Schizophrenia

Question 1

What is Psychosis?

Answer 1

Disease of the mind (severe)

“Psychosis represents an inability to distinguish between symptoms of hallucination, delusion and disordered thinking from reality.”

Question 2

What is Neurosis?

Answer 2

Disease of the nerves (mild)

Question 3

What are hallucinations?

Answer 3

Hallucinations
> Have the full force and clarity of true perception

> Located in external space

> No external stimulus

> Not willed or controlled

5 special senses
> auditory or visual
> tactile
> olfactory and gustatory

Question 4

What are delusions, can you think of examples?

Answer 4

“ a delusion is an unshakeable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction.”

Examples
> grandiose
> paranoid (correctly persecutory)
> hypochondriacal
> self referential

Question 5

Which illnesses may have Psychotic symptoms?

Answer 5

> Schizophrenia

> Delirium

> Severe affective disorder

  - Depressive episode with psychotic symptoms
  - Manic episode with psychotic symptoms

Question 6

What percentage of the population have Schizophrenia?

Answer 6

1%

Question 7

What is the normal age of onset of Schizophrenia?

Answer 7

15-35 years old

Question 8

What are the positive symptoms within schizophrenia?

Answer 8

Hallucinations

Delusions

Disordered thinking

Question 9

What are the negative symptoms within schizophrenia?

Answer 9

Apathy

Lack of interest

Lack of emotions

Question 10

What is used to diagnose Schizophrenia?

Answer 10

The ICD 10

Question 11

Diagnostic criteria for Schizophrenia by the ICD 10?

Answer 11

For more than a month in the absence of organic or affective disorder:
At least one of the following:

a) Alienation of thought as thought echo, thought insertion or withdrawal, or thought broadcasting.
b) Delusions of control, influence or passivity, clearly referred to body or limb movements actions, or sensations; delusional perception.
c) Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body.
d) Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather).

And OR at least two of the following:

e) Persistent hallucinations in any modality, when occurring every day for at least one month.
f) Neologisms, breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech.
g) Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
h) “Negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses.

Question 12

Types of schizophrenia - paranoid?

Answer 12

Dominated by the presence of delusions and hallucinations (positive symptoms).

Negative symptoms, catatonic symptoms as well as thought disorganisation are not prominent.

This prognosis is usually better and the onset of illness later (typically 18-25 years) than the other subtypes.

Question 13

Types of schizophrenia - Hebephrenic?

Answer 13

Characterised by disorganised thought, disturbed behaviour and inappropriate flat effect.

Delusion and hallucinations (positive symptoms) are fleeting and not prominent.

Onset of the illness is earlier (15-25 years of age) and the prognosis is worse than paranoid.

Question 14

Types of schizophrenia - catatonic?

Answer 14

A rare form characterised by more catatonic symptoms.

Question 15

Types of schizophrenia - residual?

Answer 15

1 year of predominantly chronic negative symptoms which must have been preceded by at least one clear-cut psychotic episode in the past

Question 16

Aetiology of psychosis - Biological factors?

Answer 16

1) Biological:
  > Genetics
      - Hereditary 
      - Neuregulin 
      - Dysbindin
      - Di George syndrome 
  > Neurochemistry 
      - Dopamine hypothesis
      - Glutamate
      - GABA
      - Serotoninergic transmission
   > Obstetric complications
   > Maternal influenza
   > Malnutrition and famine
   > Winter birth
   >  Substance misuse

Question 17

Aetiology of psychosis?

Answer 17

1) Biological factors
2) Psychological factors
3) Social factors
4) Evolutionary theories

Question 18

Aetiology of psychosis - social factors?

Answer 18

Occupation and social class but be aware of “drift hypothesis”. This states that although often in a lower socioeconomic class this is often a result of the illness.

Migration
Recent meta-analysis of 18 studies confirms the risk in schizophrenia (Cantor-Grae et al BJPsych 2005).

Social Isolation

Life Events as Precipitants

Cultural factors NOT IMPLICATED

Question 19

Differential diagnosis in psychosis?

Answer 19

1) Schizophrenia
2) Schizophrenia-liek psychotic disorders
3) Schizoaffective disorder
4) Delusional disorder

5) Mood (Affective) disorders:
- Manic episode with psychotic features
- Depressive episode, severe, with psychotic features

6) Personality disorders (Schizotypal, borderline, schizoid, paranoid)
7) Medical causes (Endocrine, space occupying lesion etc)
8) Substance misuse
9) Dementia/delirium
10) Neurodevelopmental (Autistic spectrum)

Question 20

What is schizoaffective disorder?

Answer 20

Schizoaffective disorder describes the presentation of both schizophrenic and mood (Depressed or manic) symptoms that present in the same episode of illness, either simultaneously or within a few days of each other.

Question 21

Manic episode with psychotic symptoms?

Answer 21

Manic episode with psychotic symptoms
> Delusions of grandeur; special powers or messianic roles

> Gross overactivity, irritability and behavioural disturbance: Manic excitement

Question 22

Depressive episode with psychotic symptoms?

Answer 22

Depressive episode with psychotic symptoms
> Delusions of guilt, worthlessness and persecution

> Derogatory auditory hallucinations

Question 23

Management of schizophrenia - First episode?

Answer 23

First or second generation anti-psychotics e.g. haloperidol or olanzipine

If no response after 4 weeks change antipsychotic

Question 24

Management of schizophrenia - acute exacerbation or relapse?

Answer 24

1) Amisulpride, olanzapine or risperidone

+

2) Chlorpromaine and other low-potency first generation anti-psychotics

Question 25

Management of schizophrenia - prophylaxis to precent relapse?

Answer 25

Amisulpride, olanzapine or risperidone

+

2) Chlorpromaine and other low-potency first generation anti-psychotics

Should be continued for two years

Question 26

Management of schizophrenia - treatment resistant schizophrenia?

Answer 26

Clozapine should be offered.

Lamotrigine or sulpiride can be added for those who have had insufficient response or persistent negative symptoms

Question 27

Management of schizophrenia with cognitive dysfunction?

Answer 27

Antipyschotics and addition of acetylcholinesterase inhibitors

Question 28

Management of schizophrenia in remission who have comorbid depressive symptoms?

Answer 28

Second generation antipsychotics

Question 29

Management of schizophrenia - psychological therapies?

Answer 29

1) Cognitive behavioural therapies
2) Cognitive remediation
3) Family intervention
4) Social skills training

Question 30

Which antipsychotic should be used in breast feeding?

Answer 30

Clozapine

Question 31

Good prognostic factors in schizophrenia?

Answer 31

Absence of family history

Good premorbid function - stable personality, stable relationships

Clear precipitant

Acute onset

Mood disturbance

Prompt treatment

Maintenance of initiative, motivation

Question 32

Poor prognostic factors in schizophrenia?

Answer 32

Slow, insidious onset and prominent negative symptoms are associated with a worse outcome.

Mortality is 1.6 times higher than the general population.

Shorter life expectancy is linked to cardiovascular disease, respiratory disease and cancer.

Suicide risk is 9 times higher.

Death from violent incidents is twice as high.
36% of patients have a substance misuse problem and there are high rates of cigarette smoking.

Poorer if starts in childhood