Schizophrenia

Question 1

What is psychosis?

Answer 1

Loss of contact with external reality, characterised by impaired perceptions and thought processes.

Question 2

What is schizophrenia?

Answer 2

“Split mind”:
> Fragmentation of thoughts
>Splitting of thoughts from emotions
>Withdrawal from reality

Question 3

What is the DSM criteria for Schizophrenia?

Answer 3

A. Two or more of the following psychotic symptoms for >1 month, need 1, 2 or 3:
1. Delusions
2. Hallucinations
3. Disorganised speech
4. Grossly disorganised/catatonic behaviour
5. Negative symptoms
B. Clinically sig dysfunctioning (with normal functioning prior to symptom onset)
C. Continuous signs of disturbance for >6mths - must include at least 1 month of psychotic symptoms
(May have gradual deterioration in functioning)
D. Not better accounted for by other diagnoses (Schizoaffective, substance, autism)

Question 4

Subtypes of psychotic disorders?

Answer 4

• Schizotypal PD: eccentric ideas, not clearly delusional

* Brief Psychotic Disorder (sudden,

Question 5

What are the positive symptoms of schizophrenia?

Answer 5

• Hallucinations
• Delusions/ideation
• Formal thought disorder
• Behavioural disturbances: Disorganised, catatonia, odd mvt/behav
• Lack of insight (97%)

Question 6

What are the negative symptoms of schizophrenia?

Answer 6

(Neg symptoms –> poorer response to treatment)
• Social withdrawal (poor eye contact): Glass barrier
• Anhedonia: inability to experience joy
• Emotional blunting (66%): inappropriate emotional expression
• Confusion
• Amotivational (due to anhedonia)
• Apathy
• Self-neglect
• Poverty of speech
• Poverty of content: shallow/low

Question 7

What are hallucinations, according to the DSM5?

Answer 7

Perception-like experiences that occur in absence of any external stimulus (vivid, clear, not under voluntary control)
• Occurs in clear/normal sensory experiences
• 75% of schizophrenia patients report experiencing hallucinations from all different sensory modes

Question 8

What are the most common hallucinations reported from patients with schizophrenia?

Answer 8

60-70% report hearing voices (distinct from own thoughts)

• Voices inside head or coming from external sources
• Own thoughts spoken aloud (describing feeling/thinking, fears or worries)
• Can be comforting
• Derogatory or insulting voices
• Third person commentary
• Commands to perform unacceptable behaviours

Question 9

What are cultural differences in hallucinations experienced?

Answer 9

Hallucinations occur in similar form across cultures, but there are differences in the content and its interpretation

Question 10

What is a myth concerning aggression and schizophrenia, and what is the reality of this? What are risk factors for hostility?

Answer 10

Myth: Schizophrenics are highly dangerous
Reality: Schizophrenics not more aggressive than general population, but their management of behav is not as good.

Risk factors:

• Younger males (history of violence)
• Non-adherence with medication
• Substance abuse
• Impulsivity

Question 11

What are Delusions, according to the DSM5?

Answer 11

Delusions: False firmly beliefs despite what others believe and despite evidence to contrary

• Odd and bizarre: often uncharacteristic of person
• Often not culturally acceptable

Delusions typically categorised according to content and bizarreness

Question 12

What are different types of delusions?

Answer 12

1. Paranoid/Persecutory Delusions: Fixed, false belief one is being harmed/persecuted by particular person/group
   (most common)
2. Delusions of Reference: Neutral event interpreted to have personal meaning for individual (e.g. TV reporter special message for person)
3. Grandiose Delusions: False belief that one has special powers, abilities, influence, achievements or another identity that typically relates to power/wealth/fame
4. Nihilistic Delusions: Belief that one bodily part/world does not exist, or has been destroyed
5. Delusions of Guilt: Personal responsibility for events
6. Jealousy delusions: Belief that partner is cheating on them
7. Erotomatic Delusions: False belief that patients’ romantic feelings are reciprocated (often by famous other)
8. Misidentification Delusions:Identity of someone they know has been stolen

Question 13

What is characterised as thought disorder?

Answer 13

Formal thought disorder: Disturbances in flow and/or form of speech (vs content, as in delusions)

Question 14

What are the negative and positive symptoms of thought disorder?

Answer 14

Negative manifestations: Reduced stream of thoughts and poverty of speech
Positive manifestations:
- Circumlocution
- Derailment: Quite change in topics
- Tangential: irrelevant responses
- Echolalia: Repeat what you’re saying
- Word salad: Incomprehensible stream of words
- Neologicsms: Quirky use of words/meanings

Question 15

What is characterised as disorganised behaviour?

Answer 15

Grossly disorganised and abnormal motor behaviour:
Catatonic/agitated behaviour:
- Extreme negativism (resisting instructions)
- Immobility (“waxy flexibility”)
- Catatonic excitement: Excessive purposeless physical activity
Peculiar voluntary movements (posture, repetition, grimacing)
- Mutism, echolalia, echopraxia, imitating speech, movement

Question 16

EPIDEMIOLOGY: What is the prevalence of schizophrenia?

Answer 16

Lifetime prev: 1-2% (other disorders: 1-3%)

Male to Female ratio: 2:3 (slightly more women)

Question 17

What is the age of onset for schizophrenia?

Answer 17

Typical onset: Late adolescence and early adulthood (tend to be later for women)
Onset typically preceded by gradual deterioration in functioning followed by appearance of more acute symptoms (but can be quite sudden)
Onset often coincides with a stressful time of life, further complicated by impact of schizophrenia

Early onset associated with poorer outcomes

Question 18

What are characteristics of the course of schizophrenia?

Answer 18

Highly variable.
1+ episodes with periods of normal (or near normal) functioning between episodes
- 66% difficulty with at least one daily living
Most remain chronically unwell with a deteriorating course
- 50% classified as unable to work
-

Question 19

What are the four stages in the course of schizophrenia?

Answer 19

1. Prodromal stage: Gradual deterioration, but not too out of normal for problems
   - Median length of symptom development ~2 years (highly variable)
2. Acute phase: more pronounced symptoms
   - Response to treatment related to duration of untreated psychosis - longer untreated, worse the cond becomes
3. Early recovery phase
4. Late recovery phase: Reintegration
   - 80-90% relapse within 2-5 years of treatment (usually due to stopping medication from feeling fine)

Question 20

What are the good prognostic factors of schizophrenia?

Answer 20

• Good premorbid functioning
• Acute onset
• Later age of onset (females)
• Precipitating event (e.g. drug induced psychosis)
• Low substance use
• brief duration of active phase
• Absence of abnormal brain structure
• No family history of schizophrenia

Question 21

What are the bad prognostic factors for schizophrenia?

Answer 21

• Poor premorbid condition
• Slow insidious onset
• Prominent negative symptoms
• Longer duration of untreated psychosis
• Slower/less complete recovery
• Lower SES
• Migrant status
• Social support network
• Younger onset age (often –> longer untreated)

Question 22

What are the implicated etiological factors implicated in schizophrenia, and what are the complications in determining these factors?

Answer 22

Implicated factors:

• Genetic
• Biochemical
• Neuroanatomical
• Psychosocial
• Diathesis-Stress Model

Complications: Not very well understood etiology
- Heterogenous range of disorders with common underlying biological vulnerability

Question 23

What are the genetic factors of etiology for schizophrenia?

Answer 23

Degree of risk related to degree of genetic relatedness: Genes determine susceptibility, while disorder is triggered by other factors
- 7% for siblings
- 9% for children of one affected parent
- 46% for children with two affected parents
Twin studies:
- 12% for dizygotic twins
- 44% for monozygotic twins
Adoption studies: Higher rates among children with biologically schizophrenic parents (19%) compared to children with no bio parents with schizophrenia (10%)

Question 24

What are the biochemical factors of schizophrenia?

Answer 24

Dopamine hypothesis: Overproduction/oversensitivity of dopamine receptors

1. Excess L-Dopa in Parkinsons’ precipitate psychotic episodes
2. Amphetamine (dopamine agonist) psychosis: Abnormally large responses to low amphetamine doses - suggests over-sensitivity rather than excessive dopamine level
3. Response to anti-dop. medication - effective in 60% with more impact on positive symptoms
4. Lack of impact on negative symptoms hints at two separate syndromes
   - Positive symptoms: associated with dopamine activity
   - Negative symptoms: associated with brain degeneration

Question 25

What is the most consistent finding in patients with schizophrenia?

Answer 25

Enlarge ventricles in schizophrenia - relative size over 2x larger than normal controls --> brain tissue loss Most likely cause is loss of brain tissue: chronic schizophrenia associated with brain abnormalities

Question 26

What are the neuroanatomical factors associated with schizophrenia?

Answer 26

Brain atrophy in: pFC (exec functioning) --> Negative symptoms Smaller left hippocampal volume. Associated with: - Schizophrenia - Those with high risk of developing schizophrenia - No family history Hard to determine direction of causality. Structural brain abnormalities appear to predate onset of psychosis - worsens with progressive illness - Early neurodevelopmental damage may play a key etiological role

Question 27

What are some developmental factors associated with schizophrenia?

Answer 27

Birth trauma and maternal viral infections likely to contribute - Timing of viral infections likely to impact - Nutritional deficiencies may contribute to adverse neurological development - Birth complications - 4x higher risk than for non-complicated births - 10x greater likelihood in complicated caesarean birth Seasonal variations and place of birth - Greater likelihood in winter/spring birth - viral illnesses or vitamin D deficiency? - two-fold increase in risk for urban births - Low SES births (but drift hypothesis?)

Question 28

Developmental course of schizophrenia?

Answer 28

(refer to diagram in notes) Polygenic susceptibility --> Genetic disposition (high paternal age) --> Birth (Birth complications, viral infections, nutrition, Urban, winter/spring) --> Childhood (Childhood abuse, social stresses, urban upbringing) --> Early Adolescence (Drug use: Cannabis, Amphetamine) --> Late adolescence (idiopathic stress, social/education/work stresses) --> PSYCHOSIS ONSET (relapse, substance abuse) --> Treatment resistant disability Range of internal intracychic factors + external stressors --> Trigger of psychosis

Question 29

TREATMENT: What medicated treatments are available?

Answer 29

Medication: primary intervention. Blocks D2 and D3 dopamine receptors - 60% of those with positive symptoms respond - 10-20% do not show symptom improvement in response to medication - Relapse rates high within one year (40%) - usually due to non-compliance

Question 30

What are the side effects associated with medication treatment?

Answer 30

Sedation Extrapyramidal side effects - Parkinson symptoms - Tardive dyskinesia (abnormal movements, facial grimacing, lip smacking) - Finger tremors, shuffling gait, drooling, chewing, twisted posture Side effects often treated with anti-Parkinson drugs Weigh gain, diabetes, heart disease Clozapine: + blood abnormalities, reduced white blood cell count

Question 31

What are the treatment targets of psychological interventions?

Answer 31

Social skills for interpersonal deficits Medication compliance Managing delusions/hallucinations: - Not persuading that they don't exist, but persuading patients that hallucinations are less salient to their functioning Reduction of stresses (culture-dependent) CBT potential non-pharmacological treatment

Question 32

What does CBT aim to achieve? And what is CBT's efficacy?

Answer 32

- Notice early signs of relapse - Understand relationship between thoughts, feelings and behaviours - Challenge beliefs about not being able to manage one's thoughts and behaviours - Learn strategies to cope with symptoms and stressors - Evaluate evidence supporting delusional beliefs vs alternative beliefs (e.g. recognise inner experience such as "thoughts" can be misattributed to external sources, like "voices") Efficacy: CBT showed better outcomes than standard treatment in - Reducing relapse, hospitalisation, positive/negative symptoms - Improving social functioning - Gains maintained at 2 year follow up CBT shown to reduce numbers who go on to develop psychosis in "high risk groups"

Question 33

What was Family Therapy developed in response to? What does it provide, and what is its efficacy?

Answer 33

Family Therapy developed in response to higher relapse rates for patients from families high in Expressed Emotion Aims to provide: - Education about schizophrenia and its treatment - Realistic goal setting skills - Communications training (empathy not critical) - Problem solving skills - Promote social support Family Therapy - reduce relapse, and enhance family support