Schizophrenia And Delusional Disorders

Question 0

What diagnosis aid may be used when considering schizophrenia in a patient?

Answer 0

Refer to Schneiders first rank symptoms- this is a set of features that are indicative of the condition in the absence of organic cerebral pathology.

Question 1

What is schizophrenia?

Answer 1

A debilitating psychiatric disorder characterised by changes in thinking, perception, blunted affect and a reduced level of social functioning

Question 2

List Schneider’s First Rank Symptoms of schizophrenia

Answer 2

Auditory hallucinations- voices repeating thoughts out loud, discussing subject in the first person, running commentary

Thought insertion, withdrawal, broadcasting

Made feelings, impulses, actions

Somatic passivity
Delusional perception

Question 3

What are the three types of auditory hallucination in schizophrenia?

Answer 3

Gedankenlautwerden- voice heard through ears says thoughts out loud as they are being thought; echo de la pensee- voice repeats thoughts just after thinking them; voice says thoughts in anticipation just before they have been thought

Voices discuss the subject in third person

Voices give a running commentary

Question 4

What are the three types of thought alienation?

Answer 4

Thought insertion- do you ever feel as though thoughts being forced into your mind by someone or something else?
Thought withdrawal- have you ever experienced the sensation of having your thoughts taken away from you?
Thought broadcasting- do you ever get the feeling that your thoughts can be read by others, as if they’re being broadcast for all to see?

Question 5

What does made feelings, impulses and actions mean in Schneiders first-rank?

Answer 5

Patient may experience the feeling of free will being removed and that an external agency is controlling his feelings, impulses or actions, may feel under hypnosis

Question 6

What is somatic passivity?

Answer 6

Feeling that one is a passive recipient of bodily sensations by some other external agency.
Do you ever feel as though someone/thing outside yourself is causing you to have odd bodily sensations that you can’t control?

Question 7

What is a delusional perception?

Answer 7

A real perception that is misinterpreted to have special significance or meaning e.g door left open—> I am king of Spain!
Green traffic light—> they’re coming for me!

Question 8

How many types of schizophrenia are there?

Answer 8

9 types
Paranoid (most common)
Hebephrenic
Catatonic (less now)
Undifferentiated 
Residual 
Post schizophrenic depression? 
Simple
Other
Unspecified

Question 9

Describe other symptoms of schizophrenia not included in first rank?

Answer 9

Other persistent delusions- religious or political identity, superhuman powers
Persistent hallucinations- any modality, esp if occur every day, often accompanied by fleeting/ half formed delusions without clear affective content, persistent overvalued ideas

Breaks or interpolations of thought- result in incoherence or irrelevant speech, may cause neologisms

Catatonic behaviour- alternate between stupor (unresponsive, akinetic, mute and fully conscious) and excitement; bizarre posturing; waxy flexibility - limbs can be moulded into position and will stay for long amounts of time; negativism - motiveless resistance to instructions/ attempts to be moved

Negative symptoms- chronic apathy, poverty of speech, lack of drive, slowness and blunting or incongruity of affect—> social withdrawal and decline in social performance

Change in personal behaviour- loss if interest, aimlessness, idleness, self-preoccupied and isolation

Question 10

What is a neologism?

Answer 10

A made up word or existing word used in novel, inappropriate way as a result of thought disorder in schizophrenia

Question 11

What is an overvalued idea?

Answer 11

An unreasonable and sustained intense belief/ preoccupation that is demonstrably false and not normally held by others of the patients subculture. It is maintained with less than delusional intensity but with marked emotional investment.

Question 12

What other MH issues should be screened for in consideration of negative symptoms in schizophrenia?

Answer 12

Depression and antipsychotic medication side effects

Question 13

What is the clinical picture of paranoid schizophrenia?

Answer 13

Delusions of persecution - others are plotting/ out to get them
Delusions of reference- believing that strangers/TV/radio or newspapers are referring to the patient
Delusions of exalted birth- having a special mission, the messiah
Delusions of bodily change
Delusions of jealousy
Hallucinatory voices of a threatening nature or issuing commands
Non- verbal auditory hallucinations e.g whistling, laughing, humming
Hallucinations in other modalities- smell, taste, sexual, visual, other somatic

May not look psychiatrically unwell until paranoid symptoms exposed!

Question 14

What is the clinical picture of hebephrenic schizophrenia?

Answer 14

Irresponsible unpredictable behaviour- exhibiting mannerisms and playing pranks
Rambling and often incoherent speech
Affective changes- incongruous affect, shallow mood, giggling and fatuousness
Poorly organised delusions
Fleeting and fragmentary hallucinations

Onset is normally young 15-25 years And generally has poorer prognosis due to onset of negative symptoms

Question 15

What is catatonic schizophrenia?

Answer 15

Catatonic symptoms of stupor and excitement are present, bizarre posturing, moulding limbs into position, resistance to being moved/ instructed, echolalia, echopraxia

May stop eating and drinking!

Rule out organic conditions eg encephalitis

Question 16

What is the clinical picture of simple schizophrenia?

Answer 16

Not often used, lazy. Meant to have insidious onset of negative symptoms, only made confidently in retrospect.

Question 17

What is residual or chronic schizophrenia?

Answer 17

Acute positive symptoms + chronic negative symptoms - long term diagnosis

Question 18

What is Lyddle’s classification of schizophrenia?

Answer 18

He classified the symptoms into 3 syndromes
Psychomotor poverty- poverty of speech, flatness of affect and decreased spontaneous movement
Disorganisation- disorders of thought form and inappropriate affect
Reality distortion- occurrence of delusions and hallucinations
All can coexist in the same person

Question 19

What does PET scan research show about Lyddle’s 3 syndromes?

Answer 19

Each is associated with perfusion changes to brain regions
Psychomotor (word generation test) - prefrontal cortex ⬇️
Disorganisation (stroop test) - anterior cingulate cortex ⬆️
Reality distortion (internal monitoring of eye movements) - parahippocampal gyrus/ medial temporal region

Question 20

What other schizophrenia classifications are there?

Answer 20

Lyddle’s syndromes
Neurodevelopmental - congenital (poor prognosis ⬆️ negative); adult onset (⬆️positive and mood symptoms, exist on spectrum from bipolar ➡️schizoaffective➡️schizophrenia); late onset (paraphrenia, 60+, good premorbid functioning, associated with auditory and visual deprivations, more common in females, often with organic pathology)

Question 21

What investigations are carried out for a person presenting with schizophrenic symptoms?

Answer 21

Further info/ hx
FBC, TFTs, U+Es, LFTs, CRP, fasting g
Consider HIV testing, syphilis serology
Lipids should be checked pre commencing long term antipsychotic meds
MSU
Urine drug screen
CT scan if indicated
EEG (temporal lobe epilepsy esp if visual hallucinations, confusion) 

Symptom rating scales
OT assessment of activities of daily living
Social work assessment of housing, finances, and carers needs
Collateral history

Question 22

What are schizoid/ schizotypal traits when considering premorbid personality?

Answer 22

Solitariness, cold affect, suspiciousness and abnormal speech patterns- traits found in 25% of patients
Preclinical manifestation or risk factor?
Studies show schizotypy doubles risk but far from guarantees disease outcome

Question 23

What traits do patients with affective psychosis show when they were younger?

Answer 23

None, no difference from peers in national child development survey
Significant difference in schizophrenia patients

Question 24

Describe the schizophrenia prodrome/ At risk mental state

Answer 24

``` Subjective difficulties in attention focusing (irrelevant from pertinent stimuli in somebody's speech etc) Clouded thinking Minor perceptual disturbances Anxiety and perplexity Reduced sense of control ``` Typically late teens/ early 20s drops out of college or work, seeming distant and isolate self in room (hard to distinguish between depression, substance misuse, normal teen behaviour!) Much more common for anxiety, depression and negative symptoms to precede psychosis

Question 25

What is the lifetime risk of schizophrenia?

Answer 25

1%

Question 26

What is the age of onset for schizophrenia?

Answer 26

Typically between 15-45 | Rarely can present in childhood but often associated with developmental delay

Question 27

Male to female ratio of schizophrenia?

Answer 27

Equal but males often get it earlier and tend to have it more severely

Question 28

What genetic basis is there for schizophrenia?

Answer 28

Lifetime risk increases from 1 to 10% for first degree relatives, nearly 50% if both parents have it/ monozygotic twins, but in 60% no FH known No single gene, but multiple susceptibility genes interacting together

Question 29

What obstetric complications can predispose to schizophrenia?

Answer 29

Prenatal malnutrition, viral infections (rates higher in those born jan-march in northern hemisphere) Pre-eclampsia, low birth weight, emergency c section➡️ reflect underlying genetic abnormalities or hypoxia brain damage

Question 30

What role does substance misuse play in schizophrenia?

Answer 30

Can precipitate the disorder- cannabis, amphetamines, coke and LSD can all produce psychotic symptoms Cannabis doesn't cause but increases overall risk, contributing to development in susceptible people, skunk particularly dangerous Smoking cannabis more than 50 times as a teenager increases risk sixfold, brain vulnerable since still developing

Question 31

What is the physiological link between cannabis and schizophrenia?

Answer 31

``` COMT enzyme breaks down dopamine Two alleles code for it: Val and Met Val -Val gas highest risk of precipitating schizophrenia in cannabis users Heterozygous - intermediate risk Met-met- low risk ```

Question 32

What are the social risk factors for schizophrenia?

Answer 32

Disadvantage/ lower SES, related to downward drift due to social withdrawal and unemployment Urban life and birth ( drift or stress of environment?) Migration/ ethnicity - first or second generation immigrants have higher rates ( threefold compared to indigenous) Black carribbean/ African showing highest rates Family- high expressed emotion e.g criticism or over-involved relatives doubles risk of relapse, but not causative Schizotypal premorbid personality Adverse life experience/ abuse

Question 33

What is the histopathological evidence for schizophrenia?

Answer 33

* Neuronal changes in limbic system and temporal lobes * Loss of normal cerebral asymmetry * Abnormal expression of developmental markers: NCAM and GAP-43

Question 34

What have CT/ MRI studies shown?

Answer 34

Enlarged ventricles, overall smaller and lighter brains No gliosis at post mortem, changes occur before adulthood? * Decreased brain volume * Smaller limbic system and thalamus * Reduced cortical grey matter (esp. prefrontal cortex and superior temporal regions) * Increased ventricular volume * Widened sulci * Present at onset Initial brain abnormalities progress as ongoing pruning of synapses and myelination, evolve into overt symptoms

Question 35

What is the dopamine hypothesis?

Answer 35

Schizophrenia is a result of dopamine over and underactivity in certain areas of the brain * Increased mesolimbic DA activity leads to positive symptoms (hallucinations and delusions) * Decreased mesocortical DA activity leads to negative symptoms Antipsychotics all bind to dopamine receptors and tackle positive symptoms better * Amphetamine, cocaine, L-Dopa and bromocriptine (which release dopamine) makes symptoms worse * However, antipsychotic biochemical effects only take days, where anti-psychotic effects take weeks- more must be going on!

Question 36

What other neurotransmitter theories exist?

Answer 36

5-HT and glutamate 5-HT- antipsychotic clozapine binds to 5-HT receptors and prevents hallucinations LSD acts at serotonin receptors Glutamate Reduced glutamate activity leads to negative symptoms PCP causes psychosis via NMDA receptors

Question 37

What happens in formal thought disorder?

Answer 37

Thoughts become disconnected, loosening of associations, vagueness progresses to very disjointed speech, poverty of thought and thought blocking may occur Word salad- sentences become nonsensical

Question 38

What is the assessment structure for schizophrenia?

Answer 38

``` Psychiatric history Informant history MSE Cognitive testing Physical exam Hearing and vision - sensory deprivation ```

Question 39

What is the dDx for schizophrenia?

Answer 39

Organic - substance misuse (drug free inpatient admission), dementia/ delirium, epilepsy, medication side effects (steroids, dopamine agonists), other eg brain tumour, stroke, HIV, Wilson's disease, porphyria, neurosyphilis Acute transient psychotic episode- resolves within a few months, can be stress related Mood disorder- depression and mania may produce psychotic symptoms, schizophrenia should not be diagnosed in presence of severe mood problems unless the sch symptoms came first! Schizoaffective disorder- even balance between schizophrenic and affective symptoms Persistent delusional disorder- delusions with few if any hallucinations Schizotypal disorder- state of eccentricity with abnormal thoughts and affect (personality disorder) person is cold, suspicious and aloof with odd ideas

Question 40

What is the biological management of psychosis?

Answer 40

Antipsychotics - dopamine antagonists, block post synaptic D2 receptors Greater affinity- the more effective Typical- older eg chlorpromazine, haloperidol and depot preparations flupentixol decanoate Cause distressing EPSEs but still used as effective, cheap and provide depot options (long acting injection) Atypical antipsychotics- olanzapine, risperidone (available as injection) quetiapine, clozapine, amisulpride, aripiprazole Indicated in first line treatment in newly diagnosed schizophrenia, unacceptable SEs/ relapse from typical drugs, Fewer EPSEs, don't tend to increase prolactin levels as much Block dopamine and 5ht2 receptors Avoid using more than one antipsychotic!!!

Question 41

List the side effects of antipsychotics

Answer 41

Extrapyramidal - Dystonia, akathisia (restless agitative state), Parkinsonism, tardive dyskinesia Hyperprolactinaemia- Galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism Sexual dysfunction ⬆️osteoporosis risk Weight gain (esp olanzapine or clozapine) Sedation ⬆️dm risk Dislipidaemia - raised triglycerides and chol (fusilli daemon) Anticholinergic side effects - Dry mouth, blurred vision, constipation, urinary retention and tachycardia Arrhythmias Seizures (clozapine most risk, reduction of seizure threshold) Neuroleptic malignant syndrome

Question 42

What is neuroleptic malignant syndrome?

Answer 42

Rare but life threatening Triggered by new antipsychotic or dose increase Idiosyncratic response to dopamine antagonism Symptoms - muscle stiffness, rigidity, altered consciousness, disturbance of autonomic nervous system - fever, tachycardia and labile BP Raised creatine kinase and white cell count Treatment- stop treatment immediately, get urgent medical care, oft intensive Cause of death numerous, kidney failure secondary to skeletal muscle breakdown (rhabdomyolysis)