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Year 3 Clinical > Schizophrenia and Other Psychoses > Flashcards

Schizophrenia and Other Psychoses Flashcards

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1
Q

What is psychosis?

A

Mental disorder in which the thoughts, affective response or ability to recognise reality and the ability to communicate and relate to other are sufficiently impaired; this interferes grossly with the capacity to deal with reality and is harmful to their functioning and interpersonal relationships

It inv. an inability to distinguish between subjective experience and reality

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2
Q

Classic characteristics of psychosis?

A
  1. Hallucinations
  2. Delusions
  3. Disorder of thought form

These patients have a LACK OF INSIGHT (i.e: unaware that anything is wrong with them)

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3
Q

Types of psychotic experiences?

A
  1. Hallucinations
  2. Passivity phenomena
  3. Delusions
  4. Formal thought disorder
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4
Q

What are hallucinations?

A

Perception that occurs in the absence of an external stimulus; they may occur in any sensory modality

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5
Q

Features of hallucinations?

A

Experienced as originating in real space, not just in their thought, i.e: it is not like inner speech; they are a misrepresentation of inner experiences as having an external origin

They have the same qualities as a normal perception, i.e: they are vivid, solid and compelling

Not subject to conscious manipulation, e.g: patient cannot make their hallucination say what they want it to say

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6
Q

When are hallucinations significant?

A

Only in the context of other relevant symptoms

NOTE - patients can have auditory hallucinations and be aware of them, i.e: they have onset; they have no other symptoms and function normally otherwise

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7
Q

How can hallucinations be induced?

A

Can be induced in most people, e.g: by sensory deprivation

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8
Q

Types of hallucinations?

A

Simple, e.g: a formless sound

Complex, e.g: a voice

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9
Q

Sensory modalities in which hallucinations can occur?

A
  1. Auditory
  2. Visual
  3. Olfactory
  4. Gustatory
  5. Somatic (bodily sensations), e.g: insects crawling under skin or a sensation of being touched
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10
Q

Pathophysiology of auditory hallucinations?

A

Pattern of brain activity during the auditory hallucination is very similar to that of normal volunteers generating inner speech

EXCEPT

Patients who are hallucinating have issues in the:
• Supplementary motor area - monitors self-generated actions
• Hippocampus and parahippocampal gyrus - detects mismatch between perceived and expected activity

i.e: patients do not recognise self-generated inner speech as such and it is attributed to external reality

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11
Q

Types of auditory hallucinations?

A

2nd person - voice that directly addresses the patient, i.e: “you”

3rd person - voices that discuss the patient or provide a running commentary on his actions

NOTE - there is no such thing as a 1st person auditory hallucination

Thought echo - rare; the patient experiences they own thoughts and these are then ‘spoken or repeated’ aloud

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12
Q

Occurrence of visual hallucinations?

A

Often assoc. with altered consciousness / organic impairment

They are less common than auditory hallucinations

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13
Q

Types of visual hallucinations?

A

Simple, e.g: flashes of light

Complex, e.g: face / figure

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14
Q

What is passivity phenomena?

A

Behaviour is experienced as being controlled by an external agency rather than by the individuals

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15
Q

Features of passivity phenomena?

A

Affects the following:

  1. Thoughts:
    • Thought insertion - feeling as if one’s thoughts are not one’s own, but rather belong to someone else and have been inserted into one’s mind
    • Thought withdrawal - belief that thoughts have been removed from the patient’s mind
    • Thought broadcasting - belief that others can hear or are aware of the patient’s thoughts
  2. Actions:
    • Made actions - do not recognise their actions as being self-generated; think that someone is making them do it
  3. Feelings:
    • Made feelings - think that someone is making them feel the way they do
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16
Q

Describe the content of delusions

A

Specific content is culturally defined, e.g:
• Persecutor in the delusion is often recognisable to society / culture as a danger/threat, e.g: IRA, mafia, MI5, KGB, CIA, etc
• Used to be more common that control was by ghosts / spirits; now, common to hear about X-rays / radio transmitters
• Used to be more common to fear plague; now, more common to fear cancer and AIDs

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17
Q

Origin of delusions?

A

Rarely, they are primary

Often, they are secondary, i.e: attempts to explain anomalous experiences, like hallucinations, passivity experiences, depression

NOTE - a description of an inner, abnormal experience is not a delusion, e.g: ‘my thoughts are not my own, it’s like they are coming from outside of me’; ‘they are being transmitted by the mafia’ is an explanatory delusion

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18
Q

What are self-referential experiences?

A

Belief than external events are related to oneself

These can vary in intensity:
• Brief thought (most of us experience this at some point)
• Frequent, intrusive thoughts
• Delusional intensity (AKA self-referential delusions OR delusions of reference)

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19
Q

Examples of self-referential experiences?

A

Feeling that other are speaking/laughing about you

Belief that TV/radio is transmitting a message for you

Belief that car reg numbers contain a hidden code for you

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20
Q

Differential diagnosis of psychotic symptoms?

A

Schizophrenia

Psychoactive substance use

Mania

Depression

Delirium

Dementia

Other organic cause

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21
Q

What is schizophrenia?

A

Diagnosis based on a cluster of symptoms

It is a genetically determined neurodevelopmental vulnerability later triggered by environmental stressors

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22
Q

Core psychotic symptoms of schizophrenia?

A

AKA Schneider’s symptoms of first rak

Auditory hallucinations - may have thought echo or 3rd person auditory hallucinations (often a running commentary); 2nd person auditory hallucinations occur but there are less diagnostic

Passivity phenomena - feel they being imposed on or controlled by an external agency

Delusional perception - rare; a fully-formed delusion that arises from a real/genuine perception

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23
Q

Categories of symptoms in schizophrenia?

A 
Positive symptoms (feelings / behaviors that are usually not present):
• Hallucinations
• Delusions
• Passivity phenomena
• Disorder of the form of thought

Negative symptoms (lack of feelings/behaviors that are usually present); these do not occur due to depression or anti-psychotic drugs:
• Reduced amount of speech
• Reduced motivation/drive
• Reduced interest/pleasure
• Reduced social interaction
• Blunting of affect, i.e: restricted range of affect

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24
Q

Occurrence of schizophrenia?

Study These Flashcards
A

Lifetime risk 1%

Onset is in young adults:
• Males - 15-25 years
• Females - 25-35 years

Higher incidence in lower SE class

25
Natural history of schizophrenia?
Pre-morbidly - subtle motor, cognitive and social deficits in childhood that become greater as time goes on, e.g: delay in speech/walking Prodromal - gradual onset of non-specific symptoms; patients have odd ideas and experiences, eccentricity, altered affect and odd behaviours
26
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27
Bad prognostic indicators in schizophrenia?
Poor pre-morbid adjustment Insidious onset Early onset (in childhood/adolescence) Cognitive impairment Enlarged ventricles
28
Good prognostic indicators in schizophrenia?
Older age of onset Female gender Marked mood disturbance, esp. elation FH of mood disorder
29
Suicide rate in schizophrenia?
10-15%
30
Genetics of schizophrenia?
Having affected relatives increases risk significantly, esp. if they are 1st degree relatives, twins or if both parents are affected
31
Biggest known risk factor for schizophrenia?
+ve FH
32
Other risk factors for schizophrenia?
``` Patients with schizophrenia have a higher rate of perinatal complications than controls, e.g: • Prematurity • Prolonged labour • Foetal distress • Hypoxia ``` 2nd trimester prenatal exposure to viral infections or malnutrition
33
Findings in the brain of a patient with schizophrenia?
1. Enlarged lateral ventricles with little progression over time 2. Reduced fronto-temporal volume (neurones are not as well developed, i.e: smaller size and have fewer arborisations) 3. Reduced activation of prefrontal areas on specific tasks; tasks inv. the frontal areas are impaired, e.g: executive function 4. NTs are implicated, mainly serotonin receptors, glutamate receptors and dopamine
34
Task used clinically to test frontal areas?
Stroop test
35
Dopamine hypothesis of schizophrenia?
Hypothesised that schizophrenia is related to over-activity of dopamine pathways in the brain Theories that: • Subcortical dopamine hyperactivity leads to psychosis • Mesocortical dopamine hypoactivity leads to -ve and cognitive symptoms
36
Evidence for the dopamine hypothesis?
Drugs that release dopamine in the brain, e.g: amphetamines, produce a psychotic state D2 receptor agonists, e.g: apomorphine, produce a psychotic state Dopamine receptor antagonists are used to treat the symptoms of schizophrenia
37
Dopaminergic pathways in the brain and their functions?
Nigrostriatal: • Extra-pyramidal motor system Mesolimbic / cortical: • Motivation and reward systems Tuberoinfundibular: • Control of prolactin release
38
Explain the effect of amphetamine on the dopamine synapse
........
39
Explain the effect of anti-psychotics on the dopamine synapse
..........
40
Sub-types of dopamine receptors?
D1 receptor family (D1 and D5) - stimulate cAMP D2 receptor family (D2, D3 and D4) - inhibit adenylyl cyclase and voltage-activated Ca2+ channels; open K+ channels
41
Distribution of dopamine receptors?
D1 and D2 are in both the limbic and striatal areas The other sub-types are smaller in no. and have a more discrete distribution
42
Gene alterations in schizophrenia?
Neuregulin - signalling protein that mediates cell-cell interactions and plays a role in growth & development of multiple organ systems Dysbindin - for adaptive neural plasticity DISC-1 - inv. in neurite outgrowth and cortical development, via its interaction with other proteins
43
Neurodevelopmental model of schizophrenia?
Environmental risk factors act in utero; children who later develop schizophrenia have identifiable impaired behaviour, motor and intellectual development from infancy Ventricular enlargement is PRESENT AT DIAGNOSIS and is NON-PROGRESSIVE There is no gliosis
44
Effects of stress of schizophrenia?
May act to precipitate onset / relapse
45
Presentation of drug-induced psychosis?
Florid symptoms or chronic symptoms but they tend to be short-lasting, once access to the psychoactive substance is removed NOTE - a patient can have schizophrenia or BPAD and also substance misuse, i.e: psychotic symptoms and the use of substances does not necessarily mean drug-induced psychosis
46
Describe depressive psychosis
Typified by mood congruent content of psychotic symptoms, i.e: • Delusions are of worthlessness / guilt / hypochondriasis / poverty • Hallucinations are accusing / insulting / threatening voices (usually 2nd person)
47
Describe mania with psychosis
Typified by mood congruent content of psychotic symptoms, i,e: • Delusions are of grandeur / special abilities / persection / religiosity • Hallucinations are auditory, e.g: God's voice • Flight of ideas
48
What is delirium?
Acute, transient disturbance, e.g: during infection, alcohol withdrawal, medical / surgical inpatients, organ failure, etc
49
Features of delirium?
Clouding of consciousness - ranges from subtle drowsiness to unresponsiveness Disorientation in time, place and person Fluctuating severity over time (they have lucid intervals) Worse at night Impaired conc. / memory (esp. for new info)
50
Symptoms and signs of delirium?
Visual hallucinations / illusions +/- auditory hallucinations (often threatening) Persecutory delusions Psychomotor disturbance (agitation or retardation) Irritability Insomnia
51
What does the differential diagnosis of psychosis?
Nature of psychotic experiences, e.g: • 3rd person auditory hallucinations suggest schizophrenia • Self-referential delusions are not specific to any part. diagnosis Assoc. psychiatric symptoms Natural history of symptoms
52
Types of anti-psychotics?
``` Typical (1st generation) anti-psychotics: • Chlorpromazine • Thiordazine • Fluphenazine • Haloperidol • Zuclopentixol ``` ``` Atypical (2nd generation) anti-psychotics; these are less likely to induce extra-pyramidal side effects: • Olanzapine • Risperidone • Quetiapine • Clozapine • Aripiprazole • Amisulpride ```
53
Uses of atypical anti-psychotics?
Better efficacy against -ve symptoms Effective in patients unresponsive to typical drugs
54
Side effects of anti-psychotics?
Due to D2 blockade: • Extra-pyramidal side effects (EPSE) • Hyperprolactinaemia Due to 5-HT2 blockade: • Metabolic syndrome Due to histamine blockade: • Sedation • Increased appetite Due to to α-adrenergic blockade: • Orthostatic hypotension Due to muscarinic blockade, there is blockage of the parasympathetic NS
55
EPSE of anti-psychotics?
Acute dystonic reaction Parkinsonism Akathisia Tardive dyskinesia
56
Use of clozapine?
Used 3rd line, for treatment-resistant schizophrenia It has major adverse effects: • Agranulocytosis • Myocarditis
57
Ix with clozapine?
``` Check FBC: • Weekly for the first 6 months • Every fortnight for the next 6 months • Every 4 weeks thereafter • For 1 month after cessation of Clozapine ```
58
Differential diagnosis of psychotic symptoms?
ADD TABLE SLIDE 88

Year 3 Clinical (100 decks)

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