MEDI7301 Study Guide - Final Guide: Family Therapy, Hypocalcaemia, Agranulocytosis
Schizophrenia
Schizophrenia
Etiology Genetic
10% (one parent affected) or 40% (two parents affected)
Neurochemistry
Excess dopamine in mesolimbic dopamine pathway = +ve symptoms
Decreased dopamine in mesocortical dopamine pathway of prefrontal
cortex = -ve and cognitive symptoms
Neuroanatomy
Reduced frontal lobe function, basal ganglia function
Asymmetrical temporal/ limbic function
Enlarged lateral and third ventricles
Decrease in cortical volume, especially temporal lobes (including
hippocampus) and thalamus
Neuroendocrinology
Abnormal growth hormone, prolactin, cortisol, ACTH
Neuropsychology
Global defect in attention, language and memory
Environmental
Cannabis use (it accelerates pre-disposed schizophrenia onset by 2.5yrs)
Geographical variance
Migration, urbanisation, social class drift (drift from higher to lower SES)
Winter season of birth
Obstetric complications (birth hypoxia)
Nutritional deficiencies
Prenatal viral exposure
Theory
Adolescent brain goes through episode of excessive neuron destruction
(pruning) caused by a specific gene that tags certain neurons for destruction; possible link
of schizophrenia to overexpression of gene
Clinical stages Pre-psychotic or prodromal (ultra-high risk state)
First episode psychosis
Incomplete remission
Recurrence or multiple relapses
Severe, persisting illness
DSM-5 criteria At least 2 of the following sx (whereby at least 1 must be delusions, hallucinations
or disorganised speech) each present for a significant portion of time during a 1 month period
Delusions (persecutory, jealously, capgras etc)
Hallucinations (visual, auditory, tactile etc)
Disorganised speech (tangentiality, circumstantiality, word salad)
Grossly disorganised or catatonic behaviour (inappropriate smile/ laughter,
poor self care, waxy flexibility)
Negative symptoms (alogia, avolition, amotivation, anhedonia, affective
flattening)
NOTE: only 1 sx required if bizarre delusion or commentative auditory
hallucination or 2+ conversing voices in auditory hallucination
Also absent insight and loss of contact with reality
An episode is continuous for at least 6mths, which includes at least 1mth of active
symptoms mentioned above + periods of prodromal or residual symptoms (-ve symptoms or 2+
symptoms listed above)
For a significant portion of the time since onset, at least 1 area of social/
occupational functioning has experienced a dramatic decline from level achieved prior to sx
onset
Adults = work, interpersonal relations, self care
Children = interpersonal relations, academic, occupational functioning
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The disturbance is not attributable to schizoaffective disorder, bipolar or depressive
disorder with psychotic features, substance induced (meds, drugs) or another medical condition
Subtypes Paranoid
Preoccupation with delusions (usually persecutory or grandiose) or frequent
auditory hallucinations
Relative preservation of cognitive functioning and affect
Onset later in life
Best prognosis
Catatonic
At least 2 of the following sx are present
oMotor immobility (catalepsy or stupor)
oExcessive motor activity (purposeless)
oExtreme negativism (resistance to instructions/ attempts to be
moved) or mutism
oPeculiar voluntary movement (posturing, stereotyped movements,
prominent mannerisms)
Example - rigidity (wax like structure), mutism, abnormal posture
Disorganised
Disorganised speech and behaviour
Flat or appropriate affect
Poor premorbid personality
Early and insidious onset
Continuous course without significant remissions
Undifferentiated
It meets criteria for schizophrenia but doesn't fall into previous 3 subtypes
Residual
No longer experience prominent delusions, hallucinations, disorganised
speech, grossly disorganised or catatonic behaviour
Continuing evidence of residual illness (-ve sx, attenuated sx of those
mentioned above)
MSE findings Speech/
language
Disjointed speech
Echolalia (repetition of speech)
Stilted speech
Affect Flat or blunted
Thought
content
Racing thoughts
Self reference
Delusions of persecution, jealousy, control, guilt/ sin, grandiosity,
mind reading, reference, replacement, nihilism, somatic
Thought broadcasting, insertion, withdrawal
Magical thinking
Thought
stream
Poverty of thought
Poverty of content
Incoherence
Derailment
Looseness of associations
Tangentiality
Rambling
Circumstantiality
Clanging
Neologism
Flight of ideas
Word salad
Thought blocking
Perception Hallucinations (auditory, visual, olfactory, tactile, gustatory)
Cognition Illogical thinking
Insight Loss of goal
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Comorbidities Substance
abuse
Most predominant comorbidity to schizophrenia (47% patients in
ECA study)
Commonly abused substances include alcohol, cannabis, nicotine
and prescription drugs (tranquilisers, sleep medication)
Main consequences
Increased +ve symptoms
Psychosis relapse, increase in medical comorbidities
Heightened risk of violence, suicide
Increased risk ending up in hospital or jail
Legal complications (increased risk of incarceration)
Medication non-adherence
Greater propensity to anti-psychotic-related SEs
Greater problems with physical health, finances, housing
and personal relationships
Theories
Alcohol or drugs may induce schizophrenia
Early cannabis exposure in adolescence/ early adulthood
is related to schizophrenia onset in later life
Cannabis use worsens +ve and disorganization symptoms
Self-medication with substances is to counteract or
reduce effects of anti-psychotic medications
Recovery process for substance abuse + schizophrenia is
prolonged and greater risk of relapse
Medical
comorbidities
Physical comorbidity accounts for 60% premature deaths
unrelated to suicide, such as cardiovascular disease, smoking-related lung
disease & type II diabetes
Schizophrenia + concurrent smoking is responsible for
lung disease
Schizophrenia + anti-psychotic SE of metabolic syndrome
is responsible for type II diabetes
Highest recorded rates for viral hepatitis, constipation and
Parkinson's disease; under-recognition for cardiovascular disease (AF, HTN,
CAD, PVD) perhaps caused by reduced presentation to GP, monitoring
and/or treatment
Differentials Major depressive or bipolar disorder with psychotic or catatonic features
Schizoaffective disorder (it requires concurrent MD or manic episode +
schizophrenic sx, but mood sx present for majority of total duration)
Schizophreniform disorder and brief psychotic disorder (schizophreniform is
<6mths, and brief psychotic is between 1 day - 1 month)
Delusional disorder (absence of other schizophrenic sx like hallucinations,
disorganised speech, disorganised behaviour or negative sx)
Schizotypal personality (persistent personality features)
Substance induced psychosis (relevant to onset and withdrawal of substance)
Medical condition induced psychosis (head injury, CNS infection/ tumour, post-
epileptic states, hypernatremia, hypocalcaemia, hyperthyroidism, Cushings)
Delirium or dementia (cognitive impairment, altered LOC)
OCD and body dysmorphic disorder
PTSD (it relates to reliving or reacting the event)
ASD or communication disorders
Sleep related disorder (relevant to waking up or whilst falling asleep - hallucinations)
Management General Anti-psychotic drugs are important to diminish +ve symptoms
(hallucinations, delusions, thought disorder) and other symptoms of excitement,
but have limited impact on cognitive impairment, -ve symptoms and mood
disturbance
Risk assessment - suicide, violence/ aggression, absconding, self
care
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
10% (one parent affected) or 40% (two parents affected) Excess dopamine in mesolimbic dopamine pathway = +ve symptoms. Decreased dopamine in mesocortical dopamine pathway of prefrontal cortex = -ve and cognitive symptoms. Decrease in cortical volume, especially temporal lobes (including hippocampus) and thalamus. Cannabis use (it accelerates pre-disposed schizophrenia onset by 2. 5yrs) Migration, urbanisation, social class drift (drift from higher to lower ses) Adolescent brain goes through episode of excessive neuron destruction (pruning) caused by a specific gene that tags certain neurons for destruction; possible link of schizophrenia to overexpression of gene. At least 2 of the following sx (whereby at least 1 must be delusions, hallucinations or disorganised speech) each present for a significant portion of time during a 1 month period. Grossly disorganised or catatonic behaviour (inappropriate smile/ laughter, poor self care, waxy flexibility) Negative symptoms (alogia, avolition, amotivation, anhedonia, affective flattening)
