Psychotic Disorders

Question 1

What is the epidemiology of schizophrenia ?

Answer 1

1% lifetime risk
Age of onset: male 18-25 female 25-35
Incr prevalence in lower socio economic classes
Genetic risk, monozygotic twins show 50% concordance

Question 2

What anatomical abnormalities are thought to be associated with schizophrenia?

Answer 2

Ventricular enlargement

Reduced brain size

Question 3

What is the hypothesised pathophysiology of schizophrenia?

Answer 3

Over activity of the mesolimbic dopamine pathway

Based in the effects of conventional antipsychotics which block D2 receptors
Drugs which potentiate the pathway e.g. Amphetamines are known to cause psychotic sx

Question 4

What are the main psychotic disorders?

Answer 4

Schizophrenia
Delusional disorder
Schizoaffective disorder
Acute + transient psychoses

Question 5

What can increase relapse risk in schizophrenic patients?

Answer 5

High expressed emotion in family members

Compliance failure: 80%

Question 6

What is the first line treatment for schizophrenia?

Answer 6

Atypical antipsychotics:
Olanzapine
Risperidone

Question 7

What is treatment resistant schizophrenia?

Answer 7

Lack of satisfactory clinical improvement
Despite sequential use of two antipsychotics (one being an atypical) for 6-8 wks
Start on clozapine asap

Question 8

How can compliance be improved in schizophrenic patients?

Answer 8

depot IM 2-4 wkly (risperidone)
Increased social support
Patient education

Question 9

What is the role of benzodiazepines in the treatment of schizophrenia?

Answer 9

Short term relief of:
Insomnia, aggression, agitation, behaviour disturbance
No antipsychotic effect

Question 10

What are negative symptoms?

Answer 10

Apathy: anhedonia, flat affect

Poverty of thought + speech

Question 11

What are the positive symptoms?

Answer 11

Delusions
Hallucinations
Thought disorder

Question 12

What is the role of antidepressants in schizophrenia?

Answer 12

Sometimes used to augment antipsychotics in treatment resistant cases
Especially with significant affective symptoms
Used in schizoaffective disorder + post schizophrenia depression

Question 13

What is the role of ECT in treatment of schizophrenia?

Answer 13

Rarely used

Indicated only with severe catatonic symptoms

Question 14

What is the role of CBT in treatment of schizophrenia?

Answer 14

Effective in reducing symptoms as an adjunct to pharmacological treatment
Improves insight and compliance

Question 15

What is the role of family psychological interventions in treating schizophrenia ?

Answer 15

Can help reduce expressed emotion:
Expressions of hostility and criticism
Reducing relapse and admission rates

Question 16

How should acute behaviour disturbance be managed?

Answer 16

Environmental + behavioural interventions

Medical:
Oral - benzo +- atypical antipsychotic or typical antipsychotic
Refusing oral - IM lorazepam 0.5-2mg +- IM haloperidol

Question 17

What is paranoid schizophrenia?

Answer 17

Schizophrenia dominated by florid positive symptoms

Delusions may be built into a complex conspiracy theory
Paranoid: sense of things occurring around them having special personal significance

Question 18

What is simple schizophrenia?

Answer 18

Presents only with negative symptoms

Question 19

What is hebephrenia?

Answer 19

Mix of positive and negative symptoms
Insidious onset
Adolescent onset 15-25
Disorganised + chaotic: mood, behaviour and speech
Shallow/inappropriate affect
Behaviour seems aimless

Question 20

What organic causes might you want to rule out in a schizophrenic picture?

Answer 20

Complex partial seizures- temporal lobe epilepsy
Cerebral lesions
Hypothyroidism
SLE
Alcoholism, illicit drug use, medications causing hallucinations

Question 21

What is a hallucination ?

Answer 21

A perception in the absence of stimulus

Question 22

What is a delusion?

Answer 22

A fixed, false belief held despite rational argument or evidence to the contrary.
That cannot be explained by the patient’s cultural, religious or educational background

Question 23

What are the three stages of schizophrenia?

Answer 23

At risk mental state: prodrome
Acute phase: positive symptoms predominate
Chronic phase: negative symptoms predominate

Question 24

What are the features of the at risk mental state?

Answer 24

Low grade symptoms of:
Social withdrawal
Loss of interest in work/study/relationships
No frank psychotic symptoms

Question 25

What are diagnostically significant hallucinations?

Answer 25

Thought echo Voices giving running commentary on patient's actions Voices discussing/arguing about the patient

Question 26

What are diagnostically significant delusions?

Answer 26

Delusional perception: real stimulus delusional interpretation Passivity: movement, sensation, emotion or impulse being controlled by an external force Thought interference: withdrawal/insertion/broadcasting

Question 27

What symptoms might be expected in the chronic phase of schizophrenia?

Answer 27

``` Apathy Blunted affect Anhedonia Social withdrawal Poverty of thought and speech ```

Question 28

What is catatonic schizophrenia?

Answer 28

``` Stupor Excitement Posturing Rigidity Waxy flexibility Automatic obedience Perseveration ```

Question 29

What are Schneider's first rank symptoms?

Answer 29

Delusional perception Passivity Delusions of thought interference: insertion, withdrawal, broadcasting Auditory hallucination: thought echo, third person, running commentary

Question 30

What is the differential diagnosis in a patient seemingly presenting with schizophrenia?

Answer 30

``` Organic causes: substance misuse, dementia, delerium, epilepsy esp temporal lobe, medication, brain tumour, stroke, HIV, wilson's, porphyria, neurosyphillis Acute and transient psychotic episode Mood disorder Schizoaffective Persistent delusional disorder Schizotypal disorder ```

Question 31

How would you investigate a patient with apparent schizophrenia?

Answer 31

FBC, TFTs, U&Es, LFTs, CRP, fasting G, ?HIV, ?Syphillis, lipids MSU Urine drug screen CT if cerebral pathology suspected, EEG if epilepsy suspected Symptom rating scale OT Assessment of activities of daily living Social work assessment of housing, finances, carers needs Collateral history

Question 32

What is DUP?

Answer 32

Duration of untreated psychosis Time delay from first symptoms to first ever effective treatment Psychosis is toxic: greater the DUP, the greater the damage to cognitive abilities, insight and social situation The sooner treatment started the better the prognosis Hence early intervention services aim to keep DUP

Question 33

Why is there increased risk of CVD in schizophrenic patients?

Answer 33

Antipsychotic medication | Increased smoking rates