Schizophrenia

Question 1

Define schizophrenia.

Answer 1

Psychotic disorder in absence of organic diseas,e substance abuse or withdrawal. Not secondary to mood changes.

Question 2

What are the ICD-10 schizophrenia subgroups?

Answer 2

Paranoid

Hebphrenic

Catatonic

Simple

Residual

Question 3

How is paranoid schizophrenia characterised?

Answer 3

Characterised by persecutory/grandiose delusions

Derogatory auditory hallucinations

Question 4

How is hebephrenic schizophrenia characterised?

Answer 4

Disorganisation syndrome:

• Formal thought disorder
• Affective flattening/incongruity
• Bizarre behaviour

Question 5

How is catatonic schizophrenia categorised?

Answer 5

Multiple motor, volitional and behavioural disorders

Stupor and excitement

Question 6

How is simple schizophrenia categorised?

Answer 6

Insidious but progressive impoverishment of mental life

Without development of florid symptoms

Question 7

What is the aetiology of schizophrenia?

Answer 7

Genetic basis: Twin studies and 10% risk with 1st degree relative.

Hypoxic brain injury at birth higher chance

Cannabis use theory: Neurochemical theories of excess/low D2 in different brain areas.

Schizophrenic symptoms more common in those with Huntington’s and temporal epilepsy.

Question 8

Summarise the epidemiology of schizophrenia.

Answer 8

1% prevalence. Onset in 20-30s.

Question 9

What is the natural history of schizophrenia?

Answer 9

Minimum of 1 month of symptoms including:

Minimum of 1 of:

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

OR Minimum 2 of:

• Persistent hallucinations in any modality
• Thought disorder
• Catatonic behaviour
• Negative symptoms

Question 10

What are the positive signs and symptoms of schizophrenia?

Answer 10

Appearance: Normal or inappropriate dress

Behaviour: Withdrawn or restless and noisy

Mood: Incongruent, guarded

Speech: Reflects underlying thought disorder

Thought: Formal disorder, 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 11

What are the negative signs and symptoms of schizophrenia?

Answer 11

Appearance: Poor self care/unkempt

Behaviour: Tardive dyskinesias/poor eye contact/apathy

Mood: Flattened and blunted

Speech: Poor speech

Thought: May be formal thought disorder, may be persistent delusions

Perceptions: May have persistent auditory hallucinations

Cognition: Specific cognitive defects

Question 12

What are two grouping systems which can be used to categorise the symptoms of schizophrenia?

Answer 12

Schneider’s first rank symptoms

Bleuer’s 4As

Question 13

What are Schneider’s first rank symptoms?

Answer 13

Auditory hallucinations (3 person, running commentary, hearing thoughts spoken aloud)

Passive phenomena (somatic passivity, actions influenced by others, thought withdrawal, thought insertion, thought broadcast)

Delusional perception

Question 14

What are Bleuer’s 4As?

Answer 14

Autistic thought: Inner world of fantasy

Affective incongruity: e.g. Smiling when describing sad event

Associations loosened: Thought disorder

Ambivalence: Conflicting feelings

Question 15

What are investigations for schizophrenia?

Answer 15

Exclude organic cause: Frontal space occupying lesion, FBCs, TFTs, glucose, LFTs, Ca2+, B12/folate, VDRL)

?CT

Question 16

What is the management for schizophrenia?

Answer 16

Risk assess: Suicide risk very high. Risk to others and self neglect.

Consider need for hospital treatment with or without multi-health systems. Involve family, carers, GP, community. Depot given if compliance is a problem.

Antipsychotics mainstay of treatment. Choice depends on side effect profile. Clozapine if heavy resistance.

CBT for persisting delusions and hallucinations. Social rehabilitation etc.

Question 17

What are complications associated with schizophrenia? What is the prognosis of schizophrenia?

Answer 17

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

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 18

What is schizoaffective disorder?

Answer 18

Overlap syndrome 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.

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

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

Question 19

What is delusional disorder?

Answer 19

Delusional idea without persistent hallucinations and not fitting criteria or diagnosis of schizophrenia.

Most common 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.