Schizophrenia - F20

Question 1

What are some epidemiological features of schizophrenia?

Answer 1

1% will have diagnosis in lifetime
Prevalence – 200/100,000
Incidence – 20/100,000
18-25 incidence most common in men
25-30 incidence most common in women
Higher in inner city, low socioeconomic environments
25yrs premature mortality - suicide, CVD, resp, infection

Question 2

What are some genetic risks for schizophrenia?

Answer 2

Population risk – 1%
If sibling has condition – 10%
If parent has condition – 10-15%
If both parents have condition – 45% 
Monozygotic twin - 50%

Question 3

What are some medical and environmental risk factors?

Answer 3

Obstetric complications - higher incidence

Environmental - negligible? some adoption studies show same risks as non-adopted children; some studies suggest urban environment is a slight risk

Question 4

What are some individual risk factors?

Answer 4

Childhood - if withdrawn, eccentric, clumsy

Sensitive personalities - tendency to perceive criticism harshly, even taking not critical comments as such

Question 5

What are some risks for the triggering of schizophrenia?

Answer 5

Increased stress
Intense emotion – positive or negative
Increased levels of criticism from friends and family members

Drugs

i) Hallucinogens
ii) Stimulants
iii) Alcohol
iv) Cannabis*
v) Steroids

Question 6

What is some suspected pathophysiology of schizophrenia?

Answer 6

Excess dopaminergic activity - evidenced by antipsychotic drugs and the converse effects of dopamine agonists
Glutamate - glutamate agonists can also cause psychotic effects; Often increased glutamate receptors in the frontal cortex of patients with schizophrenia but decreased in the medial and temporal lobes
Anatomy - Imaging sometimes shows:
Increased lateral ventricle size; Reduced brain size, esp temporal lobes; Negative symptoms correlate with reduced blood flow and other frontal cortex abnormalities; Reduced connections between different brain areas on EEG

Question 7

What is the prodrome to schizophrenia?

Answer 7

Loss of interest; Social withdrawal; Self-neglect Depression; Anxiety; Brief psychotic episodes
Long prodrome can mean delayed diagnosis and poor prognosis

Question 8

What is the difference between positive and negative symptoms in schizophrenia?

Answer 8

Positive - feelings or behaviours that are not usually present
Negative - lack of feelings or behaviours that are usually present

Question 9

What are some examples of positive symptoms?

Answer 9

Hallucination - auditory, visual etc
Delusions - primary, persistent, secondary
Thought disorder - insertion, broadcast, withdrawal
Passivity experiences

Question 10

What are some types of auditory hallucination?

Answer 10

Third person – talking about the individual who hears them; single/multiple; often critical; may not disappear with treatment (but may get quieter/nicer); most common auditory hallucination in schizophrenia
Thought echo – individual hears thoughts spoken aloud, simultaneous with speech of thought or just following
Second person – talking to the individual; also present in other mental disorders
Auditory hallucinations in which the person talks to the voice they hear are most commonly the result of trauma or are fictitious

Question 11

What other hallucinations can occur?

Answer 11

Visual, olfactory etc

Also common in other, organic brain disorders - underlying cause must be medically investigated

Question 12

Define a delusion

Answer 12

Unshakable belief that is not in keeping with person’s social, cultural or educational background for which there is no evidence

Question 13

What are primary delusions?

Answer 13

Primary delusions – appear with no precipitating event and not in correlation with some other psychopathology; individual may appear in a ‘perplexed’ state for several days or months → as perplexity disappears, delusion develops

Question 14

What are persistent delusions?

Answer 14

Persistent delusions – arise with the period of perplexity; can be diagnostic for schizophrenia if other symptoms are present; if not present – can indicate delusional disorder

Question 15

What are secondary delusions?

Answer 15

Secondary delusions – arise when other symptoms of schizophrenia have been present for a period of time before the delusion and arise from strange experiences the individual has because of their schizophrenia

Question 16

What is thought insertion?

Answer 16

Patient believes somebody is ‘planting’ thoughts in their mind against that persons will

Question 17

What is thought broadcast?

Answer 17

Patient believes thoughts are ‘broadcast’ to others against their will

Question 18

What is thought withdrawal?

Answer 18

Patient believes thoughts are being removed from their mind against their will, leaving their minds ‘blank’

Question 19

What is a neologism?

Answer 19

Made up a word or give an existing word a new meaning that is only apparent to the individual and does not make sense

Question 20

What is ‘word salad’?

Answer 20

The form of sentences makes no sense at all, words are mixed up

Question 21

What is ‘flight of thought’, ‘knight’s move thinking/derailment’ and ‘pressure of speech’?

Answer 21

FoT - patient moves quickly from one idea to another, often halfway through a sentence with association between ideas just tangible
KMT - patient moves from one idea to another with strange illogical associations between ideas
PoS - patient speaks at a faster rate than normal

Question 22

What is circumstantiality?

Answer 22

Excessive long-windedness i.e. patient take forever to reach the point when they talk

Question 23

What is a passivity experience?

Answer 23

i) Patient believes movements, emotions or will is being altered by somebody else like a puppet

Question 24

What are mannerisms?

Answer 24

i) Strange and pointless movements, often repeated frequently and accompanied by a strange facial expression

Question 25

What is catatonia?

Answer 25

A state where the person may not respond to stimuli and exhibit strange physical behaviours
Associated with other disorders also
Rare now as a feature of chronic untreated disorder

Question 26

What are some catatonic behaviours?

Answer 26

Stupor – patient is unable to move or speak, apart from their eyes
Strange postures – that are normally very difficult to hold
Waxy flexibility – patient maintains position placed in after being manipulated by another person
Negativism – patient does exact opposite of what they are asked
Automatic obedience

Question 27

What are some examples of negative symptoms?

Answer 27

Alogia 
Poverty of content of thoughts 
Blunting of affect 
Avolition 
Slowness of thought and movement 
- are a poor prognostic sign

Question 28

How do you differentiate depression from the negative symptoms of schizophrenia?

Answer 28

Careful depression history

Exclude weight change, sleep problems, feelings of guilt, low self worth and hopelessness

Question 29

What is alogia?

Answer 29

general impoverished level of thinking including poverty of speech – very short answers and will not voluntarily give input to conversations, unable to elaborate on their thoughts and feel their mind is empty

Question 30

What is poverty of thoughts?

Answer 30

Less extreme than poverty of speech, can give answers but unable to explain as thought processes aren’t properly utilised

Question 31

What is blunting of affect and avolition?

Answer 31

Blunting of affect – person has a lack of emotion Avolition – lack of interest in life, self care, social activities and motivation

Question 32

What are some other symptoms of schizophrenia?

Answer 32

Depression; Anxiety
Agitation; Withdrawal; Inappropriate eating behaviour i.e. stuffing face then vomiting; Incontinence; Self harm; Destruction of possessions
Psychogenic polydypsia: massive intake of water (from any source) → water intoxication → hyponatraemia → delirium/coma/death

Question 33

What is post-psychotic depression?

Answer 33

Prolonged depressive episode after resolution of the psychosis
Can also result from antipsychotic medication
Have a high risk of suicide, especially if they have particular feelings of hopelessness

Question 34

How do you differentiate post psychotic depression from the negative symptoms of schizophrenia?

Answer 34

Schizophrenia – negative symptoms change in conjunction with the severity of the positive symptoms
Post psychotic depression – negative (depressive) symptoms do not change in concordance with the positive symptoms
Correct diagnosis is important for correct (different) treatment
Patient often has good degree of insight because depression is in response to their diagnosis

Question 35

How do you assess risk of suicide and harm to others?

Answer 35

Suicide - Thoughts of? Plans of? Auditory hallucinations concerning? Self neglect – if to a great degree, patients health can be put at risk
Risk to others - Violence is low unless history of such or those with impulsive tendencies; Passivity experiences, morbid jealousy or persecutory delusions directly involving others are all behaviours that might put others at risk

Question 36

How do you investigate schizophrenia?

Answer 36

Drug screening - to rule out amphetamines and cannabis use
EEG - to rule out epilepsy
Fasting glucose - to rule out diabetes
Full neuro exam - to check for organic cause
CT/MRI head - to check for lateral ventricle atrophy or space occupying lesions (though are a rare cause of schizophrenia)
Other bloods - to check baseline levels before starting antipsychotic medications

Question 37

What are Schneider’s first rank symptoms of schizophrenia?

Answer 37

• If present, are strongly suggestive of schizophrenia - only need 1
  i) Auditory hallucinations - 3rd person
  ii) Thought withdrawal, insertion and interruption, thought broadcasting
  iii) Delusional perception - normal perception (e.g. a number place) skewed by delusional idea (e.g. the government is contacting me through the number plate)
  iv) Passivity phenomena

Question 38

What are the ICD-10 diagnostic criteria for schizophrenia?

Answer 38

Symptoms must be present for at least one month at some time/during most of the day
One of:
- thought echo/insertion.withdrawal/broadcasting
- delusions of control, influence or passivity; delusional perception
- hallucinating voices - commentary or third person
- persistent delusions that are inappropriate and impossible ie being able to control weather

OR two of:

• persistent (every day) hallucination (any modality) + delusion or over-valued ideas
• neologisms
• catatonic behaviour
• negative symptoms (not secondary to medication)

Also not attributable to organic cause ie drug intoxication, dependency or withdrawal

Question 39

What are some differential diagnoses?

Answer 39

Brief psychotic disroder - symptoms present <1 month
Delusional disorder
Bipolar disorder
Alcoholic hallucinations - withdrawal may present with hallucinations for c.2wks
Organic psychosis - known organic cause ie drug abuse or neurological disorder
Drugs - cannabis, steroids; cocaine, ecstasy, LSD etc

Question 40

What are some neurological/medical conditions that can present with schizophrenia-like symptoms?

Answer 40

Epilepsy – temporal lobe seizures
Dementia 
B12 deficiency 
Hypoglycaemia 
Trauma/head injury – voices often speak to them, different from schizophrenia

Question 41

What does a treatment plan look like for someone identified as being at risk of developing a psychotic disorder?

Answer 41

Psychotherapy + family therapy
Treatment of co-existing mental disorder
Therapeutic trial on an oral antipsychotic + monitoring for first 12 months/until condition stabilised
Care plan - crisis plan + advance statements on treatment + key clinical contacts in an impending crisis

Question 42

What pharmacological management is available for schizophrenia?

Answer 42

Typical or atypical antipsychotics ie haloperidol or clozapine etc - depends on local services and patient health etc (more info on pharmacology deck)

Question 43

What can ECT be used for?

Answer 43

To help treat the catatonic symptoms

Question 44

What can psychological therapies be used for?

Answer 44

Useful for treating the negative symptoms and LOF
CBT - 16 sessions
Family therapies - 10 sessions over 3-12/12 - education of family to recognise signs of an attack and help them be more supportive, removing any precipitating factors from the direct environment
Arts therapies offered

Question 45

What social and personal support is necessary?

Answer 45

Regular contact with support workers and social care

Structured weekly activities gives purpose

Question 46

What is the prognosis for people with schizophrenia?

Answer 46

20% will make a full recovery with drug and supportive treatments + 35% will have long periods of remission;
35% will have persistent mild positive and negative symptoms that are community managed;
10% will have treatment resistant schizophrenia - require institutionalised care;
Small % will require forensic care due to high risk

General increase in severity between episodes over the years, gradual decrease in mental state/personality

Question 47

What are some factors that negatively affect prognosis?

Answer 47

Pre-morbid factors

i) Poor educational background
ii) Poor achievement at work
iii) Social problems

Drug and alcohol abuse

Features of the condition

i) Long slow onset
ii) Delay of first treatment
iii) Catatonia
iv) Strong negative symptoms
v) Thought disorders

Current social/living situation

i) Lack of structure to daily living
ii) Lack of social network
iii) Exposure to stress and high emotions at home

Question 48

What are some specific types of delusions?

Answer 48

Erotomania - the idea that one is loved by someone else, usually of higher status; often elements of paranoia about people taking measures to keep them apart; signals received from the lover from the environment

Capgras -

Cotard - the idea that one is dead or disembodied

Follie a Deux -

Delusions of reference - that the environment sends signals to you personally ie a TV anchor is communicating with you by blinking

Question 49

What is magical thinking?

Answer 49

The belief that one’s own thoughts, wishes or desires can influence the external world

Common also in young children (omnipotence)

Question 50

What is apophenia?

Answer 50

To mistakenly perceive connections and meaning between unrelated things

Coined by Klaus Conrad (1958) in reference to prodromal symptoms of schizophrenia

Also simply a normal part of human nature

Pareidolia - a type involving perceptions of images or sounds - faces in inanimate objects is a common one ie the man in the moon (usually an FFA mistaken processing)

Gamblers fallacy - gamblers rationalising their behaviour by saying they can see patterns in numbers etc

Some theories of mechanism:
Failure in pattern recognition - failures in retrieval of info from LTM/STM/WM and matching to perceptual stimuli
Error management theory - Skinner hungry pigeon experiment (random release of food pellet to pigeon, develops superstitious behaviours to continue getting it)