THE PERSON WITH PSYCHOTIC SYMPTOMS
SCHIZOPHRENIA “divided in the mind”
< 1% of population (20 /100 000 or 16000 new cases in NSW) DDX
Ø 1/3RD do NOT becoming lifelong Ø Drug-induced psychosis (e.g. from recent steroid usage)
Epi Ø 20 year shorter life expectance Ø Psychotic disorder = disorders manifesting with delusional beliefs
ranging from è brief psychotic disorder è psychosis
Ø Higher rates in low SES, ATSI, pacific islanders
• NO specific biological marker
• Strong inheritance – FHx (e.g. specific deletions – 22q11) ® of schizophrenia, substance abuse
• Pregnancy / birth complications (e.g. malnutrition, toxin or viral exposure ante-natal period)
RF • Use of psychoactive drugs during teens and young adulthood (Nb: persistent drug use predicts re-admission BUT does NOT increase risk of
being diagnosed with schizophrenia)
• Childhood trauma
Schizophrenia = neurodegenerative manifestation group of disorders [AS AVERAGE BRAIN VOL lower at diagnosis)
PP • LOSS OF GRAY MATTER + ENLARGED VENTRICLE + LOSS OF SYNAPSES
• Abnormal dopamine pathways (NOT imbalance of dopamine) ® causes Movement disorders
• Has prodrome (period between onset of premorbid mood changes (e.g. irritable, communication issue, social isolation) AND
symptoms of psychosis – acute manic episode, hallucinations, delusions
o Often incorrectly diagnosed as ADHD
Define Ø DSMV criteria for schizophrenia = 2 -for-6-ophrenia (> 2 symptoms for 6 months) ® AT LEAST ONE MUST BE 1,2 OR 3
/Sx
Positive (1st rank) Schneider symptoms Negative symptoms (5 A’s)
Increased mesolimbic and nigrostriatal pathway (XS dopamine) Hypoactive mesocortical pathway
Good
prognosis 1) Delusion = firm fixed beliefs (MAIN) Ø AFFECT / APATHY – BLUNTED
signs: a. Delusion of thought interference (thought insertion, Ø AMBIVALENCE – self-neglect (poor hygiene)
withdrawal or broadcasting – someone knows their Ø ALOGIA - Poverty of speech – naturally quiet (due to
• Acute thoughts OR thought control) voices in head)
onset b. Delusional perception (e.g. picking up coin make me Ø ANHEDONIA
• Catatonia the son of God) Ø ASOCIALITY - social withdrawal / isolation
• Low mood 2) Hallucinating (visual, somatic, olfactory, auditory – voices in 3rd Ø impaired cognitive function (memory, attention)
person or running commentary) OFTEN more disabling than positive symptoms AND less
3) Disorganised speech, (e.g. clanging, word salad, neologisms) responsive to treatment
• Disorganised or catatonic behavior (motor symptoms) *Negative Sx makes schizophrenic a chronic condition
• Delusional disorder [does NOT meet criteria A of schizophrenia)
o ≥ 1x delusions >1/12
o Does NOT impair social/occupational function
o Manic, MDD are brief and related to delusion
• Schizophreniform disorder = schizophrenia syndrome <6/12 duration
o Has episode of mood disturbance occurs in the presence of 1-3 above, AND
o mood symptoms present in both the active and residual phase of the illness
• Brief psychotic disorder = schizophrenia syndrome <1/12 duration ® delusion remit
with return of insight
• Schizo-affective disorder = distinct episodes of mania or severe depression (mood
changes) >2 weeks PLUS schizophrenia syndrome
DDx. • Psychosis NOT otherwise specified (NOS)
SUBSTANCE-induced psychosis (SIP) = TOXIC DELIRIUM Substance exposed schizophrenia (SES)
• Prolonged and heavy substance use • Small doses need
• Prolonged insomnia • 1st rank symptoms – auditory hallucinations,
• Illusions NOT hallucinations thought broadcasting
• Normal thought and behaviour (e.g. fear) • Schizophrenic disorder of form of thought
• Ideas NOT delusions of reference (e.g. believing people in passing city bus • Basis of Beliefs often bizarre
are talking about them) • Residual negative symptoms
• Plausible persecutory beliefs
• High level of arousal and anxiety
• Other psychiatric conditions (anxiety, depression) Poor prognosis
• Social impairment (work, finances, relationships) Ø No trigger ® Gradual onset with prodrome of social withdrawal
Comp. • Substance abuse (e.g. alcohol, nicotine) Ø Low IQa
Ø FHx
• Suicide risk ® RoSH to others and community
Ø prodro
• Physical exam (neurological) Specific tests for encephalitis • ECG
• FBC, EUC, LFT, • Anti-NMDAR - autoimmune encephalitis • MRI brain – smaller brain volume
Ix • Fasting BSL, lipids, • Anti-VGKC - Limbic autoimmune encephalitis, • Urine drug screen
• TFT epilepsy, neuromyotonic (Isaac’s syndrome) • EEG
• HIV and Hepatitis screen • Anti-GAD – T1DM • STI screen (if indicated – neurosyphilis)
Non-Pharm Pharmacological
• De-escalate verbally if possible • Anti-psychotics (Dopamine antag)
• CBT or psychodynamic psychotherapy o 1st line = PO risperidone OR
• MDT (best) = (1) rehab then provide (2) social support o PO clozapine (weak D2 blocker) for Rx resistant schizo
to meet residual disability (e.g. case management) o reduce/abolish both +ve symptoms [mainly] and -ve symptoms
Mx o SANE Australia
*Olanzapine taken the longest by sufferers BUT wt gain
• Generate insight of illness and need for treatment NB:
• Treat comorbid substance use (S/A/D) • 1/3rd of patients are resistant to medications –
(most are smokers!!!)
• Fast vs slow metabolisers = start slow and titrate up
• Treat depression (6% die from suicide)
• Become less responsive with time
• ECT (last resort)
, STAGING OF SCHIZOPHRENIA
SCHIZOPHRENIA “divided in the mind”
< 1% of population (20 /100 000 or 16000 new cases in NSW) DDX
Ø 1/3RD do NOT becoming lifelong Ø Drug-induced psychosis (e.g. from recent steroid usage)
Epi Ø 20 year shorter life expectance Ø Psychotic disorder = disorders manifesting with delusional beliefs
ranging from è brief psychotic disorder è psychosis
Ø Higher rates in low SES, ATSI, pacific islanders
• NO specific biological marker
• Strong inheritance – FHx (e.g. specific deletions – 22q11) ® of schizophrenia, substance abuse
• Pregnancy / birth complications (e.g. malnutrition, toxin or viral exposure ante-natal period)
RF • Use of psychoactive drugs during teens and young adulthood (Nb: persistent drug use predicts re-admission BUT does NOT increase risk of
being diagnosed with schizophrenia)
• Childhood trauma
Schizophrenia = neurodegenerative manifestation group of disorders [AS AVERAGE BRAIN VOL lower at diagnosis)
PP • LOSS OF GRAY MATTER + ENLARGED VENTRICLE + LOSS OF SYNAPSES
• Abnormal dopamine pathways (NOT imbalance of dopamine) ® causes Movement disorders
• Has prodrome (period between onset of premorbid mood changes (e.g. irritable, communication issue, social isolation) AND
symptoms of psychosis – acute manic episode, hallucinations, delusions
o Often incorrectly diagnosed as ADHD
Define Ø DSMV criteria for schizophrenia = 2 -for-6-ophrenia (> 2 symptoms for 6 months) ® AT LEAST ONE MUST BE 1,2 OR 3
/Sx
Positive (1st rank) Schneider symptoms Negative symptoms (5 A’s)
Increased mesolimbic and nigrostriatal pathway (XS dopamine) Hypoactive mesocortical pathway
Good
prognosis 1) Delusion = firm fixed beliefs (MAIN) Ø AFFECT / APATHY – BLUNTED
signs: a. Delusion of thought interference (thought insertion, Ø AMBIVALENCE – self-neglect (poor hygiene)
withdrawal or broadcasting – someone knows their Ø ALOGIA - Poverty of speech – naturally quiet (due to
• Acute thoughts OR thought control) voices in head)
onset b. Delusional perception (e.g. picking up coin make me Ø ANHEDONIA
• Catatonia the son of God) Ø ASOCIALITY - social withdrawal / isolation
• Low mood 2) Hallucinating (visual, somatic, olfactory, auditory – voices in 3rd Ø impaired cognitive function (memory, attention)
person or running commentary) OFTEN more disabling than positive symptoms AND less
3) Disorganised speech, (e.g. clanging, word salad, neologisms) responsive to treatment
• Disorganised or catatonic behavior (motor symptoms) *Negative Sx makes schizophrenic a chronic condition
• Delusional disorder [does NOT meet criteria A of schizophrenia)
o ≥ 1x delusions >1/12
o Does NOT impair social/occupational function
o Manic, MDD are brief and related to delusion
• Schizophreniform disorder = schizophrenia syndrome <6/12 duration
o Has episode of mood disturbance occurs in the presence of 1-3 above, AND
o mood symptoms present in both the active and residual phase of the illness
• Brief psychotic disorder = schizophrenia syndrome <1/12 duration ® delusion remit
with return of insight
• Schizo-affective disorder = distinct episodes of mania or severe depression (mood
changes) >2 weeks PLUS schizophrenia syndrome
DDx. • Psychosis NOT otherwise specified (NOS)
SUBSTANCE-induced psychosis (SIP) = TOXIC DELIRIUM Substance exposed schizophrenia (SES)
• Prolonged and heavy substance use • Small doses need
• Prolonged insomnia • 1st rank symptoms – auditory hallucinations,
• Illusions NOT hallucinations thought broadcasting
• Normal thought and behaviour (e.g. fear) • Schizophrenic disorder of form of thought
• Ideas NOT delusions of reference (e.g. believing people in passing city bus • Basis of Beliefs often bizarre
are talking about them) • Residual negative symptoms
• Plausible persecutory beliefs
• High level of arousal and anxiety
• Other psychiatric conditions (anxiety, depression) Poor prognosis
• Social impairment (work, finances, relationships) Ø No trigger ® Gradual onset with prodrome of social withdrawal
Comp. • Substance abuse (e.g. alcohol, nicotine) Ø Low IQa
Ø FHx
• Suicide risk ® RoSH to others and community
Ø prodro
• Physical exam (neurological) Specific tests for encephalitis • ECG
• FBC, EUC, LFT, • Anti-NMDAR - autoimmune encephalitis • MRI brain – smaller brain volume
Ix • Fasting BSL, lipids, • Anti-VGKC - Limbic autoimmune encephalitis, • Urine drug screen
• TFT epilepsy, neuromyotonic (Isaac’s syndrome) • EEG
• HIV and Hepatitis screen • Anti-GAD – T1DM • STI screen (if indicated – neurosyphilis)
Non-Pharm Pharmacological
• De-escalate verbally if possible • Anti-psychotics (Dopamine antag)
• CBT or psychodynamic psychotherapy o 1st line = PO risperidone OR
• MDT (best) = (1) rehab then provide (2) social support o PO clozapine (weak D2 blocker) for Rx resistant schizo
to meet residual disability (e.g. case management) o reduce/abolish both +ve symptoms [mainly] and -ve symptoms
Mx o SANE Australia
*Olanzapine taken the longest by sufferers BUT wt gain
• Generate insight of illness and need for treatment NB:
• Treat comorbid substance use (S/A/D) • 1/3rd of patients are resistant to medications –
(most are smokers!!!)
• Fast vs slow metabolisers = start slow and titrate up
• Treat depression (6% die from suicide)
• Become less responsive with time
• ECT (last resort)
, STAGING OF SCHIZOPHRENIA
