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Psychosis / Schizophrenia - Coggle Diagram
Psychosis / Schizophrenia
Psychosis
Definition
Impairement in
reality testing
, where ability to distinguish between external reality and internal experience is impaired
Experience of hallucinations or delusions
Occurs in clear conciousness (delerium no considered psychotic disorder)
Hallucinations
Sensory perceptions in the absence of external stimuli
Modalities
Visual
Auditory
Tactile
Somatic
Gustatory
Visceral
Functional
Abnormal consciousness States
Hypnagogic (wake → sleep)
Hypnopompic (sleep → wake)
Sensory deprivation
Illusions
Types
Completion
Affect related
Pareidolia
Delusions
Fixed false beliefs inconsistent with euction and cultural background and not amenable to reasons
Types
Persecution
Reference
Guilt
Religious
Grandiose
Nihilistic
Hypochondrical
Shared
Erotic
Infidelity
Passivity (delusion of control) (eg thought insertion)
Causes
Functional / Idiopathic
Schizophrenia
Bipolar disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorders
Due to Medical Condition
Temporal lobe epilepsy (TLE)
Neurogenederation - dementia
Infection - encephalitis, syphilis
Autoimmune - NMDR, thyroid, SLE
Trauma - ABI, Brain tumour
Substance Induced
Cannabis
Cocaine
Alcohol
Amphetamines
Mephedrone
Psilocybins
Steroids
L-dopa
Anti-malarials
Symptoms
Hallucinations
Delusions
Thought Disorder
Catatonia
Epidemiology
Rate of psychotic disorders 1.5-3%
Schizophrenia point prevalence 2:10,000/1,000
Schizophrenia reduces life expectance by 17 yrs
Comorbidities (smoking)
Poor health seeking behaviour
Suicide 5%
30-40% respond poorly to treatment
Diagnosis of Psychotic Disorders
Defined by clinical syndromes - clinically reliable but not based of mechanism of disease
Duration
Symptom profile
Relationship to mood symptoms
Cause
Schizophrenia
Clinical Features
Psychosis (delusions and hallucinations)
Disorganised speech (though disorder)
Disorganised or catatonic behaviour
Negative (deficit) symptoms
Affect flat,
Alogia (reduced amount / content of speech)
Avolition (lack of motivation / interest)
Mood and anxiety symptoms
Cognitive deficits (attention / memory etc)
DMS 5 Criteria
A. Two or more of the following (one must be 1,2 or 3)
Delusions
Hallucinations
Disorganised speech (eg derailment)
Grossly disorganised or catatonic behaviour
Negative symptoms (affect flattening, alogia, avolition)
B. Social / occupational dysfunction
C. Duration
Over 6 months
D-E Exclusion of schizoaffective / mood disorder / substance / general medical condition
F: If co-existing pervasive developmental disorder (autism) additional SZ diagnosis only made if prominent delusions / hallucinations present for >1 month
Differential Diagnosis
Shorter Duration
Brief Pyschotic Disorder
1 day - 1 month
Schizophreniform disorder
1month - < 6 months
Only delusions
Delusional Disorder
Significant Mood Symptoms
Bipolar Disorder with Psychosis
A Persistent period of elevated, expansive or irritable mood, increased activity / energy lasting at least 1 week
B Two or more of following present for significant period of time during 1 month period
Inflated self esteem
Decreased need for sleep
Pressure of speech
Flight of ideas (racing thoughts)
Distractibility
Increased goal directed activity
Activites potentially reckless
Schizoaffective Disorder
A Major mood episode concurrent with Criterion A for SZ
B Delusions / hallucinations for 2+ weeks in absence of major mood disorder during lifetime duration of illness
C Symptoms that meet criteria for major mood episode present for majority / total duration of illness
Catatonia
Three or more of following
Stupor
Catalepsy
Waxy flexibility
Mutism
Negativism
Posturing
Mannerism
Stereotyoy
Agitation
Grimacing
Echolalia
Echopraxia
Epidemiology
Lifetime risk 1%
1:1 sex
Age of onset
Earlier in males
Lat teens / early twenties
Increased mortality - lifespan reduced 17 yrs
Suicide
young
male
insightful
-high premorbid function
depression
chronic relapsing
Increased CVD
Accidents
Lack of health-seeking behaviour
Risk Factors
Development
Prenatal : Paternal age
Perinatal
Maternal infection
Maternal stress / malnutrition
Perinatal hypoxia
Early life trauma
Brain trauma / infection
Childhood adversity
Genetics
Cannabis
Urbanisation
Migration
Stages
Stage 0
Increased risk with mild or non-specific neurocognitive features
(Linguistic, motor, behaviour, social, cognitive anomalies)
Stage1
Ultra-High Risk (prodrome)
Odd ideas
Eccentric interests
Changes in affect speech or social function
Subthreshold
Stage 2
First episode
Full threshold symptoms with functional decline
Stage 3
Incomplete remission
Recurrence or relapse but no residual symptoms
Relapses with impairment between episodes
Stage 4
Severe, persisten illness with ingoing psychotic symptoms
Pathology
Brain Structure
Reduced brain volume
Increased ventricular volume
Early reduction in hippocampus amygdala, thalamus, insula and anterior cingulate
Later DLPFC, left superior temporal gyrus
Auditory Hallucinations
Increased fronto-temporal activity - area involved in speech generation and processing
Dopamine
Relationship between D2 receptor occupancy and antipsychotic effect
Aetiology Hypotheses
Receptors
Dopamine Hypothesis
D2 agonists induce psychotic symptoms
D2 receptor blockers treat psychosis
Increased pre-synaptic Dopamine syntheis and excessive stimulus induced release
Only explains positive / psychotic symptoms
Glutamate & GABA Systems
Glu antagonists cause psychosis
Imbalance of excitatory & inhibitory systems may explain syndrome
Genetics
Common risk variants
25% of risk
250 loci identified
Small effect on individual
Rare Mutations
10-20 identified
Larger effect on individual
Polygenic
Genetic overlap with other psychiatric disorders
Developmental
Brain Connectivity
Differences in network organisation in SZ
Liekly explains electrophysiological abnormalities
Psychosis symtpms as abnormal salience processing
Negative symptoms as reduced ventral striatal responses to reward and attenuation of amygdala activation
Management
History + Collateral
Mental state exam
Risk assessment
Investigations
Routine bloods
Urine toxicology
Imaging
Pharmacotherapy
Typical Antipsychotics
Haloperidol
Perphenazine
Chlorpromazine
Atypical antipsychotic
Olanzapine
Risperidone
Quetiapine
Amisulpiride
Clozapine
Other intervention
Family behavioural therapy
CBT for psychosis
Cognitive remediation therapy
Vocation training / rehab
Treatment Challenges
Biomed
Acute vs maintenance
Comorbidities
Managing side effects
Psychology
Individual : Psychoeducations / relapse prevention / CBT
Families: Psychoeducation / relapse prevention
Social
Support
Accommodation
Social skills training