Firm 1 Teaching Firm 1 Teaching Project: Project:

SchizophreniaSchizophrenia

Rosemary King Rosemary King 44thth November 2009 November 2009

ContentsContents Experience of Experience of

SchizophreniaSchizophrenia

Powerpoint PresentationPowerpoint Presentation– Case StudiesCase Studies

History Taking and History Taking and Mental State ExaminationMental State Examination

QuizQuiz

Experience of SchizophreniaExperience of Schizophrenia 1) Write the first 3 words that you think 1) Write the first 3 words that you think

of when you hear the term of when you hear the term “Schizophrenia” on the flipchart.“Schizophrenia” on the flipchart.

2) Define Schizophrenia.2) Define Schizophrenia.

3) Has anyone met a patient with 3) Has anyone met a patient with Schizophrenia during their placement?Schizophrenia during their placement?

DefinitionDefinition Schizophrenia (‘split Schizophrenia (‘split

mind’) is a mind’) is a disintegrative disintegrative psychosis, psychosis, characterized by the characterized by the ‘splitting’ of normal ‘splitting’ of normal links between links between perception, mood, perception, mood, thinking, behaviour thinking, behaviour and contact with and contact with reality.reality.

EpidemiologyEpidemiology Incidence:Incidence:

– 10-20/100000 annually10-20/100000 annually– Men – begins between the ages of 15 – 35Men – begins between the ages of 15 – 35– Women – begins laterWomen – begins later– Similar worldwide, however it may be higher in Similar worldwide, however it may be higher in

certain ethnic groups, e.g. Afro-Caribbean certain ethnic groups, e.g. Afro-Caribbean immigrants in the UKimmigrants in the UK

Prevalence:Prevalence:– Point prevalence – 4/1000Point prevalence – 4/1000– Lifetime risk – 10/1000Lifetime risk – 10/1000– Higher in socioeconomically deprived areasHigher in socioeconomically deprived areas

Homeless people – 100/1000 prevalenceHomeless people – 100/1000 prevalence

AetiologyAetiology UncertainUncertain Evidence for several risk Evidence for several risk

factors: factors: 1) Genetic:1) Genetic:

Child of a schizophrenic parentChild of a schizophrenic parentDizygotic twin of a schizophrenic parentDizygotic twin of a schizophrenic parent

Adopted offspring of a schizophrenic parent Adopted offspring of a schizophrenic parent Monozygotic twin of a schizophrenic parentMonozygotic twin of a schizophrenic parent

Sibling of a schizophrenic parentSibling of a schizophrenic parent

AetiologyAetiologyRisk factorRisk factor Relative risk of Relative risk of

developing schizophrenia developing schizophrenia (%)(%)

Monozygotic twin of a schizophrenic Monozygotic twin of a schizophrenic parentparent

4040

Dizygotic twin of a schizophrenic Dizygotic twin of a schizophrenic parentparent

1515

Child of a schizophrenic parentChild of a schizophrenic parent 10-1510-15

Sibling of a schizophrenic parentSibling of a schizophrenic parent 10-1510-15

Adopted offspring of a schizophrenic Adopted offspring of a schizophrenic parentparent

1212

AetiologyAetiology 2) Environmental problems:2) Environmental problems:

– a) Predisposing factors:a) Predisposing factors: Abnormalities of pregnancy and delivery – 2% RRAbnormalities of pregnancy and delivery – 2% RR

– CT and MRI scans display increased ventricular size and small amounts CT and MRI scans display increased ventricular size and small amounts of grey matter lossof grey matter loss

Maternal influenza (second trimester) – 2% RRMaternal influenza (second trimester) – 2% RR Fetal malnutrition – 2% RRFetal malnutrition – 2% RR Winter birth – 1.1% RRWinter birth – 1.1% RR Low birth weightLow birth weight

– b) Precipitating factors:b) Precipitating factors: Stressful live events occurring shortly (3 weeks) before the onset of Stressful live events occurring shortly (3 weeks) before the onset of

the disorderthe disorder

– c) Maintenance factors:c) Maintenance factors: Strongly expressed feelings, especially in the form of critical Strongly expressed feelings, especially in the form of critical

commentscomments

AetiologyAetiology 3) Dopamine hypothesis:3) Dopamine hypothesis:

– Dopamine excess or overactivity in mesolimbic pathwaysDopamine excess or overactivity in mesolimbic pathways

– Increased dopamine receptors at post-mortemIncreased dopamine receptors at post-mortem

– Little direct evidence that abnormal dopaminergic Little direct evidence that abnormal dopaminergic transmission is the cause of schizophreniatransmission is the cause of schizophrenia

4) Drug abuse:4) Drug abuse:

– Chronic use of stimulant drugs and cannabis - linked with Chronic use of stimulant drugs and cannabis - linked with subsequent onset of schizophrenia in vulnerable subsequent onset of schizophrenia in vulnerable individuals.individuals.

AetiologyAetiology 5) Abnormal family processes:5) Abnormal family processes:

– Skew - overprotective dominant mother and oversubmissive Skew - overprotective dominant mother and oversubmissive fatherfather

– Schizm – hostility between parentsSchizm – hostility between parents– High expressed emotionHigh expressed emotion

6) Neurodevelopmental disorder:6) Neurodevelopmental disorder:

– Current theoryCurrent theory– 1 or more genes interacting with environmental factors1 or more genes interacting with environmental factors– Brain abnormalities, particularly in the temporal lobesBrain abnormalities, particularly in the temporal lobes– Developmental problems during childhoodDevelopmental problems during childhood

Clinical FeaturesClinical Features 1) The acute syndrome:1) The acute syndrome:

– A previously healthy 20-year-old male student A previously healthy 20-year-old male student has been behaving in an increasingly odd way. has been behaving in an increasingly odd way. At times he appeared angry and told his At times he appeared angry and told his friends he was being followed by the police and friends he was being followed by the police and secret services; at other times he was seen to secret services; at other times he was seen to be laughing to himself for no apparent reason. be laughing to himself for no apparent reason. For several months he had spent more time on For several months he had spent more time on his own, apparently pre-occupied with his own his own, apparently pre-occupied with his own thoughts, and his academic work had thoughts, and his academic work had deteriorated. deteriorated.

Clinical FeaturesClinical Features– When seen by the family doctor he was When seen by the family doctor he was

restless and appeared frightened. He said restless and appeared frightened. He said that he had heard voices commenting on that he had heard voices commenting on his actions and abusing him. He also said his actions and abusing him. He also said that the police had conspired with his that the police had conspired with his university teachers to harm his brain with university teachers to harm his brain with poisonous gases and take away his poisonous gases and take away his thoughts, and that the police had thoughts, and that the police had arranged for items referring to him to be arranged for items referring to him to be inserted into television programmes.inserted into television programmes.

Clinical FeaturesClinical Features 1) The acute syndrome: Positive symptoms1) The acute syndrome: Positive symptoms

a)a) Appearance and behaviour:Appearance and behaviour:

Preoccupied, Preoccupied, withdrawnwithdrawn, inactive, inactive Restless, noisy, inconsistentRestless, noisy, inconsistent

b) b) Mood:Mood:

Mood change – depression, anxiety, irritability or Mood change – depression, anxiety, irritability or euphoriaeuphoria

Blunting – reduction in the normal variations of moodBlunting – reduction in the normal variations of mood Incongruity – emotion not keeping within the situationIncongruity – emotion not keeping within the situation

Clinical FeaturesClinical Featuresc) c) Disorders of thinking:Disorders of thinking:

Vagueness – difficult to grasp the meaning of thoughtVagueness – difficult to grasp the meaning of thought

Formal thought disorder:Formal thought disorder:– Concrete thinkingConcrete thinking

Difficulty dealing with abstract ideasDifficulty dealing with abstract ideas– Preoccupation with vague pseudoscientific or mystical Preoccupation with vague pseudoscientific or mystical

ideasideas– Loosening of associationsLoosening of associations

Lack of connection between ideasLack of connection between ideas Word salad – totally incoherent thought and speechWord salad – totally incoherent thought and speech

Disorders of the stream of thought:Disorders of the stream of thought:– Pressure of thought – rapid, abundant and varied thoughtsPressure of thought – rapid, abundant and varied thoughts– Poverty of thought – slow, few and unvaried thoughtsPoverty of thought – slow, few and unvaried thoughts– Thought blocking – the mind is suddenly empty of thoughtsThought blocking – the mind is suddenly empty of thoughts

Clinical FeaturesClinical Featuresd) d) HallucinationsHallucinations::

AuditoryAuditory– A frequent symptom of schizophreniaA frequent symptom of schizophrenia– Simple noises or complex sounds of voices or musicSimple noises or complex sounds of voices or music– Single words, phrases, brief phrases or whole conversationsSingle words, phrases, brief phrases or whole conversations– CommandsCommands– Running commentaryRunning commentary

VisualVisual– Less frequent than auditory hallucinationsLess frequent than auditory hallucinations– Seldom occur without other kinds of hallucinationsSeldom occur without other kinds of hallucinations

Tactile, olfactory, gustatoryTactile, olfactory, gustatory

Clinical FeaturesClinical Featurese) e) Delusions:Delusions:

Primary - occur occasionallyPrimary - occur occasionally

Secondary:Secondary:– Arise from a previous mental changeArise from a previous mental change– May be preceded by delusional mood or a hallucinationMay be preceded by delusional mood or a hallucination– Persecutory delusions Persecutory delusions – people trying to inflict harm – people trying to inflict harm

etcetc– Delusions of reference Delusions of reference – objects, events etc have a – objects, events etc have a

special significance for the patientspecial significance for the patient– Delusions of control – feeling of being controlled by an Delusions of control – feeling of being controlled by an

external agencyexternal agency– Delusions of the possession of thought – thought Delusions of the possession of thought – thought

insertion, withdrawal or broadcastinsertion, withdrawal or broadcast

Clinical FeaturesClinical Features f) f) Normal orientationNormal orientation

g) g) Cognitive function:Cognitive function:

Impaired attentionImpaired attention Normal memoryNormal memory

h) h) Insight:Insight:

ImpairedImpaired

Clinical FeaturesClinical Features 2) The chronic syndrome:2) The chronic syndrome:

– A middle-aged man lives in a group home for A middle-aged man lives in a group home for psychiatric patients and attends a sheltered psychiatric patients and attends a sheltered workshop. In both places he withdraws from workshop. In both places he withdraws from company. He is usually dishevelled and unshaven, company. He is usually dishevelled and unshaven, and cares for himself only when encouraged to do and cares for himself only when encouraged to do so by others. His social behaviour is odd and so by others. His social behaviour is odd and awkward. His speech is slow, and its content awkward. His speech is slow, and its content vague and incoherent. When questioned, he says vague and incoherent. When questioned, he says that he is the victim of persecution by that he is the victim of persecution by extraterrestial beings who beam rays at him. extraterrestial beings who beam rays at him.

Clinical FeaturesClinical Features– He seldom mentions these ideas He seldom mentions these ideas

spontaneously and he shows few signs spontaneously and he shows few signs of emotion about them or about any of emotion about them or about any other aspects of his life. For several other aspects of his life. For several years this clinical picture has changed years this clinical picture has changed little except for brief periods of acute little except for brief periods of acute symptoms, which are usually related to symptoms, which are usually related to upsets in the ordered life of the group upsets in the ordered life of the group home.home.

Clinical FeaturesClinical Features 2) The chronic syndrome: Negative symptoms2) The chronic syndrome: Negative symptoms

– ‘‘Schizophrenic defect state’Schizophrenic defect state’

– a) a) Lack of drive and activityLack of drive and activity

– b) b) Social withdrawalSocial withdrawal

– c) c) Abnormalities of behaviour:Abnormalities of behaviour: Impaired daily living skillsImpaired daily living skills Broken social conventions – eg. shouting obscenities in Broken social conventions – eg. shouting obscenities in

publicpublic

Clinical FeaturesClinical Features d) d) Abnormalities of movement:Abnormalities of movement:

Catatonic:Catatonic:– Stupor – immobile, mute and unresponsive; can change Stupor – immobile, mute and unresponsive; can change

quickly to excitementquickly to excitement– ExcitementExcitement– If prominent = catatonic schizophreniaIf prominent = catatonic schizophrenia

Abnormal movements:Abnormal movements:– Odd and awkwardOdd and awkward– Stereotypies – not goal directedStereotypies – not goal directed– Mannerisms – goal directedMannerisms – goal directed

Abnormal tonusAbnormal tonus

Clinical FeaturesClinical Features e/f) e/f) Speech, form of thought and mood:Speech, form of thought and mood:

Abnormal as in the acute syndromeAbnormal as in the acute syndrome

g) g) Thought content:Thought content:

Delusions:Delusions:– Encapsulated - beliefs, work and social life not Encapsulated - beliefs, work and social life not

influencedinfluenced

h) h) Cognitive function:Cognitive function:

Orientation – age disorientationOrientation – age disorientation Attention and memory – normalAttention and memory – normal

i) i) Insight:Insight: variable variable

DiagnosisDiagnosis Clinical presentation (history and examination)Clinical presentation (history and examination)

Exclude other disordersExclude other disorders

ICD-10 Diagnostic Criteria:ICD-10 Diagnostic Criteria:

– 1) Schneider’s ‘first rank’ symptoms1) Schneider’s ‘first rank’ symptoms

– 2) Symptoms more frequent but less discriminating, e.g. 2) Symptoms more frequent but less discriminating, e.g. prominent hallucinations, flat affectprominent hallucinations, flat affect

– 3) Impaired social and occupational functioning3) Impaired social and occupational functioning

– 4) A minimum duration; 1 month ICD-10, 6 months DSM-IV4) A minimum duration; 1 month ICD-10, 6 months DSM-IV

– 5) Exclusion of other disorders5) Exclusion of other disorders

DiagnosisDiagnosis Schneider’s ‘first rank’ symptoms:Schneider’s ‘first rank’ symptoms:

– 70% patients who meet the full diagnostic criteria70% patients who meet the full diagnostic criteria– High positive predictive valueHigh positive predictive value

– a) Hearing thoughts spoken alouda) Hearing thoughts spoken aloud– b) ‘Third person’ hallucinationsb) ‘Third person’ hallucinations– c) Hallucinations in the form of a commentaryc) Hallucinations in the form of a commentary– d) Somatic hallucinationsd) Somatic hallucinations– e) Thought withdrawal or insertione) Thought withdrawal or insertion– f) Thought broadcastingf) Thought broadcasting– g) Delusional perceptiong) Delusional perception– h) Feelings or actions experienced as made or h) Feelings or actions experienced as made or

influenced by external agentsinfluenced by external agents

Other psychosesOther psychoses 1) Duration too short:1) Duration too short:

Acute psychotic disorders – cases lasting less than Acute psychotic disorders – cases lasting less than one monthone month

Schizophreniform (DSM-IV) – cases less than 6 Schizophreniform (DSM-IV) – cases less than 6 monthsmonths

2) Prominent affective symptoms:2) Prominent affective symptoms: Schizoaffective disorderSchizoaffective disorder

3) Delusions without other symptoms of schizophrenia:3) Delusions without other symptoms of schizophrenia: Persistent delusional disorder (ICD-10) Persistent delusional disorder (ICD-10) Delusional disorder (DSM-IV)Delusional disorder (DSM-IV)

Differential diagnosesDifferential diagnoses 1) Organic syndromes1) Organic syndromes

– Drug-induced states/psychosesDrug-induced states/psychoses Amphetamines, phencyclidine, cocaine, ecstasy, LSDAmphetamines, phencyclidine, cocaine, ecstasy, LSD Prescription drugs – steroids, dopamine agonistsPrescription drugs – steroids, dopamine agonists

– Temporal lobe epilepsyTemporal lobe epilepsy Condition is brief and there is evidence of clouding of Condition is brief and there is evidence of clouding of

consciousnessconsciousness

– Delirium – hallucinations; clouding of consciousnessDelirium – hallucinations; clouding of consciousness

– Dementia – persecutory delusions; memory lossDementia – persecutory delusions; memory loss

– Diffuse brain diseases – neurosyphilisDiffuse brain diseases – neurosyphilis

Differential diagnosesDifferential diagnoses 2) Psychotic mood disorder2) Psychotic mood disorder

– Degree and persistence of the mood Degree and persistence of the mood disorderdisorder

– Congruence of any hallucinations or Congruence of any hallucinations or delusions to the prevailing mooddelusions to the prevailing mood

– The nature of the symptoms in any The nature of the symptoms in any previous episodes (if predominantly previous episodes (if predominantly mood, then mood disorder is more likely)mood, then mood disorder is more likely)

Differential diagnosesDifferential diagnoses 3) Personality disorders3) Personality disorders

– Prolonged observations for first rank symptoms Prolonged observations for first rank symptoms and other features of schizophrenia neededand other features of schizophrenia needed

4) Schizoaffective disorder4) Schizoaffective disorder

– Definite schizophrenic symptoms and a greater Definite schizophrenic symptoms and a greater predominance of affective (depressive or predominance of affective (depressive or manic) symptomsmanic) symptoms

Course of illness and Course of illness and prognosisprognosis

At least 30% (up to 50%) patients either recover completely At least 30% (up to 50%) patients either recover completely or suffer minimal symptoms in the long termor suffer minimal symptoms in the long term

Acute illness with complete recovery: 20%Acute illness with complete recovery: 20%

Recurrent acute illness: 20% Recurrent acute illness: 20% – Gradual deteriorationGradual deterioration– Relapse – non compliance with medication, life events, high Relapse – non compliance with medication, life events, high

relatives’ expressed emotionrelatives’ expressed emotion

Chronic illness starting acutely: 20%Chronic illness starting acutely: 20%

Chronic illness starting insidiously: 20%Chronic illness starting insidiously: 20%

Suicide: 10-15%Suicide: 10-15% Young people in the early stage of the disorderYoung people in the early stage of the disorder

Course of illness and Course of illness and prognosisprognosis

Poor outcome predictors:Poor outcome predictors:

– Features of the illness:Features of the illness: Insidious onsetInsidious onset Long first episodeLong first episode Previous psychiatric illnessPrevious psychiatric illness Negative symptomsNegative symptoms Younger age at onsetYounger age at onset

Course of illness and Course of illness and prognosisprognosis

– Features of the patient:Features of the patient: MaleMale Single, separated, widowed, or divorcedSingle, separated, widowed, or divorced Poor psychosexual adjustmentPoor psychosexual adjustment Poor employment recordPoor employment record Social isolationSocial isolation Poor compliancePoor compliance

ManagementManagement The acute episode:The acute episode:

– Supervision by psychiatristSupervision by psychiatrist

– Inpatient informally/sectionedInpatient informally/sectioned

– Physical treatmentsPhysical treatments

– Social treatmentsSocial treatments

ManagementManagement 1) 1) Physical treatments:Physical treatments:

– a) Antipsychoticsa) Antipsychotics Tranquilize and sedate the patient (non-specifically) - Tranquilize and sedate the patient (non-specifically) -

immediatelyimmediately Therapeutic effect on the ‘positive symptoms’ – up to Therapeutic effect on the ‘positive symptoms’ – up to

3 weeks3 weeks Administered orally, intramuscularly or by long-acting Administered orally, intramuscularly or by long-acting

depot injections – long term prophylaxis and depot injections – long term prophylaxis and increased complianceincreased compliance

i) Typical antipsychoticsi) Typical antipsychotics ii) Atypical antipsychoticsii) Atypical antipsychotics

ManagementManagement i) i) Typical antipsychotics:Typical antipsychotics:

– First generation/conventionalFirst generation/conventional– Chlorpromazine - post-synaptic (D1, D2, D3 and Chlorpromazine - post-synaptic (D1, D2, D3 and

D5 antagonism)D5 antagonism)– Haloperidol – dopaminergic receptor blockageHaloperidol – dopaminergic receptor blockage– Side effects:Side effects:

Sedation – 70-80% (H1, Sedation – 70-80% (H1, αα1 and 1 and αα2 receptors)2 receptors) Anticholinergic (M1/M2) and antiadrenergic effects Anticholinergic (M1/M2) and antiadrenergic effects

((αα1/1/αα2 ) – 10-50% (dry mouth, constipation, blurred 2 ) – 10-50% (dry mouth, constipation, blurred vision, urinary retention and tachycardia)vision, urinary retention and tachycardia)

Extrapyramidal side effects – 60% (dopamine Extrapyramidal side effects – 60% (dopamine receptors) – parkinsonism, dystonia, akathisia)receptors) – parkinsonism, dystonia, akathisia)

Endocrine effects – galactorrhea and oligomenorrhoeaEndocrine effects – galactorrhea and oligomenorrhoea Weight gain, sexual dysfunction and allergyWeight gain, sexual dysfunction and allergy

ManagementManagement ii) ii) Atypical antipsychotics:Atypical antipsychotics:

– Second generationSecond generation– Dopamine and serotonin activityDopamine and serotonin activity– Less extrapyramidal side effects, but more Less extrapyramidal side effects, but more

expensiveexpensive– More commonly usedMore commonly used– Risperidone – dopamine antagonismRisperidone – dopamine antagonism– Olanzapine – antagonism at serotonin receptors?Olanzapine – antagonism at serotonin receptors?– ClozapineClozapine– Side effects: sedation, weight gain, orthostatic Side effects: sedation, weight gain, orthostatic

hypertension, hyperglycaemia, sexual dysfunctionhypertension, hyperglycaemia, sexual dysfunction

Assessment and Assessment and managementmanagement

2) 2) Social treatments:Social treatments:

– a) Community carea) Community care Care Programme ApproachCare Programme Approach MDT reviewMDT review

– b) Rehabilitationb) Rehabilitation Occupational TherapyOccupational Therapy CounsellingCounselling Supportive psychotherapy - CBT – help with delusions Supportive psychotherapy - CBT – help with delusions

and hallucinationsand hallucinations

– c) Family interventionc) Family intervention Help the family reduce their excessive ‘expressed Help the family reduce their excessive ‘expressed

emotion’emotion’

Video examplesVideo examples 1) Gerald:1) Gerald:

– http://www.youtube.com/watch?http://www.youtube.com/watch?v=gGnl8dqEoPQ&feature=PlayList&p=0655A5F779E91Dv=gGnl8dqEoPQ&feature=PlayList&p=0655A5F779E91DED&index=18ED&index=18

– Features of schizophrenia:Features of schizophrenia: Disordered thinkingDisordered thinking Loosely connected thoughtsLoosely connected thoughts Formed delusional ideasFormed delusional ideas

– GrandioseGrandiose– ParanoidParanoid

Restless, agitated behaviourRestless, agitated behaviour– Inexplicable MannerismsInexplicable Mannerisms

Mood disturbancesMood disturbances– AbsentAbsent– Totally inappropriateTotally inappropriate

Taking a historyTaking a history 1) Preparation:1) Preparation:

– Consider source of referral, safety and privacyConsider source of referral, safety and privacy

2) Introduction:2) Introduction:– Introduce yourself and the purpose of the interviewIntroduce yourself and the purpose of the interview

3) Demographics: name, age, sex3) Demographics: name, age, sex

4) Presenting complaint and history of presenting 4) Presenting complaint and history of presenting complaint:complaint:– Open-ended questionsOpen-ended questions– Complaint: onset, time-span, associated symptoms, Complaint: onset, time-span, associated symptoms,

precipitants (psychological stressors) and impact on daily precipitants (psychological stressors) and impact on daily life and functioninglife and functioning

Taking a historyTaking a history 5) PC:5) PC:

a) Thought abnormalities:a) Thought abnormalities:

– i) Can you think quite clearly or is there any interference i) Can you think quite clearly or is there any interference in your thoughts?in your thoughts?

– ii) Are thoughts put into your head that are not your own?ii) Are thoughts put into your head that are not your own?– iii) Do you ever hear your thoughts read aloud in your iii) Do you ever hear your thoughts read aloud in your

head?head?– iv) Do you ever experience your thoughts stopping quite iv) Do you ever experience your thoughts stopping quite

suddenly?suddenly?– v) Can anyone read your thoughts?v) Can anyone read your thoughts?– vi) Do you ever hear your thoughts echoed or repeated?vi) Do you ever hear your thoughts echoed or repeated?

Taking a historyTaking a history b) Hallucinationsb) Hallucinations

– i) Auditoryi) Auditory

Do your hear voices like tapping or music?Do your hear voices like tapping or music? Does it sound like muttering or whispering?Does it sound like muttering or whispering? Can you make out the words?Can you make out the words? What does the voice say?What does the voice say? Do you hear several voices talking about you?Do you hear several voices talking about you? Do they refer to you as he or she?Do they refer to you as he or she? Do they speak directly to you?Do they speak directly to you? Are they threating or unpleasant?Are they threating or unpleasant? Do they give orders?Do they give orders?

Taking a historyTaking a history– ii) Visualii) Visual

Have you had visions, or seen things that Have you had visions, or seen things that other people can’t see?other people can’t see?

With your eyes or in your mind?With your eyes or in your mind? What did you see?What did you see? Were you half asleep at the time?Were you half asleep at the time? Did you realise you were ‘seeing things’?Did you realise you were ‘seeing things’? Did the vision seem to arise out of a pattern Did the vision seem to arise out of a pattern

on the wallpaper or a shadow?on the wallpaper or a shadow? How do you explain it?How do you explain it?

Taking a historyTaking a history c) Delusionsc) Delusions

– i) Control – Do you feel under the control i) Control – Do you feel under the control of some force or power other than of some force or power other than yourself?yourself?

– ii) Reference – Did you at any time that ii) Reference – Did you at any time that things have a special meaning for you?things have a special meaning for you?

– iii) Grandiose – Are you special in any iii) Grandiose – Are you special in any way?way?

Taking a historyTaking a history 6) Past psychiatric history:6) Past psychiatric history:

– Diagnosis givenDiagnosis given– Current professionals involvedCurrent professionals involved– Previous contact with psychiatric Previous contact with psychiatric

services and frequency of contactsservices and frequency of contacts– Admission to psychiatric hospitalsAdmission to psychiatric hospitals– Detentions under MHADetentions under MHA– Previous treatmentsPrevious treatments– DSHDSH

Taking a historyTaking a history 7) Past medical history:7) Past medical history:

– Major physical illnessesMajor physical illnesses– Head injuryHead injury– Epilepsy/seizuresEpilepsy/seizures– Any current symptomsAny current symptoms

8) Drug history:8) Drug history:– Current prescribed medicationCurrent prescribed medication– AllergiesAllergies– Previous psychotropicsPrevious psychotropics

Taking a historyTaking a history 9) Family history:9) Family history:

– Family structureFamily structure– Family history of psychiatric illnessFamily history of psychiatric illness

10) Social history:10) Social history:– Substance use – smoking, alcohol, illicit drugsSubstance use – smoking, alcohol, illicit drugs– Current employmentCurrent employment– FinancesFinances– HousingHousing– Social supports/networksSocial supports/networks– Premorbid personality:Premorbid personality:

When did they last feel well?When did they last feel well? How would friends/family describe you when you are well?How would friends/family describe you when you are well? How would you describe yourself?How would you describe yourself?

Taking a historyTaking a history 11) 11) Forensic history:Forensic history:

– All offencesAll offences– Time in prisonTime in prison– Violent crimes, sexual crimes and persistent offendingViolent crimes, sexual crimes and persistent offending

12) 12) Personal history:Personal history:– Birth and childhoodBirth and childhood

Complications at birth or early life, developmental milestones, Complications at birth or early life, developmental milestones, family life, relationships with siblings, any abusefamily life, relationships with siblings, any abuse

– EducationEducation Schooling, age of leaving school, qualifications, bullying/truancySchooling, age of leaving school, qualifications, bullying/truancy

– OccupationsOccupations Type and duration of jobs, reasons for leavingType and duration of jobs, reasons for leaving

– Hobbies and interestsHobbies and interests– RelationshipsRelationships

Current – married/cohabiting, length and quality of relationshipCurrent – married/cohabiting, length and quality of relationship Previous relationships – duration and why endedPrevious relationships – duration and why ended Sexual historySexual history

Mental State ExaminationMental State Examination 1) Appearance1) Appearance

– DressDress– General impression – self care, buildGeneral impression – self care, build– Face – eye contact, facial expressions Face – eye contact, facial expressions

increased/decreasedincreased/decreased– Level of consciousnessLevel of consciousness

2) Behaviour2) Behaviour

– Rapport – hostile, suspicious, guardedRapport – hostile, suspicious, guarded– Motor – speed, repetitive or rhythmic movementsMotor – speed, repetitive or rhythmic movements

Mental State ExaminationMental State Examination 3) Speech3) Speech

– RateRate– Rhythm – flow of speech – Rhythm – flow of speech – thought blockingthought blocking– VolumeVolume– ToneTone

4) Mood and affect4) Mood and affect

– SubjectiveSubjective– ObjectiveObjective

Euthymic, low, elated, irritable, anxiousEuthymic, low, elated, irritable, anxious ReactivityReactivity LabileLabile CongruityCongruity

– Suicidal thoughtsSuicidal thoughts

Mental State ExaminationMental State Examination 5) Thought5) Thought

– ContentContent DelusionsDelusions

– Persecutory, grandiose, guilt, referencePersecutory, grandiose, guilt, reference– CongruityCongruity

Overvalued ideasOvervalued ideas Obsessions and compulsionsObsessions and compulsions

– FormForm Loosening of associationsLoosening of associations Flight of ideasFlight of ideas PerseverationPerseveration

– StreamStream Pressure of thoughtPressure of thought Poverty of thoughtPoverty of thought Thought blockThought block

– PossessionPossession PassivityPassivity Thought possessionThought possession

Mental State ExaminationMental State Examination 6) Perception6) Perception

– HallucinationsHallucinations ModalityModality AuditoryAuditory

– Number of voicesNumber of voices– 22ndnd/3/3rdrd person person– Male or femaleMale or female– ContentContent– Running commentaryRunning commentary– CommandCommand

Pseudo-hallucinationsPseudo-hallucinations IllusionsIllusions

Mental State ExaminationMental State Examination 7) Cognition7) Cognition

– Orientated in time, place and personOrientated in time, place and person

8) Insight8) Insight

– What is the patient’s perspective of presenting What is the patient’s perspective of presenting problems?problems?

– Do you think you are unwell/have a mental Do you think you are unwell/have a mental illness/need to be treated/need to be in hospital?illness/need to be treated/need to be in hospital?

QuizQuiz ““Points mean prizes!”Points mean prizes!”

QuizQuiz 1) Does schizophrenia begin earlier 1) Does schizophrenia begin earlier

in men or women?in men or women?– MenMen

2) Which is the biggest risk factor 2) Which is the biggest risk factor genetically?genetically? Monozygotic twin of a schizophrenic parentMonozygotic twin of a schizophrenic parent

QuizQuiz 3) Name 3 predisposing factors, one precipitating 3) Name 3 predisposing factors, one precipitating

factor and one maintenance factor.factor and one maintenance factor. Abnormalities of pregnancy and delivery – 2% RRAbnormalities of pregnancy and delivery – 2% RR

– CT and MRI scans display increased ventricular size and small amounts of CT and MRI scans display increased ventricular size and small amounts of grey matter lossgrey matter loss

Maternal influenza (second trimester) – 2% RRMaternal influenza (second trimester) – 2% RR Fetal malnutrition – 2% RRFetal malnutrition – 2% RR Winter birth – 1.1% RRWinter birth – 1.1% RR Low birth weightLow birth weight Stressful live events occurring shortly (3 weeks) before the onset of the Stressful live events occurring shortly (3 weeks) before the onset of the

disorderdisorder Strongly expressed feelings, especially in the form of critical commentsStrongly expressed feelings, especially in the form of critical comments

4) Name four other proposed aetiological causes.4) Name four other proposed aetiological causes.– Dopamine hypothesis, drug abuse, abnormal family Dopamine hypothesis, drug abuse, abnormal family

processes and neurodevelopmental disorderprocesses and neurodevelopmental disorder

QuizQuiz 5) What are the 5 ICD-10 diagnostic criteria?5) What are the 5 ICD-10 diagnostic criteria?

– 1) Schneider’s ‘first rank’ symptoms1) Schneider’s ‘first rank’ symptoms– 2) Symptoms more frequent but less discriminating, e.g. prominent 2) Symptoms more frequent but less discriminating, e.g. prominent

hallucinations, flat affecthallucinations, flat affect– 3) Impaired social and occupational functioning3) Impaired social and occupational functioning– 4) A minimum duration; 1 month ICD-10, 6 months DSM-IV4) A minimum duration; 1 month ICD-10, 6 months DSM-IV– 5) Exclusion of other disorders5) Exclusion of other disorders

6) What are Schneider’s first rank symptoms?6) What are Schneider’s first rank symptoms?– a) Hearing thoughts spoken alouda) Hearing thoughts spoken aloud– b) ‘Third person’ hallucinationsb) ‘Third person’ hallucinations– c) Hallucinations in the form of a commentaryc) Hallucinations in the form of a commentary– d) Somatic hallucinationsd) Somatic hallucinations– e) Thought withdrawal or insertione) Thought withdrawal or insertion– f) Thought broadcastingf) Thought broadcasting– g) Delusional perceptiong) Delusional perception– h) Feelings or actions experienced as made or influenced by external agentsh) Feelings or actions experienced as made or influenced by external agents

QuizQuiz 7) What is the name for the disorder in 7) What is the name for the disorder in

which patients commonly have which patients commonly have prominent affective symptoms?prominent affective symptoms?– Schizoaffective disorderSchizoaffective disorder

8) What percentage of patients either 8) What percentage of patients either recover completely or suffer minimal recover completely or suffer minimal symptoms in the long term?symptoms in the long term?– 30-50%30-50%

QuizQuiz 9) Name four predictors of a poor 9) Name four predictors of a poor

outcome.outcome. Insidious onsetInsidious onset Long first episodeLong first episode Previous psychiatric illnessPrevious psychiatric illness Negative symptomsNegative symptoms Younger age at onsetYounger age at onset MaleMale Single, separated, widowed, or divorcedSingle, separated, widowed, or divorced Poor psychosexual adjustmentPoor psychosexual adjustment Poor employment recordPoor employment record Social isolationSocial isolation Poor compliancePoor compliance

QuizQuiz 10) Name one typical antipsychotic and one atypical 10) Name one typical antipsychotic and one atypical

psychotic and state how they differ, in terms of cost, psychotic and state how they differ, in terms of cost, pharmacological action and side effects.pharmacological action and side effects.– Typical:Typical:

Chlorpromazine - post-synaptic (D1, D2, D3 and D4 Chlorpromazine - post-synaptic (D1, D2, D3 and D4 antagonism)antagonism)

Haloperidol – dopaminergic receptor blockageHaloperidol – dopaminergic receptor blockage

– Atypical:Atypical: Risperidone – dopamine antagonismRisperidone – dopamine antagonism Olanzapine – antagonism at serotonin receptors?Olanzapine – antagonism at serotonin receptors? ClozapineClozapine Dopamine and serotonin activityDopamine and serotonin activity Less extrapyramidal side effects, but more expensiveLess extrapyramidal side effects, but more expensive More commonly usedMore commonly used

QuizQuiz 11) 11) Name 2 other management strategies.Name 2 other management strategies.

– a) Community carea) Community care Care Programme Approach and MDT ReviewCare Programme Approach and MDT Review

– b) Rehabilitationb) Rehabilitation Occupational Therapy Counselling and Supportive Occupational Therapy Counselling and Supportive

PsychotherapyPsychotherapy– c) Family interventionc) Family intervention– d) ECTd) ECT

12) Name all the stages in the psychiatric 12) Name all the stages in the psychiatric history and mental state examination.history and mental state examination.– Preparation, introduction, demographics, PC, HPC, Past Pscyh Preparation, introduction, demographics, PC, HPC, Past Pscyh

Hx, PMH, DHx, FHx, SHx, Pre-morbid personality, Forensic Hx, Hx, PMH, DHx, FHx, SHx, Pre-morbid personality, Forensic Hx, Personal Hx, Appearance and Behaviour, Speech, Mood and Personal Hx, Appearance and Behaviour, Speech, Mood and Affect, Thought, Perception, Cognition and Insight Affect, Thought, Perception, Cognition and Insight

Thankyou! Thankyou for listening. Are there any

questions?

References Gelder, M., Geddes, J., Mayou. R.

Psychiatry: An Oxford Core Text. Oxford: Oxford University Press. 2005: 3rd edition.

Katona, C., Cooper, C., Robertson, M. Psychiatry at a Glance. Wiley-Blackwell. 2008:4th edition.