Schizophrenia

Question 1

DIAGNOSTIC GUIDELINES:

At least 1 very clear Sx. w duration >1 month. If <1 month=acute schizophrenia-like psychotic disorder.

Answer 1

a) thought echo,insertion/withdrawal, broadcasting.
b) delusions of control/influence/passivity clearly referred to body/limb movements or specific thoughts, actions or sensations; delusional perceptions.
c) auditory hallucinations giving running commentary/discussing patients among themselves/coming from some body part.
d) Bizzare delusions=persistent delusions/other kinds that are culturally inappropriate and completely impossible.

≥2 of:
e) other hallucinations when accompanied by fleeting/half-formed delusions wout clear affective content or by persistent over-valued ideas or when occuring every day for weeks/months.

f) Thought disorganization: loosening of associations/incoherence/irrelevant speech, or neologisms.
g) catatonic behaviour
h) negative Sx not attributed to depression/neuroleptic medication
i) significant and constant change in overall quality of some aspects of behaviour: aimlessness, social withdrawal, loss of interest

Question 2

Dx cautions

Answer 2

X Dx in presence of extensive depressive/manic Sx unless schizophrenic Sx before affective disturbances.

X Dx in presence of overt brain disease/drug intoxication/withdrawal

Question 3

Prodromal phase

Answer 3

Loss of interest, self-neglect, generalised anxiety and mild depression may preceed onset.

Question 4

Schneider’s first-rank Sx. of schizophrenia

Answer 4

1. Delusional perception
2. Delusions of thought control: insertion, withdrawal, broadcasting
3. Delusions of control: passivity experiences of affect, impulse, volition and somatic passivity
4. Auditory hallucinations: audible thoughts/thought echo, voices discussing patient, running commentary.

Question 5

SUBTYPES:

1. Paranoid schizophrenia
2. Disorganized/Hebephrenic Schizophrenia
3. Catatonic schizophrenia
4. Residual schizophrenia

Answer 5

1. • Dominated by positive Sx. ie delusions and hallucinations.
   • Negative Sx., Catatonic Sx. and Thought disorganizations not prominent
   • Better prognosis and later onset.
   • need to exclude epilepsy and drug-induced psychoses

2.

• Thought disassociation, disturbed behaviour, inappropriate/flat affect
• Delusions/hallucinations not prominent/fleeting
• Earlier onset(15-25y)
• Poorer prognosis.
• premorbid personality usually shy and solitary.
• need to cont. observe for 2-3 months to reliably Dx.

3. Rare
4. Predominantly chronic negative Sx. persist for 1y after ≥1 psychotic episode

Question 6

SCHIZOAFFECTIVE DISORDER

Answer 6

• within same episode of illness, presence of ≥1, preferably ≥2 typical Sx.(a-d) of schizophrenia and meet criteria for manic/depressive episode.

Question 7

DELUSIONAL DISORDER

Answer 7

• Excludes typical schizophrenic delusions and hallucinations.
• Single set of delusions for ≥3 months.
• May have fleeting non-schizophrenic hallucinations,brief depressive Sx.
• otherwise affect, speech, behaviour, social skills preserved.

*Induced delusional disorder/folie a deux=Harley Quinn

Question 8

EPIDEMIOLOGY

Answer 8

1. Lifetime risk 1%
2. Prevalence 1%
3. Male : Female 1.4:1
4. Male 18-25y, Female 25-35y
5. Increased incidence in urban and migrant populations.

Question 9

AETIOLOGY

Answer 9

1. Genetic
   - genes involved in neurodevelopment and glutamate and dopamine metab.
   - monozygotic twin concordance: 50%
   - parent/sibling w schizophrenia: 10% risk
2. Developmental f.
   - complications drg. pregnancy and birth.
3. Brain abn.
4. Neurotransmitter abn.
   - mainly dopamine; amfetamines, antiparkinsonian drugs
   - serotonin and glutamate
5. Stressful life events
   - Unsure if cause or result
6. Increased expressed emotion from those around
   - over-involved/over-hostile
   - increased risk of relapse

Question 10

MANAGEMENT

1. Tx. setting
2. Pharmacological
3. Physical Health
4. Psychological Tx.
5. Social Input

Answer 10

1. a) Preferably home, admission if first episode, significant risk to others/self.
   b) MHA detention w reduced insight and impaired judgement.
   c) Long-term community Mx. ie CPN
   d) Primary care if Sx. stable,well-controlled.
2. Long term Antipsychotics.
   - 2nd gen usually first-line
   - Clozapine best one but SE profile worrying. used in tx-resistant cases
   - Tx. resistant when ≥2 drugs used sequentially for 6-8w with 1 drug being 2nd generation.
   - benzodiazepine for aggression, agitation, insomnia
   - antidepressant/lithium for affective Sx.
3. Increased risk of CV disease
   - annual CV risk f. screen
   - ECG prior to antipsychotics if in hospital or risk f.
4. a) Social support, education
   b) CBT: offer to all pts. helps patients come to terms with illness, improves concordance.
   c) Family psychological interv.
   - reduces ‘expressed emotion’
   - reduces relapse rates.
5. SANE, MIND; finance, occupation, activities, social supports and support for carers. Care programme approach

Question 11

DRUG INFO

1. 1st generation
2. 2nd generation
3. Common SE’s
4. Drug-specific SE’s

Answer 11

1. Chlorpromazine, Haloperidol, Flupentixol, Zuclopenthixol
2. Olanzapine, Quetiapine, Risperidone, Aripiprazole, Clozapine
3. Somnolence, Extra pyramidal SEs, Weight gain(except for aripiprazole)
4. a) Chlorpromazine: Photosensitivity
   b) Haloperidol: QT prolongation
   c) Clozapine: Agranulocytosis(1%) needing regular blood monitoring,neutropenia(3%) hypersalivation, reduced seizure threshold, induce seizure in up to 3%

*Antipsychotics can cause acute dystonia which can be tx. w anticholinergics ie procyclidine

Question 12

ACUTE BEHAVIOURAL DISTURBANCE

Answer 12

1. Environmental intervention
2. Behavioural intervention.
   - talking calmly, distracting w questions about eating/sleeping etc
3. Rapid tranquilisation
   a) Accepting oral meds
   - Lorazepam 1-2 mg, 0.5 mg in elderly
   - oral antipsychotic if psychotic
   b) Risk to self/others
   - IM lorazepam 1-2 mg, 0.5 mg in elderly
   - olanzapine 10 mg 1h after IM lorazepam; haloperidol 5 mg if psychotic
   * repeat tranquilisations as req. every 45-60 mins
4. If parenteral tranquilisation, monitor BP, TPR regularly

Question 13

PROGNOSIS

Answer 13

1. average life span shortened by 15y
2. Cause of death usually suicide, increased smoking, socioeconomic deprivation, CV, resp, accidents.
3. Risk f for suicide: male of higher education, some insight into illness.
4. Better prognosis in low-income countries
   - likely due to better extended family social support.
5. Good prognosis f: female, married, older age of onset, abrupt onset, precipitated by life stress, earlier tx initiation, paranoid subtype, absence of negative Sx., illness characterized by prominent mood Sx., good premorbid fn.

Question 14

EPIDEMIOLOGY:

Answer 14

• Onset typically after puberty.
• Incidence highest in males 15-25y; in females 20-30y
• Prevalence equal in both