Paranoid Psychoses

Question 1

What is the strongest risk factor for developing a psychotic disorder?

Answer 1

family history

Question 2

What is psychosis?

Answer 2

• A mental disorder in which thoughts, affective response or ability to recognise reality, and the ability to communicate and relate to others, are sufficiently impaired to interfere grossly with the capacity to deal with reality
• The characteristics are hallucinations, delusions and disorder of the form of thought
• By definition there is a lack of insight

Question 3

Define a hallucination?

Answer 3

• This is a perception which occurs in the absence of an external stimulus
• It is experienced in real space, has the same qualities as normal perception i.e. is vivid, solid and compelling and it is not subject to conscious manipulation (you can’t turn a hallucination off)
• Hallucinations can occur in any sensory modality but most commonly they are auditory or visual

Question 4

Two types of auditory hallucination?

Answer 4

Auditory hallucinations can be second person where the voice is addressing the patient or third person where the patient hears a voice or voices speaking about them or giving a running commentary on what they are doing

Question 5

Third person auditory hallucinations are typical of ______
Second person auditory hallucinations more commonly occur in _____

Answer 5

third person - schizophrenia
second person - psychotic depression or mania

Question 6

Define ideas of reference?

Answer 6

• Innocuous or coincidental events will be ascribed significant meaning by the person
• e.g. a news report is really commenting about them and talking to directly to them
• e.g. a radiostation is broadcasting songs in a certain way to tell them something

Question 7

Define a delusion?

Answer 7

• A delusion is a fixed falsely held belief held with unshakeable conviction, impervious to logical argument or evidence to the contrary
• It is held out with the usual social, cultural and educational background of the patient
• The delusion is often bizarre or impossible but it does not have to be, a delusion is a delusion because of how the patient came to the belief

Question 8

Explain the difference between primary and secondary delusions

Answer 8

• Primary delusions arrive fully formed in the consciousness without need for explanation
• Secondary delusions are built around trying to understand what is going on, starts with a delusional mood and builds up over time, the dopamine misfiring in schizophrenia causes you to misinterpret events which leads to this delusional mood where eventually a full delusion is thought of to explain the strange feelings (secondary delusions are more common)

Question 9

List some examples of themes of delusions?

Answer 9

1. Paranoid
2. Persecutory (people out to get you or others)
3. Grandiose (belief of greatness)
4. Religious
5. Misidentification (Capgrass= you think someone has been replaced with an imposter. Fregoli= you think that different people are all actually the same person changing their appearance constantly or in disguise)
6. Guilt
7. Sin
8. Poverty
9. Nihilistic (believe you are dead or decomposed)
10. Erotomanic (believe that someone is in love with you, de Clerambault delusion= belief a public figure is in love with you)
11. Jealousy (believe your spouse is cheating on you, in psychiatry this is a red flag as these delusions can result in homicide)
12. Delusions of reference

Question 10

Explain the meaning of paranoid in psychiatry?

Answer 10

• Paranoid has a different meaning in psychiatry and simply means that is happening to the person
• Often paranoid is used to described persecutory delusions
• Persecutory delusions are delusions in which a person believes someone is out to get them or others
• If persecutory delusions are about specifically the person i.e. people are out to get me, it would be a paranoid persecutory delusion
• Paranoid delusions do not have to be persecutory e.g. if you believed you were the second Christ that would be a paranoid grandiose and religious delusion

Question 11

The specific content of delusions tends to be culturally defined what does this mean?

Answer 11

a persecutor is often recognized by society/ culture as a danger or threat
* Hence in the past control was often by ghosts or spirits but now patients are more likely to complain of x-rays, transmitters, satellites or the internet
* Delusions around illness shift to fears of the time e.g. used to be about the plague now they are about COVID-19

Question 12

Thoughts cannot be directly observed so inferred from pattern of speech, what may give clues of thought disorder?

Answer 12

• Clanging (associating words on sound) and punning (relating words that are similar)
• Neologisms (new words or expressions)
• Word salad/ verbigeration (fluent words but the sentences don’t make sense)
• Circumferentiality (when asked a question the patient talks about something else but eventually comes back to the point)
• Tangentiality (patient goes off on a tangent and never comes back to the point)

Question 13

What is meant by thought interference?

Answer 13

• Thought insertion = someone else putting thoughts in their head
• Thought withdrawal = someone is stealing their thoughts
• Thought broadcasting= everyone can hear their thoughts
• Thought blocking= half way through a thought and then just stop, nothing in their head

Question 14

Give some examples of passivity phenomena?

Answer 14

• Passivity of volition= made actions “someone moved my legs and I couldn’t stop them”
• Passivity of affect= “someone is controlling my emotions”
• Passivity of urges= made urges “someone made me jump out into traffic”

Question 15

List 4 categories of causes of psychosis?

Answer 15

1) organic conditions e.g. delirium, dementia, strokes, brain injury

2) Manic Depressive psychosis

3) Schizophrenia and other paranoid psychoses

4) Substance use: acute intoxication, withdrawal, delirium tremens

Question 16

Manic depressive psychosis tends to be ____

Answer 16

mood congruent
in depression the delusions are of worthlessness, guilt, nihilism, hallucinations of accusing, insulting voices
in mania the delusions are grandiose, hallucinations of god telling you you’re great etc

Question 17

What is schizoaffective disorder?

Answer 17

both features of schizophrenia and affective disorders but not enough to meet the criteria of either

Question 18

Define, illusion, missed perception and pseudohallucination?

Answer 18

• First you have illusions which are mismatches between the objective and perceived properties of an object present in the environment – these persist even when you are aware of them
• Missed perception involves stimulus that has a meaning attached to it
• Pseudohallucination – either the person knows the hallucination is not real or it is not external and they hear the voices from within their head

Question 19

What ages tend to get schizophrenia?

Answer 19

• Illness can begin at any age but is rare after puberty
• The peak age of onset is in the early twenties

Question 20

Aetiology of schizophrenia?

Answer 20

• No single cause has been identified
• Daily cannabis use is likely a risk factor
• There is some genetic aetiology
• Dopamine excess/ abnormal dopaminergic neuron firing is thought to explain the positive symptoms

Question 21

Simply what are the first rank symptoms of schizophrenia?

Answer 21

hallucinations
delusions and disordered thought
passivity phenomena

Question 22

Criteria for schizophrenia?

Answer 22

a-d are essentially first rank symptoms
* At least two of the following symptoms must be present (by the individual’s report or through observation by the clinician or other informants) most of the time for a period of 1 month or more. At least one of the qualifying symptoms should be from item a) through d) below:
a. Persistent delusions
b. Persistent hallucinations
c. Disorganized thinking
d. Experiences of influence, passivity or control .
e. Negative symptoms such as affective flattening, alogia or paucity of speech, avolition, asociality and anhedonia.
f. Grossly disorganized behaviour that impedes goal-directed activity
g. Psychomotor disturbances such as catatonic restlessness or agitation, posturing, waxy flexibility, negativism, mutism, or stupor.

• The symptoms are not a manifestation of another medical condition (e.g., a brain tumour) and are not due to the effects of a substance or medication (e.g., corticosteroids) on the central nervous system, including withdrawal effects (e.g., from alcohol).

Question 23

The movement symptoms of schizophrenia generally arise ______ so _______

Answer 23

generally arise when people have been untreated for a long time and these points are therefore seen less now

Question 24

What is meant by waxy flexibility?

Answer 24

if examiner moves patient’s arm it would stay in that position until moved again

Question 25

Explain what is meant by negative and positive symptoms and what they are?

Answer 25

• Positive symptoms – does not have any normal counterpart e.g. tachycardia has a normal counterpart of normal heartbeat
• Negative symptoms – reduction or removal of normal processes
• Positive symptoms= hallucinations, delusions, passivity phenomena, disorder of thought form
• Negative symptoms= reduced amount of speech, reduced motivation/ drive, reduced interest and pleasure, reduced social interaction, blunting of affect

Question 26

What are 3 subtypes of schizophrenia? What one is most common?

Answer 26

paranoid schizophrenia - 80%
hebephrenic - next most common
catatonic

Question 27

Paranoid schizophrenia is characterised by _____

Answer 27

first rank symptoms

Question 28

Hebephrenic schizophrenia characteristics?

Answer 28

• Affective changes are prominent, delusions and hallucinations are fleeting and fragmentary
• Get negative symptoms developing more quickly
• Behaviour is irresponsible and unpredictable
• Mannerisms are common (habitual ways of speaking and behaving)
• Tend to have shallow and inappropriate mood
• Thought is disorganized
• Speech is incoherent
• Tendency to social isolation and negative symptoms

Question 29

Catatonic schizophrenia symptoms characteristics?

Answer 29

• Movement disorder predominates
• Alternating between stupor and hyperkinesis
• Automatic obedience (exaggerated co-operation), posturing and waxy flexibility may be seen

Question 30

List/ describe some other paranoid psychotic disorders aside from schizophrenia?

Answer 30

• Persistent delusional disorder: systematized fixed delusions, don’t tend to have hallucinations, not causing impairment of functioning
• Schizotypal disorder: under DSM this is classed as a personality disorder but under ICD it is classed as a type of psychosis (basically the person doesn’t quite meet the criteria for schizophrenia)
• Acute and transient psychotic disorder: schizophrenia symptoms lasting less than a month
• Induced delusional disorder: folie a deux and folie a plusiers, a group of people share the same delusions
• Schizoaffective disorder: episodic disorder in which both affective and schizophrenic symptoms are present but the criteria for neither is met