psychosis (EIP) Team (age >14yo; CAMHS can tx ≤17yo)
- Used for individuals presenting with their first episode
- Psychosis is toxic, the longer a patient is psychotic, the more it will affect them
- Early treatment leads to a better prognosis
- Aim to keep Duration of Untreated Psychosis (DUP) <3 months
- Tx: antipsychotics, psychosocial interventions
Early Intervention Service
- Age: 18-35
- Used for individuals presenting with their first episode
- Psychosis is toxic, the longer the patient is psychotic, the more it will affect their cognitive abilities, insight and social situation
- Assessment should be done without delay
- If the service cannot provide urgent intervention, refer to CRISIS RESOLUTION TEAM and HOME TREATMENT TEAM
Rapid tranquilisation:
-1st line = Lorazepam (oral -> IM)
2nd line = Haloperidol (5mg) + lorazepam (1mg)
Inpatient admission if…
- Suicide/homicide risk
- Severe symptoms (psychotic, depressive or catatonic)
- Lack capacity
- Failure of OPD treatment
- Significant medication changes
- Address comorbid conditions
Biopsychosocial management
1st Line: Atypical (2nd Generation) antipsychotic
“Start low, go slow”
Olanzapine
* Strong, more SE
* Weight gain
Risperidone (available as depot)
- Strong, more SE
- Hyperprolactinaemia, EPSEs, sedation
Quetiapine
- Less strong, less SE
- Sedation and weight gain
Aripiprazole
- Less strong, less SE
- akathisia
Amisulpride
NOTE: Avoid using > 1 atypical antipsychotic
Augmentation
- BDZ (i.e. diazepam) if non-acute anxiety
- Mood stabiliser (i.e. lithium, anticonvulsant) if schizoaffective disorder suspected
2nd line Typical antipsychotic (older drugs)
- Chlorpromazine
- Haloperidol
- Flupentixol decanoate
NOTE: these can cause more extrapyramidal side effects and cardiac risk, cheap and effective, provide depot option
3rd line: Clozapine (treatment resistant ONLY)
- Usually oral but in forensics esp if really not compliant, can use IM clozapine
Tx-failure = failure to respond to ≥2 antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
- Use depot/ long-acting IM injectables (can be monthly/ 3 monthky):
- i.e. zuclopenthixol decanoate 200mg depot injection; ‘Clopixol’
- If prefer such treatment after acute episode
- Where avoiding covert non-adherence is clinical priority in treatment plan
No improvement after 6w -> change to a different atypical OR try a typical
No improvement after a further 6w -> clozapine (a ‘dirty’ drug that is difficult to manage)
- All are DA agonists apart from aripiprazole which is partial DA agonist
Psychological interventions
Individual CBT
- This can be offered for prevention (i.e. to those at risk of developing schizophrenia) +/- family therapy, and as a treatment
- Offer to all pts, regardless the level of schizophrenia
- Improves outcomes when combined with antipsychotics
- People establish links between thoughts, feelings and actions and their current or past symptoms
- Re-evaluate perceptions, beliefs or reasoning, encouraging to think about evidence and alternative explanations
– i.e. if the Prime Minister is watching you, how do they find time to run the country?
- Monitor their own thoughts, promoting alternative ways to cope, reducing stress, improving function
- At least 16 sessions
Family intervention
- Either single family or multi-family group intervention
- To help control the highly expressed emotions of schizophrenia (helps fam cope)
- Take account of relationship between main carer and patient
- Specific supportive, educational or treatment function- negotiated problem solving or crisis management work
- At least 10 sessions over 6-12 months
Social Interventions
- Psychoeducation- vital to reduce relapse
Needs to address:
- Education, training and employment
- Skills (e.g. budgeting, cooking)
- Housing (e.g. supported accommodation, independent flats)
- Accessing social activities
- Developing personal skills (e.g. creative writing)
- Care-coordination - monitoring mental health, physical health, medication, drug use, identifying and resolving social problems
- Arts therapy- good for alleviating negative symptoms
- Networks, support and MDT
- Psych nurse
- OT, PT
- Organisations – SANE, Rethink
- Vocational rehab and individual placement and support
General Management
Physical health
- Offer combined healthy eating and physical activity programme
- Offer interventions for metabolic complications of antipsychotics (e.g. weight gain, high cholesterol)
- Help with smoking cessation (consider nicotine replacement therapy or bupropion or varenicline)
- Bupropion- for schizophrenia
- Varenicline- psychosis or schizophrenia
WARNING: increased risk of adverse neuropsychiatric symptoms so monitor closely for first 2-3 weeks
- Regularly monitor weight and other CV/ metabolic parameters
- Support for Carers
- Offer support- including education and support programmes
- Inform them of their right to a form carer’s assessment (available for free through social services)
- Consider peer support (support from someone who has recovered from psychosis)
Drug monitoring
Baseline Measurements before starting an antipsychotic:
- Basic obs: weight, waist circumference, pulse and BP
- Bloods: FBC, U&E, LFTs, fasting BM, HbA1c, lipid profile, prolactin, (more frequent if on clozapine)
- Assessment of any movement disorders
- Assessment of nutritional status, diet and physical activity (incl. CVD assessment)
- ECG (if cardiovascular risk factors present or recommended by the chosen medication)
Monitoring – there is a high CVD risk in patients on schizophrenia medications…
- Response to treatment and side-effects
- Emergence of movement disorder
- Monitoring – appointments at…
Adherence 1) 1, 2, 3, 4, 5, 6 weeks weight, waist
Overall physical health 2) 12 weeks weight, waist, HR, BP
3) Annual weight, waist, HR, BP
Basic obs:
- Weight and waist circumference (weekly for 6 weeks, at 12 weeks, annual thereafter)
- Pulse and BP (at 12 weeks, annual thereafter)
Complications
- Risk of self-harm or suicide
- Premature death- increased risk of certain physical disorders (e.g. CVD, T2DM, smoking-related), substance misuse, social exclusion
- Side effects of antipsychotics:
- Extrapyramidal effects (EPSEs)- typical > atypical
- Acute dystonia
- Continuous spasms and muscle contractions- involuntary, painful, sustained
E.g. torticollis- neck twists to one side
E.g. Oculogyric crisis- eyes twist up and can’t look down
E.g. mouth opening and can’t close - Early onset, sometimes within hours
TREATMENT: IM procyclidine (anticholinergic) 5mg bolus
4.Akathisia
- Subjective sense of psychomotor restlessness
- Onset is hours to weeks
- TREATMENT: review medication (↓ drug dose or change to atypical antipsychotic), consider propranolol, benztropine
5.Parkinsonism
- TRIAD: tremor, rigidity, bradykinesia
- May have hypomimetic facies, postural instability, and shuffling gait
- Onset in days to weeks
- TREATMENT: review medication (i.e. use lowest possible dose or change to atypical), procyclidine or another antimuscarinic drug but review frequently and do not prescribe prophylactically
6.Tardive dyskinesia
- Rhythmic involuntary movements of the mouth, face, limbs and trunk
- Patient may grimace, make chewing and sucking movements with their mouth or tongue
- Onset after months or years
- This may be irreversible
- TREATMENT: ↓ dose, avoid anticholinergics (worsens problem), switch to atypical or clozapine, trial Tetrabenazine
7.Hyperprolactinaemia
- Galactorrhoea, amenorrhoea, gynaecomastia and hypogonadism
- Sexual dysfunction
- Increased risk of osteoporosis
- NOTE: Aripiprazole: good alternative as it has less hyperprolactinaemia S/E
8.Weight gain (especially with olanzapine and clozapine)
9.Sedation
10.Increased risk of diabetes (olanzapine)
11.Dyslipidaemia
12.Smoking cessation + alcohol binges can increase clozapine levels
13.CV effects
- Stroke in elderly (olanzapine + risperidone)
- Myocarditis and cardiomyopathy (clozapine)
- Arrhythmias
- Long QTc on ECG
14.Sexual dysfunction
- All the atypicals can cause this e.g. erectile dysfunction, low libido, anorgasmia
- This can be due to increased prolactin, reduced semen volume and viscosity
- Retrograde ejaculation (a1 receptor antagonism e.g. with risperidone)
15.Anticholinergic side-effects:
- Dry mouth
- Blurred vision
- Constipation
- Urinary retention
- Tachycardia
- Seizures (reduces seizure threshold, more with atypicals + clozapine)
Neuroleptic malignant syndrome:
- Hyperthermia (> 38oC)
- Generalised muscle rigidity
- Altered level of consciousness
- Autonomic instability
Investigations: ↑CK (due to rhabdomyolysis), ↑WCC, ↑U&Es, ↑ ALT/AST
TREATMENT: ABCDE, call ambulance (if on psych ward), STOP antipsychotics, urgent medical help + treatment supportive- cool patient, IV fluids, dialysis, provide CV and respiratory support (ITU), administer dantrolene or bromocriptine
- Symptoms resolve in 1-2 weeks
- Death can occur from various causes e.g. AKI secondary to rhabdomyolysis
Prognosis
Some negative symptoms may remain
Schizophrenia is relapsing and remitting
The bipolar type of schizoaffective disorder has a better prognosis than the depressive type as the latter usually results in long-term mood disturbance
Factors associated with poor prognosis of Schizophrenia
Good prognostic indicators
- sudden onset
- late stressful event
- no FHx
- higher IQ
- Shorter duration of untreated psychosis
Bad prognostic indicators
- gradual onset
- early onset
- lack of precipitant
- Prodromal social withdrawal
- FHx
- low IQ
