Schizophrenia

Question 1

Definition of schizophrenia?

Answer 1

IS A COMMON CHRONIC RELAPSING CONDITION OFTEN PRESENTING IN EARLY ADULTHOOD WITH PSYCHOTIC SYMPTOMS, DISORGANISATION SYMPTOMS, NEGATIVE SYMPTOMS AND SOMETIMES COGNITIVE IMPAIRMENT.

Question 2

What are group 1 symptoms and signs of schizophrenia?

Answer 2

• Thought insertion, thought echo, thought withdrawal or thought broadcasting
• Delusions of control or passivity, delusions of perceptions
• Hallucinations (commentary, voices discussing the patient or voices coming from some part of the body)

Question 3

What are group 2 signs and symptoms of schizophrenia?

Answer 3

• Persistent hallucinations for at least a month accompanied by delusions with no clear affective content
• Neologism or thought disorder
• Catatonic behaviour (excitement, posturing, waxing flexibility, negativism, mutism and stupor)
• Negative symptoms (apathy, poverty of speech, blunt or incongruous affect)

Question 4

What are the types of schizophrenia ?

Answer 4

paranoid, hebephrenic, catatonic, residual, simple

Question 5

What is paranoid schizophrenia?

Answer 5

Stable, often paranoid delusions, often accompanied by hallucinations. Disturbances of affect, volition, speech and catatonia are rare.

This is the commonest subtype and predominated by hallucinations and delusions

Question 6

What is hebephrenic schizophrenia?

Answer 6

affective changes are prominent e.g. shallow inappropriate or facile delusions and hallucinations are fragmented and fleeting, behaviour is irresponsible and unpredictable. Mannerisms are common. Usually diagnosed in young people.(age of onset usually 15-25 y/o)

Has a poor prognosis
There is a prominent fluctuating affect and fleeting, fragmented hallucinations and/or delusions

Question 7

What is catatonic schizophrenia?

Answer 7

Prominent psychomotor disturbances e.g. hyperkinesis, stupor, automatic obedience, negativism, posturing, waxy flexibility

Question 8

What is residual schizophrenia?

Answer 8

Chronic stage of schizophrenia often with negative symptoms, underactivity, blunt affect apathy, poverty of speech, lack of facial expression and eye contact, poor self-care and social performance.

predominated by negative symptoms

Question 9

What is simple schizophrenia?

Answer 9

insidious but progressive development of odd behaviour and inability to meet demands of society and decline in performance

predominated by negative symptoms

Question 10

What is the lifetime risk of schizophrenia?

Answer 10

1%

Question 11

What is the female:male ratio of incidence

Answer 11

1:1 (but men are more likely to have more negative symptoms and more severe forms of schizophrenia)

Question 12

When is the peak onset?

Answer 12

20s-30s ( but second peak seen in late middle age - late onset schizophrenia)

Question 13

What is the lifetime expectancy?

Answer 13

Patients tend to die 25 years younger than the general population

Question 14

What is there increased risk and mortality from with schizophrenia?

Answer 14

Increased risk of suicide and increased risk of mortality from CVD, respiratory disease and infection

Question 15

What is the genetic risk?

Answer 15

parent has it, 1 in 10 chance, if identical twin has it 1 in 2 chance (this shows that there are also environmental factors involved)

Question 16

How much does the use of cannabis increase the risk?

Answer 16

doubles (x2) - but in heavy users can increase the risk to 6 times

Question 17

What is often found in a patient withs schizophrenia’s personal history?

Answer 17

Childhood history of stress/dysfunction

Question 18

What are the risk factors of schizophrenia?

Answer 18

• Family History
• Intrauterine and perinatal complications
• Intrauterine infections
• Abnormal early cognitive/neuromuscular development
• Social isolation/migrants
• Abnormal family interactions

Question 19

What are first rank symptoms of schizophrenia?

Answer 19

• AUDITORY HALLUCINATIONS – third person, commentary, thoughts spoken aloud (most common)
• THOUGHT ALIENATION – Thought insertion, Thought broadcast, Thought withdrawal
• DELUSIONAL PERCEPTION
• PASSITIVITY PHENOMENA

These symptoms are mainly POSITIVE SYMPTOMS

Question 20

What are secondary symptoms of schizophrenia?

Answer 20

• PERSISTENT HALLUCINATIONS IN ANY MODALITY – somatic, visual, tactile, which occur everyday for weeks on end
• Delusions
• Second person auditory hallucinations
• Thought disorder – thought interruption, thought block
• Catatonic behaviour (Strange, purposeless behaviour)
• Negative symptoms  apathy, incongruent affect, paucity of speech, blunting or flat affect, self-neglect, Low motivation, underactivity, poor non-verbal communication, clear deterioration in functioning
• Lack of insight

Question 21

What are positive symptoms?

Answer 21

hallucinations, passitivity phenomena, thought alienation, lack of insight, disturbace of mood and delusions

Question 22

What sort of symptoms do people usually present with acutely?

Answer 22

Positive symptoms

Question 23

as the disease becomes more chronic which symptoms are more likely to be seen?

Answer 23

Negative symptoms

Question 24

What are negative symptoms?

Answer 24

apathy, incongruent affect, paucity of speech, blunting or flat affect, self-neglect, Low motivation, underactivity, poor non-verbal communication, clear deterioration in functioning

Question 25

What are prodromal symptoms?

Answer 25

These are symptoms that precede most first episodes of psychoses by up to 18 months

Question 26

What are prodromal symptoms characterised by?

Answer 26

Characterised by a gradual deterioration in functioning. Includes: transient psychotic symptoms, odd behaviour, beliefs and thoughts, concentration problems, altered affect, social withdrawal and reduced interest in daily activities.

Question 27

How is schizophrenia diagnosed?

Answer 27

* Main criteria is to have at least one very clear FIRST RANK SYMPTOM (usually two or more if less clear-cut) * Diagnosis is held off unless the symptoms last >6 months and symptoms are present most of the time for at least a month, AND there is marked impairment in work or home functioning. * RULE OUT other causes of psychosis: Bipolar, CNS tumours, drugs/alcohol, head injury

Question 28

Organic DDx of schizophrenia?

Answer 28

o Drug induced psychosis - Cannabis o Temporal Lobe epilepsy (seizures) o Dementia o Encephalitis o Alcohol hallucinosis o Delirium – due to many causes (VITAMIN CDE) o Cerebral syphilis o Neurological  Huntington’s disease, MS etc. o Endocrine  thyroid, adrenal (Cushings, phaeo)

Question 29

Psychiatric DDx of schizophrenia?

Answer 29

``` o Mania o Psychotic depression o Some personality disorders o Panic disorders o Dissociative identity disorder ```

Question 30

What is the dopamine hypothesis of schizophrenia?

Answer 30

Over activity of dopamine (D2) receptors – mesolimbic – hallucinations and delusions (THIS ONE HAS HIGH HEREDITABILITY, SO PSYCHOSIS CAN RUN IN FAMILIES) Under activity of dopamine receptors (D1) – mesocortical – blunted emotion, anhedonia, apathy

Question 31

What Ix would be taken out for potential schizophrenia diagnosis?

Answer 31

Bloods and urinalysis to rue out any organic/physical causes or drugs or alcohol

Question 32

management of schizophrenia?

Answer 32

antipsychotics, psychological interventions

Question 33

How can antipsychotics be subtyped?

Answer 33

first generation(typical) and second generation (atypical)

Question 34

What are examples of first generation (typical) antipsychotics?

Answer 34

* Haloperidol * Chlorpromazine * Prochlorperazine * Pipothiazine * Zuclopenthixol * Flupenthixol * Sulpride

Question 35

what is the mechanism of action for first gen (typical) antipsychotics?

Answer 35

These work by blocking D2 receptors in the brain but this can cause Extra-pyramidal side effects (EPSEs).

Question 36

What are the extra-pyramidal side effects?

Answer 36

* Acute dystonic reaction – can occur within hours of treatment with antipsychotic meds. Is MUSCLE SPASM, ACUTE TORTICOLIS, OCCULAR GYRATE CRISIS * Parkinsonism – can occur days after having treatment –cause tremor, bradykinesia * Akathisia – can occur days – weeks after taking meds, causing ‘inner restlessness’, manifests as pacing and agitation, often very intolerable. * Tardive Dyskinesia – can occur months – years after going on meds, causes grimacing, tongue protrusion, lip smacking, ‘gurning’

Question 37

What is the acute dystonic reaction? and how quickly does this side effect become apparent?

Answer 37

MUSCLE SPASM, ACUTE TORTICOLIS, OCCULAR GYRATE CRISIS | Can occur within hours of taking the medication

Question 38

What is Parkinsonism? and how quickly can this SE become apparent?

Answer 38

Causes tremor and bradykinesia | Can occur within days after administering treatment

Question 39

What is akathisia? and how quickly can this SE become apparent?

Answer 39

Akathisia causes 'inner restlessness', manifests as pacing and agitation and is often intolerable. this can occur weeks after administering treatment

Question 40

What is Tardive dyskinesia? and how quickly does this SE become apparent

Answer 40

causes grimacing, tongue protrusion, lip smacking, ‘gurning’ | This can occur months or years after going on medication

Question 41

What are examples of second generation (atypical) antipsychotics? and their side effects

Answer 41

* Olanzipine (SE: weight gain, sedation) * Risperidone (SE: Hypotension, nausea) * Clozapine (SE: AGRANULOCYTOSIS) * Aripiprazole (SE: nausea, agitation) * Amisulpride (SE: Increased prolactin, weight gain) * Queliapine (SE: hypotension, nausea)

Question 42

Do second generation antipsychotics cause EPSEs?

Answer 42

no due to a slightly different pharmacological mechanism so that they have serotonin (5HT2a) occupancy

Question 43

When is clozapine used?

Answer 43

in drug resistant schizophrenia. | Only used after trying at least 2 antipsychotics to treat schizophrenia which have no effect

Question 44

Why is it very important to monitor bloods on clozapine?

Answer 44

Agranulocytosis - the loss of WCC and neutrophils

Question 45

how can agranulocytosis present?

Answer 45

Sore throat and white spots on tongue

Question 46

what can be the impact of delaying antipsychotics?

Answer 46

Worsening of negative symptoms

Question 47

What psychological interventions are available for schizophrenia?

Answer 47

* CBT – general or targeted on auditory hallucinations * Working with the family (family therapy) * Social support

Question 48

When is the prognosis better with schizophrenia?

Answer 48

Prognosis is better when it is sudden onset, no negative symptoms, supported at home, of the female sex, later onset of illness, no CNS ventricular enlargement, and no family history.

Question 49

Overall, what percentage of patients only experience one episode of schizophrenia?

Answer 49

10%

Question 50

with treatment, how many patients with schizophrenia need intensive input/hospitisation for more than 2 years after the first admission?

Answer 50

<7%

Question 51

What percentage of patients have recovered at 15 years?

Answer 51

40%

Question 52

What is the incidence of suicide in the acute phase?

Answer 52

10%

Question 53

What is the incidence of suicide in the chronic phase?

Answer 53

4%

Question 54

How many patients recover?

Answer 54

1 in 5

Question 55

How many patients recover but have relapses?

Answer 55

3 in 5

Question 56

How many patients keep having symptoms and develop depression?

Answer 56

1 in 7

Question 57

What is catatonic schizophrenia dominated by?

Answer 57

• Dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesia and stupor, or automatic obedience and negativism. may also have some episodes of violent excitement in this condition

Question 58

What is catatonia?

Answer 58

state of apparent unresponsiveness to external stimuli in a patient who appears to be awake

Question 59

What is Catalepsy?

Answer 59

state characterised by patient keeping uncomfortable, rigid and fixed posture despite external stimulus or resistance.

Question 60

What may the catatonic phenomena be combined with?

Answer 60

a dream-like state with vivid scenic hallucinations

Question 61

Which form of schizophrenia has affective changes as a prominent feature with delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable and mannerisms common.

Answer 61

hebephrenic