01.2 psychosis
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PSYCHOSIS
Dr Niall Boyce
ST3 Psychiatry Research
Dr Claudia Cooper
MRC Research Training Fellow in Health Services
Research
Locum Consultant Old age Psychiatry
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Treat acute episode
Intervene early: prompt treatment associated with better outcome
Reduce risk of relapse
Promote long term recovery
ANTIPSYCHOTICS
Lowest effective dose
Usually oral (occasionally depot, im)
Monitor side effects
Adherence
Maintenance treatment
reduced relapse rate if continued > 1-2 years after acute episode
Maintenance treatment
PSYCHOLOGICAL THERAPY
Self help to come to terms with symptoms/illness
Family therapy to reduce expressed emotion
CBT to help manage residual symptoms
Art therapy helps negative symptoms
SOCIAL SUPPORT
Focus on engagement, hope, reduce stigma
Support to reduce substance misuse
Support employment and study
Appropriate accommodation
Management of psychosis
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Timetable What is psychosis?
Abnormal thought content and form
Abnormal perceptions
BREAK
Making a diagnosis
Diagnostic hierarchy
Vignettes
Video
LUNCH
Schizophrenia and other psychotic disorders
Management
MCQ
Summary
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Objectives
Define psychosis and recognise hallucinations, delusions and thought
disorder
Identify which patients have psychosis
Know the diagnostic criteria for schizophrenia and schizoaffective disorder
Use a framework to make a diagnosis in a psychotic patient
Know about the aetiology and treatment of schizophrenia
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What is psychosis?
A severe mental illness that prevents people from being able to
distinguish between the real world and the imaginary world. Symptoms
include:
Hallucinations (seeing or hearing things that aren't really there)
Delusions ( believing things that arent true)
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Thought content
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Initiation of ideas
After a perception
Following a memory
Arise out of an atmosphere or mood state
Autochthonous
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False beliefs
Primary and secondary delusions
Overvalued ideas
Sensitive ideas of reference
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Delusions
An idea or belief that is:
false
unshakeable and firmly held
despite clear evidence to contrary, and
out of keeping with educational, cultural and social background
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Content of delusions
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Delusions of persecution
belief that someone or something is interfering with the person in a malicious or destructive way
Examples:
Someone (or an organisation e.g. MI5) is trying to kill or harm them
The neighbours are harassing them
People are monitoring their movements or following them
VIDEO 1
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Asking about delusions of persecution
Are there times when you worry that people are against you/ trying to
harm you?
Do you have any concerns for your safety?
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Grandiose delusions
belief of being a famous, having supernatural powers, having
enormous wealth
Suggestions for interview: Do you have any exceptional abilities or
talents?
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Delusions of reference
belief that actions of other people, events, media etc. are either directly referring to the person or are communicating a message
Suggestions for interview:
Have there been times when you have overheard people talking about you?
Do you ever see things on the TV or hear things on the radio which you think are about you?
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Delusions of misidentification
Capgras syndrome
someone close has been replaced by an identical looking impostor
Fregolis syndrome
belief that strangers are actually familiar people in disguise
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Delusions of control
passivity phenomena: made actions, feelings or impulses
the boundaries between self and the world are broken
thoughts, actions or feelings are subject to outside influences
thought insertion, withdrawal, broadcasting
often accompanied by delusional explanations
VIDEO 9
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Asking about delusions of control
Thought interference: Have you ever felt that your thoughts were being
directly interfered with or controlled by another person?
Was this just because people were distracting you or being persuasive, or did it
come about in a way many people would find hard to believe, for instance
through telepathy?
Passivity: Have you ever felt that another person was able to control what
you did directly, as if they were pulling the strings of a puppet?
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Religious delusions:
Beliefs about having contact with God, having religious powers,
being a religious leader
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Delusions of love
Morbid jealousy
a strong feeling of jealousy coupled with a sense that the loved person belongs to
me
Erotomania
a preoccupation with the belief that a person is in love with them
usually the person is a stranger of unattainable status or position
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Delusions of guilt, unworthiness, poverty and
nihilism
e.g. beliefs that they are dead or rotting inside would be nihilistic
delusions
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Somatic delusions
beliefs about body,
including
illnesses (hypochondriacal delusions)
infestations (Ekboms syndrome).
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Primary and secondary delusions
A primary delusion is a delusion which arises "out of the blue".
Secondary delusions are secondary to a morbid event, such as a change
in mood, an hallucination, or another delusion.
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Types of primary delusions
Autochthonous delusions
arising de novo
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Types of primary delusions
Autochthonous delusions
Delusional perceptions
a normal perception is interpreted with delusional meaning
objects or persons take on new delusional personal significance
VIDEO 2
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Types of primary delusions
Autochthonous delusions
Delusional perceptions
Delusional atmosphere / mood
experiencing surroundings as sinister, apprehensive & peculiar in a vague
way
something funny is going on
VIDEO 3
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Types of primary delusions
Autochthonous delusions
Delusional perceptions
Delusional atmosphere / mood
Delusional memory
fictitious event is remembered as really having occurred
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Overvalued ideas
acceptable and comprehensible ideas
pursued beyond the bounds of reason
preoccupy & dominate the persons life.
similar quality to passionate political, religious or ethical convictions
But not fulfilling criteria for delusion
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Sensitive ideas of reference
in a rigid, suspicious person
interpreting information as pertaining to themselves
in a critical, derogatory way.
But not fulfilling criteria for delusion
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Disturbances in form of thought
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Normal thought form
I went to the shop.to buy a loaf of bread
because I was hungry.
Meaning link
Meaning link
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In flight of ideas, there are links between phrases but they are
clang associations.
Clang associations are associations of words similar in sound
but not in meaning. Links may be rhymes or puns
This occurs in mania and hypomania and usually with
pressure of speech.
You come in here swinging your stethoscope.telling me about my
horoscope
VIDEO 6
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In loosening of association there is no link between phrases.
Knights move thinking is a type of loosening of association
where there is an abrupt jump from one idea to another
midway through the first thought e.g.
Inferior schools! Inferior schools! Preferably Dr Sims? Your tablets have
been a miserable failure. I have had to sit with these mad surgeries. With
regard to these tablets it will depend what the lord wants. With these
women it is certainly destiny humph
A Simms1988
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In word salad, there is no link between words.
Blue does runs shaky lovely very
VIDEO 8
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Neologism
New word created by the patient which only has meaning to them
E.g. a patient believed that his thoughts were being influenced by a
process called telegony
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Circumstantiality
Overinclusion of details and parenthetical remarks
Takes a long time to get to the desired point
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Tangentiality
Inability to have goal-directed associations of thought
Never gets from desired point to desired goal
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Echolalia
Repeating of words or phrases of another person
Can occur in schizophrenia, mental retardation or dementia
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Perseveration
Persisting response to a prior stimulus after the new stimulus has been
presented
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Thought block
Abrupt interruption in train of thinking before a thought or idea is finished
After a brief pause the person indicates no recall of what was being said
or what was going to be said
May be explained by the patient as thought withdrawal
VIDEO 7
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PERCEPTIONS
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Imagery or fantasy
complex experience
created voluntarily
based on perceptions, memories, wishes
can easily tell the difference between fantasy and reality
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Abnormal perceptual experiences
Sensory distortions (the quality, intensity or feeling associated with a
perception is altered)
E.g. hyperacusis (things seem louder)
Visual hyperaesthesia (colours seem more vivid)
Derealisation/depersonalisation (loss of usual feelings of familiarity with self and
surroundings)
VIDEO 4
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False perceptions
Illusions
Completion
Affect
Pareodolic
Hallucinations
Pseudohallucinations
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Completion Illusions
An incomplete perception is filled
in from previous experience
Rely on inattention
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Affect illusions
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Pareidolic illusions
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2. Hallucinations
occur spontaneously
not distortions of real perceptions
indistinguishable from normal perceptions
can occur in any sensory modality
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Auditory hallucinations
Occasionally elementary sounds (e.g. in organic states)
Rarely music
Usually voices
VIDEO 5
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Asking about voices
Have there been times when you heard or saw things others couldnt?
Have you ever heard a voice when there was no one around to account
for it?
Could you tell me what it said?
Has the voice ever told you what to do?
How do you feel when you hear the voice?
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Visual hallucinations
characteristically occur in organic states
Asking about visual hallucinations:
Have you ever seen a vision?
Have you ever seen something that others couldnt see?
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Somatic hallucinations
Also called tactile / haptic hallucinations
These may be sensations of being:
touched or strangled
feeling that insects are crawling beneath the skin (formication) e.g. occurs in cocaine users
feelings of sexual stimulation.
They can be classified as superficial (skin), kinaesthetic (involving joints/ muscles) or visceral (inner organs)
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Olfactory and gustatory hallucinations
involve smell and taste respectively.
often have strong affective component.
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3. Pseudohallucinations
These are similar to hallucinations but differ in some important aspects, either:
they do not appear to the patient to be real and instead located in the mind (i.e. in subjective inner space)
e.g. visual pseudohallucinations - seen by inner eye
Auditory pseudohallucinations - voice in my head
Or they seem to occur in the outside world but patient views it as unreal.
They may occur in, for example, borderline personality disorder, fatigue, bereavement
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Why make a diagnosis?
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Importance of diagnosis
Wrong diagnosis =
wrong treatment
wrong risk assessment
wrong prognosis etc etc...
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Organic disorders
Psychotic disorders
Mood disorders
Anxiety disorders
Personality disorders
The diagnostic hierarchy Includes delirium, dementia, medical causes of psychosis, drug and
alcohol related psychoses
Includes schizophrenia, delusional
disorder
Includes bipolar affective
disorder, psychotic depression
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Medical conditions can cause:
Delirium
(which may include psychotic symptoms)
Psychosis
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Definition of Delirium
Generalized impairment of cognitive functions (perception, thinking
memory, orientation), emotion, psychomotor activity and sleep-wake
cycle
NB: impaired consciousness/ attention
Characterized by confusion, perceptual disturbances and disordered
thinking and behaviour => easily mistaken for psychosis
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Medical disorders presenting with psychotic symptoms
Psychoactive drug use
Alcohol: withdrawal, intoxication, hallucinosis
Infection: sepsis, encephalitis
Cerebral neoplasm, trauma, stroke
Neurological disorders: Parkinsons, epilepsy
Dementia
Lewy body, Alzheimers etc.
And many more..........
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Psychiatric disorders presenting with psychotic symptoms
Schizophrenia spectrum disorders
Schizophrenia, delusional disorder, schizoaffective disorder etc
Mood disorders
Bipolar disorder
Depression
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Disorders whose symptoms can appear psychotic
Obsessive compulsive disorder
Post traumatic stress disorder
Borderline personality disorder
Schizoid personality disorder
Hypochondriasis
Factitious disorder, malingering
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Approach to making a diagnosis
Similar principles to any other branch of medicine
history and examination etc.....
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Detailed account of the psychotic symptoms
nature
onset
degree
longitudinal course
previous episodes
collateral information
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Further history
Other symptoms and signs ?
Sleep, appetite
Context of the symptoms?
Drug use, bereavement
Family history of mental illness
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Examination
Mental state
level of consciousness
cognition
hallucinations, delusions, thought disorder
mood incongruent or bizarre
Physical examination
Investigations
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General pointers (1) Elementary hallucinations (noises), visual or olfactory hallucinations
? organic conditions
Episodic delusions and hallucinations ? epilepsy, substance
abuse
Delusions / hallucinations + altered level of consciousness = delirium
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General pointers (2)
Bizarre delusions and hallucinations ? Schizophrenia spectrum
disorders
Mood congruent delusions and hallucinations
? Mood disorders
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Vignettes
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Case 1
A 52 year old man in brought to A&E by the police, after he was found
shouting in the street. He is sweating and appears terrified.
He can see rats running around
This has never happened before
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Case 1 What will you ask about?
Alcohol
Drugs
How long ?
Urine drug screen
FBC
Temperature
(Glucose)
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Case 2
An 84 year old woman is referred by social services. She has been
shouting at her neighbours, neglecting herself and has started to refuse
meals on wheels as she believes they are poisoned
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Case 2
Her explanation
Medical problems
Mood
Alcohol
Collateral
MMSE
FBC
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Case 3
A 30 year old woman attends A&E having made superficial cuts to her
forearms with a razor. She has numerous scars on her arms and casualty
records show past overdoses. She cant remember ever feeling happy or
normal. She cut herself because she heard voices in her head telling her
to.
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Case 3
Why unhappy
Why now
Anything else to harm themselves
Characteristics of voices
Anhedonia
Blood drug levels (paracetamol/salicylate)
Review medical records
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Case 4
45 year old man presents to A&E saying that his life is in danger. He is
dishevelled, and appears suspicious and anxious. He confides in you that
he believes MI5 are following him.
He has previously be sectioned under the MHS (section 2) for a drug
induced psychosis.
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Case 4
Why is life in danger?
Substances?
How long?
Collateral from nurse
Orientation
FBC
Glucose
(U&E, Drug screen)
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Psychotic disorders
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psychotic symptoms, not clinically relevant: > 17%
Any psychotic
Illness: 3%
Life time prevalence of psychosis
Includes:
Schizophrenia (1%)
Schizoaffective disorder (0.2%)
Delusional disorder (0.03%)
Acute & transient psychotic disorders
Induced delusional disorder
(Bipolar affective disorder (1%))
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Psychosis - diagnoses
Schizophrenia
Schizoaffective disorder
Delusional disorder
Acute and Transient psychotic disorders
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Schizophrenia
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First-rank symptoms of schizophrenia
Strongly suggestive of schizophrenia if present:
auditory hallucinations:
hearing thoughts spoken aloud
hearing voices discussing him/her or giving a running commentary (3rd person)
thought withdrawal, insertion and broadcast
somatic hallucinations
delusional perception
Made feelings, impulses or actions (passivity)
Kurt Schneider (1959)
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ICD-10 Schizophrenia
At least one of: thought echo, insertion, withdrawal, and broadcast
delusions of control, influence, or passivity
voices giving a running commentary or discussing
persistent delusions of other kinds
or at least two of: other hallucinations
thought disorder
catatonic behaviour,
"negative" symptoms
a significant and consistent change in behaviour
for at least a month, in absence of intoxication, brain disease or extensive manic / depressive symptoms
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Under-activity
Few leisure interests
Lack of convention
Social withdrawal
speech
motivation
emotional responsiveness (flat affect)
Positive symptoms Negative symptoms Hallucinations
Delusions
Ideas of reference
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Sub-types 1. Paranoid schizophrenia
Stable delusions, usually + hallucinations
2. Hebephrenic schizophrenia
Fleeting delusions & hallucinations Behaviour & thought disorganized
3. Residual schizophrenia after a period of positive symptoms, negative
symptoms predominate
4. Simple schizophrenia negative symptoms, no initial positive symptoms
(rare)
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5. Catatonic schizophrenia
Rare
Disturbances of voluntary motor activity
including
Stupor
Periods of over-activity
Rigidity
Posturing
Waxy flexibility (maintenance of limbs
and body in externally imposed positions)
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WHO: International Pilot Study
Lack of insight 97 %
Auditory Hallucinations 74 %
Ideas of reference 70 %
Suspiciousness 66 %
Flat Affect 66 %
Delusions of Persecution 64 %
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WHO: International Pilot Study
Social withdrawal 74 %
Under-activity 56 %
Lack of convention 54 %
Few leisure interests 50 %
Slowness 48 %
Over-activity 41 %
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Function
Schizophrenia can have a devastating effect on :
interpersonal relationships
work
self-care
other goal directed behaviours
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DSM-IV
This classifies schizophrenia in a broadly similar way
Main difference is that it requires symptoms to have been present for 6
MONTHS
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Aetiology of schizophrenia
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Genetics of schizophrenia
Strong evidence of a genetic component from
Epidemiological studies
Molecular genetic studies
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Genetic epidemiology: Risk of developing
schizophrenia
0 10 20 30 40 50 60
General population
1st cousin
Niece/ nephew
Grandchild
Parent
Sibling
Children
Non-identical twin
Identical twin
%
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Genetics of schizophrenia
Molecular genetic studies
Linkage studies: eg regions of chromosomes 5 and 8 replicated
Genes found to be associated with schizophrenia in genetic association studies
(typically case control) include 8 and 13
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Genetics of schizophrenia
The mechanism for genetic component of schizophrenia may be:
1) solely genetic
2) gene-gene interaction
3) gene-environment interaction
4) A combination
Evidence for 1 and 3 at the moment
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Aetiology of schizophrenia
genetics
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Neurodevelopmental hypothesis
result of an early brain insult
affects brain development leading to abnormalities which are
expressed in the mature brain
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Perinatal risk factors
Spring birth. Seems to be related to greater exposure to viruses in utero
(in winter months)
birth complications
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Childhood risk factors Developmental delay
Children aged 2 who later became schizophrenic
responsiveness
positive affect
eye contact
75% of people who develop schizophrenia have 'soft' neurological signs as children (abnormal gaits, dysgraphaesthesia, proprioceptive errors; tics and epilepsy)
Poor academic performance
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Radiological changes
Volume lateral ventricles
Volume brain
Especially Temporal lobe, Amygdala / hippocampal complex
Same changes found in newly diagnosed patients as chronic
schizophrenics
Appear to be non-progressive
Neuropathological changes suggestive of neuronal degeneration
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Males with schizophrenia
Earlier onset
More negative symptoms
More structural brain abnormalities
More susceptible to neurodevelopmental disorders
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Aetiology of schizophrenia
neurodevelopmental
genetics
Perinatal factors School problems
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Cannabis and schizophrenia
People who smoke cannabis are more likely to develop schizophrenia
The younger a person smokes/uses cannabis, the higher the risk for schizophrenia, and the worse the schizophrenia is when the person does develop it.
A gene-environment interaction between COMT (catechol-O-methyl transferase) gene and cannabis suggested and finding replicated, but no primary association of schizophrenia with alleles at the COMT locus has been demonstrated
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Aetiology of schizophrenia
neurodevelopmental
genetics
cannabis Perinatal factors
School problems
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Life events
Increased incidence of events in 3 weeks prior to onset
46 % Vs. 14 % in control group
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Family Interaction
Higher relapse rates for :
Families with high Expressed Emotion
critical comments
hostility
over-involvement
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Social class and urbanicity
Schizophrenia is more common in people from lower social classes and
urban areas.
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Developmental delay
genetics
Expressed
emotion
cannabis
Perinatal factors School
problems,
abuse
Life event,
deprivation,
adversity,
migration
Neurodevelopmental hypothesis
Final common
pathway is Dopamine
5HT glutamate
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Migration
In the UK, the incidence of all psychoses is significantly higher in African-
Caribbean and Black African populations compared with the White British
population
Incidence rates of schizophrenia in Caribbean countries are similar to those
found in the indigenous UK population.
The rate for schizophrenia in second-generation AfricanCaribbean people
born in the UK appears to be higher than in the first generation.
This pattern is strongly suggestive of an environmental effect (? Social
adversity ? Discrimination).
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Aetiology of schizophrenia
neurodevelopmental
genetics
Expressed emotion migration
cannabis Perinatal factors
School problems
Life event
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Neurotransmitter changes
We dont yet know exactly how these aetiological factors actually
result in psychosis. The answer is very likely to include
neurotransmitters.
In schizophrenia there is:
dopamine activity (amphetamine is a dopamine agonist)
glutamate activity (PCP blocks glutamate receptors)
5-HT activity (LSD is a serotonin agonist)
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Schizophrenia
After 10 years, of the people diagnosed with schizophrenia:
25% Completely Recover
25% Much Improved, relatively independent
25% Improved, but require extensive support network
15% Hospitalized, unimproved
10% Dead (Mostly Suicide)
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Poor Prognostic Indicators
Male
Insidious onset
Long duration of untreated psychosis
Drug use
Family environment
Non-compliance
Neuro-cognitive deficits
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Risk of relapse after first episode of psychosis
(schizophrenia or schizoaffective disorder)
90% of people experiencing a first psychotic episode will be well within a
year
About 80% will have a further episode within 5 years
Those who discontinue antipsychotic medication may be 5 times more
likely to relapse over this time
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Schizoaffective disorder
Both affective and psychotic symptoms are prominent within illness
episode, simultaneously or within a few days of each other
Therefore criteria for schizophrenia and depressive/ manic episode not met
Usually less impairment between episodes and social impairment than for
schizophrenia (but more than in bipolar affective disorder)
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Spectrum
Bipolar Affective Schizoaffective Schizophrenia
Functioning between episodes:
Good Poor
Prognosis:
Poor Good
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Delusional Disorder
Delusions constitute the most conspicuous or the only clinical
characteristic
Often function well outside area of delusion
Present for at least 3 months
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Acute and Transient psychotic disorders
the onset of psychotic symptoms must be acute (2 weeks or less from a
nonpsychotic to a clearly psychotic state);
If the schizophrenic symptoms last for more than 1 month, the diagnosis
should be changed to schizophrenia.
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ATPD - prognosis
Diagnosis less stable than for schizophrenia. A year later:
15% schizophrenia
28% affective disorder
Psychosocial functioning maintained
10 years after diagnosis:
A third had been medication free with no relapse for at least two years
79% had experienced at least one relapse
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Management
Risk assessment
Care Programme Approach
Treatment
DVD
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Risks to consider
Self harm and suicide
Self-neglect
Harm to others
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UK Deaths per year
Suicides 5,000
Road Traffic Accidents 4,000
Homicides 6-700
Dangerous driving / drunk driving 300
Homicides + contact with mental health services in past year
40
Homicides by stranger + contact with mental health services in past
year 3-4
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Self report violence in previous year
2% of non mentally ill
12 % of mentally ill
25 % of people with substance abuse problems
60 % of people with substance abuse problems + schizophrenia /
depression / mania.
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Risk assessment
Identify risk
Assess risk
How can risk be altered ?
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Assess risk
Past including precedents
Current
Other factors e.g.drugs
From patient and other sources
-
How can risk be altered ?
Treatment strategy
Planned response
Review date
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Care Programme Approach
Assess health & social needs
Agreed care plan
Assess carer needs
Named Care co-ordinator
Regular monitoring & review (CPA) meetings
Interagency & multi-disciplinary working
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Early Intervention in Psychosis services
These are being set up in many areas
Specialist teams who treat people experiencing their first episode of
psychosis (aged 18-35)
Aim to reduce the Duration of Untreated Psychosis, because shorter
time to treatment associated with better outcome
Therefore focus on early detection and treatment and maintaining contact
to try to prevent relapse
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Management : General Principles
Biological
Psychological
Social
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Antipsychotic medication
Typical antipsychotics
Chlorpromazine
Haloperidol
Atypical antipsychotics
Risperidone
Olanzapine
Quetiapine
Amisulpiride
Aripiprazole
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Antipsychotic medication (2)
Antipsychotic medication are started at low dose and increased gradually
They take affect after 1-6 weeks
They should be continued for a minimum of a year after a person is
asymptomatic. There is probably benefit in continuing for up to 5 years,
but many people are reluctant to do so.
Adherence to medication is key.
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Psychological
Family therapy
CBT for psychosis
-
Family Interaction
Higher relapse rates for :
Families with high Expressed Emotion
critical comments
hostility
over-involvement
-
Family Intervention
Relapse rates 9 months post discharge:
Antipsychotic medication
+ low EE family 12%
Antipsychotic medication
+ high EE family (35 hours) 92%
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CBT for psychosis
Recommended by NICE as a treatment in addition to medication for
people with persistent positive symptoms of psychosis.
Typically, around 50-65% of people who receive therapy benefit in some
way.
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CBT for psychosis (2)
Identify a clients main difficulties, how they arose, and what they
understand about them.
The aim is not necessarily to get rid of symptoms, but to alleviate distress
and disability, by helping them find:
New ways to reframe their experiences
New strategies to cope with their symptoms
-
Social
Support
Socialisation
-
Any Questions ?
-
Objectives (recap)
Define and recognise psychosis, hallucinations, delusions and thought
disorder
Know the diagnostic criteria for schizophrenia and schizoaffective
disorder
Distinguish between positive and negative symptoms of schizophrenia
Use a framework to make a diagnosis in a psychotic patient
Be able to outline the aetiology of schizophrenia
Be able to discuss the setting and types of treatment for psychosis
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