Schizophrenia and Related Disorders

Question 1

What are the DSM criteria for schizophrenia?

Answer 1

• 2+ of the following features (one must be bold) for a significant period during 1 month
  
  • Delusions (e.g. thought insertion/broadcast/withdrawal, body parts being controlled)
  • Hallucinations
  • Disorganised speech
  • Grossly disorganised or catatonic behaviour
  • Negative symptoms e.g flatness of affect, removal of attributes - eye contact, facial expression, engagement, initiative, motivation
• Continuous signs of the disturbance persist for > 6 months
• Sociooccupational dysfunction, not due to other mental or physical illness

Question 2

Outline the general principles of treatment for someone with schizophrenia

Answer 2

• Engagement
• Medications
  
  • Antipsychotics e.g. risperidone: all equally effective (care with sedation, weight-gain, extrapyramidal effects)
    
    • First episode - normally a second generation anti-psychotic
    • Maintenance therapy - continue antipsychotic for 2 years past first episode, 5 past relapse
    • Clozapine: second-line
• Psychological intervention e.g. CBT for residual symptoms
• Family interventions
• Social interventions e.g. housing and employment

Question 3

What are some negative symptoms of psychosis?

Answer 3

• Flatness of affect, removal of attributes - eye contact, facial expression, engagement, initiative, motivation

Question 4

When do psychotic symptoms most commonly manifest?

Answer 4

• Median age of onset 25
  
  • Males more commonly here
  • Females more commonly at 65+

Question 5

What are some poor prognostic indicators of schizophrenia?

Answer 5

• Males, early onset, insidious onset, poor premorbid function, neurological soft signs, structural abnormalities, severe negative symptoms, absence of affective symptoms

Question 6

What is the difference between a hallucination and a delusion?

Answer 6

• Delusions: fixed beliefs not amenable to change in the light of conflicting evidence
• Hallucinations: perception-like experiences occurring without an external stimulus

Question 7

How might you approach the initial pharmacological treatment of schizophrenia?

Answer 7

• Begin with low-dose atypical
  
  • Response good? - continue for 12 months then wean
  • Response poor after 2-4 weeks? - increase dose
    
    • Response good? - continue for 12 months then wean
    • Response poor after 3-6 weeks - change to another atypical or augment with valproate (or lithium if schizoaffective)
      
      • No response? - trial typical antipsychotic or clozapine
• Consider depot atypical if poor adherence or poor response to typical depots

Question 8

What are some augmentation therapies utilised in the treatment of schizophrenia?

Answer 8

• Combination antipsychotics - mixed results
• Antidepressants
• Mood stabilisers e.g. carbamazepine, lithium - mixed results. Valproate commonly used, lamotrigine good for positive symptoms
• Benzodiazepines - mixed results
• Stimulants - may enhance cognitive function but worsen psychosis
• Glutamatergic agents - ketamine benefits positive, negative and cognitive symptoms, glycine decreases negative symptoms
• ECT - only evidence for catatonic schizophrenia
• TMS - mixed results

Question 9

What differentiates schizophreniform disorder and brief psychotic disorder from schizophrenia?

Answer 9

• Schizophreniform - <6/12, BPD - <1/12. Socio-occupational disturbance less predominant