Transcript Diapositiva 1 - Intranet for MMHSCT SHOs

Schizophrenia
Greg Chick
SHO Psychiatry, Royal Manchester
Children’s Hospital
What do I Really Have to Know?
Prevalence (quoted as 1% worldwide)
Age of onset 20ish, (40ish, 70ish)
Differential Diagnosis
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Think ORGANIC!
Drug-induced psychosis, Psychotic depression,
mania, (schizoaffective disorder), schizotypal
personality disorder
Psychopathology
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Define: Delusion, Hallucination
WHY do I need to know about Sz?
GP
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Front line service
Early detection improves prognosis!
worried relatives asking you to section people
Increased burden
Surgeons / Obs & Gynae – delusional pts insisting on
unnecessary operations
A&E – pts present with overdose, bizarre behaviour &
complaints
Paediatrics – child protection issues; early onset
psychosis
Psychiatry – bread & butter!
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frequent LONG admissions
Definition of Schizophrenia
a “severe and enduring mental illness”
A clinical syndrome
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“a collection of features which tend to occur together”
Refined over last 200 years or so
Recognised pattern of outcome
Same methods of treatment
Biological basis; severe psychosocial consequences
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No definitive cause or mechanism yet identified
(multifactorial – see Theory Lecture)
Neurochemical imbalance
‘reality testing’ and ‘theory of mind’ defective
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+ loss of ‘ego boundaries’ – (what is Me and what is
Outside)
BUT there is still no single concise definition!
Myths & Misconceptions
‘Schizophrenia’ does literally mean ‘separated
mind’
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Greek – applied by Bleuler in 1911
BUT is nothing to do with ‘split personality’
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Let alone ‘multiple personality’ (very rare)
HAS to do with the brain’s functions separating
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Eg. Hear a voice but don’t recognise it’s come from
your own mind
Heritable Risk
Risks for family members with
schizophrenia
Single parent: 10% risk
Both parents: 25% risk
Sibling: 10% risk
Twin: 50% risk
Clear-cut genetic loading proven by adopted away
twin studies
Not 100% genetic since risk with identical twins is
only 50%.
Multifactorial with multiple genes and environmental
factors (viral, toxins, drugs, alcohol, psychological
stressors)
Clinical features
“Prevalence 1% in all countries”
Gradual onset
Onset at late adolescence/early adulthood
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But can occur AT ANY AGE
Smaller peak around 40yrs (late onset)
Even smaller peak around 70yrs! (late late onset)
Progressive decline in function
Deficit symptoms predominate
Family history of schizophrenia
Age of Onset – Bimodal Distribution
Historical – spotting the patterns,
grouping the symptoms
1900’s Kraepelin and Bleuler
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Kraepelin’s ‘Dementia praecox’
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premature loss of mind; inevitable decline (13%
recovered)
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Bleuler’s 4 A’s:
‘Autism’ (withdrawal into own fantastic world)
Associations loosened (eg chaotic thinking & speech)
Affect (blunted or incongruous)
Ambivalence (love & hate, want / not want)
Historical – spotting the patterns,
grouping the symptoms
1950’s - Schneider’s 1st Rank Symptoms:
1. Primary Delusion = ‘delusional percept’
2. Own thoughts spoken aloud = ‘thought echo’
3. Voices arguing or discussing
4. running commentary voices
5. thought withdrawal and/or thought block
6. Thought insertion
7. thought broadcasting (others are thinking it at the same time as you)
8. Made to feel… ‘passivity of affect’
9. Made to want… ‘passivity of impulse’
10.Made to do… ‘passivity of volition’
11.Done to my body ‘somatic passivity’ eg probed by aliens
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Some may occur in illnesses other than schizophrenia eg mania, dementia, delusional
disorder
Natural History & Prognosis
Often poor
Commonly leads to social disability
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Many long admissions to hospital
Unemployment, reliance on benefits
Homelessness (though not usually ‘on the streets’)
Isolation – loss of contact with friends, not making new ones
stigma
Lack of insight => non-compliance with meds, despite need for life-long
treatment in most cases. * psycho-education, relapse prevention, family work
Tardive dyskinesia
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Occurs even without drug Rx but seems worse with Dopamine antag’
(involuntary facial / truncal twitching / writhing movements – essentially
untreatable)
Much more physical disease
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Also side effects of medication
5 Year Outcome after First Presentation
one episode,
no impairment
16%
impairment
increasing with
each episode
43%
9%
residual
impairment,
several
episodes
32%
several
episodes,
minimal
impairment
Types of Schizophrenia: ICD-10
F20 Schizophrenia
 F20.0 Paranoid Schizophrenia
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F20.1 Hebephrenic Sz
F20.2 Catatonic Sz
F20.3 Undifferentiated Sz
F20.4 Post-Schizophrenic Depression\
F20.5 Residual Sz
F20.6 Simple Sz
Types of Schizophrenia: ICD-10
F20.0 Paranoid Schizophrenia
most common type – hallucinations & delusions
‘paranoia’ from the Greek – reference to the Self
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(it’s ME they’re out to get, not anyone else)
Hebephrenic Sz
Cartoon mad person – laughing inappropriately, crying, chaotic
Only seen in young people
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Catatonic Sz
Historical asylum cliché – strange postures / muteness / manerisms
Less commonly seen now, more common in mania or severe
depression
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Residual Sz – chronic low-grade oddness
Simple Sz – hermit-like retreat from society
Prodromal / Early Symptoms
Symptoms one month to one year before psychotic
crisis
Person feels something strange or weird is
happening to them
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Perplexity, “delusional atmosphere”
Misinterprets things in the environment
Feelings of rejection, lack of self-respect,
loneliness,hopelessness, isolation, withdrawal, and inability to
trust others.
Categories of Symptoms
Symptoms may be classified as
 “Positive” – symptoms i.e. hallucinations, delusions,
bizarre behavior, disorganized speech
 “Negative” – lack of normal experiences:
apathy, lack of motivation, anhedonia (inability to enjoy
normal pleasures)
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Cognitive - i.e. difficulty with selective attention,
memory, planning and problem solving
Disorganized – i.e. disorganized speech,
inappropriate affect
Differential diagnosis
THINK ORGANIC first!
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Delirium tremens, alcoholic hallucinosis, brain tumor,
toxins
Rare metabolic disorders
Huntington’s Disease (psychiatric symptoms
predominate!)
Drug induced: cannabis, amphetamines, Cocaine,
LSD, PCP
Mania; depression with psychotic features
Schizoaffective disorder (equal proportion of
psychotic & affective symptoms)
Mental state abnormalities in Sz
Thought
Perception
Behaviour
Catatonia
Form
Content
Illusions
Hallucinations
Pseudohallucinations
Delusions
Circumstantiality
Fusion
Auditory
Knight´s Move Thinking
Tactile
Derailment
Visual
Word Salad
Olfactory & Gustatory
Thought Block
Overvalued Ideas
Delusions - definition
“A delusion is a false, unshakeable idea or belief which
is out of keeping with the patient’s educational, cultural
and social background” – Simms
* we can never understand how they arrived at the
belief – defies normal logic *
BUT
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Need not be totally unshakeable – cognitive therapy for
delusions
Need not be false (eg delusional jealousy then discover
partner actually IS unfaithful)
Wrongly ARRIVED at belief
Primary Delusion – ‘out of the blue’
Secondary Delusion – arises out of eg. hallucination
Delusions - examples
I am the son of George W Bush
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…by a somali woman. They were on holiday there
and left me behind.
I have a microchip in my brain which transmits
my thoughts to MI5
There’s a man living in my loft who’s trying to
drive me out of my house. He kills pigeons and
eats them.
My family are poisoning my food. It tastes funny
Hallucination
A perception, which feels real, but has no real stimulus
Modalities:
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Auditory
heard as if coming from outwith your head inc. from another part of
the body!
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Visual (more indicative of organic pathology!)
Somatic / Sexual
Gustatory
Olfactory
Non-pathological
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Hypnagogic (going off to sleep)
Hypnopompic (waking up)
When it’s NOT a hallucination
Illusion = misperception of a REAL stimulus
Daydream = imagery
Pseudohallucination
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Occurs in inner subjective space
eg voices INSIDE your head
May have quality of your own thoughts
Distressed patients not interested in this distinction!
Thought Disorder in Schizophrenia
Circumstantiality (goal eventually reached but tortuously indirect
and over-inclusive)
Knight’s Move Thinking
 Illogical jumping between ideas. Listener can’t follow train of
thought.
 “I can’t go to the zoo, no money. Oh... I have a hat - these
members make no sense, man… What’s the problem?”
 NOT the same as Flight Of Ideas, which you CAN follow
Derailment (just losing the plot – goal of speech not reached)
Fusion (themes recur but in odd order, hard to follow)
Thought Block (‘snapping off ’ train of thought. No thoughts
left)
Case Vignette - 2
Brian began to be a worry to his parents at the age of 17. After doing quite
well in his GCSEs, he seemed to lose interest and his ability to concentrate on
his studies. He began to spend more time alone in his room listening to music
and when he went out with his friends, he appeared dazed and distant on
returning home.
His parents suspected he was taking drugs but he denied this. When his
mother went into his bedroom to tidy up one day, she found that he had
draped a cloth over the mirror. He explained this by saying that he avoided
looking at his face because he had a strange look in his eyes, as though he had
become hypnotised. His parents tried to persuade him to visit their GP, but
he refused to go. He became very quarrelsome and one day he punched one
of his friends without warning. That evening, he removed all the light bulbs
from their sockets after complaining that they were emitting dangerous
radiation. His parents took him to hospital and he was admitted.
Negative Symptoms
Develop over time
May not be detected (masked by positive
symptoms
Negative symptoms include: poverty of speech
content, thought blocking, anergia, anhedonia,
affective blunting, and lack of volition.
Where can I find out more?
“Symptoms in the Mind” Andrew Simms
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(the ‘bible’ for descriptive psychopathology)
NICE guidelines
www.abpi.org.uk/publications/publication_details/targetSchizophrenia2003/section2.asp
Bryan L. Roth, rothlab, (ppt presentation)
Melinda Hermanns (ppt presentation)
Douglas Ziedonis (ppt presentation)
Quiz
2) Can you diagnose Sz in a patient who has been hearing voices for 2 weeks?
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No. Need >= 1 month of symptoms
3) do drugs cause Sz?
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Cannabis use in susceptible individuals increases risk X 6
Amphetamine, cocaine/crack cause identical syndromes
4) do pts with Sz smoke more than other people?
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70-90% are addicted to smoking
Neuropsychological basis for this – startle response
Lack of other activities in hospital & outside
5) Are pts with Sz more violent than the rest of the population?
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Essentially not. Paranoia & hallucinations make pts frightened. Restraining people
ditto. Sz pts have higher rates of drug & alcohol problems, lower IQ in general
6) ‘Psychotic’ nowadays refers to the bizarre phenomena described above (eg
hallucinations, delusions), the perplexed state and being out of touch with
reality. Not about being violent or cruel as per Hollywood usage.
1) still have other questions?