Schizophrenia

Overview

Overview Schizophrenia is a complex syndrome often presenting in late teens/early 20s with positive, negative and cognitive symptoms. Positive symptoms include behaviours and thoughts that are not normally present (psychosis). Negative symptoms include social withdrawal and affective flattening. Finally, cognitive symptoms are expressed as a broad set of cognitive dysfunction. The average lifetime prevalence of narrowly defined schizophrenia is just under 1%, but only about half of those affected ever obtain treatment. Schizophrenia on average has a shorter life than the rest of the population. Primary management are 1st and 2nd generation antipsychotics.

Definition
Pscyhosis: "Loss of contact with reality"
Delusion: strongly held false belief that are not typical of patient background and culture
Bizarre Delusions: Delusions that are totally implausible (eg, having been captured by aliens).
Non-Bizzare Delusions: Delusions that are plausible (eg, wife cheating on me).
Hallucination: Wakeful sensory experiences of content that is not actually present
Illusions: Distortion or misinterpretation of real sensory stimuli

Psychiatric Interview

Interview

History

  • History of presenting Illness
  • Medical history - Psychiatric as well
    • Admissions
  • Medication history
  • Drug and Alcohol
  • Forensic History
  • Social History
    • Relationship
    • Work
  • Developmental history
  • MSE
Mini State Examination (MSE) Findings in Shizophrenia
Appearence and Behaviour Desheveled, internally preoccupied, ↓eye contant/intesnse stare, stiff/agitated/slowed
Speech Mumbled, ↓content and spontaneity
Mood and affect Depressed, angry, anxious, flattened and inappropriate affect
Thought form and though content Disorganised, vague, tangential (word salad), focused/preoccupied, bizarre delusions
Cognition Deficits common
Insight Variable
Perception Responds to stimuli

Mental State Examination (ABCDEFGHIJ)

  • Appearence and Behaviours
  • Cognition
  • Delusion (Thought content) 
  • Emotion (mood and affect) 
  • Thought Form
  • Gab (speech)
  • Hallucinations and illusions (perception)
  • Insight and Judgement
When Can Confidentiality be breeched
Duty of Care - patient harm to self/others
Mandatory reporting - child abuse, STI
Criminal Law - police want information
Guardianship act - cases of anorexia
Court ordered - stepede

Risk Factors

  • Prenatal and perinatal events - complication in fetal life and born in late winter, early spring increases risk
  • Paternal age - older fathering increased risk of child
  • Urban environment - more common in disadvantaged areas (less support)
  • Migration status - increased rates amongst migrants
  • Drug abuse - persistant abuse of amphetamine, methamphetamine and cocaine. Cannabis increases rates of psychotic episodes.
  • Social adversity - physical abuse, sexual abuse, maltreatment and bullying

Stages of Schizophrenia

Stages of Schizophrenia and its features 
Stage Description Features
I Risk (Premorbid)
  • Genetic and environmental risk
  • Asymptomatic
II Prodrome
  • Cognitive and social deficits
  • Help seeking
III Acute psychosis
  • Relapse and remitting
  • Suicide risk
IV Chronic psychosis (Residual)
  • Medical complications
  • Disability

Signs and Symptoms

There are two categories of symptoms: positive and negative. The symptoms of schizophrenia usually begin between late adolescence and the mid-30s.

Positive symptoms

  • Hallucination
  • Delusions
  • Disorganised thoughts and speech
  • Disorganised behaviour

Negative Symptoms

  • Apathy
  • Self-neglect
  • Blunted mood
  • Decreased motivation
  • Withdrawal

Cognitive Symptoms

Definition
Disorganized speech (thinking): derailment/loose associations (switching from one topic to another); tangential (answers rarely/loosely related); incoherent/word salad.

Differential Diagnosis

Remember Before diagnosing schizophrenia, remember to rule out any substance abuse, medications, or medical conditions that could be causing the psychotic symptoms.
CHARACTERISTICS OF SCHIZOPHRENIA AND MOOD DISORDERS
 Diagnosis  Psychotic symptoms  Mood Disorder
Schizophrenia  Present Brief duration of mood symptoms
Shizoaffective disorder Present along with and in the absence of mood disorder Present only with psychotic symptoms
Mood disorder Present only during mood disorder Present in the absence of psychotic symptoms

 

Primary psychosis (Illnesses with Psychosis) Clinical features
Schizophrenia
Schizophreniform Duration of symptoms is at least one month but less than six months
Schizoaffective disorder Mood episode concurrent with active-phase symptoms; mood symptoms present for a substantial portion of the disturbance; delusions present for two weeks without prominent mood symptoms
Delusional disorder Nonbizarre delusions, absence of hallucinations, disorganized speech or behavior, negative symptoms
Schizoital personality disorder
PTSD Traumatic inciting event; symptoms relate to reliving or reacting to the event
Obsessive compulsive disorder Prominent obsessions, compulsions, and preoccupations with appearance or body odor, hoarding, or body-focused repetitive behaviors
Substance induced Abnormal vital signs, needle marks, poor nutrition.

 

Secondary psychosis Features
Thyroid disease Coarse hair and skin, exophthalmos, goiter, pretibial myxedema, tachycardia/bradycardia, tremor
Adrenal disease Abdominal striae, buffalo hump, hirsutism, moon face, proximal muscle weakness
Hepatic encelopathy Ataxia, dysarthria, hepatomegaly, hyperreflexia, jaundice, Kayser-Fleischer rings in the cornea
Wilson's Disease
Alzhiemers Disease Cognitive/memory deficits, abnormal results on Mini-Mental State Examination
Huntington's
Stroke
Malignancy Focal neurologic deficits

Investigations

  • FBC
  • Thyroid function test - rule out hyperthyroidism
  • Drug screening
  • HIV screening - HIV can cause psychotic symptoms
  • CT/MRI - rule out malignancy/dementia

Pathophysiology

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Management

Non-pharmacological

  • Cognitive behavioral therapy (commence at risk groups)
  • Medication review
  • Regular review
  • Motivational interviewing, social skills training
  • Electroconculsive therapy

Pharmacological 

First Generation (typical) antipsychotics

  • Haloperidol

Second Generation (atypical) antipsychotics (fewer side effects)

  • Risperidone
  • Olanzapine (not first-line)
  • Closzapine (not first-line)
Pharmacology
First Generation (Typical) Antipsychotics - D2 receptor antagonist in mesolimbic and mesocortical pathways. Side effects: extrapyramidal symptoms (dystonias, Parkinsonan symptos, and akathisia), prolactinemia (impotence, amenorrhea, hynecomastia), and tardive dyskinesia.
Second generation (Atypical) Antipsychotics - D2 receptor antagonist and serotonin 2A receptor antagonist. Side effects: metabolic syndrome, obestiy.

Serious Side-effects of Anti-psychotics

  • Unfortunately, tardive dyskinesia is usually a permanent condition and can be both disfiguring and disabling.
  • Neuroleptic malignant syndrome (NMS) is the most severe potential side effect and can occur with any antipsychotic at any time during treatment
  • Clozapine is beneficial, especially in treatment-resistant schizophrenia, but has a significant adverse effect in that it can cause agranulocytosis.
Scheduling (must assess patient within 24hrs of admission)
Mentally ill or disorder
Facility and treatment available
Risk to themselves or others
Least restrictive method
Practioner must not be a carer or friend
They wont admit voluntarily

Complications and Prognosis

Consequences/Complications

  • Psychological – depression (70%), suicide (10%), substance abuse
  • Social – isolation, relationship loss, interpersonal issues, poor social function
  • Financial – poor academic / work attendance & performance, cost of treatment
  • Family – guilt, worry, shame, stigma
  • Community – discrimination, social disruption, burden on healthcare system

Prognosis

  • 20% -> full recovery
  • 30% -> multiple episodes with reasonable inter-morbid function
  • 50% -> significant ongoing impairment
Good prognostic factors Poor prognostic factor
Acute onset Poor premorbid functioning (most important)
Later age at onset Early onset
Shorter duration Negative symptoms
Female gender Single, divorced, or widowed status
Good cognitive function Poor support system
Good premorbid function
No family history Family history of schizophrenia
Presence of affective symptoms
Absence of structural brain abnormalities
Good response
Good support systems

 

Chronic Schizophrenia

Chronic schizophrenia is an enduring syndrome of delusions, hallucinations, flatness of affect, poverty of speech or incoherence of speech. Other symptoms may occur, including mood symptoms, cognitive problems and movement disorders.

  • Symptoms of schizophrenia may be episodic or continuous.
  • Up to 90% of people with schizophrenia have a chronic physical illness.
  • There is a two-to-three-fold increase in mortality from suicide, accidents and medical disease
  • Increase risk of cardiovascular disease
Remember Ideally, people with chronic schizophrenia should have ongoing access to specialist services, such as a private psychiatrist or public mental health services. Some people with chronic schizophrenia are managed solely by their GP. Many patients struggle to find specialist services that are available, accessible, affordable and acceptable

Treatment

  • Pharmacological
    • Atypical antipsychotics - most frequently used medications in the management of schizophrenia.
    • Atypical antipsychotics
  • Non-pharmacological
    • Education
    • Be aware of, and encourage, engagement with community-based services.
    • Support family and/or carers.
    • Consider practical needs (eg housing)
    • Consider language and cultural barrier
    • CBT - treat persistent auditory hallucinations
    • Regular daily exercise

Monitoring

  • Smoking status
  • Weight
  • Waist circumference
  • Blood Pressure
  • Fasting glucose
  • Lipids
  • Prolactin
  • ECG
  • LFT
  • Neurological examination
  • Eye examination
  • Contraception (women)
Remember Metabolic syndrome has become more prevalent due to the use of newer antipsychotics, which have been associated with greater weight gain and higher fasting glucose, cholesterol and lipid levels

References

UpToDate
Best Practice
Holder., SD & Wayhs., A, (2014). Schizophrenia. American Family Physician. 90 (11). 775-782.
Hope., J, Keks., N, (2015). Chronic schizophrenia and the role of the general practiontioner
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