Schizophrenia + Psychosis Flashcards
A 24-year-old student presents with a 3-month history of social withdrawal and
low mood. She is difficult to interview because she talks about random themes
and has difficulty answering questions. She has vague paranoid ideation. She is
childish and pulls faces at you during the interview. The most likely diagnosis is:
A. Hebephrenic schizophrenia
B. Catatonic schizophrenia
C. Paranoid schizophrenia
D. Residual schizophrenia
E. Simple schizophrenia
A. Hebephrenic schizophrenia
Classifying schizophrenia into subtypes is by no means simple in
psychiatry. The term schizophrenia encompasses a heterogenous group
of disorders, and as yet there has been no system of classification that
has adequately been able to predict development of specific subtypes
or reliable prognosis. That said, our current classification systems have
divided schizophrenia into various types, and it does appear that, within
limits, there is some utility to these categories. Hebephrenic schizophrenia
(A) (sometimes referred to as ‘disorganized’ schizophrenia), is characterized
by the predominance of thought disorder and affective symptoms. Social
withdrawal is common. The affect is often fatuous and childlike. Delusions
and hallucinations are often present, but are usually fragmented and are
not the most striking feature. Negative symptoms tend to develop early
and quickly, and for this reason this subtype is considered to have a
poor prognosis. Catatonic schizophrenia (B) is characterized best by
psychomotor disturbances, or catatonic behaviour. Catatonia is another
complex concept which appears to have heterogenous aetiologies. In this
subtype, there may be marked psychomotor retardation, with stupor, or
florid over-activity. There are often unusual symptoms such as automatic
obedience, in which people will follow a command without questioning,
or the opposite (negativism). In severe cases, people may take on odd
postures for long periods, or the limbs may be moved into positions and
will remain there (waxy flexibility). Hallucinations and delusions may
be present but again do not dominate the picture. For some unknown
reason, catatonia appears to be much less common than in the middle
part of the last century. Paranoid schizophrenia (C) is often thought of as
the ‘classical’ subtype, and is dominated by delusions and hallucinations.
Thought disorder is less common (although this is also contentious).
Residual schizophrenia (D) refers to late-stage schizophrenia in which
the syndrome of ‘positive’ symptoms (delusions, hallucinations, thought
disorder) are replaced by predominately ‘negative’ symptoms (apathy,
social withdrawal, avolition, blunting of affect, poverty of speech, selfneglect).
Simple schizophrenia (E) is defined by ICD-10 as ‘the insidious
development of oddities of conduct, inability to meet the demands of
society, and decline in total performance’. There are usually no overt
psychotic symptoms.
What is the lifetime prevalence of schizophrenia in the UK?
A. 0.01 per cent
B. 0.1 per cent
C. 0.4 per cent
D. 4 per cent
E. 10 per cent
C. 0.4 per cent
Traditionally, the lifetime prevalence has always been quoted as 1
per cent, although most recent studies would suggest it is lower than
this at around 0.4 per cent (with, obviously, some range around this).
Regardless, this means the answer could only realistically be (C).
Incidence rates are reported as lower (because of the chronic nature of the
disease), usually between 0.17 to 0.54. Apart from a few exceptions, the
prevalence of schizophrenia tends to be fairly standard across countries,
with little overall sex differences.
A 19-year-old identical twin is diagnosed with schizophrenia. His mother makes
an appointment to see you at the GP practice and asks what the likelihood is of
his twin developing schizophrenia. What should you tell her?
A. It is inevitable that schizophrenia will develop in the brother
B. There is no increased risk of developing schizophrenia
C. The risk is about one in 100
D. The risk is about one in 10
E. The risk is about one in two
E. The risk is about one in two
Schizophrenia is undoubtedly a disease with both genetic and
environmental substrates. It is generally held that the genetic component
accounts for approximately 50 per cent of susceptibility. Although there
is some debate around this (more recent studies suggest heritability up to
around 80 per cent, although there is large heterogeneity), (E) would be
the only really feasible answer. There is undoubtedly an increased risk (B)
of schizophrenia between identical twins, that is beyond that of sharing
an ‘environment’. The risk of 1 in 100 (C) is approximately the risk in the
general population (although see the question above; the prevalence may
well have been overestimated in earlier studies). The risk of 1 in 10 (D)
could be estimated to be the risk of developing schizophrenia if you have
one first degree relative with the disease.
A 19-year-old man with schizophrenia is brought to accident and emergency by
his sister as he has become unwell over the last few days. He has recently been
started on risperidone. He is confused, sweaty and tremulous. On examination
the signs include tachycardia, low blood pressure, pyrexia and lead-pipe rigidity.
His Glasgow Coma Scale score is decreased at 12/15. What is the most likely
diagnosis?
A. Acute dystonia
B. Malignant hyperthermia
C. Neuroleptic malignant syndrome
D. Serotonin syndrome
E. Tyramine reaction
C. Neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) (C) is a medical and psychiatric
emergency. It often presents to accident and emergency or general practice
so you must be familiar with recognizing it and the fundamentals of
treatment – without treatment it has a mortality of up to 30 per cent. NMS
occurs as a complication of antipsychotic medication use (and occasionally
other psychotropics) and is thought to be the result of dopamine blockade
in the hypothalamus (pyrexia) and nigrostriatal pathway (extrapyramidal
symptoms such as tremor and rigidity). Peripheral blockade can cause
changes in skeletal muscle contractility, which may exacerbate stiffness
and cause muscle breakdown (with the consequent risk of rhabdomyolysis
and renal failure). It must be treated as an emergency (although the
syndrome is on a spectrum, and only mild or subclinical features
may manifest) and appropriate referral is essential. As far as medical
treatment is concerned, the offending antipsychotic must be immediately
discontinued. Supportive treatment to ensure cardiovascular stability
is the priority. Severe pyrexia may require other specialized cooling
treatments. Some patients may actually require mechanical ventilation.
It is unclear why some people develop NMS and others do not. It may
be triggered on commencing treatment with antipsychotics, increasing
dose or other environmental factors such as dehydration or exhaustion.
A 23-year-old man is diagnosed with schizophrenia. He has had florid
persecutory beliefs and auditory hallucinations for the past 3 months. In
terms of medical history he has poorly controlled insulin-dependent diabetes
and is obese. On admission to hospital he was so distressed he required
intramuscular rapid tranquilization. On administration of 5 mg of haloperidol,
he developed an acute dystonia in his neck muscles which was excruciatingly
painful. What would be the most appropriate drug to commence to control
his schizophrenia?
A. Aripiprazole
B. Clozapine
C. Olanzapine
D. Oral haloperidol
E. Sertraline
A. Aripiprazole
Aripiprazole (A) is a relatively newer antipsychotic. It appears to have less
propensity to weight gain than other ‘second-generation’ antipsychotics
(such as olanzapine) as well as a lower incidence of extrapyramidal side
effects such as acute dystonias, although it does have its own side effect
profile, notably nausea and insomnia. Out of the list, this would therefore
be the best choice. Clozapine (B) is an extremely effective antipsychotic
but is reserved for treatment-resistant schizophrenia because of its side
effect profile. In this man, therefore, you would want to have trialled
at least one (and probably two) other antipsychotics before moving to
clozapine. Olanzapine (C) is one of the most commonly used secondgeneration
antipsychotics. It is effective in treating positive symptoms,
but has a marked propensity to cause weight gain and may worsen
diabetic control. This would clearly be undesirable in this case. Oral
haloperidol (D) would still be likely to cause acute dystonia – the patient
is clearly very sensitive to these. Extrapyramidal side effects may be
caused by either oral or intramuscular formulations. Sertraline (E) is an
SSRI, a class of antidepressant, and would therefore not be an appropriate
choice of drug in this case.
A 24-year-old man with a diagnosis of schizophrenia, last admitted 6 months ago
under Section, is brought in by police to the Mental Health Unit under Section 136.
He has been harassing his ex-girlfriend with constant threatening phone calls and
turning up at her house. He says he believes she is twisting his bones at night,
preventing him sleeping and causing him massive pain, through witchcraft. He
states that he is going to kill her if it goes on one more night and has purchased a
special knife from a ‘witchcraft’ shop on the internet. He is experiencing auditory
hallucinations directing him in the best way to use the knife against her. Against
the advice of his consultant he has recently stopped his medication, which usually
keeps him well. His symptoms typically follow these themes of violence and the
supernatural when unwell. He claims that being in hospital will just allow her to
target him more easily and will not stay voluntarily. What Section of the Mental
Health Act (MHA) is most likely to be appropriate in this case?
A. Section 135
B. Section 2
C. Section 3
D. Section 4
E. Section 5(2)
C. Section 3
While you would be unlikely to need in-depth knowledge of the MHA,
many doctors (not just psychiatrists) may be called upon to use these
Sections of the Act and it is a good idea to have some basic knowledge
about the various ways that people are detained. Section 3 (C) is used
to detain people for up to 6 months for treatment. It should not be used
unless the person is known to services (and preferably to one of the
professionals carrying out the assessment). According to the Department
of Health’s code of practice, Section 3 should be used when: ‘the nature
and current degree of the patient’s mental disorder, the essential elements
of the treatment plan to be followed and the likelihood of the patient
accepting treatment on a voluntary basis are already established’. This
is therefore the most appropriate Section – an established and successful
treatment plan has been in place previously. He will not come into
hospital voluntarily and his pattern of relapse is similar to previous
episodes. While a Section 2 is arguably less restrictive (being for a
shorter period of time), he has also had a recent previous admission
under Section. Both Sections require two medical recommendations and
an application by an Approved Mental Health Professional (AMHP).
The man described above is admitted under Section 3 of the Mental Health Act. On
admission to the ward, he is acutely disturbed and becomes violent towards others
and himself. He has slapped a member of staff. Staff try to calm him down but it
is felt that the risks are escalating. He was prescribed 2mg lorazepam orally which
he has spat into the nurse’s face. He has no prior recorded adverse drug reactions.
What is the most appropriate pharmacological management of the patient?
A. Haloperidol decanoate (depot) 50mg intramuscular
B. Haloperidol 10mg orally
C. Lorazepam 2mg intramuscular
D. Lorazepam 2mg slow intravenous injection
E. Propofol 120mg intravenous injection
C. Lorazepam 2mg intramuscular
Rapid tranquilization should only be used when non-pharmacological
methods have failed and the risks to the patient or those around them
are sufficiently high. Do not use rapid tranquilization without senior
advice. This man is obviously unwilling to take oral medication, which
makes (B) an inappropriate choice. Haloperidol decanoate (A) is a depot
medication and would therefore not have an immediate effect, making
this an inappropriate choice also. While lorazepam may be given as
a slow intravenous injection (D), it is more likely to cause difficulties
such as respiratory depression using this route, and on a mental health
unit there are unlikely to be staff or equipment capable of monitoring
this. Propofol (E) is used to induce anaesthesia so clearly would not be
an appropriate medication. Lorazepam intramuscularly is a commonly
used drug for rapid tranquilization, and this would be a reasonable
starting dose. It is often combined with intramuscular haloperidol (not
the depot formulation). Patients prescribed rapid tranquilization should
be carefully monitored by nursing and medical staff to ensure there is
no evidence of respiratory depression or other side effects. Before giving
parenteral benzodiazepines, ensure the ward has a supply of flumazenil
(a benzodiazepine antagonist).
A 22-year-old man with paranoid schizophrenia has been treated with three
different antipsychotics and remains unwell. His team decide to prescribe clozapine
which he has now been on for 3 weeks. He comes in for his regular blood test and
the nurse in the clozapine clinic asks the junior doctor to see him as he appears
unwell. On examination, he is sweaty and tachycardic with a temperature of
38.5°C. He has no chest pain but is coughing purulent sputum. What would the
most likely isolated abnormality be on blood testing?
A. High eosinophil count
B. High platelet count
C. Low haemoglobin
D. Low lymphocyte count
E. Low neutrophil count
E. Low neutrophil count
Clozapine has been known to cause neutropenia (E) or even agranulocytosis.
This can lead to infection and sepsis, which would fit with the clinical
picture here. This requires urgent treatment and the clozapine must be
immediately stopped. This could also be neuroleptic malignant syndrome
from the clinical picture, but the haematology does not particularly fit –
you would expect to see raised leukocytes. There have been reports of
eosinophilia (A) with the use of clozapine, but the exact mechanisms of
this are complex and unclear. It is likely to be related to the side effects
of myocarditis or colitis that can sometimes be seen with the use of
clozapine. Either way, the clinical picture does not quite fit with this.
Thrombocytosis (B) has been reported with clozapine but this would
be unlikely to lead to this clinical picture. Similarly, anaemia (C) has
occasionally been seen, but the clinical picture is closer to one of sepsis
rather than anaemia. A low lymphocyte count (D) may be present as part
of an overall decrease in all white blood cells with clozapine, but would
be unlikely as an isolated abnormality
A 54-year-old man with schizophrenia has been on depot antipsychotics for the
last 27 years as he hates taking tablets and has stopped them in the past. He has
not been unwell in terms of his schizophrenia for the last decade. His community
psychiatric nurse notices that he has developed odd movements around his mouth
over the last few months, where he purses and smacks his lips. It is causing him
difficulty speaking and it is distressing for him and his family. Which is the most
appropriate course of action for managing this symptom?
A. Gradual decrease in depot medication
B. Offer emotional support
C. Start anticholinergic such as procyclidine
D. Start ‘second-generation’ antipsychotic such as
olanzapine
E. Stop depot immediately to prevent further deterioration
A. Gradual decrease in depot medication
This symptom is tardive dyskinesia (TD), which generally occurs in those
taking antipsychotics (particularly older depot antipsychotics) over many
years. It is distressing as well as socially, if not physically, disabling.
There are numerous theories about why it occurs, although none has
been universally proven. The best course of action in this case would
be to try a gradual decrease in the depot medication (A), particularly
as the man has been well for so long. This should be done with
extreme caution and under regular medical supervision. Approximately
50 per cent of cases of TD improve. Decreasing the depot may cause an
initial worsening of symptoms which should be explained to patients.
A 22-year-old single man is diagnosed with schizophrenia. This is followed by
a very rapid psychotic breakdown characterized by well-defined persecutory
delusions. There is no mood component to his symptoms. He has shown a poor
response to treatment. Which of the following indicates a positive prognostic
feature of this man’s illness?
A. Absence of mood symptoms
B. Being male
C. Being young
D. Poor initial response to treatment
E. Rapid onset of symptoms
E. Rapid onset of symptoms
Curiously, having a rapid onset of symptoms (E) appears to confer
a positive prognosis in schizophrenia. All of the other options are
associated with a poor prognosis – being male (B), having no mood
symptoms in the clinical picture (A), being younger at onset (C), and
showing an initial poor response to treatment (D). Other poor prognostic
markers include lack of social networks, being single, poor pre-morbid
educational attainment, having predominantly negative symptoms and
having a long duration of illness before treatment.
A 38-year-old single woman is arrested outside the house of a celebrity TV chef
after shouting outside all night. On interview she claims that the man has declared
his love for her several times but is being prevented from seeing her by his wife
who is keeping him handcuffed inside. She states it is he that has made several
advances to her by sending her special messages when he is cooking on television.
What syndrome or symptom is being described here?
A. Capgras syndrome
B. de Clérambault’s syndrome
C. Folie à deux
D. Othello syndrome
E. Querulant delusions
B. de Clérambault’s syndrome
This is a classic example of de Clérambault’s syndrome (B), also
sometimes known as ‘erotomania’, in which the sufferer, usually a single
woman, becomes delusionally convinced that someone of ‘exalted’ (in
current society usually famous) status has become infatuated with them.
The delusion is often meticulously constructed, as the sufferer can explain
why the object of their affection cannot reveal their feelings, although
obviously the explanations are often outlandish or bizarre. The syndrome
can cause considerable problems for the targeted person. Note this
is not the same as stalking, although some stalkers will suffer with
this syndrome. It is often, but not always, part of the picture of a
schizophrenic illness
A 27-year-old man has been started on haloperidol, a ‘first-generation’
antipsychotic, for control of his symptoms of schizophrenia. A few weeks later
he comes to his GP in a highly embarrassed state, claiming that the CIA are
experimenting on him, turning him into a woman. When the GP asks how he
knows this, the man states that he has noticed his chest growing into ‘breasts’ and
he can no longer get an erection with his girlfriend. What is the most likely cause
of these symptoms?
A. Alpha-blockade
B. Drug-induced hepatitis
C. Hyperprolactinaemia
D. New-onset diabetes
E. Prostatic hypertrophy
C. Hyperprolactinaemia
C This is likely to represent hyperprolactinaemia (C), which is a relatively
common side effect of many antipsychotics, and by no means limited
to the older antipsychotics. It is caused by dopamine blockade of
the tuberoinfundibular pathway which regulates prolactin secretion.
Symptoms of raised prolactin include gynaecomastia and sexual
dysfunction. It is a significant side effect that must be treated seriously.
Ignoring it may lead to poor compliance and, in the long term, sustained
prolactin levels may lead to osteoporosis. Alpha-blockade (A) from
antipsychotic use may lead to sexual dysfunction but would not explain
the gynaecomastia. Drug-induced hepatitis (B) would be an unusual
finding with haloperidol but it has been reported. Also, these symptoms
would be unlikely to be the ones causing hepatitis to present. New-onset
diabetes (D) is unlikely to cause sexual dysfunction at early stages, and
gynaecomastia would only develop in the context of chronic kidney
disease. This is therefore an unlikely option, especially as haloperidol is
far less likely than some of the newer antipsychotics to cause problems
with blood sugar.
Which of the following is not recognized as a diagnostic feature of schizophrenia
according to ICD-10?
A. Formal thought disorder
B. Grandiose delusions
C. Running commentary
D. Symptoms lasting at least 1 month
E. Thought broadcasting
B. Grandiose delusions
This question refers to the ICD-10 diagnosis of schizophrenia, and should
not be mistaken with first-rank symptoms, which is a common mistake
made. Grandiose delusions (B) are more commonly associated with mania,
and as such are not specified in ICD-10 for the diagnosis of schizophrenia.
Some delusions in schizophrenia, however, can sometimes appear to have
a grandiose characteristic, such as believing that the CIA are targeting the
individual using brain waves – this would more accurately be described
as a ‘persecutory delusion’. Formal thought disorder (A), including
neologisms (new words being used), metonyms (existing words used
in unusual ways) and tangential thinking (unusual connections made
between thoughts) are relatively common in schizophrenia, particularly
in the acute stages of the illness. Running commentary (C) is when one
or more hallucinatory voices comment continuously on what the patient
is doing, for example, ‘he’s walking to the shop now, turning left, over
the road, why does he look so stupid when he does that?’. It is strongly
suggestive of schizophrenia. For a diagnosis according to ICD-10, the
symptoms must have been present for most of the time for a period of at
least 1 month, or at some time on most days (D). Thought broadcasting (E),
in which the sufferer believes that their thoughts are being transmitted so
others can hear them, is also relatively common in schizophrenia. Similar
symptoms include thought insertion and thought withdrawal and are
sometimes collectively known as symptoms of thought alienation.
A 28-year-old woman presents in the GP surgery. She is over-talkative and overfamiliar
with you. It is difficult to get a full history, but it seems for the last
4 weeks she has been elated and experiencing voices telling her that her mother
was a descendant of the Virgin Mary and that she is a female ‘second coming’. This
was the result of an experiment by the Nazi party who genetically engineered her
grandparents. She believes that remnants of the Nazi party are now controlling her
arms and legs, which results in her alternately trying to hug you and then kicking
out at the desk. What is the most likely diagnosis?
A. Hebephrenic schizophrenia
B. Induced delusional disorder
C. Paranoid schizophrenia
D. Schizoaffective disorder
E. Schizoptypal disorder
D. Schizoaffective disorder
This appears to be a schizoaffective disorder (D) of the manic type.
The nature of these disorders is a topic of some debate, but according
to ICD-10 they occur when both schizophrenic (in this case delusions
of passivity in terms of being controlled by the Nazi party as well as
auditory hallucinations) coexist with a diagnosable affective disorder (in
this case clear manic symptoms). Both must be present within the same
episode for the diagnosis to be made. This is not a classic presentation
of hebephrenic schizophrenia (A) in which delusions and hallucinations
are fleeting and not predominant, but a shallow and inappropriate affect
tends to dominate the clinical picture. Disorganized behaviour and speech
are also more prominent. An induced delusional disorder (B) is another
term for a ‘folie à deux’ in which a delusion appears to be ‘passed on’
from someone with a psychotic belief to someone close to them, usually
in an isolated relationship from the rest of the world. An example
would be an isolated couple in which the wife wrongly believes she is
pregnant and this belief is then shared by the husband.
Which of the following is the least likely to be a side effect of antipsychotic
treatment?
A. Akathisia
B. Convulsions
C. Hypotension
D. Renal failure
E. Tachycardia
D. Renal failure
There is almost no evidence for antipsychotics causing renal failure (D),
although of course if they precipitate neuroleptic malignant syndrome
then this may lead to renal failure through rhabdomyolysis. Also, most
antipsychotics are metabolized hepatically, so dose adjustment even in
renal disease is usually not indicated (although there are exceptions such
as amisulpride). Akathisia (A), or restlessness, is certainly a recognized
and common side effect of antipsychotics, particularly those with a
propensity for extrapyramidal side effects. Convulsions (B) can occur
with antipsychotic use as they tend to lower the seizure threshold.
Clozapine significantly reduces seizure threshold, and seizures are a very
real possibility for those taking this drug. Hypotension (C) occurs in
antipsychotics with adrenergic blockade properties and is usually dose
related. These medications should be titrated initially to prevent sudden
hypotension and collapse, particularly in the elderly. Tachycardia (E) is
also a recognized side effect of antipsychotics. It may be a portent of
other more serious cardiac abnormalities with antipsychotic use, such
as cardiac arryhythmias and prolonged QT interval, which may lead to
sudden cardiac death.
