Schizo

Question 1

What is psychosis defined by?

Answer 1

1. Delusions: A fixed false belief, which is firmly held despite evidence to the contrary
   and goes against the individual’s normal social and cultural belief system.
2. Hallucinations: A perception in the absence of an external stimulus. It is a common
   feature of psychosis.
3. Thought disorder: An impairment in the ability to form thoughts from logically
   connected ideas.

Question 2

Epidemiology of psychosis

Answer 2

Psychotic disorders are relatively common, with schizophrenia being the most common.
The incidence of psychosis in England is roughly 31.7 per 100 000 people.
UK studies suggest a possible higher prevalence of psychosis in the black and ethnic
minority populations compared to the white population.
There are a variety of conditions that can present with psychosis (Fig. 4.1.1).
Non-organic causes of psychosis other than schizophrenia are covered in

Question 3

Non-organic causes of psychosis

Answer 3

Schizophrenia
Schizotypal disorder
Schizoaffective disorder
Acute psychotic episode
Mood disorders with psychosis
Drug-induced psychosis
Delusional disorder
Puerperal psychosis

Question 4

Organic causes of psychosis

Answer 4

Drug induced (Alcohol, acid, cannabis, mdma, cocaine, amphetamines)
Iatrogenic medications (Levodopa, methyldopa, steroids, antimalarials)
Delirium
Dementia
Huntington’s
SLE
Syphilis
Cushings
Vitamin b12 deficiency
Porphyria

Question 5

What is the definition of schizotypal disorder?

Answer 5

Also known as latent schizophrenia, it is characterized by eccentric
behaviour, suspiciousness, unusual speech and deviations of thinking and
affect that is similar to those suffering from schizophrenia. These
individuals however, do not suffer from hallucinations or delusions. There
is an increased risk of schizotypal disorder in those who have first-degree
relatives with schizophrenia.

Question 6

What is the definition of acute and transient psychotic disorders

Answer 6

A psychotic episode presenting very similarly to schizophrenia but lasting
<1 month and so not meeting the criteria for schizophrenia.

Question 7

What is the definition of schizoaffective disorder?

Answer 7

Characterized by both symptoms of schizophrenia and a mood disorder
(depression or mania) in the same episode of illness. The mood symptoms
should meet the criteria for either a depressive illness or a manic episode
together with one or two typical symptoms of schizophrenia

Question 8

What is the definition of persistent delusional disorder?

Answer 8

development of a single or set of delusions for a period of at least 3
months in which the delusion is the only, or the most prominent, symptom
with other areas of thinking and functioning well preserved, unlike in
schizophrenia. The content of the delusion is often persecutory, grandiose
or hypochondriacal in nature. The onset and content of the delusion is
often related to the patient’s life situation. Symptoms often respond well to
antipsychotics.

Question 9

What is induced delusional disorder?

Answer 9

Induced delusional disorder, also known as ‘shared paranoid disorder’, is
an uncommon disorder characterized by the presence of similar delusions
in two or more individuals. Folie imposée is where a dominant person
(‘primary’) initially forms a delusional belief during a psychotic episode and
imposes it on another person(s) (‘secondary’). Folie simultanée is when
two people considered to suffer independently from psychosis, influence
the content of each other’s delusions so that they become identical or very
similar.

Question 10

Definition of mood disorders with psychosis

Answer 10

Psychosis occurs secondary to depression or mania. On the other hand,
schizophrenia usually develops spontaneously

Question 11

Puerperal psychosis (post-partum psychosis) definition

Answer 11

The acute onset of a manic or psychotic episode shortly after childbirth
(usually develops in the first 2 weeks following birth). It affects
approximately 0.2% of women.

Question 12

Late paraphrenia definition

Answer 12

A term that is sometimes used to describe late-onset schizophrenia. It is
not coded for in ICD-10. Hallucinations and delusions (particularly
paranoid) are prominent, whereas thought disorders and catatonic
symptoms are rare.

Question 13

ICD-10 Classification of schizophrenia and other psychotic disorders:

Answer 13

1. Schizophrenia
2. Schizotypal disorder
3. Persistent delusional disorder
4. Acute and transient psychotic disorders
5. Induced delusional disorder
6. Schizoaffective disorder
7. Other non-organic psychotic disorders
8. Unspecified non-organic psychosis

Question 14

What is the definition of schizophrenia?

Answer 14

Schizophrenia is the most common psychotic condition, characterized by hallucinations,
delusions and thought disorders which lead to functional impairment. It occurs in the absence of
organic disease, alcohol or drug-related disorders and is not secondary to elevation or
depression of mood.

Question 15

Aetiology of schizophrenia

Answer 15

The aetiology of schizophrenia involves both biological and environmental factors.
There is an increased likelihood of schizophrenia in those with a positive family history, and
monozygotic twin studies show a 48% concordance rate.
Factors that interfere with early neurodevelopment such as obstetric complications, fetal
injury and low birth weight lead to abnormalities expressed in the mature brain.
Adverse life events and psychological stress increase the likelihood of developing
schizophrenia.
Expressed emotion is the theory that those with relatives that are ‘over’ involved or that
make hostile or excessive critical comments are more likely to relapse.

Question 16

Pathophysiology of schizophrenia

Answer 16

The dopamine hypothesis states that schizophrenia is secondary to over-activity of mesolimbic dopamine pathways in the brain. This is supported by conventional antipsychotics which work by blocking dopamine (D2) receptors, and by drugs that
potentiate the pathway (e.g. anti-parkinsonian drugs and amphetamines) causing psychotic
symptoms.

Question 17

Epidemiology of Schizophrenia

Answer 17

Schizophrenia affects approximately 24 million people worldwide. The incidence of
schizophrenia is estimated to be 5 per 100 000 people.
Peak age of onset is 15–35 years.
Males and females are equally affected but a systematic review showed men aged <45
years had twice the rate of schizophrenia as women.

Question 18

Predisposing factors to schizophrenia

Answer 18

Biological- Genetic: Monozygotic twinstudies – 48% concordance
Neurochemical: ↓
dopamine, ↓
glutamate, ↓
serotonin, ↓ GABA
Neurodevelopmental:
Intrauterine infection,
premature birth, fetal
brain injury and
obstetric
complications
Age 15–35
Extremes of parental
age: ≤20 years or
≥35 years
Psychological- Family
history: The
closer the
family relationship
to an affected
relative, the
higher the
risk
Childhood
abuse
Social: Substance misuse
Low socioeconomic
status
Migrants-Higher
incidence in migrant
populations (e.g.
African-Caribbean),
but not in offspring
born in the new
location
Living in an urban
area – although this
could be as a result
of urban drift into
cities.

Question 19

Precipitating factors of schizophrenia

Answer 19

Smoking cannabis or
using
psychostimulants
Adverse life
events
Poor coping
style
Adverse life events

Question 20

Perpetuating factors of schizophrenia

Answer 20

Substance misuse
Poor compliance to
medication
Adverse life
events
↓ Social support
Expressed emotion

Question 21

Difference between positive and negative schizophrenia

Answer 21

The symptoms of schizophrenia can be referred to as positive (the acute syndrome) when
there is the appearance of hallucinations and delusions. This is in contrast to negative
symptoms (the chronic syndrome) which refers to loss of function.

Question 22

What is positive schizophrenia?

Answer 22

Most common
Dominated by positive symptoms (hallucinations and delusions)

Question 23

Postschizophrenic depression

Answer 23

Depression predominates with schizophrenic illness in the past 12 months with some schizophrenia symptoms still present

Question 24

What is hebephrenic schizophrenia?

Answer 24

Thought disorganisation predominates
Onset of illness is earlier (15-25) and has poorer prognosis

Question 25

What is catatonic schizophrenia?

Answer 25

Rare form characterised by one or more catatonic symptoms

Question 26

What is simple schizophrenia?

Answer 26

Rare form when negative symptoms develop without psychotic symptoms

Question 27

What is undifferentiated schizophrenia?

Answer 27

Meets diagnostic criteria for schizophrenia but does not conform to any of the other subtypes

Question 28

What is residual schizophrenia?

Answer 28

1 year of chronic negative symptoms preceded by a clear-cut psychotic episode

Question 29

What are the positive symptoms of schizophrenia? What is the acronym to remember

Answer 29

Delusions Held Firmly Think Psychosis
Delusions
Hallucination
Formal thought disorder
Thought interference
Passivity phenomenon

Question 30

What is a delusion?

Answer 30

A delusion is a fixed false belief, which is firmly held despite evidence to the
contrary and goes against the individual’s normal social and cultural belief system. Usually
persecutory, grandiose, nihilistic, or religious in nature. Ideas of reference are thoughts in
which a patient infers that common events refer to them directly (e.g. personal messages
from television and newspapers).

Question 31

What is a hallucination?

Answer 31

A hallucination is a perception in the absence of an external stimulus. They
are usually third person auditory hallucinations which may be of running commentary nature

Question 32

What is formal thought disorder?

Answer 32

Abnormalities of the way thoughts are linked together.

Question 33

What is thought interference?

Answer 33

This could either be the feelings that thoughts are being inserted
(thought insertion), removed (thought withdrawal) or heard out loud by others (thought
broadcast)

Question 34

What is passivity phenomenon?

Answer 34

Actions, feelings or emotions being controlled by an external force

Question 35

What are Schneider’s first rank symptoms?

Answer 35

Delusional perception: A new delusion that forms in response to a real perception without
any logical sense, e.g. ‘the traffic light turned red so I am the chosen one.’
Third person auditory hallucinations: usually a running commentary.
Thought interference: thought insertion, withdrawal or broadcast.
Passivity phenomenon.

Question 36

What are the negative symptoms of schizophrenia (A factor)

Answer 36

Avolition (↓ motivation): Reduced ability (or inability) to initiate and persist in goal-directed
behaviour.
Asocial behaviour: Loss of drive for any social engagements.
Anhedonia: Lack of pleasure in activities that were previously enjoyable to the patient.
Alogia (poverty of speech): A quantitative and qualitative decrease in speech.
Affect blunted: Diminished or absent capacity to express feelings.
Attention (cognitive) deficits: May experience problems with attention, language, memory,
and executive function.

Question 37

ICD-10 criteria for schizophrenia (Group A)

Answer 37

A. Thought
echo/insertion/withdrawal/broadcast.
B. Delusions of control, influence or
passivity phenomenon.
C. Running commentary auditory
hallucinations.
D. Bizarre persistent delusions.

Question 38

ICD-10 criteria for schizophrenia (Group B)

Answer 38

E. Hallucinations in other modalities that are
persistent.
F. Thought disorganization (loosening of
associations, neologisms, incoherence).
G. Catatonic symptoms.
H. Negative symptoms.

Question 39

Whats needed to diagnose schizophrenia according to ICD-10?

Answer 39

At least one very clear symptom from Group A (A–D) or two or more from Group B (E–H) for at
least 1 month or more. Schizophrenia should not be diagnosed in the presence of organic
brain disease

Question 40

History taking questions for people with schizophrenia?

Answer 40

‘Have you ever had the experience of hearing noises or voices talking when there
is nobody around and nothing else to explain it?’ (auditory hallucinations)
‘How many voices are there?’ (type of auditory hallucination)
‘Do these voices speak directly to you or about you?’ (second or third person
auditory hallucination respectively)
‘Do these voices ever make comments about what you’re doing?’ (third person
auditory hallucinations – running commentary)
‘Are you afraid that someone else is trying to harm you?’ (persecutory delusion)
‘Have you noticed that people are doing or saying things that have a special
meaning to you?’ ‘When you watch television or read the newspaper do you ever
worry that there are messages specifically for you?’ (delusions of reference)
‘Do you have any special powers or abilities?’ (grandiose delusions)
‘Have you ever felt that thoughts are being taken out of your mind?’ (thought
withdrawal)
‘Have you ever experienced thoughts inside your head that are not yours and
have been put there by someone else?’ (thought insertion)
‘Have you ever felt under the control of an outside force?’ (passivity phenomenon)

Question 41

MSE of schizophrenic

Answer 41

ppearance Can be normal (positive), or inappropriate with poor self-care
(negative).
Behaviour Preoccupied, restless, noisy or suspicious (positive). A few show
sudden, unexpected changes in behaviour. Withdrawn, poor eye
contact and apathy (negative).
Speech May reflect underlying thought disorder (loosening of associations,
pressured and distractible speech), interruptions to flow of thought
(thought blocking), and poverty of speech (negative).
Mood Incongruity of affect or mood changes such as depression, anxiety or
irritability. Flattened affect (negative).
Thought Delusions (e.g. persecutory, delusions of control, delusions of
reference), thought insertion/withdrawal/broadcast, formal thought
disorder (loosening of associations, word salad, concrete thinking,
circumstantiality/tangentiality) (all positive).
Perception Hallucinations (especially third person auditory in nature) (positive).
Cognition Normal orientation. Attention and concentration often impaired
(positive). May be evidence of premorbid cognitive impairment.
Specific cognitive deficits (negative).
Insight Generally poor

Question 42

What is involved in the management of schizophrenia?

Answer 42

Risk assessment is vital and the use of the Mental Health Act may be required for those
who refuse informal admission.
The care of the schizophrenic patient is a joint effort between primary and secondary care
and a combination of inpatient and outpatient care. Involvement of the psychiatric
consultant, community psychiatric nurses, GPs, Crisis resolution team, social workers,
carers and voluntary organizations is essential. A care programme approach may be used
For a first presentation of psychosis, the early intervention in psychosis team should be
involved. They provide interventions targeted at reducing the duration of untreated
psychosis (a strong prognostic indicator).
It is essential to assess social circumstances and involve family where possible.
The principle management of schizophrenia is outlined using the bio-psychosocial model

Question 43

What are the biological approaches to management for schizophrenia

Answer 43

Antipsychotics can be broadly divided into typical and atypical.
Atypical antipsychotics are first-line, e.g. risperidone and
olanzapine.
Depot formulations should be considered if the patient prefers or
there is a problem with non-compliance.
Clozapine is the most effective antipsychotic and used for
treatment-resistant schizophrenia
Benzodiazepines can provide short-term relief of behavioural
disturbance, insomnia, aggression and agitation.
Antidepressants and lithium can be used to augment antipsychotics.
ECT May be appropriate in patients who are resistant to pharmacological
agents. Effective for catatonic schizophrenia.

Question 44

Psychological management of schizophrenics

Answer 44

CBT: CBT is strongly recommended by NICE. Reduces residual
symptoms.
Family intervention: Particularly useful for families of patients with schizophrenia who
have persisting symptoms. Psychoeducation helps families reduce
high levels of expressed emotion which reduces relapse rates.
Art therapy NICE recommends art therapy (e.g. music, dancing, drama) for the
alleviation of negative symptoms in young people.
Social skills
training
Uses a behavioural approach to help patients improve interpersonal,
self-care and coping skills needed in everyday life.

Question 45

Social support for schizophrenics

Answer 45

Support groups National support groups such as Rethink and SANE can help
facilitate successful rehabilitation back into the community.
Peer support Delivered by a peer support worker who has recovered from
psychosis or schizophrenia and remains stable.
Supported
employment
programmes
Recommended by NICE for patients with schizophrenia who wish to
find or return to work.

Question 46

A management plan for schizophrenic

Answer 46

Anti-psychotic or 2nd gen antipsychotic > Titrate to minimum effective dose > adjust dose according to response and tolerability > assess over 2-3 weeks >1. Effective- continue at dose 2. Not tolerated or poor compliance - Discuss with patient and change drug/ consider depot 3. Not effective - change drug and use either typical or atypical antipsychotic > not effective > clozapine

Question 47

Poor prognostic factors for schizophrenia

Answer 47

Strong family history.
Gradual onset.
↓ IQ.
Premorbid history of social withdrawal.
No obvious precipitant.