Schizophrenia

Question

Answer

What is schizophrenia?

A long-term mental health disorder causing psychosis and disturbances in thinking, perception, behaviour, motivation, and social functioning.

Does schizophrenia mean split personality?

No. It does not mean multiple personalities; it refers historically to a split from reality.

Are people with schizophrenia usually violent?

No. They are rarely violent; self-harm and suicide are more common concerns.

What is psychosis?

A state where a person struggles to distinguish reality from their own thoughts, beliefs, or perceptions.

What is the approximate prevalence stated in the notes?

Around 7.2 per 1000 people globally; over 21 million people worldwide were cited.

At what age does schizophrenia commonly begin?

Usually late teens to mid-thirties.

How does onset differ by sex?

Men often develop symptoms earlier (mid-20s), women later (late-20s).

What is the male:female risk ratio mentioned?

Approximately 1.4:1 male to female.

How does schizophrenia affect life expectancy?

Reduced life expectancy due to poor physical health, cardiovascular, respiratory, and infectious disease burden.

What are the two broad symptom categories in schizophrenia?

Positive symptoms and negative symptoms.

What are positive symptoms?

Experiences added to normal function such as hallucinations, delusions, and disorganised thought/speech.

What are negative symptoms?

Reduced or absent normal functions such as motivation, emotional expression, self-care, and social engagement.

Give examples of positive symptoms.

Hallucinations, delusions, disorganised speech, bizarre behaviour, thought disorder.

Give examples of negative symptoms.

Apathy, social withdrawal, flat affect, poor hygiene, low motivation, reduced speech, loss of interest.

What are hallucinations?

Perceptions without an external stimulus.

What is the most common hallucination type?

Auditory hallucinations such as hearing voices.

Give examples of auditory hallucinations.

Hearing voices talking about the patient, hearing own thoughts spoken aloud, hearing voices using the patient's name.

What other hallucination types may occur?

Visual, olfactory, tactile.

What are delusions?

Fixed false beliefs not based in reality and not easily changed by evidence.

Give examples of delusions.

Belief that spies control thoughts, aliens control behaviour, paranoid beliefs, grandiose beliefs.

What is a paranoid delusion?

False belief that others intend harm or are out to get the person.

What is a grandiose delusion?

False belief of exceptional power, status, identity, or fame.

What is disorganised speech?

Speech that is incoherent, tangential, disjointed, or changes topic unexpectedly.

What is thought broadcasting?

Belief or experience that one's thoughts are being heard by others.

What is catatonia?

Marked psychomotor disturbance including immobility, posturing, mutism, or waxy flexibility.

What is waxy flexibility?

A person's limbs remain in positions placed by someone else.

What is flat affect?

Reduced outward emotional expression.

What is alogia?

Reduced quantity or fluency of speech.

What is avolition?

Reduced motivation to initiate and persist in goal-directed activity.

Why are negative symptoms clinically important?

They impair long-term functioning and are often harder to treat than positive symptoms.

What early vague symptoms may precede schizophrenia?

Anxiety, depression, concentration problems, behavioural changes, social withdrawal.

What is the prodromal phase?

Early stage before clear psychosis with subtle functional and behavioural decline.

What are major causes/risk factors for schizophrenia?

Genetic vulnerability plus environmental factors such as stress, cannabis/stimulants, perinatal complications, neurodevelopmental factors.

How strong is family history as a risk factor?

First-degree relatives have increased risk; monozygotic twins much higher risk.

What twin concordance figure was mentioned?

Around 40% in monozygotic twins.

What pregnancy/birth factors may increase risk?

Prematurity, low birth weight, hypoxia during birth.

What environmental adult stressors were mentioned?

Social isolation, urban living, migrant stressors.

Which neurotransmitter is central to classic schizophrenia theory?

Dopamine.

What is the dopamine hypothesis?

Excess dopamine activity contributes to schizophrenia, especially positive symptoms.

Which pathway is linked to positive symptoms?

Mesolimbic dopamine pathway hyperactivity.

Which pathway is linked to negative symptoms?

Mesocortical dopamine hypoactivity.

Where do mesolimbic/mesocortical neurons arise?

Ventral tegmental area of the midbrain.

Why do D2-blocking antipsychotics support the dopamine hypothesis?

They reduce positive psychotic symptoms.

How can amphetamines support the dopamine hypothesis?

They increase dopamine activity and can induce psychosis-like states.

What is the NMDA receptor hypothesis?

Glutamate NMDA receptor dysfunction may contribute to schizophrenia.

Which drugs can cause schizophrenia-like symptoms via NMDA effects?

Ketamine and phencyclidine (PCP).

What is the membrane hypothesis?

Abnormal neuronal membrane phospholipid metabolism may disrupt signalling.

What structural brain finding was noted?

Larger lateral ventricles in some patients.

Is there a single definitive test for schizophrenia?

No. Diagnosis is clinical and specialist-led.

How is schizophrenia diagnosed in broad terms?

Characteristic symptoms plus functional decline present for a required duration after specialist assessment.

What duration was mentioned in notes for symptoms?

At least one month of clear symptoms in described teaching notes.

What functional impact is often seen?

Impairment in personal, family, social, educational, or occupational functioning.

What are important differential diagnoses for schizophrenia?

Substance misuse, mood disorders with psychosis, delirium, dementia, PTSD, OCD, personality disorders, medical/neurological causes.

Which substances can mimic psychosis?

Alcohol, stimulants, hallucinogens, steroids, antihistamines, sympathomimetics.

Which medical causes should be excluded?

Head injury, CNS infection, brain tumour, epilepsy states, endocrine/metabolic disorders.

What is first-line pharmacological treatment according to notes?

An oral atypical antipsychotic such as risperidone or olanzapine in low doses.

What are antipsychotics also historically called?

Neuroleptics.

What are the two main antipsychotic classes?

Typical (first-generation) and atypical (second-generation).

What is the main mechanism of typical antipsychotics?

Block dopamine D2 receptors.

Give examples of typical antipsychotics.

Chlorpromazine, haloperidol, fluphenazine, flupentixol, zuclopenthixol, pimozide, sulpiride.

What is the main mechanism of atypical antipsychotics?

Block dopamine D2 and serotonin 5-HT2A receptors (broadly).

Give examples of atypical antipsychotics.

Olanzapine, risperidone, quetiapine, clozapine, aripiprazole, amisulpride, paliperidone, lurasidone, asenapine, cariprazine.

What advantage do atypical antipsychotics often have?

Lower risk of extrapyramidal side effects and some benefit on negative symptoms.

Which atypicals were noted as especially helpful for negative symptoms?

Clozapine and cariprazine.

What are extrapyramidal symptoms (EPS)?

Movement disorders caused by dopamine blockade in nigrostriatal pathways.

Examples of EPS?

Parkinsonism, rigidity, tremor, bradykinesia, akathisia, acute dystonia.

What is akathisia?

Inner restlessness with inability to stay still.

What is acute dystonia?

Painful sustained muscle spasms, often neck/jaw/eyes.

What is drug-induced parkinsonism?

Tremor, rigidity, slowed movement due to dopamine blockade.

What is tardive dyskinesia?

Late-onset involuntary repetitive movements, often face/mouth/body, after chronic antipsychotic use.

What is neuroleptic malignant syndrome (NMS)?

Rare life-threatening reaction with fever, rigidity, autonomic instability, altered mental state.

Why is NMS an emergency?

Can be fatal and requires urgent cessation/review and medical treatment.

What common side effects occur with many antipsychotics?

Sedation, weight gain, sexual dysfunction, metabolic disturbance.

Which antipsychotics are strongly associated with metabolic issues?

Olanzapine and clozapine particularly.

Why are metabolic effects important?

Increase risk of diabetes and cardiovascular disease.

What monitoring is needed for antipsychotics generally?

Weight/BMI, glucose/HbA1c, lipids, blood pressure, side effects, adherence.

Why is prolactin monitored?

Some antipsychotics raise prolactin causing sexual dysfunction, galactorrhoea, menstrual problems.

When may depot injections be useful?

Poor adherence to daily oral medication.

What is a depot antipsychotic?

Long-acting injectable antipsychotic given regularly (e.g. monthly).

Which depot drug was mentioned?

Zuclopenthixol depot.

What benefit do atypical depot preparations have?

Less EPS risk than typical depots.

Why should patients avoid driving if drowsy on antipsychotics?

Sedation and blurred vision can impair driving safety.

What is clozapine mainly used for?

Treatment-resistant schizophrenia after failure of at least two antipsychotics, including one second-generation agent.

Why is clozapine unique clinically?

Most effective option for treatment-resistant schizophrenia and can reduce suicide risk.

Why is clozapine not first-line?

Serious adverse effect burden and intensive monitoring requirements.

What blood disorder is clozapine famous for causing?

Agranulocytosis/neutropenia.

Why is agranulocytosis dangerous?

Severe reduction in white cells causing life-threatening infection risk.

What monitoring programme is required with clozapine?

Mandatory clozapine patient monitoring service / regular blood tests.

What routine clozapine monitoring parameters were listed?

FBC, ECG, troponin, CRP, LFTs, U&Es, HbA1c, fasting lipids/glucose, weight, pulse, BP.

Why are troponin and CRP monitored with clozapine?

Risk of myocarditis/inflammation.

What GI complication of clozapine can be fatal?

Severe constipation leading to faecal impaction/ileus.

When should clozapine be stopped urgently?

Agranulocytosis, myocarditis/cardiomyopathy, severe constipation/impaction, seizures, severe liver disorder.

Why is smoking relevant to clozapine?

Smoking induces CYP1A2 and increases clozapine metabolism; stopping smoking can raise levels and cause toxicity.

What should happen if a clozapine patient stops smoking?

Urgent review and likely dose/level monitoring.

Why must clozapine doses not be omitted for >48 hours?

Risk of relapse and need for cautious re-titration.

What is cariprazine?

A newer atypical antipsychotic partial agonist at D3/D2 receptors used especially for prominent negative symptoms.

What advantages of cariprazine were noted?

Helps positive, negative, and cognitive symptoms with relatively less metabolic burden.

What common side effects of cariprazine were noted?

EPS, akathisia, short-term weight gain.

Why are antipsychotics not changed too quickly?

They often require weeks for full therapeutic response.