Schiophrenia

Question 1

What is the umbrella term for schizophrenia?

Answer 1

An umbrella term for a complex syndrome characterised by a broad spectrum of cognitive, perceptual, behavioural, language and emotional dysfunctions.

Question 2

What is the prevalence of schizophrenia

Answer 2

1%
Before 10 years and after 60 is rare
equal across genders
Evidence that being born in urban areas is associated with greater sick

Question 3

DSM for Schizophrenia

Answer 3

Two or more of the following for at least a one-month (or longer) period of time, and at least one of them must be 1, 2, or 3:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms, such as diminished emotional expression
Impairment in one of the major areas of functioning for a significant period of time since the onset of the disturbance: Work, interpersonal relations, or self-care.
Some signs of the disorder must last for a continuous period of at least 6 months. This six-month period must include at least one month of symptoms (or less if treated) that meet criterion A (active phase symptoms) and may include periods of residual symptoms. During residual periods, only negative symptoms may be present.
Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out:
No major depressive or manic episodes occurred concurrently with active phase symptoms
If mood episodes (depressive or manic) have occurred during active phase symptoms, they have been present for a minority of the total duration of the active and residual phases of the illness.
The disturbance is not caused by the effects of a substance or another medical condition
If there is a history of autism spectrum disorder or a communication disorder (childhood onset), the diagnosis of schizophrenia is only made if prominent delusions or hallucinations, along with other symptoms, are present for at least one month

Question 4

What is catatonia

Answer 4

performing a repeated behaviour (e.g. repeated gesturing) or even holding a limb in the same awkward position for a long period of time without reference to it

Question 5

what are some negative symptoms?

Answer 5

Affective flattening
Anhedonia
Alogia (poverty of speech)
Avolition (apathy lack of motivation)
Social withdrawal

Question 6

What are some neurocognitive symptoms?

Answer 6

Attention, memory and learning deficits, lower executive funciton, processing speef, visiospatial and auditory deficits

Question 7

What are delusions?

Answer 7

Erroneous beliefs taht usually involve a misinterpretation of perceptions or experiences
Held with stong convictions despite clear contradictory evidence
Bizare (clearly implausible and non understandable) vs non-bizarre delisions

Question 8

What are the types of delusions?

Answer 8

Persecutory: i.e. paranoid
Referneital (ideas of reference)- where the person takes something trivial/unimportant and frames it as having personal significance)
Grandiose (delusions of grandeur)
Somatic (false belief that their body is abnormal- i.e. infected with disease)
Religious
Thought alienation (insertion or withdrawal)- believe their thoughts have been inserted
Broadcasting (belive their thoughts are being broadcast to the wider population)
External (external forces are controlling their behaviour)
Misidentification (delusions occur when the person beleive other peopela round them are replaced by impostors)

Question 9

Why do delusions form?

Answer 9

Deficit theory: brain dysfunction creating erroneous perception
Motivational theory: to relieve anxiety or distress and provide alternate preoccupation- view delusions as extreme instances of self deceptions

Question 10

What are hallucinations?

Answer 10

The experience of a sensory event in the absence of the normal eliciting stimulus

Question 11

What are the common types of hallucinations?

Answer 11

Any modality (auditory, visual, olfactory, gustatory and tactile)- can also be a combination
Auditory are the most common

Question 12

How do hallucinations form?

Answer 12

Metacognition (thinking about thinking)- listening to own voice/thoughts- they cant tel that they’re thinking
Misattribution (less able to identify their own voice recording)
Aberrant sensory perceptions- they have different atered pathways in brain regions associated with speech production

Question 13

What is echolalia

Answer 13

repetition of a single word

Question 14

What is echopraxia

Answer 14

mirroring behaviour of others

Question 15

What is schizotypal personality disorder?

Answer 15

Considered within the schizophrenia spectrum, but detailed in the DSM-5 in the chapter on Personality Disorders.
Characterised by a pervasive pattern of social and interpersonal deficits, including reduced capacity for close relationships, cognitive or perceptual distortions, and eccentricities of behaviour, usually beginning by early adulthood, sometimes in childhood or adolescence.
The abnormalities of beliefs, thinking and perception are below the threshold for the diagnosis of a psychotic disorder.

Not as severe as schizophrenia

Question 16

What is attenuated psychosis syndrome?

Answer 16

Peoplec linically at risk of developing a psychotic disorder

Question 17

What is the SCID-5?

Answer 17

A structured clinical interview to help with diagnosis

Question 18

What is the cross-cutting symptom measure

Answer 18

It focuses on the symptoms more, and also is useful for sub-clinical patients
Argues that psychotic symptoms/experiences lie on a spectrum

Question 19

Good outcomes are achieved by how many people?

Answer 19

20% of people will ahve good outcomes. 80% of sufferes will continue to require daily living support.

Question 20

What is the aetiology of schizophrenia

Answer 20

Onset may be abrupt or insidious
Usaully preceeded by a prodromal phase
Ealy appearance of negative symptoms, alter emergence of positive symptoms
Early onset more likely in males
Late onset likely in females- have a better prognosis

Question 21

What are the phases of schizophrenia?

Answer 21

Prodromal: non-specific symptoms in weeks or months preceeding a psychotic episode (general loss of itnerest, avoiding work and socialising, irritability, odd beliefs and behaviours) 1-3 weeks
Active state: psychotic symptoms: 2-5 weeks
Residual state: similar to prodromal state but with blunted affect and impairment in role functioning: 9-18 months

Question 22

What is associated with a good prognosis?

Answer 22

Late onset
Acute onset
Good premorbid functioning
Remale
Associated mood disturbance
Brief ective phase

Good inter-episode functioning
Minimal residual sympotom
Good support network

Question 23

What is associated with a bad prognosis?

Answer 23

Early onset
Insidious onseet
Poor premorbid functioning
Withdrawn, autistic behaviour
Single without support
Perinatal trauma
Brain abnormalities
A family history
Lack of insight

Question 24

What is the most common predictor of non-adherance to treatment and medication?

Answer 24

A lack of insight or awareness into one’s illness is the most common predictor of: non-adherence to treatment and medication; relapse to acute phase symptoms; hospitalisation and involuntary treatment; poor psychosocial functioning; aggression; poor prognosis; and poor treatment outcomes.
Associated with greater incidence of mood symptoms and higher risk for suicide: approximately 5-6% die from suicide; further 20% attempt suicide, sometimes in response to hallucinations to harm oneself; suicidal ideation is common throughout the illness and across the lifespan.

Question 25

What is the rate of suicide/attempts for schizophrenia?

Answer 25

5-6% die, 20% attempt

Question 26

Aetiology of schizophrenia

Answer 26

-Genetic predisposistion
No one gene is responsible - multiple genes associated with vulnerability
Variation in certain genes can make some individuals vulnerable to schizophrenia
Interact with environmental factors – especially stress, trauma, substance use
Evidence has come from:
Twin studies
Adoption studies
-Neurobiological alterations
The dopamine hypothesis
Dopamine antagonists reduce symptoms
Dopamine agonists increase schizophrenia like symptoms and behaviour
Focus now on glutamatergic and endocannabinoid systems
-Neuroanatomical and neurocognitive deficits
Enlarged ventricles and atrophy of surrounding tissue
Reduced dentric spines
-Neurodevelopmental
Viral infection, malnutrition, obstetric complications
Disruption of normal maturational processes of the brain before or at birth and at critical neurodevelopmental stages (e.g. adolescence)
E.g. oxygen deprivation
Stress can disrupt dopamine functioning
Three hit model - genetic vulnerability / predisposition, perinatal complications, stress or other trigger (eg. substance use) during adolescence (brain differentiation)

-Environmental
Urbanisation 
Housing 
Reduced access to housing
Education 
Economic 
Poor economic status
Vulnerability to abuse 
Stigma 
Discrimination
- Psychological and environmental
Lack of nurturing early environment 
Expressed Emotion (EE) 
criticism / hostility / emotional over-involvement
–> If you have schizophrenia and live in a family with high EE , you are more likely to relapse than if in a family with low EE 
Gut microbiota (the gut-brain axis)- inflamatory responses in the brain

Question 27

How to treat schizophrenia

Answer 27

Control symptoms (medication? or tDCS)
Assist the person to make sense of and overcome the trauma of their illness
Prevent relapse through decreasing risk factors such as stress, substance use, family conflict and stigma
Promote protective factors such as secure accommodation and income, engagement in work or study, strong social networks and family supports, adherence to medication, management of side effects.

Question 28

What are the goals of mental health intervention?

Answer 28

Assess risk of harm to self or others; if no risks, best to keep within home environment
Reduce immediate stress and distress (e.g. time out of work and away from crises)
Establish emotional support structure
Psychoeducation – to the patient and their family
Develop trusting relationship between patient, therapist and family to achieve maximal benefits
If no major acute psychotic symptoms, could try benzodiazepines first – may help to improve sleep quality and reduce anxiety around delusional beliefs; low-dose antipsychotics commenced if active symptoms persist.

Question 29

What is social skills training?

Answer 29

Aims to enhance social performance, reduce distress and alleviate difficulties with daily functioning.
Goal is to build up individual behavioural elements into complex behaviours and thus develop more effective social communication.
Strategies include modelling, role-play and social reinforcement.

Question 30

What is life skills training?

Answer 30

Group or individual training in managing money, organising and running a home, domestic skills and personal self-care.
Distinct from, but often paired with, social skills training.
May be undertaken by health care professional such as nurses or OTs.

Question 31

What does CBT for delusions look like?

Answer 31

Cross-sectional analysis of delusional thinking reveals common cognitive biases which may distort the perception of usual life experiences:
Egocentric, externalising and intentionalising (internalising?) biases
Exaggerated self-serving biases
Tendency to jump to conclusions
Failure to consider alternative explanations for interpretations
Assess past life events and their context and appraisal, and critical events proximal to the delusion formation
Understand current events (internal or external) likely to trigger or intensify the delusions and specific consequences (emotional or behavioural) created by the delusions.
Train patient to identify links between thoughts, feelings and behaviours and the role of cognitive biases and distortions; therapist deals with interpretations and explanations, encouraging alternative strategies: e.g. what leads you to believe this is likely? What evidence supports this interpretation?

Question 32

What are relapse rates?

Answer 32

Risk of relapse to acute psychotic symptoms, following discontinuation of medication in the first year, is around 65%. On medication, up to 40% may still relapse within the first year.

Question 33

Interventions for enduring psychosis

Answer 33

Structured environments
Token economies set up to increase appropriate behaviours in institutions
Social Skills / Living Skills / Vocational training / Psychoeducation
Psychological therapies aimed to increase adherence to medications
CBT for identifying warning signs of relapse
Coping with persistent symptoms
Cognitive remediation