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PSYCHSOC REVISION SESSION 2 psychosis and schizophreniaSchedule 18:00-18:05 Introductions Chloe (PsychSoc president) 18:05-18:20 Definition, aetiology/risk factors and subtypes of schizophrenia 18:20-18:30 Clinical features 18:30-18:40 Investigations, differentials and diagnosis 18:40-18:55 Management 18:55 to end Summary and exam approachdefinition psychosis vs schizophrenia aetiology and pathophysiology of schizophrenia aetiology pathophysiology Neurodevelopmental vs dopamine theories Urbanicity and social disadvantage Obstetric Migration and complications ethnicity Genetics Schizophrenia Substance use disorderssubtypes of schizophrenia ▪ Paranoid schizophrenia ▪ Hebephrenic schizophrenia ▪ Catatonic schizophrenia ▪ Undifferentiated schizophrenia ▪ Residual schizophrenia ▪ Simple schizophreniatimeline ARMS CHRONIC PHASE Aat-risk mental Development of state negative symptoms ACUTE RECOVERY PHASE Hopefullythe Most striking patient recovers positive symptoms or remains with present symptoms for life clinical features Thought echo, insertion or withdrawal and Blunted affect broadcasting Thought disorder Hallucinations Poor self-care Apathy Lack of insight Passivity and Poverty of somatic passivity speech Social isolation Laboratory investigations ▪ Relevant laboratory investigations include: ▪ Baseline blood tests: including FBC, TFTs, U&Es, LFTs, CRP and a fasting glucose investigations ▪ Urine culture: to rule out urinary tract infection causing delirium ▪ Urine drug screen: to rule out drug intoxication ▪ HIV testing if applicable ▪ Syphilis serology if applicable ▪ Serum lipids: before starting antipsychotics ▪ Baseline ECG: before starting antipsychotics ▪ Imaging ▪ CT head: if an organic neurological cause is suspected differential diagnoses ▪ Acute and transient psychotic disorder ▪ Schizoaffective disorder ▪ Delusional disorder ▪ Schizotypal disorder ▪ Post-partum psychosis ▪ Personality disorder diagnosis 1. According to ICD-10, a diagnosis of schizophrenia requires: ➢ A first-rank symptom or persistent delusion present for at least one month: o Delusional perception o Passivity o Delusions of thought interference: thought insertion, thought withdrawal and/or thought broadcasting o Auditory hallucinations: thought echo, third-person voices and/or running commentary 2. No other cause for psychosis such as drug intoxication or withdrawal, brain disease (including dementia/delirium/epilepsy), or extensive depressive or manic symptoms (unless it is clear that schizophrenic symptoms antedate the affective disturbance).management MDT support: ▪ Early intervention team (initial referral after the first psychotic episode) ▪ Community mental health team (provide day-to-day support and treatment) ▪ Crisis resolution team (for patients experience an acute psychotic episode) Admission into acute care: ▪ Some patients with schizophrenia may require an inpatient stay. ▪ Most patients are admitted voluntarily but occasionally they may be detained under the Mental Health Act. Risk assessment: ▪ Risk to self ▪ Risk to others ▪ Risk from others antipsychotics Key points: Typical antipsychotics Atypical antipsychotics Mechanism of Dopamine D2 receptor Act on a variety of ▪ Oral atypical antipsychotics are action antagonists, blocking receptors (D2, D3, D4, 5- first-line dopaminergic HT) ▪ Cognitive behavioural therapy transmission in the mesolimbic pathways should be offered to all patients ▪ Close attention should be paid to Adverse Extrapyramidal side- Extrapyramidal side- cardiovascular risk-factor effects effects and effects and modification due to the high rates hyperprolactinaemia hyperprolactinaemia less of cardiovascular disease in common common Metabolic effects schizophrenic patients (linked to antipsychotic medication and Examples Haloperidol Clozapine high smoking rates) Chlorpromazine Risperidone Olanzapineside effects Extrapyramidal side-effects Other side-effects: (EPSEs): Risks when antipsychotics are used in elderly ▪ Antimuscarinic: dry mouth, ▪ Parkinsonism patients: blurred vision, urinary ▪ Acute dystonia retention, constipation ▪ Sustained muscle ▪ increased risk of stroke ▪ Sedation, weight gain contraction (e.g. torticollis,▪ increased risk of venous ▪ Raised prolactin oculogyric crisis) ▪ May result in ▪ May be managed with thromboembolism galactorrhoea procyclidine ▪ Impaired glucose tolerance ▪ Akathisia (severe restlessness) ▪ Neuroleptic malignant ▪ Tardive dyskinesia (late syndrome: pyrexia, muscle onset of choreoathetoid stiffness movements, abnormal, ▪ Reduced seizure involuntary, may occur in 40% High-yield threshold (greater with of patients, may be topic in atypicals) MCQs irreversible, most common ▪ Prolonged QT is chewing and pouting of jaw) interval (particularly haloperidol)monitoring Test Frequency Full blood count (FBC), urea and ▪ at the start of therapy High-yield electrolytes (U&E), liver function ▪ annually topic in tests (LFT) ▪ clozapine requires much more MCQs frequent monitoring of FBC (initially weekly) ▪ at the start of therapy Lipids, weight ▪ at 3 months ▪ annually Fasting blood glucose, prolactin ▪ at the start of therapy ▪ at 6 months ▪ annually Blood pressure ▪ baseline ▪ frequently during dose titration Electrocardiogram ▪ baseline Cardiovascular risk assessment ▪ annually prognosis ▪ Suicide: the lifetime risk of suicide is approximately 5% ▪ Cardiovascular disease: there is an increased risk of premature death due to cardiovascular disease, in addition, patients with schizophrenia are more likely to smoke ▪ Cancer: delayed diagnosis and late presentation of cancer ▪ Substance abuse: up to one-third of patients with schizophrenia use drugs ▪ Social isolation ▪ Factors associated with poor prognosis: ▪ strong family history ▪ gradual onset ▪ low IQ ▪ prodromal phase of social withdrawal ▪ lack of obvious precipitant Schizophrenia is a long-term mental health problem that affects thinking, perception and affect. Schizophrenia affects about 1 in 100 people (men and women are equally affected). There are six main subtypes: paranoid, hebephrenic, catatonic, undifferentiated, residual schizophrenia and simple. summary Symptoms can be divided into positive and negative. Patients with schizophrenia will usually be managed with a multidisciplinary care programme approach. Atypical antipsychotics are used first-line in the management of schizophrenia but regular monitoring is needed MCQ practicefollow us! @sotonpsychsocThanks Any questions?