Schizophrenia

Question 1

Screening questions for psychosis: hallucinations

Answer 1

For hallucinations:
o Have you noticed your mind is playing tricks with you?
o Do you ever see things that you know aren’t real?
o Do you ever hear things when nobody’s there?

• How many voices?
• Do you recognize them?
• How loud are they?
• How often do you hear them?
• What do the voices say?
• sometimes voices tell people to do things, Do they tell you to do things? (command)
• Are they nasty or negative to you?

Question 2

Screening questions for delusions + name of delusions

Answer 2

Are there things that you believe in that you find other people disagree with ?
Do you experience this even if not using drugs or alcohol

o Do you feel that people are out to get you? (persecutory)
- what are your plans to deal with this?

o Do you feel like you’re being watched or monitored? (paranoid)

o Sometimes, people feel that there are subtle meanings or messages directed at them personally from adverts, internet or social media. Do you get them? (referential delusions)
o Do you feel like someone is putting thoughts into your head? (thought insertion)
Do you feel like people can hear your thoughts? (thought broadcasting)
Taking thoughts out (thought withdrawal)

-Grandeur - superiority to others
- Control - “do you believe someone else s controlling you?”
- Passivity - person externally controlled

Relationships
- Jealousy e.g. partner is unfaithful
- Erotomanic - another person is in love with the patient
- Nihilistic - self/world coming to an end
- Somatic delusions

Question 3

What are the additional questions to ask for schizophrenia after screening

Answer 3

1.Negative sx of schizophrenia (+ depressive sx)
- Negative symptoms
- Alogia (poverty of speech)
- Anhedonia
- Avolition (lack of motivation)
- Flat affect
- Cognitive symptoms
- Verbal memory and learning
- Executive function
- Attention
- Spatial memory

2. mania symptoms
3. substance abuse
4. impact on life (occupational, functional impairment)

Question 4

Apart from delusion, hallucination and negative symptoms, what are the other positive symptom s of schizophrenia

Answer 4

• Ideas of reference - a real event -“everyone on the bus walking past me is judging me”
• Delusions of reference - not a real event -
  feeling that everyone is thinking about them on the bus
• Overvalued ideas - abnormal belief that is
  not delusional nor obsessional in nature but which is preoccupying to the extent of
  dominating the sufferer’s life
• Derealisation - feeling detached from
  surroundings
• Depersonalisation - feeling detached from
  body
• Disorganised behaviour/thoughts - “Do
  you feel your thoughts are all over the place? Behaviour? Speech?

Question 5

what is the diagnostic criteria for schizophrenia and other differentials for psychosis - >1 month over 6 month , <6 month, 2 + weeks, >1 day <1 month

Answer 5

Schizophrenia :
A) 2 (or more) sx with one of these must be 1-3
1. Hallucinations
2. Delusions
3. Disorganized speech
4. Disorganized or catatonic behaviour
5. Negative sx (flat affect, avolition, alogia,
anhedonia).
B) The above sx persist for≥ 1 monthover a period of≥ 6 months.
C) Sx must cause self care, interpersonal occupational impairmentlasting≥ 6 months.
D) Exclude other conditions, meds, substance abuse disorder

Schizophreniform disorder
o Schizophrenia sx BUT <6 months + no
occupational / functional impairment.
o If manic or depressive episode, it’s for the
minority of the psychotic episode.

Schizoaffective disorder
o Criterion A of schizophrenia + an
uninterrupted period of a major mood
episode (major depressive or manic)
o Delusions / hallucinations for 2+ weeks in
the absence of a major mood episode.
o Sx of major mood episode are present for the minority of illness.
o Exclude other conditions, meds, substance abuse disorder

Brief psychotic disorder
1 or more sx– present for >1 day and < 1 month, but return to normal
1. Delusions.
2. Hallucinations.
3. Disorganized speech
4. Disorganized or catatonic behaviour

Delusional disorder
o 1 or more (usually realistic) delusions for >1 month.
o Hallucinations are not prominent and related to delusional theme.
o No functional impairment

Substance induced psychosis

Personality disorders: schizotypal, schizoid, borderline

bipolar 1 or mdd with psychotic features

Question 6

what is the firstline considerations for management of schizophrenia

Answer 6

Immediate Safety Concerns
- Admission - MHA if lacking in insight and/or risk to themselves/others

Clarifying Diagnosis
- Collateral history , old notes, liase with other medical professionals

Examination & Investigations
- Physical exam - height, weight, BMI, waist
circumference
- Bloods - baseline FBC, U&Es, LFTs, TFTs, CRP. metabolic profile (glucose and blood lipids)
Urine tox , MSU
- ECG - for QT interval
- CT head - consider if first presentation of
psychosis

Low stimulus environment, 1:1 nursing

Question 7

What are biological treatments for schizophrenia (with dosage)

Answer 7

Biological Treatment aim to minimise untreated psychosis
o 1st line = atypical antipsychotics
- Risperidone: 0.5-1mg/d target 2-3mg/d
-Quetiapine: 25-50mg/day target 300-400mg
-Aripiprazole 5-10mg/d target 15-20mg
-2nd Olanzapine 2.5-5mg target 10mg
Then trial 1st generation antipsychotics - 2 agents together

o If resistant (1-3A present after >6 weeks of 2 different antipsychotics at max dose) -> clozapine
Trial for 6 weeks before changing med

ECT -> for treatment resistant schizophrenia

IF with acute mania : mood stabliser
IF agitation/ agression: benzodiazepine 1st line lorazepam 1-2mg IMI

Question 8

What are the psychological and social treatments for schizophrenia/psychosis

Answer 8

Psychological
- Treatment for any substance abuse should be sought
- CBT
- Early intensive, MDT and family-based
interventions
- Group psychosocial therapy and education
- Psychoeducation - release prevention,
treatments, medications, course of illness
education
- Compliance therapy
- Social skills programs

Social
- Family/friends support
- Work/school
- Home/living conditions - reducing
environmental stressors, social work and
occupational therapy
- Spiritual/cultural

Question 9

What is the expected prognosis of schizophrenia

Answer 9

Prognosis
- Difficult returning to premorbid level of functioning
- Majority will experience a relapsing and remitting illness
- Some are left with residual positive and/or negative symptoms

Question 10

explain to a patient, in layman’s terms their diagnosis, situation, treatments of schizophrenia

Answer 10

• You came here today because you were feeling anxious with feelings that people might be plotting to harm you/ hearing things that other people aren’t able to.
• It appears that these thoughts and experiences are causing some distress to you and often when people experience this kind of phenomena it can be related to a specific condition called schizophrenia.
• People can develop this condition for many reasons including . In addition to strange experiences people may also experience trouble with thinking, disorganised speech and lack of motivation.
• While there is no cure to schizophrenia However, with treatment, most symptoms of schizophrenia will greatly improve and the likelihood of a recurrence can be diminished.
• Treatment for this condition involves medication which helps to reduce strength of these thoughts / voices/ visions. This medication is in tablet form but some types can be given as an injection. Its important to take these medications consistently even when you are feeling well to prevent you from becoming unwell again. Your psychiatrist will aim to have you on the lowest dose possible.
• Some people also benefit from talking therapies in addition such as cognitive behavioral therapy CBT aims to help you understand links between your thoughts, feeling and actions. CBT will look at your symptoms and how they affect your life, and also at your perceptions and beliefs. CBT improves awareness of your episodes and gives you ways of coping with stress and other symptoms.

Question 11

What are the specifiers for a diagnosis of schizophrenia and phases

Answer 11

Specifier
- First episode - currently in an acute episode/
partial remission/full remission
- Multiple episodes - currently in an acute
episode/partial remission/full remission
- Continuous
- Unspecified
- With catatonia

Phases
1. Prodromal - deterioration in function prior to
onset of acute psychotic phase

2. Active - delusions, hallucinations, disorganised speech/behaviour, negative symptoms
3. Residual - functional impairment,
   abnormalities in affect, cognition,
   communication