QuestionSBA
QuestionChoice
Schizoaffective disorders are characterised by schizophrenia with episodes of mood disturbance, such as depression or mania. This patient does not display any mood disturbance.
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Schizoaffective disorder
QuestionChoice
Bipolar affective disorder presents with periods of mania and depression. There are no symptoms of depression in this case, and no reported episodes of mania, where patients typically experience increased energy, elevated mood, reduced need for sleep, and mood congruent psychotic symptoms including grandiose delusions.
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Bipolar affective disorder
QuestionChoice
Borderline (or emotionally unstable) personality disorder presents with recurrent episodes of self harm, rapid fluctuations of mood, chronic feelings of low mood and loneliness, and unstable persona relationships. This patient does not display these clinical features.
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Borderline personality disorder
QuestionChoice
This is the correct answer because this patient has classic first rank symptoms of Schizophrenia. These include thought broadcasting, thought insertion, and delusional perceptions. These are known as positive symptoms. Risk factors for developing schizophrenia include heavy cannabis use, poor maternal health, and traumatic childhood events.
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Schizophrenia
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Schizotypal personality disorder is characterised by eccentric changes in behaviour and thinking which causes difficulty with relationships and social interactions. Patients present with unusual beliefs, inappropriate emotional responses, paranoia and social anxiety.
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e
Schizotypal personality disorder
QuestionComment
would be nice to have a time frame for diagnosis 

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Jargon Kawasaki
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S p i d e r
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# Summary

Schizophrenia is a chronic or relapsing and remitting form of psychosis characterized by positive symptoms (such as hallucinations, delusions, thought disorders) and negative symptoms (including alogia, anhedonia, and avolition). Diagnosis is based on clinical criteria and supported by investigations to exclude organic causes of psychosis. Management typically includes second-generation antipsychotic medications and psychotherapy.  

# Definition

- **ICD-11 Criteria:** Symptoms present for at least 1 month, causing significant impairment.
  
- **DSM-5 Criteria:** Symptoms persist for at least 6 months, encompassing at least one month of active-phase symptoms (must include one prominent 'ABCD' symptom). 

Subtypes include:

- **Paranoid Schizophrenia:** Characterized by delusions and hallucinations, often with a persecutory theme.
- **Catatonic Schizophrenia:** Features motor disturbances and waxy flexibility.
- **Hebephrenic Schizophrenia:** Marked by disorganized thinking, emotions, and behavior.
- **Residual Schizophrenia:** Residual symptoms persist after a major episode.
- **Simple Schizophrenia:** Characterized by a gradual decline in functioning without prominent positive symptoms.


# Epidemiology

In the UK, the lifetime prevalence of schizophrenia and related disorders is approximately 14.5 per 1000 individuals, but these estimates vary. The risk of developing schizophrenia in the general population is around 1%. 

# Aetiology

The pathophysiology of schizophrenia is multifactorial and includes both genetic and environmental factors.

- Genetic Factors: The risk of developing schizophrenia is significantly increased in individuals with a positive family history, with the risk being proportional to the degree of genetic relationship. For example, the risk is:
	- 2% with an affected first cousin
	- 5% with an affected grandparent, aunt/uncle, niece/nephew
	- 10% if either a parent or sibling is affected
	- 50% if both parents are affected or an identical twin is affected
- Environmental Factors: Several environmental factors have been associated with an increased risk of schizophrenia, including: 
	- Childhood trauma, such as poor maternal bonding, poverty, or exposure to natural disasters
	- Heavy cannabis use in childhood
	- Maternal health issues, including malnutrition and infections like rubella and cytomegalovirus
	- Birth trauma, particularly hypoxia and blood loss
	- Urban living and immigration to more developed countries

# Clinical Features

**Positive Symptoms ('ABCD' Mnemonic):**

- **Auditory Hallucinations:** Commonly involving third-person auditory experiences, broadcasting of thoughts, control issues, and delusional perceptions.
- **Broadcasting of Thoughts:** Belief that one's thoughts are being broadcasted to others.
- **Control Issues:** The sense of external control over one's thoughts or actions.
- **Delusional Perception:** Distorted interpretations of reality, often with false beliefs.

**Negative Symptoms:**

- Negative symptoms that often overlap with features of depressive disorders. These include:
	- Alogia
	- Anhedonia
	- Affective incongruity or blunting
	- Avolition
- Negative symptoms are more common in chronic and treated schizophrenia.

**Risk Indicators:**

Potential risks involve harm to self or others, with violence being rare. Risk indicators include command hallucinations, a history of deliberate self-harm or suicidal ideation, and fixation on specific individuals.


# Differential Diagnosis

Differential diagnosis involves distinguishing schizophrenia from other conditions that present with similar symptoms. This is often done through a combination of history, examination, and investigations.

- Substance-induced psychotic disorder: Associated with hallucinations and delusions; typically precipitated by drug use or withdrawal
- Organic psychosis: Typically accompanied by neurological symptoms or changes in mental status; conditions such as infections, brain injuries, or CNS diseases like Wilson's disease or encephalitis can lead to organic psychosis
- Metabolic disorders: Hyperthyroidism and hyperparathyroidism can present with agitation, restlessness, and altered mental status
- Depression and dementia: May present with psychotic symptoms alongside cognitive decline and mood symptoms
- Autoimmune encephalitis: May present with subacute psychosis alongside focal neurological deficits or seizures
- Schizoaffective Disorder: Combines mood disorder features with psychotic symptoms. Distinguished by the duration of mood episodes independent of psychotic symptoms.

# Investigations

While schizophrenia is primarily a clinical diagnosis based on history and examination, investigations can help exclude organic causes of psychosis. 
This includes:

- Brain imaging (CT/MRI) to rule out structural abnormalities
- Blood tests to exclude infectious (e.g.,HIV, syphilis) or metabolic causes (e.g., thyroid function tests)
- Drug screening to identify substance misuse

# Management

The primary treatment for schizophrenia is pharmacological, with second-generation (atypical) antipsychotics such as risperidone being the first line of treatment. 

- In acute episodes, sedatives like lorazepam, promethazine, or haloperidol may be used to manage dangerous behaviour. Oral atypical antipsychotics such as risperidone/olanzepine/quetiapine (sometimes IM/depot injections may be necessary). Patients should be referred for psychiatric liaison review.
- Maintenance therapy with antipsychotics is determined and prescribed by Psychiatrists.
- All second generation antipsychotics have similar efficacy profiles, though their side effect profiles vary. See dedicated section on antipsychotic medication.
- Clozapine is considered when schizophrenia is resistant to other antipsychotics (in those who have not responded to 2 other trials of antipsychotics). Due to its potential lethal side effects, it requires intensive monitoring.

Psychotherapy, such as cognitive-behavioural therapy, is also an essential part of management. Providing support to patients and families and coordinating care with mental health professionals are critical for long-term management. 

# Prognosis

Prognosis varies significantly among individuals with schizophrenia. Factors associated with a better prognosis include higher IQ/education level, sudden onset, presence of a precipitating factor, a strong support network, and predominance of positive symptoms. According to the rule of quarters:

- 25% of individuals never have another episode
- 25% improve substantially with treatment
- 25% show some improvement
- 25% are resistant to treatment


# NICE Guidelines

[NICE CKS on Psychosis and Schizophrenia](https://cks.nice.org.uk/topics/psychosis-schizophrenia/)


# References

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Leucht, S., Cipriani, A., Spineli, L., Mavridis, D., Örey, D., Richter, F., ... & Davis, J. M. (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. The Lancet, 382(9896), 951-962.
3. McGrath, J., Saha, S., Chant, D., & Welham, J. (2008). Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiologic reviews, 30(1), 67-76.

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First-rank symptoms of schizophrenia include auditory hallucinations, thought insertion, thought withdrawal, thought broadcasting, delusions of control, delusions of reference, and perceptual disturbances, which are considered highly characteristic of the disorder
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A 17-year-old female presents to the psychiatric intensive care unit after being brought in to hospital by her friend. Her friend was concerned as she repeatedly said another person was controlling her thoughts and everyone around her was able to hear what she was thinking. Before arriving at the hospital, she said that she saw the traffic light turn green so she knew her friend was going to murder her. Her friend says that she had a similar episode a few years ago.  

Which of the following is the most likely diagnosis?
a