Define schizophrenia
MOST COMMON delusional disorder characterised by hallucinations, delusions and thought disroders leading to functional impairment
Epidemiology schizophrenia
Age / m and w / incidence
- 1/100
- M=W
- Ages: 15-35
RFs schizophrenia
Biological →
genetic
neurochemical (↑dopamine, ↓ glutamate/serotonin/GABA)
neurodevelopmental (intrauterine infection, premature birth, fetal brain injury, obstetric complications)
smoking cannabis
using psychostimulants
Psychological →
FHx
childhood abuse
Social → substance misuse childhood abuse adverse life events ↓ social support
Pathophysiology schizophrenia
Dopamine hypothesis
o Over-activity of mesolimbic dopamine pathways in brain
o Supported by fact that antipsychotics work by blockade of D2 receptors & and anti-parkinsonian drugs potentiate the pathway causing symptoms
CFs
Positive and negative symptoms (in first pack of flash cards)
Schneider’s first rank symptoms (alternative tool to ICD-10 for diagnosing schizophrenia)
- Delusional perception (a new delusion forms in response to a real perception w/out any logical sense)
- Third person auditory hallucinations
- Thought interference (insertion, withdrawal, broadcast)
- Passivity phenomenon
Paranoid schizophrenia
- Most common
* Positive symptoms dominant: Delusions + hallucinations
Hebephrenic schizophrenia
- Disorganised speech behaviour + flat or inappropriate affect
- Thought disorganisation predominates
Catatonic schizophrenia
Rare
• Catatonic (psychomotor) symptoms: stupor (no psychomotor activity), mutism, waxy flexibility (maintains position), agitiation, grimacing, echolalia (mimicking another’s speech)…etc
Residual schizophrenia
• 1yr of negative symptoms pre-ceded by a clear-cut psychotic episode (prominent negative symptoms)
Simple schizophrenia
• No delusions or hallucinations (negative symptoms develop w/out positive symptoms)
ICD-10 dx
Present for at least 1 month !!!
At least 1 group A or at least 2 group B
Group A (at least one)
- Thought interference (echo, withdrawal, insertion, broadcast)
- Delusions of control, influence or passivity phenomena
- Running commentary auditory hallucinations
- Bizarre persistent delusions
Group B (at least two)
- Hallucinations in other modalities (senses)
- Thought disorganisation (loosening of associations, neologisms, incoherence)
- Catatonic symptoms (waxy flexibility, negativism, mutism, stupor)
- Negative symptoms (e.g. no motivation, anhedonia, poverty of speech, blunting of affect)
Ix
Bloods
• FBC, U+E, LFT (assess renal function , calcium, glucose
• Suggested by examination: VDRLs (syphilis), TFTs, parathyroid hormone, cortisol, tumour markers
Radiological
• CT or MRI (SOL)
• CXR
Urine
• Drugs screen
• Microscopy + culture (Hx)
Other • EEG (rule out temporal lobe epilepsy) • Special o 24hr cortisol (Cushing’s) o 24hr catecholamine/5-HIAA (Phaeochromocytoma/carcinoid syndrome)
Also: risk assessment + use of mental health act (possible)
Rx
- risk assessment + use of mental health act
- MDT/Care programme approach: psychiatric consultant, GP, community psych nurse, crisis resolution team, social workers, carers + voluntary organisations
Bio-psychosocial approach
Biological approach to rx
o Antipsychotics*
• Atypical (1st line): risperidone
• Typical: haloperidol
• Clozapine (treatment resistant schizophrenia)
o Adjuvants
• BDZs (short-term: behavioural disturbance, aggression…etc)
• Antidepressants + lithium can augment antipsychotics
o ECT
• Appropriate in pt’s resistant to pharmacological agents
• Also good in catatonic schizophrenia
*depot injections considered if pt prefers or compliance problems
Psychological approach to rx
o CBT!!!
o Family intervention (psychoeducation)
o Art therapy (for –ve Sx’s)
o Social skills training → improve interpersonal, self-care and coping skills needed for everyday life
Social approach to rx
o Support groups (e.g. Rethink)
o Peer support worker
o Supported employment programmes
