Schizophrenia and Affective disorders

Question 1

What is Psychosis?

Answer 1

Heterogeneous syndromes of various etiologies characterized by loss of touch with reality.

Question 2

How can Psychosis be classified?

Answer 2

1.Primary or secondary
2. Affective or non affective

Question 3

What is the difference between primary and secondary psychosis?

Answer 3

Primary -there’s no identifiable external medical, neurological or substance related cause.
Secondary - there is identifiable external factor

Question 4

Give 5 examples of primary psychotic disorders?

Answer 4

1.Schizophrenia
2.Schizoaffective disorder
3.Delusional disorder
4.Schizophreniform disorder
5. Brief psychotic disorder

Question 5

List 3 ways to group secondary causes of Psychosis?

Answer 5

1.Substance/medication induced psychotic disorder
2.Psychotic disorder due to medical condition
3.Trauma to the brain

Question 6

What is the difference between affective and non affective schizophrenia?

Answer 6

1.Affective
Characterized by the presence of psychotic symptoms along with significant mood disturbances
2. Non affective
Psychotic disorders where mood disturbances are not a prominent feature.

Question 7

What are the key features of psychotic disorders?

Answer 7

Delusions
Hallucinations
Disorganized speech
Grossly disorganized or abnormal motor behavior
Negative symptoms (Avolition, Anhedonia, Alogia, Asociality, flat Affect)

Question 8

Define a delusion?

Answer 8

1.fixed false beliefs that are not based in reality and are resistant to reasoning or contrary evidence

Question 9

What is a hallucination?

Answer 9

A sensory experience that occurs without any external stimulus.

Hallucinations can be (auditory, visual, tactile, olfactory, gustatory)

Question 10

What are the types of delusions seen in psychotic disorders (14).Describe them.

Answer 10

1.Grandiose- Heightened value ,knowledge, power and identity or special relationship to a famous person.
2.Persecutory -Believing that subject or someone close to them is attacked, harassed ,deceived or conspired against
3.Delusion of reference-the belief that unrelated events in the outside world have a special or unique relevance in the subject’s life.
4.Somatic Delusion-feeling that the subject is being affected by a physical illness or having some type of physical defect.
5.Erotomania -when one imagines that another person with a higher status is in love with him or her.
6. Bizarre -a type of delusion that is total implausible in reality.
7. Delusion of perception- a delusion where the a person believes that a normal percept has a special meaning to him or her.
8..Thought echo
9.Thought withdrawal
10.Thought insertion- thinking that their thoughts are not their own but is rather inserted by an external force.
11.Thought broadcast- subject believes that their ideas are being broadcasted aloud causing other to notice them.
12.Delusional jealousy-involves feelings where one’s sexual partner is being unfaithful.
13. Mood incongruent psychotic feature
14. Mood Congruent psychotic feature.

Question 11

Describe the features of the disorganized speech in Psychosis?

Answer 11

In psychosis:
1.Their loose connections between topics. the topics are connected by less meaningful associations. e.g. a clang association where someone answers a question based on the sound of the word but not the actual meaning.
2.There is Neologism-where people make up words
3.There is Echolalia - where a patient repeats what someone else says without regard to its meaning.
4.There is Perseveration-where there is repetition of a word or phrase or thought beyond the point where it is relevant or appropriate.
5. You can have a world salad where the words coming out of the patient’s mouth are nonsense.
6.Speech can also be tangential, circumferential , incoherent speech

Question 12

Describe features of the grossly disorganized or catatonic behavior?

Answer 12

In psychosis the patient s could :
Walking around aimlessly
Repeat hand movements
Copy an action being done by someone
Be agitated /uncontrolled physical movements/ prone to attack someone
Lack movement/hypoactive or responsiveness to an external stimuli or bizarre posturing

Question 13

What is the diagnostic criteria for A brief psychotic disorder?

Answer 13

REFER TO HANDOUT

Question 14

What is the diagnostic criteria for Schizophreniform?

Answer 14

refer to handout

Question 15

What is the diagnostic criteria for Schizoaffective disorder?

Answer 15

refer to handout

Question 16

What is the diagnostic criteria for Delusional disorder?

Answer 16

Refer to handout

Question 17

What is schizophrenia?

Answer 17

It is a syndrome characterized by a heterogeneous cluster of symptoms and signs

Question 18

What was the significance of Schneider’s first rank symptoms?

Answer 18

He believed that they were highly indicative of schizophrenia.

Question 19

List the first rank symptoms ?(9)

Answer 19

1.3rd person auditory hallucinations
2.Running commentary
3.Thought echo
4.Thought withdrawal
5.Thought insertion
6.Thought broadcast
7.Delusional perception
8.Passivity (volition, affect, action)
9. Somatic hallucinations

Question 20

What is passivity?

Answer 20

• Belief that one’s thoughts or actions are influenced or controlled by an external agent.

Question 21

What is the typical age of onset in Schizophrenia? And which gender has a higher incidence?

Answer 21

Late teens to mid -30s
men between 18-25
females between 25-35

Men have a higher incidence than women( 1.4 : 1)

Question 22

List risk factors for developing schizophrenia?(8)

Answer 22

1.Genetic (monozyogotic twins (50-70%), both parents(40-60%)
2.Developmental factors
3.Brain abnormalities (big ventricles and reduced grey matter)
4.Neurotransmitter abnormalities (The Glutamate hypothesis and dopamine hypothesis)
5.Adverse life events
6.Cannabis
7.Paternal age > 35
8. Male gender

Question 23

According to DSM4 list the 5 subtypes of Schizophrenia and explain them?

Answer 23

1.Paranoid Schizophrenia – prominent hallucinations and delusions
2.Disorganized (Hebephrenic) schizophrenia – prominent disorganized
speech, affect and behavior
3.Catatonic schizophrenia – prominent catatonic features
4.Simple schizophrenia – prominent negative symptoms
5.Undifferentiated schizophrenia – no clear prominent features

Question 24

What is the glutamate hypothesis ?

Answer 24

The glutamate hypothesis is a theory that suggests an imbalance in the neurotransmitter glutamate plays a central role in the pathophysiology of schizophrenia and other psychotic disorders.
The glutamate system plays a role in regulating other neurotransmitter systems including dopamine .
Thus a dysregulation in the NMDA receptors will result in a dysfunction in dopamine leading to increased amounts in the mesolimbic pathway and reduced amounts in the mesocortical pathway

Question 25

Describe schizophrenia according to the DSM 5 criteria?

Answer 25

REFER TO HANDOUT

Question 26

What is the differential diagnosis for psychosis ?

Answer 26

Due to Psychotic disorders:
Schizophrenia
Schizophrenia like psychotic disorders???
Schizoaffective disorder
Delusional disorder

As part of mood disorders :
Manic episode with psychotic features
Depressive episode, severe with psychotic features.

Secondary to:
1.General medical condition
2.Substance use
3.Trauma to the Brain
4. Dementia/Delirium
5.Personality disorder (schizotypal, borderline schizoid and paranoid)
6.Neurodevelopmental disorders: autism spectrum

Question 27

Describe the algorithm for the diagnosis of a patient presenting with psychotic symptoms?

Answer 27

REFER TO HANDOUT

Question 28

Why are investigations done in psychotic patients?

Answer 28

1.Exclude possible medical or substance-related causes of psychosis.
2.Establish baseline values before administeringantipsychotics and other psychotropic drugs.
3.Assess renal and liver functioning - as the two are involved in drug clearance and drug metabolism respectively and so their impairment could result in:
1.Altered drug metabolism, potentially resulting in increased drug levels, side effects, or toxicity.(in the case of the liver)
2. Drug clearance being affected necessitating dosage adjustments to avoid accumulation and adverse effects.

Question 29

List the investigations done in Psychosis?

Answer 29

Bloods:
FBC, U&Es, LFTs, HIV, VDRL, TFTs, vitamin profile, fasting lipids, fasting blood sugars

Urine:
toxicology; Tetrahydrocannabinol urine strips

Imaging:
ECG

Question 30

Why do we test Vitamin B12 levels in patients suspected of psychosis?

Answer 30

Because vitamin B12 deficiency can lead to symptoms that mimic or exacerbate psychiatric conditions, including mood disturbances, cognitive dysfunction, and psychosis.

Question 31

Why do we test Thyroid Stimulating hormone levels in patients suspected of psychosis?

Answer 31

Hypo/hyperthyroidism can cause mental health symptoms like anxiety, depression, mood swings and even psychosis

Question 32

What is the importance of doing an ECG?

Answer 32

1.Cardiac Risk Assessment: Some antipsychotic medications, particularly certain atypical antipsychotics, can prolong the QT interval on an ECG, which may increase the risk of serious arrhythmias, such as Torsades de Pointes.

2.Baseline Heart Health: An ECG provides a baseline assessment of the patient’s heart health, helping clinicians identify pre-existing conditions (e.g., conduction abnormalities, arrhythmias) that could be exacerbated by antipsychotic treatment.

Question 33

What is the approach to managing Schizophrenia ? and what is the mainstay treatment?

Answer 33

Biopsychosocial
Biological treatment

Question 34

What is the biological treatment for Psychosis?

Answer 34

Use of 1st generation or 2nd generation antipsychotics

Question 35

What is the psychological treatment for Schizophrenia?

Answer 35

1.Family therapy and psychoeducation
Effective in reducing relapse
specific supportive, educational, treatment-related, problem-solving, and crisis management elements must be incorporated

2.Cognitive behavior therapy
Promotes alternative ways of coping with the target symptom, reducing distress, and improving functioning

3.Art therapy
promotes recovery where negative symptoms were prominent

4.Adherence therapy
uses motivation interviewing to enhance compliance thereby improving outcome

Question 36

What is the social treatment for schizophrenia?

Answer 36

Social work and housing involvement
Support to negotiate a phased return to normal activities i.e education or employment
Exercise (improves a range of symptoms and quality of life generally valuable for physical health)

Question 37

What is treatment resistant schizophrenia? And what is the drug of choice used?

Answer 37

Trial of at least 2 different antipsychotics at their maximum effective doses for a period of at least 6 weeks of which one antipsychotic has to be a second generation antipsychotic.

Drug of choice is Clozapine

Question 38

Why is clozapine not used as a first line medication?

Answer 38

It can cause life threatening agranulocytosis

Question 39

How does life expectancy change in patients with Schizophrenia as compared to those without it?

Answer 39

Life expectancy is lower than the general population.

Question 40

What is the commonest cause of premature deaths in schizophrenia?

Answer 40

Suicide and metabolic syndrome

Question 41

In which countries is overall prognosis of schizophrenia better ?

Answer 41

Overall prognosis is better in low-income as compared to middle and high income countries

Question 42

List 7 poor prognostic factors of Schizophrenia?

Answer 42

1.Poor premorbid functioning
2.Insidious onset
3.Childhood or adolescence onset(early onset)
4.Cognitive impairment
5.Enlarged ventricles
6.Negative symptoms
7.Isolation

Question 43

List 9 good prognostic factors for schizophrenia?

Answer 43

1.Marked mood disturbance during initial presentation especially elation
2.Family history of affective disorder
3.Female sex
4. Married/good support system
5.Older age of onset
6.Abrupt onset of illness
7.Short duration of illness prior to treatment
8.Good response to medication
9.Absence of negative symptoms

Question 44

Explain the short and long term psycho-social management of schizophrenia?

Answer 44

Short term:
Family therapy and Psychoeducation
CBT
Adherence therapy

Long term:
Family therapy
CBT
Art therapy
Occupational therapy
Adherence therapy

Question 45

Explain the recovery and rehabilitation principles in schizophrenia including relapse prevention strategies?

Answer 45

Relapse prevention strategies include :
1. Drug adherence
2. Educating the family on early warning signs
3.Psychoeducation

Question 46

what are the early warning signs of relapse in schizophrenia ?

Answer 46

1.Trouble sleeping.
2.Eating less.
3.Trouble concentrating or being disorganized.
4.Staying away from other people or disappearing unexpectedly.
5.Mood changes, nervousness, or irritability.
6.Having strange ideas or disorganized thinking.
7.Poor personal hygiene.
8.Speech that doesn’t make sense.
9.Hearing or seeing things
10.Suicidal thoughts
12Aggressive talk
13. Delusions and increased paranoia

Question 47

Discuss strategies for community integration for patients with schizophrenia ?

Question 48

Which two antipsychotics are responsible for weight gain ? how do you prevent it?

Answer 48

-Olanzapine(main culprit ) then clozapine.