Schizophrenia and Psychotic Disorders

Question 1

Psychosis definition

Answer 1

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

Question 2

what is a delusion?

Answer 2

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 3

schizophrenia definition

Answer 3

Schizophrenia is a chronic or relapsing and remitting form of psychosis characterized by positive symptoms (such as hallucinations, delusions, thought disorders) and negative symptoms (including alogia, anhedonia, and avolition).

Question 4

schizophrenia epidemiology

Answer 4

• most common cause of psychosis
• affects 1 per 100 population
• male and females equally affected
• age of onset 15-35 years, earlier in men than women (mean of 28 years vs 32 years)

Question 5

what are the symptoms of schizophrenia?

Answer 5

Positive:
- hallucinations
- delusions
- disordered thinking

Negative:
- apathy
- lack of interest
- lack of emotions

Question 6

how is schizophrenia classified by the ICD-10?

Answer 6

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, through 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 wavy flexibility, negativism, mutism and stupor.
h) ‘negative’ symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses.

Question 7

Schizophrenia aetiology

genetic and environmental

Answer 7

Genetic Factors: risk of developing schizophrenia is significantly increased in individuals with a positive family history:
- 10% chance if either a parent or sibling is affected, - 50% chance if both parents are affected or identical twin affected.
- Neuregulin (chromosome 8p)
- Dysbindin (chromosome 6p)
- Di George syndrome

Environmental factors associated with increased risk of schizophrenia:
- childhood trauma, such as poor maternal bonding, poverty, or exposure to natural disasters.
- heavy cannabis use in childhood.
- maternal health issues, including malnutrition and infections like rubella and cytomegalovirus.
- birth trauma, particularly hypoxia and blood loss.
- urban living and immigration to more developed countries.

Question 8

list the neurological abnormalities that can be observed in a patient with schizophrenia

Answer 8

• Reduced brain volume 3%
• Ventricular enlargement 25% (but overlaps with normal)
• Cytoarchitectural abnormalities
• Reduced frontal lobe performance
• Eye tracking (saccadic) abnormalities
• Soft neurological signs
• EEG abnormalities

Question 9

Schizophrenia differential diagnosis

Answer 9

• substance-induced psychotic disorder: associated with hallucinations and delusions; typically precipitated by drug use or withdrawal.
• organic psychosis: typically accompanied by neuro symptoms or changes in mental status; conditions such as infections, brain injuries, or CNS diseases like Wilson’s disease or encephalitis can lead to organic psychosis.
• metabolic disorders: hyperthyroidism and hyperparathyroidism
• depression and dementia
• autoimmune encephalitis
• schizoaffective disorder: combines mood disorder features with psychotic symptoms. Distinguished by the duration of mood episodes independent of psychotic symptoms.

Question 10

schizophrenia investigations

Answer 10

While schizophrenia is primarily a clinical diagnosis based on history and examination, investigations can help exclude organic causes of psychosis. This includes:
- brain imaging (CT/MRI) to rule out structural abnormalities
- blood tests to exclude infectious (e.g., HIV, syphilis) or metabolic causes (e.g., thyroid function tests)
- drug screening to identify substance misuse

Question 11

schizophrenia management

Answer 11

The primary treatment for schizophrenia is pharmacological, with second-generation (atypical) antipsychotics such as risperidone being the first line of treatment.
- In acute episodes: sedatives like lorazepam, promethazine, or haloperidol may be used. Oral atypical antipsychotics such as risperidone/olanzepine/quetiapine.
- Maintenance: antipsychotics
- Clozapine is considered when scizophrenia is resistant to other antipsychotics (in those who have not responded to 2 other trials of antipsychotics). Due to its potential lethal side effects, requires intensive monitoring.
- Psychotherapy such as CBT. Providing support to patient and families and coordinating care with mental health professionals are critical for long-term management.

Question 12

schizophrenia prognosis

Answer 12

Prognosis varies significantly among individuals with schizophrenia. Factors associated with a better prognosis include higher IQ/education level, sudden onset, presence of a precipitating factor, a strong support network, and predominance of positive symptoms. According to the rule of quarters:

25% of individuals never have another episode
25% improve substantially with treatment
25% show some improvement
25% are resistant to treatment