Schizophrenia

Question 1

What characterises schizophrenia?

Answer 1

• Psychosis
• Hallucinations
• Delusions
• Disorganised speech and behaviour
• Flattened affect
• Cognitive deficits
• Occupational and social dysfunction

Question 2

What is psychosis?

Answer 2

Loss of contact with reality

Question 3

What are hallucinations?

Answer 3

False perceptions: may be auditory, visual, olfactory, gustatory or tactile. Auditory most common.

Question 4

What are delusions

Answer 4

False beliefs maintained despite clear contradictory evidence
(e.g. persecutory: pt believes being tormented, followed, tricked, spied on)

Question 5

What is flattened affect

Answer 5

Restricted range of emotions

Question 6

What are cognitive deficits of schizophrenia?

Answer 6

Impaired reasoning and problem solving

Question 7

Symptom onset schizophrenia?

Answer 7

Adolescence - early adulthood
Women: early - mid 20s
Men: slightly earlier, 40% by 20y

Question 8

Duration required for diagnosis schizophrenia?

Answer 8

One or more episodes of symptoms must last >6mo before dx made

Question 9

Brain alterations observed in schizophrenia?

Answer 9

• Enlarged cerebral ventricles
• Thinning of cortex
• Decreased size of ant hippocampus and other regions
• Altered neurotransmitters (esp dopamine and glutamate)

Question 10

Posited cause of schizophrenia?

Answer 10

Neurodevelopmental vulnerabilities (interact with environmental stressors to give relapse-remitting)

Question 11

What may cause neurodevelopmental vulnerability?

Answer 11

• Genetic predisposition
• Intrauterine/birth/postnatal complications
• Viral CNS infection

Question 12

Which factors increase risk of schizophrenia?

Answer 12

• Maternal exposure to famine and influenza during 2nd/3

- Birth weight

Question 13

Risk of schizophrenia in general population vs 1st degree relative v monozygotic twin affected?

Answer 13

1% general,10% with 1st degree, 50% monozyg twin

Question 14

Endophenotypes of schizophrenia?

Answer 14

• Aberrant smooth pursuit eye tracking
• Impaired cognition and attention
• Deficient sensory gating

Question 15

Significance of schizophrenia endophenotypes?

Answer 15

Also occur in 1st degree relatives –> may represent inherited component of vulnerability

Question 16

Stressors promoting emergence/recurrence schizophrenia?

Answer 16

-Biochem (e.g. marijuana)
-Social (losing job, leaving home, etc)
Not CAUSATIVE

Question 17

Common outcomes schizophrenia?

Answer 17

• Unemployment
• Isolation
• Deteriorated relationships
• Diminished quality of life

Question 18

Phases of schizophrenia?

Answer 18

• Premorbid
• Prodromal
• Middle
• Late

Question 19

What characterises premorbid phase?

Answer 19

-No Sx or
- impaired social competence
-mild cognitive disorganisation or perceptual distortion
-anhedonia
May be mild OR have impact on social / academic / work fxn

Question 20

What characterises prodromal phase?

Answer 20

Subclinical symptoms:
-withdrawal / isolation
-irritability
-suspiciousness
-unusual thoughts
-perceptual distortions
-disorganisation
Onset of overt schiz (delusions and hallucinations) may be sudden (d->w) or slow (years)

Question 21

What characterises middle phase of schizophrenia?

Answer 21

Symptomatic periods may be episodic or continuous

Functional deficits worsen

Question 22

What characterises late illness?

Answer 22

• Illness pattern established

- Disability may stabilise or diminish

Question 23

Categories of symptoms?

Answer 23

• Pos: excess/distortion of N fxns
• Neg: diminution / loss N fxns
• Disorganised: thoughts d/o and bizarre behaviour
• Cognitive: deficits in information processing and problem solving

Question 24

How may positive symptoms be classified?

Answer 24

Delusions or hallucinations

Question 25

What are delusions of reference?

Answer 25

Puts believe passages from books newspapers, song lyrics or other cues directed at them

Question 26

Delusions of thought insertion / withdrawal?

Answer 26

Pts believe others can: - read their mind - thoughts being transmitted to others - thoughts and impulses being imposed on them by outside forces

Question 27

What are disorganised symptoms?

Answer 27

``` Thought disorders and bizarre behaviours -thinking disorganised -rambling, non directed speech; shifts from one topic to another Behaviour: -childlike silliness, - agitation and -inappropriate appearance / hygiene / conduct. -Catatonia (extreme) ```

Question 28

How may schizophrenia be classified?

Answer 28

Deficit (prominent negative symptoms) and non-deficit (+ve symptoms but relatively fee of neg symptoms)

Question 29

Major cause of premature death in schizophrenics?

Answer 29

Suicide: 5-6% commit, 20% attempt

Question 30

Most at risk of suicide?

Answer 30

Young men with schizophrenia and substance abuse

Question 31

Relationship between violence and schizophrenia?

Answer 31

Modest risk factor for violence: - threats / minor outbursts not seriously dangerous behaviour - substance abuse, persecutory delusions or command hallucinations, non Rx comp - attack . murder someone they perceive as source of difficulties (very depressed / isolated / paranoid puts)

Question 32

How is schizophrenia diagnosed?

Answer 32

Hx, symptoms and signs. DSM-5: 1. >2 characteristic Sx (delusions, hallucinations, disorganised speech, disorganised behaviour, negative symptoms) for sig portion 1mo period 2. Prodromal or attenuated signs of illness with social, occupational or self care impairments for 6mo period including 1mo active symptoms Must r/o other causes (e.g. psychosis due to medical d/o or substance abuse)

Question 33

Factors associated with good prognosis?

Answer 33

- Good premorbid function - Late / sudden onset - FHx mood d/o (other than schiz) - Min cognitive impairment - Few negative symptoms - Shorter duration untreated psychosis

Question 34

Factors ass/w poor prognosis?

Answer 34

- Young age at onset - Poor premorbid function - FHx of schizophrenia - Many -ve symptoms - Longer duration untreated psychosis

Question 35

How does substance abuse interact with schizophrenia?

Answer 35

- Significant predictor of poor outcome - May lead to: - drug non adherence - repeated relapse - frequent rehospitalisation - declining function - loss of social support (inc homelessness)

Question 36

Treatment of schizophrenia?

Answer 36

- Antipsychotics - Rehab (inc comm support services) - Psychotherapy

Question 37

Goals of schizophrenia Rx?

Answer 37

- Reduce symptoms severity - Prevent recurrences and deterioration of function - Help function at highest level possible - Teach illness self management

Question 38

Conventional v second gen antipsychotics?

Answer 38

-SGAs modestly greater efficacy (-alleviate +ve Sx, lessen -ve Sx) -Reduced likelihood of movement disorder (less extrapyramidal AEx, less tardive dyskinesia) -Increase prolactin slightly or not at all (except risperidone) -Less cognitive blunting BUT -increased risk metabolic syndome

Question 39

DDx for poor motivation in previously psychotic individual?

Answer 39

- -ve Sx schizophrenia - AEx Rx e.g. sedation - Major depression - Schizoaffective d/0: depressive ep - BPAD, depressive ep - Substance use - Underlying organic d/o (e.g. hypothyroidism, anaemia) - grief - normal adolescence

Question 40

Long term Mx of schizophrenia?

Answer 40

-Case management with eventual transition to GP care >regular MSE for +ve Sx -revise dx -drug Mx -metabolic syndrome -beware suicidal ideation -D+A: motivational interviewing -Continuous psychoeducation: (CBT for EWS, psychotherapy, family/group therapy) -Continuous grief process -Psychosocial rehabilitation ($, transport, occupation, housing, social)

Question 41

what are the 4 principles for motivational interview?

Answer 41

1. Engage 2. Point out differences 3. Roll with resistance 4. Empower

Question 42

What is schizoaffective d/o?

Answer 42

Pt with both mood d/o and psychotic features without clear relationship between them.

Question 43

What is schizophreniform disorder?

Answer 43

Features parallel schizophrenia but duration must not exceed 6/12 i.e. pts with abrupt onset who respond well to treatment and are free or residual symptoms.