Schizophrenia

Question 1

Genetic factors predisposing to schizophrenia

Answer 1

45% monozygotic concordance
Parent if a schizophrenic 6% lifetime risk
Child of a schizophrenic 13% lifetime risk
Second degree relative 3%

Question 2

Non genetic factors predisposing to schizophrenia

Answer 2

Maternal vial infection in the 2nd trimester

obstetric complications

Question 3

Precipitating factors of schizophrenia

Answer 3

Life events
High expressed emotion
Illicit drug use

Question 4

Dopamine hypothesis

Answer 4

Excessive dopamine activity in the brain causes schizophrenia

• > all effective antipsychotics have some D2 receptor activity
• > however 30% don’t respond and clozapine has less D2 blocking activity

Question 5

Brain abnormalities associated with schizophrenia

Answer 5

Seen even prior to treatment
Ventricular enlargement
Reduced brain size
Reduced connectivity between brain regions

Question 6

Schneiders first rank symptoms

Answer 6

Thought disorder (content/delusions) 
-insertion
-withdrawal
-broadcasting 
Passivity phenomena
-somatic-> being controlled by something else 
-delusions of control
3rd person auditory hallucinations
Thought echo
Running commentary
Delusional perceptions -> normal perception, delusional interpretation

Question 7

ICD-10 classification

Answer 7

Present for most of the time during at least one month
Exclusion of organic brain disorder
1 or more of:
-> thought echo, insertion, withdrawal or broadcasting
-> delusions of control, passivity or perception
-> auditory hallucinations
-> bizarre delusions

Question 8

Paranoid schizophrenia

Answer 8

Most common 
Prominent hallucinations +\- delusions 
Delusions of control, passivity and persecution 
Better prognosis
Later onset

Question 9

Hebephrenic schizophrenia

Answer 9

Thought disorganisation 
Disturbed behaviour
Inappropriate or flat affect 
15-25 years 
Poorer prognosis

Question 10

Catatonic schizophrenia

Answer 10

Rigidity -> maintaining fixed postures
Posturing-> unusual postures
Negativism-> motiveless resistance to instructions/attempts to be moved
Waxy flexibility
Agitation
Stupor -> ahenesis, mutism, extreme unresponsiveness

Question 11

Differential diagnosis of schizophrenia

Answer 11

Acute and transient psychotic disorder
Persistent Dellusional disorder 
Schizoaffective disorder 
Affective disorder with psychotic symptoms
Drug induced
Temporal lobe epilepsy
SLE
Cerebral infection, trauma

Question 12

Acute and transient psychotic disorder

Answer 12

Develops over 1-2 weeks
Symptoms similar to schizophrenia
Resolves within a few months
Preceded by a stressful life event

Question 13

Persistent delusional disorder

Answer 13

Variety of disorders where persistent delusions are the most prominent
3m
Middle aged

Question 14

Schizoaffective disorder

Answer 14

Both schizophrenic and mood disorder in the same episode

Question 15

Investigations

Answer 15

Collateral history
Physical examination- neuro and endocrine
Urine drug screen
Bloods-> FBC, U+E, TFT, LFT, ESR, glucose, Ca2+
-exclude medical or substance related disorders
-establish baseline values
-assess renal and liver function
ECG
Ct/MRI of brain for abnormal cases

Question 16

Management 1) treatment setting

Answer 16

Treatment setting 
Depends on presentation and severity 
Hospital for first psychosis and high risk
Long term-> community management 
Stable-> primary care

Question 17

Biological management of schizophrenia, typical antipsychotics

Answer 17

Haloperidol, chlorpromazine, trifluoperazine,

• more like to cause pyramidal side effects
• Parkinsonism
• akathisia
• dystopia
• tardiness dyskinesia
• raised prolactin levels

Question 18

Biological management of schizophrenic atypical antipsychotics

Answer 18

Olanzapine, risperidone, quetiapine, aripiprazole, clozapine
* less D2 R blocking-> less extra pyrimidal side effects
* weight gain
* increased risk of T2DM
Newly diagnosed, acute episodes

Question 19

Choosing an antipsychotic

Answer 19

Only of benefit in reducing the positive symptoms
Little difference in efficacy apart from clozapine
Choose based on tolerability
Treatment resistance-> lack of improvement after sequential use of at least 2 antipsychotics for 6-8w -> clozapine
Increase concordance with depot injections

Question 20

Other biological treatments of schizophrenia

Answer 20

Benzodiazepines -> short term relief of behavioural disturbances, insomnia, aggression and agitation
Antidepressants and lithium-> sometimes used to augment antipsychotics
ECT-> catatonic States

Question 21

Physical health monitoring

Answer 21

CV risk is increased
ECG prior to treatment -> increased risk of long QT
FBC for clozapine

Question 22

Psychological treatments of schizophrenia

Answer 22

Psychoeducation 
CBT 
-improves insight
-increase awareness of early warning signs
-NICE
Family interventions 
-alliance building
-reduce expressed emotion
-set appropriate expectations

Question 23

Social treatments for schizophrenia

Answer 23

Financial benefits
Occupation 
Accommodation 
Day time activities 
Increase social network
Support groups
Asses for care programs approach

Question 24

Course and prognosis of schizophrenia

Answer 24

Generally chronic relapsing remitting 
20% have a single episode
50% have a poor outcome 
10% die of suicide
Lifespan decreased by 15 years 
-smoking
-deprivation
-cv diseases
-accidents

Question 25

Factors that improve prognosis

Answer 25

Female
Married 
Older onset
Abrupt onset
Precipitated by stress
Good response to medication 
Paranoid
Absence of negative symptoms
Illness characterised by prominent mood symptoms
Good premorbid state 
No FH
low expressed emotion

Question 26

Epidemiology of schizophrenia

Answer 26

20/100,000 incidence per year
Lifetime risk is 1%
Equal sex ratio
Peak onset 15-25 m 25-35 f
Increased prevelance in lower social classes 
Increased incidence in urban areas