Schizophrenia and related disorders
Schizophrenia and related disorders
Treatment resistant schizophrenia
Failure to respond to 2 or more antipsychotics given the therapeutic doses for 6 weeks or more. Patients with refractory symptoms have more severe functional impairment and are more likely to have abnormalities in cerebral structure and neuropsychology
Clozapine last resort
Clozapine resistant if there are persistent psychotic features despite daily doses of 300-900mg for 8 weeks to 6 months and plasma levels of 350ng/mL or higher
Management - Firstly clarify diagnosis, address co-morbidity, check for non-compliance and try clozapine depot (most strongly supported)
Antipsychotic and individual CBT
Subsequent acute epsiodes
Crisis and community treatment team support
How to choose an antipschotic
Metabolic effects - weight gain, DM
Avoid olanzapine, risperidone, quetiapine
Hormonal effects - prolactin
Avoid risperidone, amisulpride
Cardiovascular effects - QT interval, arrythmia
Extrapyramidal effects - akasthesia, dyskinesia and dystonia
Avoid typical antipsychotics
Gently titrate dose upwards and do not use a loading dose
Trail effectiveness for 4-6 weeks on optimum dose
May relapse if stop medication within 2 years of acute attack
Step 1: Commence atypical antipsychotic
Consider BZD e.g. diazepam to control non-acute anxiety/ behavioural disturbance
Step 2: Low potency typical antipsychotic e.g. chlorpromazine 74-200mg/day and then increase dose according to clinical effect and need for sedation. Note that above 400-600mg/day there is no antipsychotic benefit, but there is a sedation benefit.
If clozapine is prescribed, secondary negative symptoms can be managed by prescribing an antidepressant or lamotrigine.
At least one of
: thought echo, thought insertion, thought withdrawal or thought broadcasting OR delusions of control, influence or passivity OR auditory hallucinations of voices giving a running commentary or discussing patient OR persistent delusions that is culturally inappropriate or implausible.
OR at least two of:
persistent hallucinations in any modality; breaks in train of thought resulting in incoherent/ irrelevant speech; catatonic behaviour; negative symptoms of marked apathy, paucity of speech, blunting of emotional responses; loss of interest, aimlessness behaviour or social withdrawal
Lasting for a duration of at least
Onset in 20s
Disorder characterised by presence of positive symptoms (delusions and hallucinations) and negative symptoms (lack of will, lack of interest, isolation without loneliness, in own world) which may occur at separately or at the same time.
1/3 have one psychotic episode
1/3 have recurrent psychotic episodes
1/3 have psychotic episodes and some residual changes to personality
Specific forms of Schizophrenia
Delusions and hallucinations
Disorganised speech and behaviour with flat/inappropriate effect
Meets general criteria without specific symptom subtype predominating
Some residual symptoms, but depression dominates clinical picture
Previous positive symptoms less marked with prominent negative symptoms
No delusions or hallucinations, where negative symptoms occur as the defect state without an acute episode
Risperidone 2mg od
Little evidence for psychological intervention, but highly structured CBT best idea
A disorder characterised by an enduring pattern of inability to establish close relationships coupled with cognitive or perceptual distortions, odd beliefs and speech, and eccentric behaviour and appearance.
Classified as related schizophrenic disorder in ICD-10, but personality disorder by DSM-4
Features must be present for 2 years, but criteria for schizophrenia never met themselves.
Acute and transient psychotic disorders
Sudden onset, variable presentation and resolving within 3 months
Induced delusional disorder (shared delusional disorder)
Delusions of a primary psychotic individual adopted by healthy individual (seperation often cures healthy individual)
Two people with a primary psychotic illness develop the same delusion at the same time
After a period of resistance, healthy individual adopts psychosis of psychotic individual
Pre-exiting primary psychosis in both patients, followed by one individual adopting psychosis of another
If medication is given it should be for the primary partner. Normally seperation is first line treatment.
Delusional misidentification syndrome
Usually manifesting as symptoms of underlying disorder (e.g. schizophrenia)
People have been replaced by near perfect doubles
Unknown person is someone patient actually knows in disguise
Patient can see people change into someone else
Subjective doubles delusion
Patient believes they have a double who exists and functions independently
Sees themselves as a double projected onto objects or other people
Reverse subjective double syndrome
Patient believes they are an imposter in the process of being replaced
Reverse fragoli syndrome
Patient believes others have completely misidentified them
Uncommon condition which presents with non-bizzare delusions but no hallucinations, thought disorder, mood disorder, or significant blunting of affect.
Symptoms must be present for 3 months for diagnosis of "delusional disorder"
Diagnostic overlapping with paranoid PD
Fixed firmly held belief that is usually false but held despite evidence to the contrary, that cannot be reasoned away and is out of keeping with sociocultural norms.
Grandiose, persecutory, hypocondriacal, reference, guilt, erotomanic etc
Questioning using interested scepticism
Perception in the absence of external stimulus
Visual often accompany delirium
Olfactory hallucinations indicate frontal lobe pathology (olfactory bulb damage)
"Pseudohallucinations" - Internal voices
Formal thought disorder
Sentence structure does not follow one another
Disorders of self
Difficulty distinguishing self and other, continuity in time, self as an agent, self an unity of experience and self in private space
How we make sense of the world...
Perception (making sense of step 1)
Thought and meaning (what does step 2 mean to you)
"The dreamer awake"
Schizophrenic and affective symptoms simultaneously present and both equally present.
Excludes patients with separate episodes of schizophrenia and affective disorders when episodes are in the context of substance use or other medical disorders.
As if treating for schizophrenia but manic/depressive symptoms as if treating bipolar disorder
Better than schizophrenia but worse than affective disorder
Schizophrenic-like psychosis failing to fulfuil duration criteria for schizophrenia. Most common in adolescence.
Psychosis lasts for more than 1 month but not as long as 6 months