Which mental disorders cause thought insertions?

schizophrenia

Abstract

Schizophrenia is a clinical picture in which - depending on the course form - various psychopathologies cause complex symptoms. As a rule, parts of perception, thinking, the boundaries between the ego and the environment, the affect and the psychomotor system are disturbed. The resulting predominant symptoms are primarily hallucinations (especially acoustic), delusions, and ego disorders. In addition to these “positive symptoms”, schizophrenia can also be associated with “negative symptoms” such as a flattening of affect and social withdrawal.

The diagnosis is made based on the criteria of the ICD-10 catalog. The "classic" paranoid schizophrenia is differentiated from other forms of schizophrenia (e.g. hebephren, kataton) and delusional disorders.

Therapeutically, mainly substances from the group of antipsychotics are used, which mainly via a dopamine antagonism at the D2- and / or D4-Receptor unfold their effect. Therapy with antipsychotics should initially be carried out in a gradual dosage as monotherapy. The choice of antipsychotic should be made individually, taking into account the side effects (typical antipsychotics → EPS, atypical antipsychotics → various side effects such as metabolic syndrome, QT time prolongation, etc.).

Epidemiology

  • Lifetime prevalence
    • Worldwide: 0.5-1.6%
    • Lifetime prevalences are increased with family history
  • gender
  • Age: Preferred occurrence in young adulthood between 16 and 35 years

Unless otherwise stated, the epidemiological data refer to Germany.

etiology

Schizophrenia is a disease of multifactorial origin, whereby the vulnerability-stress-coping model offers an explanatory approach for its development.

  • Vulnerability-Stress-Coping Model
    • Vulnerability: It is assumed that there is a neuropsychological susceptibility to schizophrenia well before the first clinical symptoms
    • Stress: Endogenous (e.g. hormonal changes) and exogenous environmental factors
      • Cannabis use is a well-known "trigger" for triggering schizophrenia
    • Coping: In stressful situations, coping skills are no longer sufficient to deal with the delusional symptoms that have arisen

Symptoms / clinic

Classification according to K. Schneider

Symptoms of the 1st order

Symptoms of 2nd rank

Classification according to positive-negative symptoms

Positive symptoms

Positive symptoms are productive symptoms that are triggered by schizophrenia. Put simply: Compared to the "normal state", there is something more.

Negative symptoms

Negative symptoms are non-productive symptoms of schizophrenia that are primarily associated with limitations in normal experience. To put it simply: Compared to the "normal state", something is deducted.

Gradient and special forms

The various forms differ in their symptoms. The most common is paranoid schizophrenia, which is why it is usually synonymous with the term schizophrenia.

Paranoid schizophrenia (F20.0)

Hebephrenic schizophrenia (F20.1)

  • clinic
    • Hebephrenia: Affect disorder with inappropriate, ridiculous behavior and expressions
    • Usually no hallucinatory symptoms
    • Flashy Personality: A preference for philosophy, religion, and other abstract subjects
  • Age of onset: adolescence (15-25 years)
  • Bad prognosis: frequent transition to paranoid schizophrenia

Catatonic schizophrenia (F20.2)

In catatonic schizophrenia, psychomotor disorders are in the foreground, which can be accompanied by excessive excitement on the one hand and stupor on the other

  • Clinic of catatonia: syndrome of motor and psychological symptoms
    • Mentally
    • Motorized
      • Akinesia, stupor
      • Mannerisms
      • Postural stereotypes
        • Catalepsy ≈ stiff posture
          • Postures are maintained by the patient for a long time, even if they are uncomfortable and the patient would be physically able to change the posture
            • Example: Oreiller psychique (French = "psychological pillow")
        • Flexibilitas cerea (from the Latin flexibilitas = "flexibility" and cereus = "waxen"): When the examiner moves passively, the limbs are waxy, tough mobility due to increased muscle tone
      • Stereotypes of movement
        • Repetitive movements that do not fulfill any function (e.g. shaking hands, rocking trunk movements, hitting yourself)
      • Catatonic excitation: Raptus
  • Age of onset: adolescence (15-25 years)
  • Complications
  • therapy

Other forms of schizophrenia

  • Undifferentiated schizophrenia (F20.3)
    • Clinic: Undifferentiated schizophrenia describes a clinical picture in which the criteria for schizophrenia are met, but cannot be assigned to paranoid, hebephrenic or catatonic schizophrenia
  • Schizophrenic residual (F20.5)
    • clinic
      • Chronic negative symptoms (flattening of affect, social withdrawal, etc.) for at least 12 months
      • A history of at least one diagnosed schizophrenic episode
      • DD: Chronic depressive syndrome, dementia, organic psychoses etc.
  • Schizophrenia simplex (F20.6)
  • Coenesthetic schizophrenia: The focus is on coenesthesia

Acute transient psychotic disorders (F23)

  • Acute schizophrenia-like psychotic disorder (F23.2)
    • clinic
      • Symptoms of schizophrenia persist for less than a month, and that month meets the ICD-10 criteria for schizophrenia
      • If symptoms persist for more than a month, a diagnosis of schizophrenia (F20) should be made
    • Therapy: Therapy with antipsychotics usually leads to a rapid cessation of the symptoms
  • Acute polymorphic psychotic disorder (F23.0, F23.1)
    • clinic
      • Hallucinations, delusional phenomena and perceptual disorders are temporary and can change within a very short time (hours to days)
      • The disturbance begins abruptly and ends also abruptly after a few days
      • If the criteria of schizophrenia are met, the diagnosis F23.1 is made, otherwise the disease is coded with F23.0
    • Therapy: Therapy with antipsychotics usually leads to a rapid cessation of the symptoms

Diagnosis

Diagnostic criteria

According to the ICD-10 diagnostic criteria, the following criteria must be in place continuously for at least one month.

At least one of the following criteria (based on the ICD-10 diagnostic criteria):

  1. Ego disorders: Thought inspiration, thought withdrawal, thought spreading
  2. Delusional phenomena: delusions of persecution, delusions of control, delusions of intoxication, delusions of influence, feeling of what has been made, delusions
  3. "Bizarre" delusion: Persistent, culturally inappropriate or completely unrealistic, e.g. having superhuman powers
  4. Acoustic hallucinations: commentary or dialogical voices, or voices that come from part of the body

Or at least two of the following criteria (based on the ICD-10 diagnostic criteria):

  1. Persistent hallucinations of any sensory modality
  2. Formal thought disorders: tearing off thoughts and inserting them into the flow of thoughts, experience of thinking, talking alongside, neologism
  3. Catatonic symptoms: symptoms such as stupor, postural stereotypes, waxy flexibility (Flexibilitas cerea), negativism, mutism and arousal
  4. Negative symptoms: Noticeable apathy, speech impoverishment, inadequate affect and social withdrawal
  5. Serious changes in behavior: aimlessness, indolence

Diagnostics to rule out organically caused psychosis[1]

According to the recommendation of the S3 guideline, the following diagnostics should always be carried out when schizophrenia develops for the first time:

If there is any suspicion of a space-consuming or inflammatory process, the following tests should also be carried out:

Differential diagnoses

Schizotypic disorder (schizotypal personality, schizotypal personality disorder, F21)

In the broader sense, schizotypic disorder is a personality disorder in which those affected exhibit eccentric behavior with paranoid bizarre ideas and anomalies of thinking that have a schizophrenic effect on third parties. Typical are reduced affect, behavior that is strange compared to social norms, and social withdrawal. There are psychosis-like episodes with delusional ideas and acoustic hallucinations that are self-limiting and do not have the consequences of paranoid schizophrenia at regular intervals.

Delusional disorder (F22)

The delusional disorders are characterized by a long-lasting delusion as the only symptom or clearly in the foreground, whereby the ICD-10 criteria of paranoid schizophrenia or another diagnosis with a delusional component are not met.

  • Clinic: The symptoms must have been present for at least three months

Induced delusional disorder (folie à deux, F24)

Induced delusional disorder is a delusional disorder that affects two people who are in a close emotional relationship. One of the two people suffers from a psychotic disorder, usually delusional. The other person develops a symbiotic delusion, i.e. they develop the same delusion as the sick partner. If the couple separates, a decrease in the symbiotic madness can also be expected.

Further differential diagnoses

  • Organic mental disorders, e.g. dementia, delirium, including withdrawal delirium (alcohol withdrawal delirium, benzodiazepine withdrawal delirium)
  • Pharmacological causes, for example anti-Parkinson drugs, antidepressants
  • Substance-induced psychoses, e.g. alcohol, cannabinoids
  • Somatic causes, e.g. inflammatory / infectious CNS diseases, endocrinopathies

AMBOSS makes no claim to completeness for the differential diagnoses listed here.

therapy

Generally

  • Treatment goal: The treatment goal is a self-determined life that is largely independent of the schizophrenic symptoms. The focus is on pharmacotherapy, which is supported by psychotherapeutic and social measures
  • Procedure: Clinical suspicion → Exclusion of organic causes and diagnosis → Individual choice of an approved antipsychotic taking into account the side effects → Start of monotherapy (dosage creep in)
  • Supportive measures
    • Psychoeducation
    • Cognitive behavioral therapy
    • Family therapy
    • Social measures: day clinics, professional reintegration procedures, social supportive measures
  • Adaptation to special situations: Situational and physical changes (e.g. hormonal changes due to the menstrual cycle, pregnancy or menopause) can influence the symptoms, so that treatment adjustments may be necessary

Drug pharmacotherapy

  • Antipsychotics
    • Atypical antipsychotics: Atypical antipsychotics show less EPS, but more other side effects (metabolic syndrome, QT time prolongation, etc.). Clozapine is the only "real" atypical, as it is the only active ingredient of the antipsychotics that has no effect on the D2Receptor shows
    • Typical antipsychotics
      • Highly potent antipsychotics: This class of substances is a very important option in acute treatment, as it shows good effectiveness against acute plus symptoms (paranoid ideas, hallucinations) and states of restlessness. In this way coercive measures for the patient can be avoided and the long-term prognosis can be improved
      • Low- and medium-potency antipsychotics: Due to their limited antipsychotic effect, they are rarely used for antipsychotic therapy. Their antihistaminergic effect is used for sedation in case of restlessness and sleep disorders
  • Benzodiazepines: Sedation for acute anxiety, restlessness and catatonic states.
  • Antidepressants: Supportive for depressive symptoms