Schizophrenia

1. Psychiatry

2. Schizophrenia A disorder of thoughts, feelings and perceptions which usually result in a disturbance of behaviour. Some patients present a variety of typical symptoms, others overall pattern of symptoms and outcome confirms the diagnosis. Presentation varies with each pt, symptoms may change over time in a pt. Diagnosis often by exclusion of other possible causes of psychosis Precise cause unknown. ? Disturbance of brain structure and function due to Genetic&Environmental factors Devastating social and emotional consequences for the pt . Reduces potential in school, relationships etc Large burden on families Suicide in 5-10% High economic cost due to early age of onset and chronic nature ( ill for 40-50 years) Men: onset late teens/early 20s. Women: later 20s. Young onset, though starts much earlier, takes time to nuild up and present as acute psychosis Prevalence 1/100

3. Epidemiology Age of onset: Mean: 28 Most cases: 18-30 Late onset: >60 Social drift occurs: drift down social scale and into inner city areas Population figures: Lifetime prevalence 1/100 Inception rate 15-20/100,000/year Point prevalence 3/1,000

4. Diagnostic Criteria ICD-10 Two or more of the following, present for at least one month: delusions hallucinations disorganised speech grossly disorganised or catatonic behaviour negative symptoms Social / occupational dysfunction. Continuous signs of disturbance for at least 6 months – this may include prodromal symptoms or attenuated symptoms from ‘A’. Mood disorder with psychotic features ruled out. Not due to substance abuse or a general medical condition. LOSS OF INSIGHT ‘POSITIVE’ SYMPTOMS ‘NEGATIVE’ SYMPTOMS OTHER SYMPTOMS

5. Positive Symptoms Delusions Hallucinations Disorder of thought form Incongruous affect Catatonic symptoms Respond well to medications Sheltered accommodations with carers very important in treatment and rehab Negative Symptoms Blunted/flat affect Loss of volition (drive) Poverty of speech Anhedonia Psychomotor retardation Other Symptoms Perplexity Anxiety Depression of mood Obsessional behaviours/thoughts Irritability Hostility Mannerisms

6. Delusions May be Primary : autochthonous delusion: fully formed delusion , unconnected to previous ideas/events that is psychologically reducible Secondary: arises from, and is understandable in the context of previous ideas or events Often bizarre Different themes: persecution, reference, grandiose, religious, control, jealousy, love, hypochondriosis Hallucinations May lead to 2ary delusions Can be of any sensory modality: auditory (2 nd or 3 rd person), visual, (catatonic schiz ) olfactory/gustatory, tactile, somatic

7. Consequences Affects relationships , people distance themselves from pt in reaction to their emotionlessness . Changes dynamics of most relationships Leads to depression  suicide risk 10% but decreasing Physical wellbeing decreases. Generally pts live 15years less than average (discounting suicide). Excessive smoking, lack of self care, not eating well. Anti-psychotics can stimulate appetite and contribute to raised cholesterol and DM Lack of achievement . Cognitive symptomsa nd decreased abilities so no qualifications. Lac of concentration, focus and information processing Absolute isolation Inappropriate behaviour and they don’t realise it. Generally hallucination related Family : looking after children, no drive or motivation. ?Bad hallucinations about children? Danger to them? Being able to live on their own is a challenge, lots of support required

8. Schizophrenia Disorder of thought form . Important to distinguish disorder of form from content This is determined by careful observation of how the pt presents their thoughts Various different levels: ‘concrete’ thinking Idiosyncratic use of words: NEOLOGISMS Loosening of associations: thoughts hard to follow Thought block Disturbance of Affect Blunting of flattening of affect: reduced range of emotional expression, flat vocal intonation, loss of facial expression Incongruity of affect: usually inappropriate laughing/smiling, occassionally inappropriate depression Disturbance of Drive Loss of volition/drive: main cause of disability, causes social drift and impairs self care abilities Ambivalence/indecisiveness

9. Catatonic Symptoms Negativism: resist advice/instructions and do the opposite of what you say Echolalia: repeat what you say Echopraxia : copy movements Reduced food and fluid intake Muteness Flexibilitas cerea : if you put the patient in an uncomfortable position they will hold it and stay in it until someone moves them Stupor: different to unconsciousness. Patient is able to hear and is aware of their surroundings. They remember everything. They experience lots of hallucinations and delusions. HOLD THEIR BODY IN A DISTINCTIVE WAY. Due to psychomotor inhibitions. Be very reassuring to the pt! URGENT TREATMENT OFTEN NECESSARY: ECT best

10. Abnormal Movements Stereotypies: repetitive movements with no purpose. E.g. Touching their nose Manneristic behaviour : Odd movement but with a purpose, weird way of doing something, e.g. Sticking arm out at a funny angle to fix their glasses Odd posture Dyskinesias (involuntary movements): most due to antipsychotic drugs (old ones). Some seen in drug naive cases. Commonly around the mouth/blinking. Tardive dyskinesias : neuro disorders and elderly people

11. First Rank Symptoms If any of these symptoms is elicited the Dx is very likely to be Schiz . Basically all special forms of delusions and hallucinations: Audible thoughts Voices commenting ‘made’ feeling ‘made’ impulse ‘made’ act Voices arguing Thought withdrawal Thought insertion Thought broadcast Delusion of control Delusional perception (passivity)

12. Differential Diagnosis Many symptoms occur in other disorders. The diagnosis tends to be made by excluding all other possibilities In a setting of clear consciousness & abscence of evidence of epilepsy, gross cerebral disease or drugs/alcohol, first rank symptoms point strongly to Dx . Symptoms should be present for 1 month Principal DDX: Symptomatic schizophrenia: tumour, ecomplete partial epilepsy, HD, drugs(amphetamines, LSD, cannabis) Mania/Psychotic depression Alcohol induced hallucinosis Delusional disorder Shizo -affective disorder

13. Investigation Hx from relatives and friends Examine any old notes Social work assessment of home circumstances Drug screen (young, acute onset) Tests for organic illness if clinical suspicion (EEG, CT) Investigation of physical health may not help in Dx but necessary due to probable self-neglect Course and outcome Episodes of acute relapse (+ ve symptoms) superimposed on overall functional deterioration (- ve ) Response to Rx variable: - ve symptoms, once present, little response. + ve may respond but tend to be resistant. 5% one episode, no recurrence **40% PERSISTENT SYMPTOMS and decreasing 20% fairly mild persistent symptoms 33% ‘well’ for long periods with some persistent – ve symptoms. Some residual + ves , worse on relapse 33% persistent symptoms of moderate severity. + ve and – ve . 10% Early, severe permanent deterioration Want to try prevent – ve symptoms ever developing. Factors influencing this: length of time before meds work, no relapses of acute psychosis. EARLY INTERVENTION TEAM helps prognosis

14. Aetiology GENETIC : 50% if monozygotic twin has it Environmental: increase in obstetric complications, placental size, winter births (viral infection of mother/baby?), cannabis use Neuropathology Neurochemistry Symptomatic schizophrenia: can it become the full syndrome? Poorly controlled complex partial seizures (or temporal lobe epilepsy) for >5y may result in a clinical syndrome similar to schiz but doesn’t respond to Rx. Drug use/abuse can give long term psychotic symptoms – are they schizos who abused drugs or drug induced state? Sensory impairment ( esp deafness) can predispose to paranoid illness, esp in the elderly

15. Neuropathology and Neurochemistry CT/MRI demonstrates enlargement of intra-cerebral ventricles and increased ventricle:brain ratio (VBR) Reduced hippocampal volume, reduced brain size and altered gyral folding Dopamine hypothesis: symptoms due to excess of DA Therefore aim for an anti-dopamine state in Rx. Blocking all DA receptors is bad as you induce tardive kinesia , Parkinsons , cardiac effects, hyperprolactinaemia (breast cancer, OP, gynacomastia and 2o amenorrhoea) Other neurotransmitters that might be important: Serotonin Glutamate & NMDA receptors

16. Treatment Antipsychotics: First generation: chlorpromazine, haloperidol Second generation: risperidone , clozapine, olanzipine , quetiapine Depot injections, every 2 weeks if issues with compliance e.g. Risperdal (RISPERIDONE) Any med requires frequent lipids, U&E, FBC, LFTs and TFTs . ** clozapine requires monthly FBC due to risk of agranulocytosis