The term psychosis has no generally agreed meaning. The psychotic symptoms are generally perceived as disturbances in perception (hallucinations) and in thought content (delusions). There is generally a lack of insight – the patient is unaware that they are ill. Diseases presenting with psychotic symptoms include schizophrenia, bipolar disorder, drug induced psychosis, and some cases of sever depression.

Schizophrenia is the most common disease in this ‘group’ - the incidence is 15-20 / 100,000 population; M=F; peak incidence teens→early adulthood.

Broadly speaking there are two two phases of the disease: acute and chronic

Acute scizophrenia characterised by positive symptoms e.g. hallucinations and delusions.
Chronic schizophrenia is characterised by negative symptoms e.g withdrawal from society, underactivity and apathy.

These divisions are to a certain degree arbitrary - most patients will have a mixture of symptoms. It has, however, been noted that if patients progress to the chronic form of the disease the prognosis for recovery is less good.

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Kurt Schneider (1887 - 1967) described are most suggestive of schizophrenia - many hold that they are each individually sufficient for a diagnosis of schizophrenia to be considered (about 8% will have another diagnosis).


Schneider’s first rank symptoms are: 4 hallucinations and 5 delusions

Four Hallucinations

• Auditory hallucinations in the third person (talking about the patient)
• Auditory hallucinations of a running commentary on one's own actions.
• Auditory hallucinations of hearing one's own thoughts spoken aloud either as spoken or immediately afterwards.
• Somatic hallucinations

Five Delusions

• Relating to thought: thought insertion, withdrawal, broadcast
• Delusional perception.
• Passivity phenomena (feeling of actions being controlled)

Symptoms that are not classified as first rank but which are diagnostically suggestive include
•    Delusions of persecution / grandeur
•    Delusions of reference
•    2nd person auditory hallucinations 

Abnormalities of mood (incongruity, flatness or sustained anxiety / depression / irritability / euphoria) are also common but are less diagnostically useful as they are found in many other ilnesses.

Insight is usually (but not always) impaired with patients not believing their symptoms are due to illness.

Orientation is often preserved.

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•    Apathy, poor motivation
•    Social withdrawal
•    Blunted affect (decreased emotional expression)
•    Decline in skills associated with activities of daily living (ADLs) e.g. hygiene, budgeting, cooking etc.
•    Cognitive impairments: concentration and memory deficits
•    Frontal lobe deficits: inability to formulate and execute complex plans
•    Thought disorder: derailment

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Threre are several types of schizophrenia listed in ICD-10 including catatonic, hebephrenic, paranoid, residual, simple, undifferentiated and 'other'.

It is unlikely that you will need to know any of these for finals but you can find this information in the MRCPsych version of this article [click here] (coming soon)

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Differential diagnoses:

• Brain pathology (organic disease) especially that associated with temporal lobe epilepsy can result in a delusional disorder resembling schizophrenia.
• Dementia
• Primary paranoid disorder
• Primary delusional disorder – there are five types listed in DSM-IV. Auditory and visual hallucinations (if present) must not be prominent and symptoms must have been present for at least 1 month (3 in ICD-10). The five types are:
• Persecutory
• Jealous (‘Othello’ syndrome): an abnormal belief that the partner is being unfaithful – held on irrational grounds (unsound evidence and reasoning) and unaffected by rational argument. Often there is no idea who the supposed lover might be. M>F
• Erotomanic (rare): the belief that a (usually inaccessible) person is in love with the patient. The person is often famous. F>>M
• Somatic: The belief that the patient suffers from a physical disease or deformity.
• Grandiose
• Mixed and unspecified other categories that may be used.
• Hypomania / mania: can present with psychotic symptoms including 40% who present with a first rank symptom e.g.: ideas of reference, 3rd person hallucinations, and/or delusions of persecution (e.g. doctor is jealous of patient’s ‘greatness’). These are hard to distinguish from schizophrenia but a distinguishing feature is that the psychotic symptoms rarely persist outside the overactive phase and change quickly in content. In the manic phase, pressure of speech is common as are such behaviour as dramatic indulgence in overspending or sexual behaviour. Prevalence is 0.1-0.6 / 1000 c.f. 10/1000 for schizophrenia. In schizophrenia there may be mood incongruence.

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The Mental State Examination

Always ask how often a symptom occurs and how long it lasts

Delusions
Have you experienced anything strange or unusual?

Thought insertion
•    Are thoughts put into your head that you know are not your own?
•    Where do they come from?

Thought withdrawal
•    Do your thoughts disappear or seem to be taken from your head?
•    Where do they go?

Thought block
•    Do your thoughts sometimes stop suddenly so your mind is blank even though your thoughts were flowing freely before?
•    Why does this happen?

Thought broadcast
•    Do others hear your thoughts or read your mind?
•    Can you send messages to other people with your mind?
•    How do you explain this?

Passivity
•    Are you always in control of your thoughts and actions?
•    Who else controls these?
•    How do they do this?
•    What do they get you to do/think/say?

Delusional perception:
•    When you saw … how did you know what it meant?

Somatic hallucinations:
•    Have you had any strange or unusual feelings in your body?
•    Does your body function normally?

Auditory hallucinations
•    Have you ever heard anything you believe other people cannot?
•    Do you hear voices?
•    Whose voices are they?
•    Are they clear?
•    How many are there?
•    Do they come from inside or outside your head?
•    Do they talk to you or about you?
•    What sorts of things do they say?
•    Do they give commands?
•    Do you have to obey them?

Other hallucinations:
•    Do you ever see, feel or smell something that you cannot explain?

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Management

Management of schizophrenia is manifold - for psychiatrists there are two main categories of drug: the first generation antipsychotics and the second generation antipsychotics. These are also known as the 'typical' and 'atypical' antipsychotics.


First generation antipsychotics include chlorpromazine, flupentixol, haloperidol, prochlorperazine and sulpiride.

The major side effects of first generation antipsychotics can be remembered by the Mnemonic ADAPT

Acute Dystonia: Abnormal face and body movements, most common in children and young adults. Usually seen within days of treatment.
Akathisia: Restlessness, with limbs in constant movement. May be concealed by activity such as walking. Very poorly tolerated by patients. Usually within weeks of treatment commencing.
Parkinsonism. Usually within weeks of treatment commencing. May be suppressed by antimuscarinic drugs.
Tardive dyskinesia: Rhythmic, involuntary movements of tongue, face and jaw. May decrease upon drug cessation but may not – very socially disabling. Usually after years of treatment.


Second generation antipsychotics include amisulpride, aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, and risperidone.
It used to be belived that the side effect profile of these drugs was less - it is now being acknowledged that side effects are different rather than less. The extrapyramidal side effects described above are less common (but can still occur). Instead there is an increased risk of diabetes, hyperglycaemia and weight gain that, as well as providing their own problems, may lead to cardiovascular disease.

Clozapine is worth a special mention - it was the first of the second generation antipsychotic agents and has superior antipsychotic efficacy in treatment-refractory schizophrenia (NICE). The reason it is not used more frequently is its side effect profile which includes agranulocytosis (1%) and neutropaenia (3%). The risk of both is highest at 6 - 18 weeks after starting clozapine treatment. For this reason weekly FBC monitoring (by the Clozaril patient monitoring service) by is mandatory for the first 18 weeks, after which it is done fortnightly until the end of the first year, and every four weeks thereafter. The service uses a system of green, amber and red alerts. A “green” alert indicates satisfactory count, an “amber” alert requires a repeat FBC test while clozapine can be continued, and a “red” alert warrants immediate cessation of clozapine.

Other potentially life-threatening possible side effects include myocarditis and cardiomyopathy.



Non pharmacologic treatments include (NICE guideline):

• Cognitive behavioural therapy (CBT)
• Family intervention