On Car Parks, Dead Kings, and Schizophrenia

Posted on January 25, 2013

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Hi everyone!

I’m baaaaack! 

Finally discovered in a Leicester car park, Richard III loses 528 year game of Hide and Seek.

Finally discovered in a Leicester car park, Richard III loses 528 year game of Hide and Seek.

I know it’s been a while since I last posted anything at all, so apologies all round (and especially to my mother, who I imagine sits in the dark waiting for her google alert to tell her I’ve finally updated my blog). I’ve been playing hide and seek with the internet, and although I’ve been gone a while, it certainly pales into insignificance when you think that poor old Richard III, who’s been playing hide and seek for the past 500 years, just lost. Turns out he was under a car park in Leicester this entire time. Anyway, I really have been meaning to update for a long time (promise), but life somewhat got in the way and, well, here we all are. Thanks for this new post should probably go to a new twitter follower of mine- @fakethom – who tweeted a link to my blog and made me feel bad that there hadn’t been any new material in such a long time.

Well, in my time away I’ve passed T year (that’s transition year for those not up on the lingo, first clinical year), and have since completed attachments in renal medicine, breast surgery and specialties (a 6 week whirlwind of rheumatology, dermatology, ophthalmology, ENT, audiology, plus trauma and orthopaedics). And now I’m delving deep into the mysterious world of psychiatry. I’ve had a pretty slow start, what with being based with old age psych and half the doctors being struck down with D&V, but this week everything changed.

Monday began fairly uneventfully- a referrals meeting, a few home visits. But then Tuesday came, and a new mood is DEFINITELY in the air. Tuesday morning was one of the most harrowing experiences I’ve had since being at medical school, spending the morning with the eating disorders team. Really interesting but equally upsetting, and for me quite unexpectedly so. And then on Thursday I went along to psychiatric intensive care. It’s always reassuring when you turn up on a new ward only to be handed a panic alarm. I was assured I probably wouldn’t need to use it, but still, the anxiety was starting to rise. It was the PICU ward round that has provided the inspiration for this post, as this condition was what the majority of patients were being treated for…

SCHIZOPHRENIA

It might be worth starting by saying that schizophrenia is NOT ‘split personality’, even though it translates as splitting of the mind or something to that effect- the term apparently was meant to describe “the separation of function between personality, thinking, memory and perception”.

Schizophrenia is a psychotic disorder (cf neurotic disorders), and so is a disease of abnormal thoughts and perceptions. There isn’t any one single pathology identified, and aetiology is multifactorial, with genetics, neurochemical disturbances, neurodevelopmental pathology and environmental factors all contributing.

Epidemiology

Lifetime risk of developing schizophrenia is 1%

Prevalence is 0.5-0.8%

Onset between 16 and 50 years (but most commonly in early adulthood)- interestingly, age of onset in males tends to be earlier (5 years on average)

Male : Female incidence ration is about 1.4

Similar rates are reported in all cultures.

Schneider’s 11 “First Rank Symptoms” of Schizophrenia

Well done to anyone at home who got one of the 'pointless' answers in this round.

Well done to anyone at home who got one of the ‘pointless’ answers in this round.

I’m reliably informed following a lecture this week that Schneider was a german doctor, who fought in World War I and then obtained a postgraduate degree in psychiatry. Somewhere along the way, he described his 11 “First Rank” symptoms of schizophrenia. We here at matthewheron.wordpress.com asked 100 people to name Scheider’s First Rank Symptoms, see if you can spot a ‘Pointless’ answer at home:

–       Audible thoughts (thought echo)

–       Voices heard arguing

–       Voices heard commenting one one’s actions

–       Passivity experiences (delusions of control), can be of:

  • Affect (what mood looks like on the outside, eg laughing when patient feels sad
  • Somatic (a sense that own body/sensations are out of own control)
  • Impulse (what someone is thinking)
  • Volition (what they do, sometimes called ‘made acts’)

–       Thought withdrawal (feeling like thoughts are being pulled out of their head)

–       Thought insertion (feeling that thoughts are being put into patient’s head)

–       Thought broadcasting (believing thoughts can be experienced by others)

–       Delusional perception (taking normal sensory perceptions to mean bizarre things)

Delusions- “a fixed, false belief”.

Delusions are firmly held, despite evidence to the contrary, and they are not in keeping with the patient’s socio-cultural background. It’s worth noting (because I was quizzed about this earlier in the week) that delusions can be true, even though they are defined as a “fixed, false belief”. I’ll demonstrate with an example: a man believes his wife is having an affair. This might be entirely true, his wife may indeed be having an affair. Does this mean he isn’t delusional? Not necessarily, if the reason he believes his wife is cheating on him is because his neighbours have left their Christmas lights up and it’s now March. So in this case, the delusion is true, but the man is still delusional because of the reasons underlying his belief.

Delusions can be grandiose (eg, I’m the King), persecutory etc etc.

Hallucinations- “false perceptions without an external stimulus” (cf illusions)

You can get hallucinations of any of the 5 special senses, though auditory are by far the most common in schizophrenia. And with visual hallucinations, you should be thinking about organic disease.

Formal Thought Disorder

This is another feature of schizophrenia. Thoughts are not connected in a coherent or logical manner, and this will be evident from the patient’s speech. There may be:

–       Flight of ideas – patient switches quickly from one idea to another

–       Circumstantiality – long winded talking, patient takes AGES to get to the point

–       Word salad – complete gibberish, no sense to order of words

–       Blocking – thoughts suddenly stop

–       Neologisms – making up new words

–       Clanging – sounds, rather than meaningful relationships, appear to govern words or topics. Excessive rhyming/alliteration

–       Echolalia – repeating own or other’s words (can also see echopraxia, where patient repeats own or other’s movements- I actually saw this and echolalia this week, very interesting!)

Other features can include:

–       Prodromal symptoms

  • ‘delusional mood’ – suspiciousness, withdrawal, preoccupation, distractability, moodiness etc

–       Bizarre or disruptive behaviour – results from abnormal thinking/perception

–       Negative symptoms (compare with florid ‘positive’ symptoms of psychosis, eg delusions, hallucinations)

  • Social withdrawal
  • Blunted affect
  • Loss of drive/motivation
  • Self neglect
  • Cognitive decline

Treatment

The mainstay of treatment is antipsychotic drugs, which work by blocking dopamine receptors (think about Parkinsonism and loss of dopaminergic neurons- side effects of blocking dopamine receptors with antipsychotics include extrapyramidal ones, in the same way that giving too much L dopa in Parkinson’s patients can lead to a drug induced psychosis). Atypical antipsychotics, eg olanzapine, block D2 receptors less than D1 (cf typical antipsychotics, which block both) and so have less extrapyramidal side effects. Atypicals are recommended first line treatment for schizophrenia. Whilst these drugs are good at managing acute, positive symptoms, they aren’t as good as managing the negative symptoms. Complete control of positive symptoms can take up to three months.

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