Psychotic Disorders

Question 1

What is schizophrenia?

Answer 1

Psychotic disorder in absence of organic diseas,e substance abuse or withdrawal. Not secondary to mood changes. ICD10 subgroups: paranoid, hebphrenic, catatonic, simple, residual.

Question 2

What defines the paranoid subgroup?

Answer 2

Characterised by persecutory/grandiose delusions, derogatory auditory hallucinations

Question 3

What defines the hebephrenic subgroup?

Answer 3

Disorganisation syndrome: formal thought disorder, affective flattening/incongruity, bizarre behaviour

Question 4

What defines the catatonic subgroup

Answer 4

multiple motor, volitional and behavioural disorders, stupor and excitement

Question 5

What define the simple subgroup?

Answer 5

Insidious but progressive impoverishment of mental life, without development of florid symptoms

Question 6

What is the aetiology of Schizophrenia?

Answer 6

Genetic basis: twin studies and 10% risk with 1st degree relative.
• Hypoxic brain injury at birth higher chance
• Cannabis use? Neurochemical theories of excess/low D2 in different brain areas.
• Schizophrenic symptoms more common in those with HTT and temporal epilepsy.

Question 7

What is the epidemiology of Schizophrenia?

Answer 7

1% prevalence. Onset in 20-30s.

Question 8

What is the natural history of schizophrenia?

Answer 8

Premorbid (good functionality)

Prodromal (decreasing functionality)

Progression (fluctuating functionality)

Stable/ relapsing (low baseline functionality)

Question 9

Which symptoms MUST there be one of for a schizophrenia consideration?

Answer 9

• Minimum of 1 of:
o Thought echo/insertion/withdrawal broadcast
o Delusions of control
o Running commentary or voices in patient speaking within themselves
o Persistent delusions

Question 10

Alternatively which symptoms can there be 2 of for a schizophrenia consideration?

Answer 10

o Persistent hallucinations in any modality
o Thought disorder
o Catatonic behaviour
o Negative symptoms.

Question 11

What are the positive symptoms found in an MSE of a schizo patient?

Answer 11

Appearance: normal or inappropriate dress
Behavior: withdrawn or restless and noisy
Mood: incongruent, guarded
Speech: reflects underlying thought disorder
Thought:
• Formal dosirder: derailment, loosen associations, thought blocking
• Thought alienation: withdrawal/broadcasting
• Delusions: persecutory etc
Perception: third person hallucinations, running commentary
Cognition: normal orientation, impaired attention
Insight: poor.

Question 12

What are the negative symptoms of a schizo patient in an MSE?

Answer 12

Appearance: poor self care / unkempt
Behavior: tardive dyskinesias/poor eye contact / apathy
Mood: flattened and blunted
Speech: poor speech
Thought: may be formal thought disorder, may be persistent delusions
Perceitons: may have persistent auditory hallucination s
Cognition: specific cognitive defects.

Question 13

What are schneiders first rank symptoms?

Answer 13

o Auditory hallucinations (3 person, running commentary, hearing thoughts spoken aloud)
o Passive phenomena (somatic passivity, actions influenced by others, thought withdrawal, thought insertion, thought broadcast)
o Delusional perception.

Question 14

What are Bleuer’s 4As?

Answer 14

o Autistic thought – inner world of fantasy
o Affective incongruity - i.e. smiling when describing sad event
o Associaitons loosened – thought disorder
o Ambivalence – conflicting feelings

Question 15

What investigations would you do for a schizo patient?

Answer 15

Exclde organic cause (frontal SOL, FCB, TFT, glucose, LFT, Ca, B12/folate, VDRL). ?CT.

Question 16

What is the management of a schizo patient?

Answer 16

Risk assess: suicide risk very high. Risk to others and self neglect.
Consider need for hospital Tx with or without MHS. Involve family, carers, GP, community. Depot given if compliance is a problem.
Antipsychotics mainstay of tx. Choice depends on side effect profile
Cloxapine if heavy resistance. CBt for persisting delusions and hallucinations. Social rehabilitation etc.

Question 17

What are the complications of schizo?

Answer 17

10% chronic course, 20% only one episode, 35% functional impairment, 35% increase impairment over episodes, 15% risk of suicide.

Question 18

What are the good prognostic factors of schizophrenia?

Answer 18

Good prognostic factors: old, female, married, no FHx, no other comorbidities, high IQ, positive symptoms, precipitants clear, treatment compliance, low expressed emotion, presence of mood component, acute onset.

Question 19

What is schizoaffective disorder?

Answer 19

Overlap sndrome with bipolar and schizophrenic disorder. Patient must satisfy criteria both for bipolar AND schizophrenic disorder at the same time, but where psychosis is not secondary to mood disturbance.

Question 20

What are the risk factors for schizoaffective disorders?

Answer 20

First degree relative of patients with schizoaffective disorder have significantly higher risk of both.

Question 21

How do you treat schizoaffective disorder?

Answer 21

Treat symptoms as for schizophrenic (i.e. mood symptoms improve with psychotic tx). Prognosis better than schizophrenia alone but worse than bipolar alone.

Question 22

What is delusional disorder?

Answer 22

Delusional idea without persistent hallucinations and not fitting criteria dor dx of schizophrenia.
Most comon persecutory, grandiose, hypochondriacal and jealous. Age of onset same as schizophrenia, usually >40y.
More common in those with hearing impairment. Tx with antipsychorics, prognosis poor.