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Psychosis and schizophrenia (Aetiology (Neoplastic CNS tumour,…
Psychosis and
schizophrenia
Definition
Psychosis
Psychiatric presentation
of hallucinations and/or
delusions
Schizophrenia
Psychiatric disorder
of positive and
negative symptoms
Schizotypal disorder
Eccentric behaviour with
anomalies of thinking but
not definitive of schizophrenia
Delusional disorder
Single or set of related delusions
not due to other cause
Epidemiology
Schizophrenia
1% lifetime
M=F
Onset 15-25 (M), 20-30 (F)
Risk factors
Urban living
Low SEC
African-Carribean
Clinical
presentation
Positive
symptoms
Delusions
Definition
False beliefs held with conviction
despite evidence to the contrary
Types
Persecution
Others plotting against them
Control
Thoughts/feelings/behaviour controlled by others
Thought insertion, withdrawal, broadcast
Reference
Ordinary events/objects/behaviour of others
has a specific meaning for them
Thought
disorder
Definition
Impaired ability to form thoughts in
a logical manner
Hallucinations
Definition
Perceptions indistinguishable from reality
in the absence of physical stimulus
Types
Gulstatory
Olfactory
Tactile
Visual (10%)
Auditory (commonest)
Running commentary
Thought echo
Commands
Argue about person
Negative
symptoms
Reduced self care
Reduced motivation
Reduced speech
Social withdrawal
Blunted affect
Cold, callous, introvert
Pathophysiology
Precipirating
Stressful events
Non-compliance with meds
Illicit drugs e.g. cannabis
HEE household
Perpetuating
Non-compliance with meds
Ongoing stress
Ongoing drug use
Predisposing
Family history
Pregnancy/birth complications
PMH psychosis
Biochemical
changes
Excess DA in mesolimbic area
(positive symptoms)
Neurotransmitters DA, 5HT, GABA
Natural
history
Acute/frank psychosis
Hallucinations, delusions, behaviour change, agitation
Recovery
Fully or later relapses
Prodromal period
Emotional and behaviour change
Attenuated +ve symptoms
Transient psychosis
Complications
Premature death
Medical conditions
CVD, T2DM, COPD,
cancer, infection (HIV, HCV)
Stress, lifestyle, drugs
Suicide
10% of patients
Social disability
Education
Work
Relationships
Substance misuse
Diagnosis
Examination
MSE
A+B
Self neglect, dress, movement disorder
(EPS/dyskinesias), responding to unseen stimuli
Speech
Thought disorder, neologisms
Mood
Incongruence, blunted
Thought
Abnormal form, possession, delusions,
passivity, self-harm/harm to others
Perceptions
Hallucinations (auditory),
thought echo, commands
Cognition
Impaired concentration, concrete thinking
Insight
Impaired
General
Signs organic
disease
Investigations
Bloods
FBC, U+Es, TFTs, LFTs,
glucose, urea
drug screen
Urine
Dipstick, drug screen
Imaging
CXR
CT/MRI head
EEG
History
PC, mood symptoms
PPH - psychosis, admissions
DH - OTC,herbal, illicit, compliance
FH - psychosis, mood
SH - impact on ADLs
Risk - suicide, self harm
ICD-10 criteria
Schizotypal
disorder
Timing
3-4 features for 2+ yrs,
never met criteria for schiz
Criteria
Inappropriate affect
Eccentric/odd behaviour
Social withdrawal
Odd beliefs
Suspicious/paranoid ideas
Obsessive ruminations
Unusual perceptions
Odd thinking and speech
Quasi-psychotic episodes
Schizophrenia
1+ of:
Auditory hallucination
Thought disorder
Delusions of control/influence/passivity
OR
inappropriate to cultural identity or completely improable
OR 2+ of:
Persistent hallucinations and delusions
Thought disorder
Catatonia
Negative symptoms
Personality change (oss of interest, withdrawal)
Timing
Symptoms >1 month
Delusional
disorder
Conspicious delusions for 3+ months,
no evident underlying cause
Aetiology
Neoplastic
CNS tumour
Psychiatric
Schizophrenia
Depression/BPD with psychosis
Schizoaffective disorder
Dementia/delerium
Infection
Encephalitis
Sepsis
Vascular
TIA/stroke
Drugs
Steroids
Ketamine, speed, cocaine, cannabis
Idiopathic
Epilepsy
Management
Initial ABCDE
Definitive
Conservative/social
Avoid drugs/alcohol
Social support
Finances, housing, employment
Psychological
CBT, family therapy
Community rehab
Assertive outreach
Setting
Inpatient if non-compliant, risk harm
Outpatient, home
Medical
Clozapine
Indication: refractory to 1L
MOA: D4-R antagonist
SEs: BM suppression, agranulocytosis
Typical/1st gen
MOA: D2-R antagonists
E.g. haloperidol, chlorpromazine
SEs: EPS
Atypical/2nd gen
Indication: 1L
MOA: D2-R antagonists
E.g. olanzapine, quetiapine
SEs: HTN, inc lipids, T2DM
Prognosis
Schizophrenia
Good
Female
Onset - late, sudden, short episodes
No PSH
Mainly mood symptoms
Social support
Good drug compliance
Bad
Male
Onset - young, insidious, long duration
PSH/FH
Negative symptoms
Poor SEC/social support
Poor compliance
Substance misuse
Schizotypal
Chronic, fluctuant
May evolve into schiz
(rare)