Psychosis

Question 1

Define mental disorder. How do they vary ?

Answer 1

Departure from normal psychological functioning. Vary in their:

• Manifestations (i.e. symptoms that accompany them)
• Severity (incapacitated? can still lead normal life)
• Duration (for a month? for a lifetime?)
• Prognosis (can person live their expected lifetime? Will the disorder result in premature death?)

Question 2

Identify types of manifestations which can accompany mental disorders.

Answer 2

Do people hallucinate, do they forget things or are they aggressive, do they shake or tremble?

Question 3

Define psychosis.

Answer 3

Any disorder where, in their severe forms a patient’s thoughts, moods and deeds are so grossly disturbed that they are no longer in touch with reality.

Question 4

Identify examples of disorders that would be included under the term psychosis.

Answer 4

• Schizophrenia
• Bipolar disorder (previously known as manic-depressive illness)
• Dissociative identity disorder (split-personality)
• Schizoaffective disorders
• Persistent delusional disorders (delusions tend to be less bizarre than you would expect with schizophrenia)

Question 5

Define Schizoaffective disorders.

Answer 5

Symptoms of schizophrenia and affective disorders (depression or mania) develop together

Question 6

Identify neurological disorders that can produce psychotic symptoms. Are these considered psychotic disorders ?

Answer 6

-Focal epilepsy

These differ from the psychotic disorders as the psychosis is a secondary symptom of an organic disorder.

Question 7

Define Schizo- and Phrene-

Answer 7

Schizo - ‘split’

Phrene – ‘mind’

Question 8

What proportion of the world population is diagnosed with schizophrenia ?

Answer 8

1%

Question 9

What age is a diagnosis of schizophrenia usually made ?Why ?

Answer 9

Diagnosis usually quite late:

• men early 20’s
• women late 20’s
• It is thought that it tends to appear during these times as early adulthood can be quite stressful and there are many adjustments to be made during this period as well as maturational changes.
• Not known why diagnosis occurs earlier in men

Question 10

How do patients present, before they are diagnosed with Schizophrenia ?

Answer 10

Usually patients present with major delusions and have lost touch with reality but symptoms such odd behaviour may have been occurring for many years previously.

Question 11

What proportion of patients experiencing their first ‘episode’ recover without the disorder disappearing ? What proportion recovers ‘fully’ ?

What proportion of patients experience a second episode of extreme symptoms 5 – 7 years after their first ?

Answer 11

• 80% of patients experiencing their first ‘episode’ recover, but the disorder does not disappear, they will suffer either other acute episode or a more chronic condition
• 20% who have a first episode recover without getting another episode or a more chronic condition

70% of patients experience a second episode of extreme symptoms 5 – 7 years after their first.

Question 12

Distinguish between mortality rates for schizophrenic patients cf general population. What is this difference due to ?

Answer 12

Mortality rates amongst schizophrenics is almost twice that of the general population. In males this is mainly due to a large increase in the number of accidents and suicides (Suicide is the leading cause of death amongst people diagnosed with schizophrenia).

A diagnosis of schizophrenia can result in lower life expectancy as well,

Question 13

What proportion of Schizophrenics complete suicide ? What proportion attempt it ?

Answer 13

10% of schizophrenics complete suicide, 30% attempt it at least once (UK average in men is 0.2%).

Question 14

What proportion of Schizophrenic patients work ?

Answer 14

Only 19% of schizophrenic patients work.

Question 15

Identify the main symptoms of schizophrenia (positive and negative). What is the timeline of these symptoms ?

Answer 15

• Pervasive thought disturbance
• Difficulty in ignoring irrelevant stimuli (external or internal)
• Cognitive deficits
• Withdrawal from personal contact
• Delusions
• Hallucinations
• Emotional disorder
• Behavioural disruption
• Lack of insight (not aware that they are having problems, especially during acute episodes)

Question 16

Distinguish between positive and negative symptoms.

Answer 16

Positive symptoms are those that reflect an abnormal mental process, such as delusions and hallucinations, where the process can be seen to add to what should normally occur. Positive symptoms tend to be transient and occur during acute episodes.

Negative symptoms on the other hand are those where there is a loss or blunting of normal function, such as withdrawal from personal contact, anhedonia (lack of enjoyment) or reduction in emotional response. Negative symptoms tend to be chronic.

Question 17

Describe the timeline of schizophrenia symptoms.

Answer 17

EPISODIC (tend to experience cycles of acute episodes with chronic periods in between. These chronic periods vary in length)

Question 18

Describe diagnosis of schizophrenia, according to DSM-5.

Answer 18

Anyone with suspected schizophrenia should be assessed by a specialist mental health team for diagnosis.

1) Characteristic symptom (2 required), for a significant time during a 1 month period, should include at least one of 1 - 3:
1) Delusions
2) Hallucinations
3) Disorganised speech
4) Grossly disorganised or catatonic behaviour
5) Negative symptoms (reduced emotional expression

2) AND one or more major areas of dysfunction (e.g. social, occupational)

3) AND Duration of symptoms
- Overt symptoms for 1 month and prodromal features for at least 6 months

Question 19

Identify the main guidelines for schizophrenia diagnosis.

Answer 19

Two main sets of guidelines which are used -
the DSM-IV (American Psychiatric association criteria) and the ICD-10 (the WHO published criteria)

There are some instruments such as the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI) which can be used to help aid diagnosis (these were written to match the DSM IV and ICD-10 criteria).

Question 20

Identify exclusions in the process of schizophrenia diagnosis, according to DSM-5 guidelines.

Answer 20

• Dominant mood symptoms
• Schizo-affective disorder
• Physiological effects of substance misuse
• Organic cause of symptoms

Question 21

Describe diagnosis of schizophrenia, according to ICD-10.

Answer 21

1) Characteristic symptom (2 required), for a significant time during a 1 month period:
- Thought echo / insertion / withdrawal / broadcasting
- Passivity, delusional perception
- Voices commenting or discussing
- Persistent bizarre delusions

2) OR less specific symptoms
- Other persistent hallucinations
- Thought disorder
- Catatonia
- Negative symptoms
- Significant behaviour change

3) AND duration of symptoms
- Overt symptoms for more than 1 month

Question 22

Identify exclusions in the process of schizophrenia diagnosis, according to ICD-10 guidelines.

Answer 22

• Dominant mood symptoms
• Schizo-affective disorder
• Drug intoxication or withdrawal
• Overt brain disease

Question 23

Identify the symptoms of schizophrenia displayed here:

‘I am writing on paper. The pen I am using is from a factory called ‘Perry & Co’. This factory is in England. I assume this. Behind the name of Perry & Co, the city of London is inscribed; but not the city. The city of London is in England. I know this from my school days. Then, I always like geography. My last teacher in that subject was Professor August A. He was a man with black eyes. I also like black eyes. There are also blue and gray eyes and other sorts too. I have heard it said that snakes have green eyes. All people have eyes. There are some, too, who are blind. These blind people are led about by a boy’

Answer 23

Disrupted thought – can’t stay on one logical line of thinking, jumping around topic wise.
Inability to ignore irrelevant thoughts, thoughts are impinging on the patient and they cannot ignore irrelevant ones, so they write those down, which leads them off on another track.

Question 24

Identify the specific cognitive areas where schizophrenic patients may be defective. Describe the timeline of these symptoms.

Answer 24

Cognitive deficits (Executive function):

• Sustained attention
• Planning (how to complete a task)
• Verbal and visuo-spatial working memory
• Language skills (it can be difficult to understand the speech of some schizophrenics, mainly because the thought processes behind speech are disrupted)
• Explicit learning and memory (e.g. learning new facts)
• Perceptual / motor processing (e.g. appearing to move clumsily, even in childhood before diagnosis)

Even during the chronic phases between acute episode often have one of more specific cognitive deficits (negative symptoms)

Question 25

At which point in the lifetime of schizophrenic patient do cognitive deficits appear ?

Answer 25

Cognitive deficits are often found in childhood before diagnosis or severe onset of the schizophrenia but they do tend to worsen after the first acute episode.

Question 26

Describe the main features of the “Withdrawal from personal contact” symptom of Schizophrenia.

Answer 26

• Few early friends (may be due to negative symptoms of schizophrenia as they are indifferent to social contact and may talk less spontaneously, and when they do talk may sometimes be disordered)
• Little opportunity for social reality testing (internal thoughts are not being tested against other peoples, such that they cannot tell whether they are legitimate thoughts i.e. reality, or fantasy)
• As difference between reality and fantasy blurs in their minds they are usually rebuffed by others as being ‘strange’ when they do try to engage socially, leading to further isolation and eventually they may lose touch completely

Question 27

Define social cognition. What is a possible result in disruption of this ?

Answer 27

Ability to create a representation of yourself within a social environment

Disruption to this can result in aberrant representations and psychotic symptoms.

Question 28

Describe the main features of delusion as a symptom of schizophrenia.

Answer 28

• May develop ideas of reference where external events (delusions occur in relation to external stimuli) are somehow related to them (e.g. people walking behind them in the street will be referenced as ‘these people are following me’ and television programs will be somehow try to communicate directly with them). These ideas are brought together to make sense of the world around them in a delusional system or world of their own making
• May also get changes in salience (importance of what they are experiencing may vary compared to someone without a diagnosis of schizophrenia)
• WHEN delusional system involves delusions of persecution (e.g. government plotting against patient) patient can be described as being in subcategory of paranoid schizophrenia

Question 29

To what extent do schizophrenic patient have insight into the fact that their delusions defy logic ?

Answer 29

Often people with schizophrenia in a chronic phase (not an acute episode) will acknowledge that their delusions defy logic but part of them still will believe them. In an acute phase they often have a lack of insight into their disorder

Question 30

Describe the main features of hallucinations as a symptom of schizophrenia.

Answer 30

• Perceptions that occur in the absence of external sensory input
• Auditory hallucinations particularly common, where sufferers hear a voice (sometimes can determine what the voices are saying, but not always)
• Some patients have difficulty in separating external and internal ‘events’, so that when they describe hearing ‘voices’ it is actually themselves talking, or indeed thinking, that they are interpreting as coming from ‘within’

Question 31

Identify the main emotional symptoms associated with schizophrenia.

Answer 31

• Emotional reactivity

• Early on in schizophrenia (often before diagnosis)
• Slightest rejection results in extreme emotional over-reaction and despair. This is an emotional representation of the fragmentation of thoughts.

• Lack of emotions/ inappropriate

• Later on (cf ^), over-reactivity diminishes and the opposite may occur
• Show complete indifference to the fate of themselves or others
• Faces are expressionless and their voices monotone (blunted affect)
• BUT not ALL schizophrenics show no emotions, sometimes, emotions are expressed but are just inappropriate to the situation. They may laugh at being told bad news due to some small element of the telling (link to inability to ignore irrelevant stimuli)

• Depression

• Frequently accompanies schizophrenia
• Can be a prodromal symptom (i.e. Many patients who go on to be diagnosed with schizophrenia have suffered several bouts of depression in the years leading up to the first acute episode)

Question 32

Identify the main kinds of behavioural disruptions that occur in schizophrenia.

Answer 32

Schizophrenia often results in disruption to normal movements and behaviours:

• Catatonic

• subtype of the disorder which results in patients remaining frozen in a particular posture for hours on end
• may suddenly unfreeze and become frenzied, running around and shouting, sometimes becoming violent
• Or they may carry out a stereotypical movement repeatedly for hours at a time

• Disorganised

• both thought and behaviour are disorganised and fragmented
• their speech is difficult to understood (babbling), and behaviour is often inappropriate, they may switch dramatically from laughing to being aggressive

• Abnormal motor control can be identified in people who later go on to be diagnosed with schizophrenia, e.g. children may be noticeably more clumsy

Question 33

How do schizophrenia patients differ from one another (i.e. are they uniform) ? Therefore, are there subtypes to it ?

Answer 33

Some have mainly positive symptoms, others mainly negative. Some people will respond well to standard antipsychotics whilst others do not. There are also difference in anatomical abnormalities.

All of these facts put together suggest that schizophrenia is not a unitary disorder that indeed there possibly are subtypes and that these subtypes may have differing pathophysiology.

Question 34

Identify the main subtypes of schizophrenia. Are these subtypes in clinical use ?

Answer 34

• Catatonic
• Disorganised (Hebephrenic)
• Paranoid
• Simple
• Undifferentiated
• Residual

These subtypes have been changed in DSM 5 which has moved to domains, gradients and dimensions of schizophrenia

Question 35

Define simple schizophrenia.

Answer 35

Less obvious but insidious, few delusions / hallucinations, more behavioural oddities

Question 36

Define undifferentiated schizophrenia.

Answer 36

Not one of the other subtypes

Question 37

Define residual schizophrenia.

Answer 37

Few obvious symptoms esp positive ones, chronic negative symptoms

Question 38

Define domain of psychopathology.

Answer 38

Main core symptoms experienced by people with schizophrenia. They are:

Hallucinations, delusions, disorganised thought, disorganised or abnormal motor behaviour and negative symptoms

Question 39

Define gradients in the context of schizophrenia.

Answer 39

Gradient: suggests how different from the average person the individuals symptoms are in terms of level, number and duration. .

Question 40

Define dimensions in the context of schizophrenia.

Answer 40

Dimensions are the otherpossible areas where symptoms may be experienced but are not core to schizophrenia diagnosis: cognition, depression and mania.

Question 41

Identify the main types of causes of schizophrenia.

Answer 41

Deficits in cognition, especially in the ability to keep thoughts and actions on track:

• Genetics
• Physiological
• Anatomical
• Psychosocial

Question 42

What are the chances of being diagnosed if identical twin with schizophrenia ? if non-identical twin ? What does this suggest ?

Answer 42

If you are an identical twin and your twin has already been diagnosed there is a 48% chance you also will be diagnosed with schizophrenia, compare this with the lower 15% of a non-identical twin

This suggests that there is a genetic basis for vulnerability to schizophrenia, but as identical twins do not always both develop schizophrenia this is not just a clear cut case of inheritance of the disorder.

Question 43

Describe the genes mutated in schizophrenia.

Answer 43

• There is no single gene that causes schizophrenia.
• Mutations in many genes have been associated with increased likelihood of developing schizophrenia, mainly:
• genes involved in some way with transmitter systems in the brain including of for nicotinic receptors (acetylcholine system)
• another with NMDA receptors
• another is for an enzyme involved in extracellular dopamine catabolis

• It is also likely that mutations in several genes can result in interactions which can affect the likelihood of developing schizophrenia.

Question 44

Identify the main theories explaining physiological causes of schizophrenia.

Answer 44

DOPAMINE HYPOTHESIS

DOPAMINE-SEROTONIN INTERACTION HYPOTHESIS

OTHER NT/NEUROMODULATOR INVOLVEMENT

Question 45

Describe the Dopamine Hypothesis of Schizophrenia.

Answer 45

Thought that some of the symptoms of schizophrenia may be caused by over stimulation of dopamine sensitive neurons. The evidence of the involvement of dopamine comes from the classical antipsychotics (neuroleptics) which block D2 receptors (antagonists) , reducing dopamine activity. Drugs that temporarily increase the amount of dopamine available resulting in an increase symptoms severity in patients with mild schizophrenia. Over-activity of the dopamine system results in an inability to ignore stimuli and many schizophrenics describe a ‘cognitive overload’ in retrospective accounts of their acute episodes.

Question 46

Describe the Dopamine-Serotonin Interaction Hypothesis of Schizophrenia.

Answer 46

More recent atypical antipsychotics, such as Clozapine block both dopamine and serotonin receptors and have been found to be more effective in relieving the negative symptoms compared to classical antipsychotics.

Question 47

Identify any other NT/Neuromodulators which may be involved in the physiological mechanisms of Schizophrenia.

Answer 47

Some recent evidence to implicate acteylcholine, GABA (gamma-aminobutyric acid) and glutamate in schizophrenia, particularly in the cognitive deficits. This suggests a overall alteration in the balance of actions of these neurotransmitters and neuromodulators and shows how mutations in genes involved in different neural systems could potentially result in similar symptoms being experienced by patients.

Question 48

Describe the anatomical features of Schizophrenia, including macro changes you may see on imaging. Link this to pathophysiology of Schizophrenia.

Answer 48

MRI Scan:
-Enlargement of the ventricles (because of a reduction in general brain volume) (can be seen on MRI)

PET Scan:
-Abnormal blood flow

Other structural abnormalities:
-Neuronal derangement
-Missing neurons
-Abnormally sized neurons suggesting a developmental problem in these patient
-Abnormalities in many areas of a schizophrenic brain including: 
Frontal and temporal lobes 
Basal ganglia
Amygdala and hippocampus
Cerebellum
Thalamus

These changes are thought to result in the disruption of the processing of stimuli and the generation of responses through the cortico-striato-thalamocortical loops. This leads to a disintegration of the thought processes which should lead to normal behaviour.

Question 49

Do all schizophrenic patients display anatomical abnormalities ? Are these differences due to genetic, or environmental factors ?

Answer 49

Most, but not all do.

Some of these anatomical abnormalities may have a genetic basis others may be due to environment.

Question 50

Which factor of pregnancy may increase likelihood of developing Schizophrenia ?

Answer 50

Evidence that hypoxia at birth and aspects of the environment in utero may impact on the likelihood of the development of schizophrenia.

Question 51

Identify psychosocial causes of Schizophrenia.

Answer 51

• Social class
• Minority position
• Urban environment

These^ three factors may confound each other via stress as well as having separate roles.

• Family environment
• Cannabis use?

Question 52

Explain how social class affects likelihood of developing Schizophrenia.

Answer 52

Epidemiological studies show that schizophrenia is more common in people in a lower socio-economic class. This is thought to be due to downward drift - people with schizophrenia often cannot hold down a full time job and therefore end up at the lower end of the socio-economic ladder.

Question 53

Explain how minority position increases likelihood of developing Schizophrenia.

Answer 53

Schizophrenia is more common in minority groups – this is not thought to be a genetic susceptibility of a particular ethnic minority but instead is thought to be related to the psychological minority position within a wider social environment as it can depend on the ethnic density of the area the individual lives in.

Question 54

Explain how an urban environment increases likelihood of developing Schizophrenia.

Answer 54

Increasing evidence for an association of schizophrenia with growing up in an urban environment. This is a dose response relationship with increasing prevalence with increasing urbanicity.

Question 55

Explain how family environment affects likelihood of developing Schizophrenia.

Answer 55

Current debates over family environment and whether it could cause the development of schizophrenia (patients tended to have cold, aloof and unresponsive mothers) or whether this is simply the parents way of coping with a schizophrenic child. But family environment has been shown to be important in whether someone with schizophrenia relapses into more acute episodes.

Question 56

Explain how cannabis use increases likelihood of developing Schizophrenia.

Answer 56

Cannabis use has long been associated with schizophrenia. The picture is still not clear whether this is causal or whether people with a vulnerability towards developing schizophrenia are more likely to be heavy users of cannabis (drug and alcohol misuse is higher in people with schizophrenia). The smoking rate for normal cigarettes is also 2 – 3 times higher amongst schizophrenics so it may be that schizophrenics are self medicating by smoking.

Question 57

Describe the diathesis model of development.

Answer 57

Genetics appears to generate a vulnerability towards developing schizophrenia through either physiology or anatomy.
This vulnerability then requires some kind of stressor to push an individual over a threshold resulting in the development of schizophrenia. The stressor may be environment or experience.

Also applies to other disorders such as depression.

Question 58

Identify the main treatment options for Schizophrenia.

Answer 58

Early intervention tends to result in better long-term outcomes

• Drug therapies
Classical antipsychotics
Atypical antipsychotics (more recently developed)

• Psychological interventions (normally in conjunction with drug treatment)

• Family intervention
• Cognitive Behaviour Therapy
• Social-skills training (no longer recommended that this be offered routinely, but can be useful in some instances)

Question 59

Identify the main classical antipsychotics used in Schizophrenia, and their mechanism of action.

Answer 59

Chlorpromazine and Haloperidol which reduce dopamine activity by blocking dopamine receptors (D2). They reduce the positive symptoms of schizophrenia like the delusions and hallucinations.

Question 60

Identify the main atypical antipsychotics used in Schizophrenia, and their mechanism of action.

Answer 60

Clozapine and Risperidone

They act at dopamine receptors and usually serotonin receptors sites (although some work at other receptors too such as those of cholinergic system) . Atypical antipsychotics are thought to reduce negative symptoms, as well as positive symptoms, although there still is some debate about this.

Question 61

Identify the main SEs of antipsychotics.

Answer 61

• Sedation
• Dry mouth
• Cardiac irregularities,
• Weight gain
• Extra-pyramidal symptoms muscle tremors and spasms and involuntary movements.
• Some patients who had been on these drugs for a long time develop permanent motor disorders such as Tardive dyskinesia (where patients develop repetitive involuntary movements, such as lip smacking)

Question 62

Identify the main obstacles to adherence to antipsychotics in Schizophrenia.

Answer 62

SEs, combined with lack of insight by patients (in that they do not recognise that they suffer from a disorder) can result in them not taking their medication, leading to a recurrence of their symptoms.

Question 63

Explain how family intervention works as part of psychological interventions for the treatment of Schizophrenia.

Answer 63

Patients with schizophrenia are often cared for by their family. This can mean that the families around a schizophrenic person are placed under quite a lot of strain. The needs of the family of the patient should be assessed, as well as the needs of the patient, especially as there is evidence to suggest that the greater the amount of expressed emotion in the family environment the more likely a schizophrenic patient was to relapse after being discharged. By expressed emotion we mean mainly hostility and criticism directed at the patient. There are programs for families of schizophrenic patients which educate and give other family members an opportunity to discuss their problems in adjustment, and these have been shown to reduce the relapse rates amongst patients. Adherence rates also improve.

Question 64

Explain how CBT works as part of psychological interventions for the treatment of Schizophrenia.

Answer 64

This encourages the patient to establish links between their thoughts, feelings and actions with regard to a particular symptom and to then re-evaluate these. This type of intervention can be useful, along with antipsychotic medication. It has been shown to prevent the development of full psychosis in people found to be at very high risk of such a relapse but also reduces the severity of psychotic symptoms in people who have had a full blown episode it can also reduce the likelihood of relapse in some patients.

Question 65

Explain how Social-skills Training works as part of psychological interventions for the treatment of Schizophrenia.

Answer 65

Includes helping with disability benefits, shopping or housing needs or specific training in job skills, education opportunities, conversational skills or how to manage friendships.

Question 66

Describe management for an acute episode of schizophrenia.

Answer 66

• Early and assessment (adults)

• Psychiatric
• Medical
• Physical
• Psychological
• Developmental
• Social
• Occupational and educational
• QOL
• Economic

• First line: Oral antipsychotic medication in conjunction with psychological intervention (family intervention and individual CBT)

Question 67

Describe long term management of schizophrenia.

Answer 67

• Continuing treatment and care (psychosis services or specialist community-based team)

• Offer CBT to assist in promoting recovery (particularly if persistent symptoms or in remission)
• Offer family intervention
• Consider offering depot or long-acting antipsychotic medication if the patient would prefer it after an acute episode or to avoid covert non-adherence as a clinical priority
• Monitor physical health regularly, particularly in relation to potential side effects of medication, but also overall physical health (because patients with Schizophrenia are more likely to develop comorbid disorders)

Question 68

Identify comorbid disorders associated with Schizophrenia.

Answer 68

• People with schizophrenia are more likely to develop co-morbid disorders, particularly:
-Cardiovascular disease
-Type 2 diabetes
due to weight gain from medication and the chaotic lives they lead

• They are also more likely to misuse drugs

Question 69

Describe the possible outcomes for Schizophrenia patients. State the proportion of Schizophrenia patients in each case.

Answer 69

NO CURE

-Independent (30%) (able to lead independent lives, work full time and raise families)

-Relatively dependent (50%)
(require some support, continuous medication but will be able to lead fairly independent lives)

-Highly dependent (20%) (require long term care, often have comorbid problems such as substance abuse, depression or anxiety which makes treatment choices very hard)