Schizophrenia

Question 1

Greater in males or females?

Answer 1

Males

Question 2

Peak onset of age in males and females?

Answer 2

20-28 (M)

26-32 (F)

Question 3

What are the 1st rank symptoms?

Answer 3

3rd person auditory hallucinations - running commentary
3rd person auditory hallucinations - discussion and arguing
somatic hallucinations/passivity - bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others

thought insertion
thought withdrawal
though broadcast
thought echo

delusional perception: a two stage process - where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.

Question 4

Negative symptoms? (4)

Answer 4

4A's:
Avolition: lack of motivation
Anydonia: unable to experience pleasure
Alogia: poverty of speech
Ascoiality: lack of desire for relationships

Question 5

Mechanism? (2)

Answer 5

Involves D2 receptors
Increased mesolimbic DA activity = +ve symptoms
Decreased mesocortical DA activity = -ve symptoms

Question 6

Risk Factors? (6)

Answer 6

Genetic: 50% chance if identical twin has it
Viral infections
CNS pathology: encephalitis, neurosyphilis, TLE
Life events: social exclusion, childhood trauma etc.
Substance misuse: cannabis, LSD, amphetamines
Peri-natal trauma: hypoxia, maternal stress

Question 7

Types of schizophrenia? (4)

Answer 7

Paranoid - stable, paranoid delusions, hallucinations

Hebephrenic:
Prominent affective changes
Fleeting and fragmented delusions and hallucinations
Unpredictable and irresponsible behaviour |(i.e. silly behaviour)
Shallow and inappropriate mood
Disorganised thought and incoherent speech
Social isolation with rapid negative symptoms

Catotonic:
Reduction in movement
Episodes of violent excitement may be a striking feature of the condition
The catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic hallucinations.

Simple:
symptoms are mild and not psychotic (i.e. no delusion or hallucinations)
insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance.

Question 8

Investigations? (11)

Answer 8

FBC & LFT’S (alcohol abuse), U&E’s (clozapine increased WCC & neutrophils: CRP)
Cholesterol/Lipids - increased risk of CV disease with clozapine
Syphillis blood test
Urine/serum drugs screen
Random blood glucose - increased risk of diabetes with clozapine
CT/MRI - rule of organic causes (2ry to physical disease)
EEG
ECG
Neuro exam - rule out space occupying lesion

Question 9

Biological Mx of schizophrenia (1st line)?

Answer 9

2nd generation A/P e.g. risperidone or aripiprazole

Question 10

Why is a 2nd generation A/P given?

Answer 10

Acute episode increases risk of EPS, therefore this reduces these symptoms.

Question 11

What are the extrapyramidal symptoms? (4)

Answer 11

Parkinsonism - tremor, bradykinesia, rigidity, postural instability

Dystonia - repeated involuntary muscle contraction

Tardive dyskinesia - slow onset, involuntary repeated body movements

Akathsia - restlessness

Question 12

Minimum number of weeks of use for 1st line

treatment? Why?

Answer 12

6 weeks

Inhibition of the D2 receptors takes hours – but it can take weeks for symptoms to reside

Question 13

2ry line treatment for schizophrenia?

Answer 13

Clozapine (2nd gen)

Question 14

Mechanism of clozapine? (2)

Answer 14

Binds to 5HT (serotonin) receptor and higher affinity for D4

Question 15

3rd line treatment for schizophrenia? (3)

Answer 15

Haloperidol (1st gen)
Inhaled loxapine (1st gen)
Fluphenazine

Question 16

What drugs used for rapid tranquilisations? (3)

Answer 16

IM benzodiazepines, e.g. lorazepam
Haloperidol
Inhaled loxapine

Question 17

Last line if poor response to medication?

Answer 17

ECT (sometime w/ clozapine)

Question 18

Psychosocial Mx? (3)

Answer 18

CBT - offered to all
FyT - family intervention
Relapse signature - warning symptoms of relapse e.g. social withdrawal, insomnia, lack of focus/attention
Arts therapies - for negative symptoms

Question 19

Which 1st generation A/P does the Depo use?

Answer 19

Perphenzine

Question 20

When can the diagnosis of schizophrenia NOT be made? (3)

Answer 20

Presence of extensive depressive or manic symptoms unless schizophrenic symptoms clearly pre-date the affective disturbance.

Presence of overt brain disease e.g. epilepsy
Drug intoxication or withdrawal