• Schizophrenia

    by  • 24/12/2013 • Psychiatry

    Definition: Characterized by distortions in thought and perception together with psychotic symptoms. Intellect and clear consciousness are usually maintained.

    Distinguished from other psychoses by the absence of a mood disorder (Bi-polar, Depressive, Organic- hypothyroid, Cushings etc), specific hallucinations & thought disorder, and its clinical course.

     

    Aetiology: The Dopamine hypothesis: symptoms are caused by central dopaminergic hyperactivity in the mesolimbic-mesocortical system.

     

    Clinical presentations

    Acute schizophreniaPositive symptoms

    Chronic schizophrenia Negative symptoms

     

    Acute

    • First rank symptoms
      • Delusional perceptions (a real perceived event leads to an incorrect conclusion without logical thinking).
      • Hallucinations
        • Thought echo (audible thoughts)
        • Third person running commentary (hears the voices of more than one person discussing matters between themselves).
        • Running commentary (one voice describing the patients every action)
      • Thought disorder
        • Withdrawal
        • Insertion
        • Broadcasting
      • Passivity of thought/feelings/actions (feels that they are receiving bodily sensations/actions from an outside agency).
    • Lack of insight
    • Appearance and behaviour- restless, noisy, preoccupied, withdrawn
    • Symptom duration: minimum 1 month (ICD 10 criteria) or 6 months (DSM4 criteria).
      If present for less than 1 month known as
      Schizophreniform disorder.
    • Impaired social or occupational function must also be present.

     

    Diagnosis noes not require a certain number of these features (indeed they are absent in 20% of schizophrenics), but the more there are, the more likely the diagnosis).

     

    Chronic(negative symptoms)

    • Lack of drive
    • Apathy (lack of feeling, emotion, interest)
    • Social withdrawal
    • Impaired living skills
    • Poverty of thought
    • Reduced speech
    • Blunted effect (reduction in the intensity of emotional expression)

     

    *Note: movement disorders can also occur as negative symptoms “catatonic symptoms” (stupor)

    *With increasing age there is an increased incidence of paranoia

     

    Epidemiology

    Lifetime risk of 1%

    Peak onset 25-30 years in females, 18-25 years in males. Higher incidence in males.

    Risk factors: low socioeconomic status and exposure to high level of expressed emotion (>35h week)

     

    Treatments in Acute

    Must exclude psychotic mood disorders first (bi-polar, depression, organic causes).

     

     

    Drug therapies

    • First line- atypical antipsychotics (e.g. olanzapine)
      • Response takes 3-4 weeks. Monthly depot injections can improve compliance.
    • Benzodiazepines (behavioural modifiers given for aggression)
    • Antidepressants and Lithium used for augmentation in treatment resistant cases (i.e. where two different antipsychotics have been tried for 6-8 weeks)
    • ECT is used for catatonic schizophrenia only, and severe depressive episodes.

     

    Continue antipsychotics for 6 months if patient recovers from their acute episode.

    If they do not recover, they need assessment every 6 months to look at reducing the antipsychotic dose and checking their side effects:

    • Tardive dyskinesia
    • Weight gain
    • Hyperglycaemia

    *Remember anti-cholinergics reduce parkinsonism but increase the risk of developing dyskinesias, thus it’s always important to adjust the anti-psychotic dose first.

     

    Psychological therapies

    Family therapies: to avoid high emotional expression

    CBT: to reduce preoccupations if there is drug resistant hallucinations or delusions

     

    Treatment in Chronic

    Chronis sufferers require long term MDT support and may need adjustment of the type and dosage of anti-psychotic they’re on.

     

    Important differentials

    Organic psychotic disorder

    Substance-induced psychotic disorder

    Delusional disorder

    Schizoaffective disorder

    Transient psychosis

    Schizotypal disorder

     

    Substance induced psychosis

    This should be suspected above a true psychiatric condition. Excessive cannabis often a cause.

    Delusional disorder

    It is delusions alone that make up the clinical picture. Usually starts in middle age

    Transient psychotic disorder

    Usually reaches a crescendo of symptoms within 2 weeks, with complete resolution within 3 months. It may be precipitated by a stressful life event.

    Schizotypal personality disorder

    Schizotypal personalities have a preference for their own company over that of others. They lack emotion, and may be seen as cold. May not gain pleasure from activities and have little interest in forming relationships. Thought disorders and psychoses are not present.

    Catatonic schizophrenia

    Has a prominence of catatonic symptoms: stupor (a state of unresponsiveness with immobility and mutism), excitement, posturing negativism, rigidity.

     

    Prognosis

    1 in 20 commit suicide

    ¼ Good outcome: one or two episodes with full recovery

    ½ Moderate outcome: undulating course with some persistent deficits

    1/5 Poor outcome: chronic schizophrenia with persistent functional disability

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