schizophrenia and psychotic disorders

Question 1

modern use of the term psychosis

Answer 1

severe forms of mental illness and lack of insight

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

Question 2

define psychosis

Answer 2

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

Question 3

clinical presentation of psychosis

Answer 3

hallucinations

delusional beliefs

Question 4

what are hallucinations

Answer 4

have the full force and clarity of true perception

located in external space

no external stimulus to account for them

not willed or controlled

can affect any of the 5 special senses - auditory, visual, tactile, olfactory, gustory

Question 5

what is a delusion

Answer 5

an unshakable idea/belief which is out of keeping with the person’s social/cultural background

held with extraordinary conviction

e.g. grandiose, paranoid (persecutory), hypochondriacal, self-referential

Question 6

what illnesses have psychotic symptoms

Answer 6

schizophrenia

delirium

severe affective disorder
- depressive/manic episode w/ psychotic symptoms

Question 7

what is schizophrenia

Answer 7

a severe mental illness affecting:

• thinking
• emotions
• behaviour

Question 8

how common is schizophrenia

Answer 8

most common cause of psychosis

affects 1% of population

M=F

Question 9

what is the age of onset of schizophrenia

Answer 9

15-35y/o

earlier in men than women (28 vs 32 mean age)

Question 10

symptoms of schizophrenia

Answer 10

+ve

• hallucinations
• delusions
• disordered thinking
• ve
• apathy
• lack of interest
• lack of emotions

-ve symptoms suggest poorer prognosis, +ve suggest a more acute illness and potentially better prognosis

Question 11

diagnostic criteria for schizophrenia (ICD 10)

- key symptoms (at least one of)

Answer 11

for more than 1mth in the absence of organic or affective disorder:

at least one of:

• alienation of though (though echo, thought insertion or withdrawal, though broadcasting)
• delusions of control, influence of passivity, clearly referred to body or limb movements, actions or sensations; delusional perception
• 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
• persistent delusions of other kinds that are culturally inappropriate and completely impossible

Question 12

diagnostic criteria for schizophrenia (ICD 10)

- key symptoms (AND/OR at least 2 of)

Answer 12

AND/OR at least 2 of:

• persistent hallucinations in any modality, when occuring every day for at least 1 mth
• neologisms, breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech
• catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor
• -ve symptoms e.g. marked apathy, paucity of speech and blunting or incongruity of emotional repsponses

Question 13

what are neologisms

Answer 13

making up your own new terminology

Question 14

considerations re. aetiology of psychosis

Answer 14

biological factors
psychological factors
social factors
evolutionary theories

each of the above can be considered as:

• possible predisposing factor
• precipitating factor - makes it happen now
• perpetuating factor - keeps it going

Question 15

sz and biological factors - genetics and heritability

Answer 15

• high heritability
• 50% concordance in mz twins
• 10% risk if one parent affected, 40% if 2 parents, 10% on sibling, 10% for dz twins
• also shown in adoption studies that children of sz parents adopted by those w/o illness maintain risk
• children w/o sz parents adopted by sz parents are at no increased risk

Question 16

sz associated genes

Answer 16

neuregulin - chromosome 8p

dysbindin - chromosome 6p

di george syndrome - 22q

Question 17

sz and biological factors - neurochemistry

Answer 17

dopamine hypothesis - increased level of dopamine in the brain

revised dopamine hypothesis - mesolimbic and hyperdopaminergia and mesocortical hypodopaminergia

glutamate

GABA

noradrenaline

serotoninergic transmission

Question 18

sz - biological factors

Answer 18

genetics
neurochemistry
neurological abnormalities

obstetric complications 
maternal influenza
malnutrition and famine 
winter birth 
substance misuse

Question 19

neurological abnormalities found in sz

Answer 19

reduced brain volume - 3%
25% ventricular enlargement - overlaps w/ normal 
cytoarchitectural abnormalities
reduced frontal lobe performance
eye tracking abnormalities
soft neurological signs 
EEG abnormalities

Question 20

stages in the development of delusions

Answer 20

state of fear

delusional idea appears

effort to make sense of the experience by altering one’s view of the world

final breakdown - thought disorder and behavioural symptoms emerge

Question 21

sz - phenomenology science and the anthropology of the self

Answer 21

there is a gross XS of sz in migrant populations

all individuals construct a sense of self within framework of time, morality and cultural symbols

when individuals migrate, it is probable that change will occur at all these levels

massive alteration in how one perceives oneself - neuronal correlates w/ consequent vulnerability to severe mental illness

Question 22

sz - social and psychosocial factors

Answer 22

occupation and social class - be aware of drift hypothesis
- as you become unwell you drift down the social classes

migration

social isolation

life events as precipitants

cultural factors don’t seem to be implicated

Question 23

psychosis and families

Answer 23

schizophrenogenic mother - theory not upheld

double bind theory and ambivalent communication style - not upheld by research

expressed critical emotion and high EE families - important concept and basis for family work and psychosis

Question 24

differential diagnoses for psychotic illness

Answer 24

delirium or acute organic brain syndrome - whatever cause

depressive episode w/ psychotic symptoms

manic episode w/ psychotic symptoms

schizoaffective disorder

Question 25

delirium or acute organic brain syndrome features

Answer 25

consequent upon brain or systemic disease

prominent visual experience, hallucinations and illusions

affect of terror

delusions are persecutory and evanescent

fluctuating, worse at night

Question 26

features of depressive episode w/ psychotic symptoms

Answer 26

severe depressive episode

delusions of guilt, worthlessness and persecution

derogatory auditory hallucinations

Question 27

features of manic episode w/ psychotic symptoms

Answer 27

delusions of grandeur - special powers or messianic roles

gross overactivity, irritability, behavioural disturbance, manic excitement

Question 28

what is schizoaffective disorder

Answer 28

patient has schizophrenia like symptoms and affective symptoms at the same time

Question 29

management of sz overview

Answer 29

Question 30

management of sz

Answer 30

patient information and explanation of diagnosis
access to psychiatric services
early intervention
providing support - family involvement and intervention
early psychological treatment
antipsychotic medication - continue treatment for at least 2yrs, high risk of relapse
family therapy and CBT

Question 31

prognosis and recovery in sz

Answer 31

recovery = being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms

80% for recovery after 1st episode of psychosis

early intervention and more effective treatment = better outlook

up to 50% have moderate recovery

small group w/ chronic symptoms and little recovery

Question 32

good prognostic factors for sz

Answer 32

absence of FHx

good premorbid function - stable personality, stable relationships

clear precipitant

acute onset

mood disturbance

prompt treatment

maintenance of initiative, motivation

Question 33

poor prognostic factors for sz

Answer 33

slow insidious onset, prominent -ve symptoms

mortality is 1.6x higher than the general pop
- shorter life expectancy linked to CV disease, resp disease and cancer

suicide risk 9x higher

death from violent incidents is 2x as high

36% of pts have a substance misuse problem and there are high rates of cigarette smoking

poorer prognosis if it starts in childhood

Question 34

cognition and sz

Answer 34

chronic sz pts show poorer cognition than 1st onset pts

but there is no decline in cognition in follow-up studies of 1st onset psychosis

Question 35

what are the first rank symptoms of schizophrenia

Answer 35

delusional perception
auditory hallucinations
delusions of thought interference
passivity phenomenon or delusions of control

Question 36

what are delusional perceptions

Answer 36

part of a 1y delusion

can occur out of the blue - autochthonous delusion

can occur as a 2 stage process: normal perception first and then a delusion formed around it - delusional perception

Question 37

how can auditory hallucinations present

Answer 37

3rd person auditory hallucinations - arguing or talking about patient

running commentary on person’s actions/thoughts

thought echo (gedankenlautwerden) - thoughts spoked aloud

Question 38

3 types of delusions of thought interference

Answer 38

thought insertion - put into your head
thought withdrawal - taken out of your head
thought broadcasting - other people know what you are thinking

Question 39

what is passivity phenomenon or delusions of control

Answer 39

control of the following by an external force:
impulses
actions
feelings
somatic passivity - passive recipient of bodily sensations imposed from outside forces