Schizophrenia

» Psychiatry

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 riskAsymptomatic
II	Prodrome	Cognitive and social deficitsHelp seeking
III	Acute psychosis	Relapse and remittingSuicide risk
IV	Chronic psychosis (Residual)	Medical complicationsDisability

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

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.