Schizophrenia and Psychotic Disorders

Question 1

What does Psychosis mean?

Answer 1

Psyche - Mind
-osis - Disease of

Disease of the Mind

Question 2

What is the difference between Psychosis and Neruosis ?

Answer 2

Psychosis - Disease of the mind (severe)
Neurosis - Disease of the nerves (mild)

Question 3

What is Psychosis ?

Answer 3

• Represents an inability to distinguish
  between symptoms of delusion,
  hallucination and disordered thinking from
  reality
• Severe forms of mental illness
• Lack of insight (Unable to differentiate between symptoms and reality)

*Important in capacity if you don’t believe you are suffering from an illness

*Beliefs are fixed and unshakable

Question 4

What is the (EXAM?) Definition of Psychosis

Answer 4

“Psychosis represents an inability to
distinguish between symptoms of
hallucination, delusion and disordered thinking from reality.”

Question 5

What is in the clinical presentation of Psychosis?

Answer 5

Hallucinations;
- Have the full force and clarity of true perception (KEY!)
- Located in external space
- No external stimulus
- Not willed or controlled

5 special senses;
- Auditory or visual
- Tactile (Something touching you or crawling around skin)
- Olfactory and gustatory

*LEARN

Question 6

What are Delusional Beliefs?

Answer 6

” A delusion is an unshakeable idea or belief
which is out of keeping with the person’s
social and cultural background; it is held with
extraordinary conviction.”

Examples;
- Grandiose (“You are great, superpowers”)
- Paranoid (correctly persecutory) (“Everyone against you”)
- Hypochondriacal (“Sick something wrong with me”)
- Self-referential (“Everything relates to me, that clock wouldn’t tick loudly if I wasn’t in the room)

Question 7

What is the KEY difference between Hallucination and Delusion ?

Answer 7

Hallucination perception

Delusion is a thought

Question 8

What illnesses have Psychotic Symptoms?

Answer 8

It may be more helpful not to consider psychosis as a major classification but to consider the illnesses that may have psychotic symptoms;

Schizophrenia

Delirium (Not always primarily psychiatric, but underlying could be a chest infection)

Severe affective disorder;
- Depressive episode with psychotic symptoms (Nilistic beliefs - I’m dead, rotting, I can fly)
- Manic episode with psychotic symptoms

Question 9

What is the difference between Split Personality Disorder and Schizophrenia?

Answer 9

People get confused with split personality disorder which is very rarely seen (he’s only ever seen in someone with Huntington’s which is an organic disorder)

Question 10

Why is the ‘first rank’ system not used for diagnosing Schizophrenia ?

Answer 10

Only 80% of people with Schizophrenia have first rank symptoms so would misdiagnose 20% of people

Question 11

What does Schizophrenia affect and how common is it?

Answer 11

A severe mental illness affecting;
- Thinking
- Emotion
- Behaviour

Most common cause of psychosis;
- Affects 1 per 100 population
- Males and females equally
- Age of onset 15-35 years earlier in than women (mean of 28 years vs 32 years)

*Often seen in the young and women present slightly later than men

Question 12

What are the Positive symptoms of Schizophrenia?

Answer 12

Positive Symptoms;
- Hallucinations
- Delusions
- Disordered thinking

• Positive Symptoms are also called ‘acute symptoms’, more dramatic symptoms, things you would think of when you think of a patient with severe mental illness
  Want these ones to respond to treatment

Question 13

What are the Negative symptoms of Schizophrenia?

Answer 13

Negative Symptoms;
- Apathy
- Lack of interest
- Lack of emotions

• Negative Symptoms look a little like depression, more chronic and a marker of poorer prognosis and harder to treat

Question 14

What SINGLE requirements are needed in ICD-10 and for how long to be diagnosed with Scizophrenia ?

Answer 14

For more than a month in the absence of organic or affective disorder

At least one of the following

a) Alienation of thought as thought echo, thought insertion or
withdrawal, or thought broadcasting.

b) Delusions of control, influence or passivity, clearly referring to body
or limb movements actions, or sensations; delusional perception.

c) Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body.

d) Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather).

Question 15

What are Thought Echos?

Answer 15

Thought Echo - thoughts repeated after every thought

Question 16

What is Thought Insertion?

Answer 16

Thought Insertion - alien thought being placed in mind

Question 17

What is Thought Withdrawal?

Answer 17

Thought Withdrawal - someone stealing thoughts

Question 18

What is Thought Broadcasting ?

Answer 18

Thought Broadcasting - Being played to everyone else, news, media etc

Question 19

What is an example of delusions and what condition do they suggest?

Answer 19

Delusions - can see water bottle and immediately know building will collapse, can actually see what is real but have delusional thoughts

*This is Schizophrenia (exam question?)

Question 20

What is an example of a Hallucination?

Answer 20

Hallucinatory voices - Give a running commentary of thoughts and go on all day (can be nasty thoughts on and on). Sometimes, body parts can talk to one another.

Question 21

What MULTIPLE symptoms are indicative of Schizophrenia, according to ICD-10?

Answer 21

For more than a month in the absence of organic or affective disorder

And OR at least two of the following:

e) Persistent hallucinations in any modality when occurring every day for at least one

f) Neologisms, breaks or interpolations in the train of thought, resulting in
incoherence or irrelevant speech.

g) Catatonic behaviour, such as excitement, posturing or waxy flexibility
negativism mutism and stupor.

h) “Negative” symptoms such as marked apathy paucity of speech, and blunting or incongruity of emotional responses.

Question 22

What is a change between Schizophrenia guidance from ICD-10 to ICD-11?

Answer 22

The wording has changed in ICD-11, where catatonia schizophrenia isn’t called that anymore.

Code Catatonia as an extra thing rather than a type of schizophrenia as it can happen with any type

Question 23

What is Schizoaffective disorder?

Answer 23

Mix of affective and schizophrenia like features

*Usually a 1 time disorder

Question 24

What is Acute and Transient Schizophrenia?

Answer 24

Happens quickly and goes away

Question 25

What is Delusional disorder?

Answer 25

Just delusions (still have some sort of insight as cannot have delusions without insight or is worse and Schizophrenia)

Question 26

What causes of symptoms would exclude the diagnosis of Schizophrenia ?

Answer 26

Schizophrenia cannot be diagnosed based on tumour or substance use

Question 27

What are thought to be the causes Schizophrenia ?

Answer 27

• Biological factors
• Psychological factors
• Social factors
• Evolutionary Theories

Each of the above can be considered as;
- Possible predisposing factor (Put at risk of it)
- Precipitating factor (Things happening now)
- Perpetuating factor (Things that keep it going)

Question 28

What are the Genetic factors thought to drive Schizophrenia?

Answer 28

Biological factors;

Genetic studies showing;
- 50% concordance in Monozygotic twins
- 10% risk if one parent, one sibling or one Diaziagotic twin is affected
- 40% risk if two parents are affected

• Also shown in adoption studies that children of schizophrenic parents adopted by those without the illness maintain risk.
• Children without schizophrenic parents adopted by
  schizophrenic parents are at no increased risk.

Also risk in following conditions;
- Neuregulin (chromosome 8p)
- Dysbindin (chromosome 6p)
- Di George Syndrome (22q deletion)

Question 29

What is the Neurochemistry theory behind Schizophrenia?

Answer 29

“Dopamine hypothesis” — increased level of dopamine in the brain

Revised dopamine hypothesis —mesolimbic hyperdopaminergia and mesocortical hypodopaminergia

*If you block the dopamine transmission you appear to get better. You have increased dopamine in this, but it’s not hugely consistent.

All these other neurotransmitters impact as well, hence why we have drugs targeting these things;
- Glutamate
- GABA
- Noradrenaline
- Serotoninergic transmission

Question 30

What is the Neurological Abnormality theory behind Schizophrenia ?

Answer 30

• Reduced brain volume 3%
• Ventricular enlargement 25% (but overlaps with normal)
• Cytoarchitectural abnormalities
• Reduced frontal lobe performance (usually stops doing risky things)
• Eye tracking (saccadic) abnormalities (have different rhythmic beating of eyes)
• Soft neurological signs
• EEG abnormalities

Question 31

What Biological Theories trigger Schizophrenia ?

Answer 31

• Genetics
• Neurochemistry
• Neurological Abnormalities
• Other

Question 32

What other Biological Factors contribute towards Schizophrenia ?

Answer 32

Risk Factors;
- Obstetric complications
- Maternal influenza
- Malnutrition and famine
- Winter birth
- Substance misuse (Cannabis use and then develop Schizophrenia (mixture of biology and drugs causing))

Question 33

What is Jung’s Theory for Psychological Psychosis?

Answer 33

Jung’s concept of Collective Unconscious;
- “ a storehouse of latent memory traces from man’s ancestral past. These typical symbols of
myth, fable and fairy stories are not accessible other than through altered consciousness, dreams or perhaps psychosis.”

*Collective unconscious only accessible through altered consciousness or dreams or psychosis

Question 34

What are the 2 Psychological Theories for Psychosis?

Answer 34

• Jung’s concept of Collective Unconscious
• Conrad’s concepts of Gestalt Psychology

Question 35

What is Conrad’s concepts Theory for Psychological Psychosis?

Answer 35

Conrad (1958) used the concepts of Gestalt Psychology to identify stages in the development of delusions.

• A state of fear
• The delusional idea appears
• An effort to make sense of the experience by altering one’s view
  of the world
• Final breakdown, as thought disorder and behavioural symptoms
  emerge

*Other ideas about where delusions come from - out of a state of fear. This is a way of making sense of fearful ideas by altering the perception of the world and reconciling.

Question 36

What did Harland find when studying the populations of Psychosis?

Answer 36

Recognises gross excess of schizophrenia in migrant populations

All individuals construct a sense of self within framework of time,
morality and cultural symbols

When individuals migrate it is probable that change will occur at all
these levels

This massive alteration in how one perceives oneself will have neuronal
correlates with consequent vulnerability to severe mental illness

*Prison detention rates are more common in black women in the west of Scotland. Immigrant populations are more at risk.

Question 37

What are the Social and Psychosocial Factors for Schizophrenia ?

Answer 37

Occupation and social class but be aware of “drift hypothesis” (People will move from country areas to urban areas and become more unwell and drift down in social strata)

Migration - Recent meta-analysis of 18 studies confirms the risk in schizophrenia

Social Isolation

Life Events as Precipitants

• Cultural factors NOT IMPLICATED!

Question 38

How does Psychosis present in families?

Answer 38

Concept of a “schizophrenogenic mother” - NOT UPHELD
* Women who are very highly critical of sons and that influences the biology of sons and become unwell (not shown)

“Double bind” ambivalent
communication style; ingenious but not upheld by research.

Expressed Critical Emotion “High EE Families” - *Can see this where families are highly critical and family work can help important concepts and basis for family work

Question 39

What are the differentials for Psychotic Illnesses and how might this present?

Answer 39

Delirium or Acute Organic Brain
Syndrome (however caused)
- Consequent upon brain or systemic disease
- Prominent visual experience, hallucinations and illusions
- Affect of terror
- Delusions are persecutory and evanescent
- Fluctuating, worse at night

Question 40

What are the differentials for Affective Psychoses?

Answer 40

Depressive episode with psychotic symptoms

Manic episode with psychotic symptoms

• Hard in schizophrenic as they can have blunted mood but look for signs of depression (or mania).

Question 41

What is the presentation of a Depressive episode with psychotic symptoms?

Answer 41

• Delusions of guilt, worthlessness and persecution
• Derogatory auditory hallucinations

Question 42

What is the presentation of a Manic episode with psychotic symptoms?

Answer 42

• Delusions of grandeur; special powers or messianic
  roles
• Gross overactivity, irritability and behavioural disturbance: Manic excitement

Question 43

What guidelines are used in Scotland for managing Schizophrenia?

Answer 43

SIGN 131 - Management of Schizophrenia 2013

Question 44

What does SIGN suggest about the speed of engagement in someone with Schizophrenia?

Answer 44

SIGN shows how would manage someone. Talks about how presenting and engaging with services, how can engage quickly, have access to treatments and medication and treat assertively in community before coming unwell and need to come into hospital.

Question 45

What does SIGN suggest about the Medication for someone with Schizophrenia?

Answer 45

Need to take anti-psychotics for at least 2 weeks unless intolerability (don’t change within 2 weeks). If no response look for substance abuse, differential diagnosis, and change dose if not right within 4-6 weeks.

Minimum dose, cannot come off meds until a minimum of 18 months as can relapse and get worse.

Question 46

What should be asked when a Schizophrenic patient relapses?

Answer 46

When relapses, want to check if you have been taking medicines, if you previously responded to something, you will likely respond to that medication again. Treat for longer than 19 months.

Question 47

What does SIGN recommend if a patient’s antipsychotic medication isn’t working ?

Answer 47

If patient has had 2 antipsychotics for 16 weeks or more, would be eligible for clozapine

(30% chance to respond to it if haven’t responded to antipsychotics - good rates, better than other antipsychotics).

Question 48

What other treatments are effective in Schizophrenia?

Answer 48

Therapy is effective in schizophrenia as well as family work and perinatal discussions.

Question 49

How does the Prognosis and Recovery for Schizophrenia look?

Answer 49

Recovery is not simply a reduction or abatement of symptoms. Scottish Recovery Network defines recovery as “being able to live a meaningful and satisfying life, as defined by
each person, in the presence or absence of symptoms”.

• 80% for recovery after a first episode of psychosis
• Early intervention and more effective treatment mean that
  the outlook is not as bleak as it once was.
• Up to 50% have a moderate recovery
• Small group with chronic symptoms and little recovery (around 30%)

Question 50

What are some good prognostic factors for Schizophrenic outcomes?

Answer 50

• Absence of family history
• Good premorbid function - stable personality, stable relationships
• Clear precipitant
• Acute onset
• Mood disturbance
• Prompt treatment
• Maintenance of initiative, motivation (not developing those negative symptoms)

Question 51

What are some poor prognostic factors for Schizophrenia?

Answer 51

• Slow, insidious onset and prominent negative symptoms are
  associated with a worse outcome.
• Mortality is 1.6 times higher than the general population (*Die around 10 - 15 years earlier)
• Shorter life expectancy is linked to cardiovascular disease, respiratory disease and cancer.
• Suicide risk is 9 times higher.
• Death from violent incidents is twice as high.
• 36% of patients have a substance misuse problem and there are high
  rates of cigarette smoking.
• Poorer if starts in childhood (*Although we don’t know outcomes for children being treated with modern treatment the outcome)

Question 52

What did the London and Nottingham study find from their Schizophrenic patients 10 years later?

Answer 52

• 13% had remained well
• 17% had no further admissions
• 20% were never ill for > 6 months

Functioning;
- 65% had no psychotic symptoms at 10 years
- 46% had had none for >2 years (40% of those with Schizophrenia)

Of these who had no symptoms 56% had received meds in past two years

Of those who had not recovered, 86% had received meds in past two years

*A bit odd but need to treat for a while of time, most patients don’t want to stop medication in fear of relapse

*So hard to know if medication is good but if someone hasn’t recovered you aren’t going to take them off medicine

Question 53

What did the London and Nottingham study find from their Schizophrenic Cognition 10 years later?

Answer 53

Chronic schizophrenic patients show poorer cognition than first-onset patients.

“But there is no decline in cognition in follow-up studies of first onset psychosis.

The findings in chronic patients are an artefact of selective loss of subjects — those who recover are not studied

*Ones doing well aren’t hanging around psychiatric services and loose good data

Question 54

What is the difference between Hallucination and Delusions?

Answer 54

Hallucination - Perceptions

Delusions - Thoughts

Question 55

What are the Principle Illnesses where we see psychotic symptoms?

Answer 55

• Delerium
• Schizophrenia
• Affective Psychoses

Question 56

What is the Incidence of schizophrenia?

Answer 56

Incidence of schizophrenia is around 1%

EXPECTED TO KNOW

Question 57

What is the treatment for Psychosis ?

Answer 57

1st line - Antipsychotics like Olanzapine, Risperidone, Quetiapine (2nd generation)

Newer league of these with fewer side effects;
- Lorazadone
- Aripiprazole
- Cariprazine

Work differently. Try 2 of these, usually Aripiprazole, Risperidone then 2nd line Clozapine.

2nd line - Clozapine in treatment-resistant Schizophrenia. Weight gain, hypersalivation and dry mouth.

Question 58

What is the difference between Schizoaffective disorder and Schziophrenia ?

Answer 58

Schizoaffective - There is a much more precise start of affective symptoms when psychotic symptoms start; not one follows another start together and resolves together.

Schizophrenia - How is the person functioning before coming ill? History of low mood, history of depression with psychotic symptoms (might look like schizophrenia but isn’t). Do positive symptoms start simultaneously as affective, or did one follow the other? Generally speaking, you don’t get negative symptoms at the start, or that isn’t what brings you into services initially.

They can have schizophrenia episodes, then schizoaffective, then schizophrenia episodes, but never really seen.

It goes on history and teases those bits out. Pragmatically, you treat both similarly anyway—antipsychotics for schizoaffective with depression.