Schizophrenia

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Lack of a confiding relationship. • Unemployed. • Socio-economic deprivation. • Neurochemical. • Monoamine hypothesis. • Chronic stress. • Increased cortisol.

Schizophrenia Epidemiology • 15-20/100,000 individuals per year • Peak incidence in late teens+ early adulthood Classification • Paranoid • Most common • Delusions and auditory hallucinations • Catatonic • Psychomotor disturbance • Rigidity, posturing (waxy flexibility) • Echolalia (copying speech) • Echopraxia (copying behaviour) • Hebephrenic • Early onset and poor prognosis • Behaviour irresponsible and unpredictable • Fleeting hallucinations and delusions • Simple • Only negative symptoms • Chronic • History of one or more episodes Aetiology • Genetic component • Neurodevelopmental hypothesis • neonatal - increased rates in those born in winter....increased chance of maternal influenza, obstetric complications, low birthweight and perinatal injuries • supported by Ct/MRI findings of increased ventricular size and reduced grey matter • cannabis smoking in teens • Social factors • Socio-economic deprivation • Afro-caribbean/Black African • Life-events • Predisposing factors • Increased stress • Increased emotion • Increased levels of criticism Differential Diagnosis • Brief Psychotic disorder • Delusional disorder • Manic depression • Alcoholic hallucinations • Organic psychosis (e.g. drug abuse) Management 1. Antipsychotics 2. Psychological - CBT, support, family therapy 3. Social - return to work, increase self-esteem 4. ECT (catatonic)

Clinical Features First-rank symptoms 1. Auditory Hallucinations • Third person (talking about individual) • Running commentary • Thought echo (hearing ones own thoughts out loud) 2. Thought • Withdrawal (removed from ones brain) • Insertion • Broadcast (thoughts available to others) 3. Passivity (Actions can be influenced/ controlled by outside influence) 4. Delusional Perception (ascribing a delusional meaning to a real perception) Second-rank symptoms • Catatonic behaviour • Secondary delusions • Other hallucinations Thought/Speech disorders • Neologisms (new words/ordinary words in new way) • Concrete thinking (can’t deal with abstract ideas) • Word salad • Flight of thought/knight move thinking Delusions 1. Persecutory (someone intends to harm them) 2. Paranoid (someone talking about them) Other Symptoms Depression, anxiety, agitation, withdrawal, inappropriate eating behaviour, incontinence, self harm, destruction of possessions, massive water intake Division of symptoms 1. Positive (hallucinations, delusions) 2. Negative (poverty of speech, flat effect) 3. Cognitive (poor attention & memory) Prognosis • 20% of patients will make full recovery • 35% have long periods of remission • 35% have persistent mild positive and negative symptoms that are manageable in the community • 10% unresponsive to treatment

Depression Definition “Pervasive lowering of mood with reduced enjoyment and energy and negative thinking” Classification ICD-10 1. Core Symptoms (Blue) 2. Other Symptoms (Bold) Mild Depression = 2 core + 2 others Moderate Depression = 6 symptoms (inc. 2 core) Severe Depression = 8 symptoms (inc. 3 core) which causes marked interference with daily activities Symptoms must be present every day for at least 2 weeks N.B. depression with psychotic symptoms is always severe Aetiology • Genetic susceptibility (FHx often) • Psychosocial • Life factors –i.e. social situation – e.g. single mums • Vulnerability • Lack of a confiding relationship • Unemployed • Socio-economic deprivation • Neurochemical • Monoamine hypothesis • Chronic stress • Increased cortisol • Alcohol/drug misuse • Abuse (sexual or not) – particularly in childhood • Previous psychiatric diagnosis • Chronic disease • Post natal (10% of all women who give birth!) Management Mild Depression • Watchful waiting, CBT, self-help, exercise Moderate and severe Depression • Medication • Psychological interventions High Risk • All of the above • ECT

Epidemiology • Lifetime risk 5-10% • 2F:M • Peak incidence in late 20s Clinical Features Mood/effect • Low mood with/without diurnal variation • Irritable or unreactive effect • Anhedonia Biological • Altered sleep, libido, appetite, weight • Self neglect • Increased fatiguability • Agitation/retardation Thought Content • Anxiety • Guilt • Worthlessness • Suicide/self harm • Pessimistic • Mood congruent delusions • Reduced self esteem Abnormal perceptions • 2nd person auditory hallucinations Cognition • Decreased attention & concentration • Negative cognitions (Beck’s cognitive triad: pessimistic thoughts about self, world, future) Medications 1. SSRIs (e.g. fluoxetine, citalopram) • 1st line • SEs: nausea, vomiting, abdo pain, sexual dysfunction • Allow 4-6 weeks for effect 2. Others • Tricyclic • MAOIs • NASSA • St John’s Wort

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