RCSI Course Book Chapters 18-20 Week 2

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Chapter 18

Schizophrenia, schizotypal and
delusional disorders

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Chapter 18: Schizophrenia, schizotypal and delusional
disorders

Introduction
Schizophrenia is a major psychiatric disorder, or cluster of disorders, characterised by psychotic
symptoms that alter a persons perception, thoughts, affect and behaviour.
Each person with the disorder will have a unique combination of symptoms and experiences.
Typically there is a prodromal period often characterised by some deterioration in personal
functioning. This includes memory and concentration problems, unusual behaviour and ideas,
disturbed communication and affect, social withdrawal, apathy and reduced interest in daily
activities. These are sometimes called negative symptoms.
The prodromal period is usually followed by an acute episode marked by hallucinations, delusions,
and behavioural disturbances. These are sometimes called positive symptoms and are usually
accompanied by agitation and distress.
Following resolution of the acute episode, usually after biological, psychological and other
interventions, symptoms diminish and often disappear for many people, although sometimes a
number of negative symptoms may remain. This phase, which can last for many years, may be
interrupted by recurrent acute episodes, which may need additional intervention.
A significant number of people continue to experience long-term impairments and as a result,
schizophrenia can have a considerable effect on peoples personal, social and occupational lives.
The disabilities experienced by people with schizophrenia are not solely the result of recurrent
episodes or continuing symptoms. Unpleasant side effects of treatment, social adversity and
isolation, poverty and homelessness also play a part.

ICD-10 classification
1. Schizophrenia
A. Paranoid schizophrenia.
B. Hebephrenic schizophrenia.
C. Catatonic schizophrenia.
D. Undifferentiated schizophrenia.
E. Post-schizophrenic depression.
F. Residual schizophrenia.
G. Simple schizophrenia.
2. Schizotypal disorder
3. Persistent delusional disorders
A. Delusional disorder.
B. Other persistent delusional disorders.
4. Acute and transient psychotic disorders
A. Acute polymorphic psychotic disorder without symptoms of schizophrenia.
B. Acute polymorphic psychotic disorder with symptoms of schizophrenia.
C. Acute schizophrenia-like psychotic disorder.
D. Other acute predominantly delusional psychotic disorder.
5. Induced delusional disorder
6. Schizoaffective disorders
A. Schizoaffective disorder, manic type.
B. Schizoaffective disorder, depressive type.
C. Schizoaffective disorder, mixed type.

1. Schizophrenia

ICD-10 criteria
A minimum of one of the symptoms listed under (1) below, or at least two of the symptoms listed
under (2), should be present for most of the time during a period of one month or more.
Conditions meeting such symptomatic requirements but of duration less than one month (whether
treated or not) should be diagnosed as acute schizophrenic-like psychotic disorder and reclassified
as schizophrenia if the symptoms persist for longer periods.
(1). At least one of the following must be present:
A. Thought insertion, withdrawal, echo or broadcasting.
B. Delusions of control, influence or passivity, clearly referred to body or limb movements or
specific thoughts, actions, or sensations; delusional perception.
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C. Hallucinatory voices giving a running commentary on the patients behaviour, or discussing
the patient among themselves, or other types of voices coming from some part of the body.
D. Persistent delusions of other kinds that are culturally inappropriate and completely impossible,
such as religious or political identity, or superhuman powers and abilities (e.g. being able to
control the weather, or being in communication with beings from another world).
(2). Or at least two of the following:
A. Persistent hallucinations in any modality, when accompanied either by fleeting or half-formed
delusions without clear affective content, or by persistent over-valued ideas, or when
occurring every day for weeks or months on end.
B. Breaks in the train of thought, resulting in incoherent or irrelevant speech, or neologisms (i.e.
the use of words that only have meaning to the person who uses them).
C. Catatonic behaviour such as excitement, posturing or waxy flexibility, negativism, mutism and
stupor.
D. Negative symptoms, such as marked apathy, paucity of speech and blunting or incongruity of
emotional response, usually resulting in social withdrawal and lowering of social
performance.

Subtypes
A. Paranoid schizophrenia
Paranoid schizophrenia scenario
o A 28 year old man has been experiencing third person auditory hallucinations for the past six
months and believes that the FBI have formulated a plan to destroy him.
Features of the condition
o The commonest type of schizophrenia.
o Prominent delusions and/or auditory hallucinations.
o Better prognosis than hebephrenic and catatonic schizophrenia.
Onset tends to be earlier in hebephrenic and catatonic schizophrenia.
B. Hebephrenic schizophrenia
Hebephrenic schizophrenia scenario
o A 20 year old man has a four month history of disorganised speech, flattened affect and social
withdrawal. He describes hearing multiple voices throughout much of the day.
o Prominent disorganisation of speech and behaviour, inappropriate/flat affect.
o Negative symptoms, particularly flattening of affect and loss of volition are prominent.
o Much rarer but worse prognosis than paranoid schizophrenia.
Earlier onset than paranoid schizophrenia, i.e. onset between 15-25 years.
Rapid development of negative symptoms.
C. Catatonic schizophrenia
Catatonic schizophrenia scenario
o A 26 year old man has a history of adopting bizarre postures.
o Prominent psychomotor disturbances.
o Episodes of violent excitement may be a striking feature of the condition.
o Developing > developed countries. Now rarely seen in developed countries.
o Dominated by:
Stupor: marked decrease in reactivity to the environment and in spontaneous movements.
Excitement: purposeless motor activity, not influenced by external stimuli.
Posturing: voluntary assumption and maintenance of inappropriate or bizarre postures.
Waxy flexibility: maintenance of limbs and body in externally imposed positions.
Negativism: an apparently motiveless resistance to all instructions or attempts to be
moved, or movement in the opposite direction.
Rigidity: maintenance of a rigid posture against efforts to be moved.
Other symptoms such as command automatism (automatic compliance with
instructions) and perseveration of words and phrases.
D. Undifferentiated schizophrenia
Undifferentiated schizophrenia scenario
o A 30 year old man has a history of believing that the FBI have formulated a plan to destroy
him, disorganised speech and assuming unusual postures.
o Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not
conforming to any of the subtypes, or exhibiting the features of more than one of them without
a clear predominance of a particular set of diagnostic characteristics.
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E. Post-schizophrenic depression
Post-schizophrenic depression scenario
o A 30 year old man who was discharged from hospital following the treatment of a relapse of
schizophrenia, presented with a reduced mood associated with disturbed sleep, appetite and
energy. He also reported third person auditory hallucinations which last for only a few
seconds, approximately once per week.
o A depressive episode which may be prolonged, arising in the aftermath of a schizophrenic
illness.
o Some symptoms of schizophrenia must still be present but no longer dominate the clinical
picture.
F. Residual schizophrenia
Residual schizophrenia scenario
o A 36 year old man has a history of third person auditory hallucinations and delusions that the
FBI want to harm him. These symptoms however have reduced over the past year. He now
presents with social withdrawal, affective blunting and impoverished speech.
o Clear progression from an early stage with positive symptoms of schizophrenia to
predominant negative symptoms.
o A period of at least one year during which the intensity and frequency of positive symptoms
have been minimal or substantially reduced, and negative symptoms have been present.
G. Simple schizophrenia
Simple schizophrenia scenario
o A 34 year old man presented with social withdrawal, affective blunting and impoverished
speech. He has no past history of positive symptoms.
o Negative symptoms.
o No prior positive symptoms.

Schneiders first rank symptoms
Symptoms which, if present, are strongly suggestive of schizophrenia.
The first rank symptoms of schizophrenia include:
o Auditory hallucinations
Hearing thoughts spoken aloud (thought echo).
Echo de la pensee: the patient hears the echo of his thoughts in the form of a voice
after he has made the thought.
Gedankenlautwerden: the patient hears the echo of his thoughts in the form of a
voice at the same time that he made the thought.
Third person auditory hallucinations.
Hallucinations in the form of a running commentary.
o Delusions of passivity
Thought insertion, thought withdrawal, thought broadcasting.
Note: thought block is not the same as thought withdrawal.
Feelings or actions experienced as made or influenced by external agents.
o Somatic passivity (not somatic hallucinations somatic hallucinations are not a first rank
symptom)
The patient has the feeling that he is a passive recipient of somatic or bodily sensations
from an external agent.
o Delusional perception
A delusional perception is a delusional interpretation of a normal stimulus, e.g. when I
saw the traffic lights turn red I knew that the dog I was walking was an alien in disguise,
or when I saw the cupboard door was slightly open, I knew that I was the King of
England.
The term delusional perception is misleading in that the perceptions are not abnormal. It
is the meaning attached to the normal perception that is delusional.
Note: first rank symptoms are of no predictive/prognostic value and are not heritable.
Note: first rank symptoms are not characteristic or pathognomonic of schizophrenia, i.e. in addition to
schizophrenia, first rank symptoms also occur in other psychiatric disorders, particularly in mania.
Note: first rank symptoms are not present in all people with schizophrenia. First rank symptoms are
therefore not essential for a diagnosis of schizophrenia.

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Second rank symptoms
Second person auditory hallucinations.
Secondary delusion: a false belief which arises from some preceding morbid experience, e.g. a
prevailing mood, an existing delusion or a hallucination.
Visual, tactile, olfactory and gustatory hallucinations.
Perplexity.
Emotional blunting.
Note: second rank symptoms are of less diagnostic significance than first rank symptoms.

Positive and negative symptoms
Positive symptoms
o Positive symptoms are those that appear to reflect an excess or distortion of normal functions.
o Positive symptoms include:
Delusions.
Hallucinations.
Formal thought disorder, i.e. disturbance of thought (e.g. loosening of associations).
Negative symptoms
o Negative symptoms are those that appear to reflect a reduction or loss of normal functions.
They often persist in the lives of people with schizophrenia during periods of low (or absent)
positive symptoms.
o Negative symptoms include:
Affective blunting.
Alogia (impoverished speech).
Avolition (lack of desire, drive, or motivation to pursue meaningful goals).
Apathy (a state of indifference or the lack or suppression of emotions such as concern,
excitement, motivation and passion).
Anhedonia (an inability to experience pleasure from normally pleasurable life events such
as eating, exercise, and social or sexual interaction).
Asociality (a lack of interest in relationships/social contact).
Attention disturbance.

Type 1 and type 2 schizophrenia
Prof Tim Crow hypothesised two classifications of schizophrenia known as Type 1 and Type 2.
This terminology is no longer in common usage.
Type 1 schizophrenia Type 2 schizophrenia
Type of illness in which it is
most commonly seen
Acute schizophrenia Chronic schizophrenia
Type of symptoms Positive symptoms Negative symptoms
Prior level of premorbid
functioning
Functioned well before the
appearance of symptoms (i.e. good
premorbid functioning)

History of poor social and educational
functioning prior to the appearance of
symptoms (i.e. poor premorbid
functioning)
Underlying abnormality Believed to be due to problems in
dopamine neurotransmission
Believed to be due to structural brain
abnormalities
Note: changes are therefore
noticeable on a CT scan (unlike with
Type 1 schizophrenia)
Neurological signs Absent Present
Cognition Not impaired Impaired
Response to antipsychotics Good Poor
Prognosis Good Poor
Note: the commonest symptom of acute schizophrenia is loss of insight.

Dopamine abnormalities in schizophrenia
Increased dopamine release in the mesolimbic striatum during illness exacerbations.
o Positively correlated with positive symptoms.
o Correlated with good treatment response to antipsychotic medication.
Decreased dopamine in the mesocortical system.
o Associated with deficits in cognitive function, e.g. working memory.
Note: dopamine dysregulation is not thought to be a primary abnormality in schizophrenia. The
dopamine dysregulation is thought to be secondary to a more proximal abnormality, e.g. in GABA or
glutamate systems.
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Rating scales
4-Item Positive Symptom Rating Scale and Brief Negative Symptom Assessment see Appendix
10.
Scale for the Assessment of Negative/Positive Symptoms (SANS, SAPS)
o Observer rated scales measuring the severity of positive and negative symptoms.
Positive and Negative Syndrome Scale (PANSS)
o Observer rated scale measuring the severity of positive and negative symptoms.

Differential diagnosis of negative symptoms
Depression
o Distinguished from negative symptoms by careful evaluation of the mood, thoughts (negative
cognitions, suicidal risk) and presence/absence of biological symptoms of depression.
Effects of neuroleptic medication
o Parkinsonian side effects of the dopamine receptor blocking antipsychotics can mimic some
negative symptoms.
Loss of emotional reactivity, apathy and decreased speech are part of the akinetic picture.
Distinguish from negative symptoms by looking for other features of parkinsonism and
considering any recent changes in medication.
Environmental under-stimulation
o A lack of stimulation and social interaction and/or authoritarian routines allowing minimal
individual initiative produces a lack of spontaneity, loss of emotional reactivity and drive.
Physical illness
o Endocrine disorders (e.g. hypothyroidism).
o Cerebrovascular disease.
o Some malignancies.
o Alzheimers disease.
All of the above illnesses can produce symptoms which are difficult to distinguish, in
their early stages, from negative symptoms. Distinction from negative symptoms is made
by a careful history, physical examination and laboratory investigations.
Substance misuse
o Excess use of cannabis, withdrawal from amphetamines and the use of other drugs such as
opiates can cause symptoms including apathy, social withdrawal and impaired attention and
concentration which may mimic negative symptoms.
o In addition, heavy long-term use of some drugs such as alcohol can cause organic impairment
which results in changes in affect and many of the features of a negative symptom picture.
o It is therefore necessary to take a history of alcohol and drug use and be alert to the physical
and mental state manifestations of such abuse.
Schizoid and schizotypal personality traits/disorders
o Schizoid individuals have defects in their abilities to form social relationships and often seem
aloof or withdrawn.
o Schizotypal individuals may display social isolation, odd speech, inappropriate affect as well
as other features also seen in negative symptoms.
o A full history and collateral is necessary to determine if the features have been present from
childhood/adolescence (when personality traits/disorders arise).
Autism and Aspergers syndrome
o These conditions have significant difficulties with social interaction.
Distinguished from negative symptoms by the absence of restricted and repetitive patterns
of behaviour and interests which are a feature of autism and Aspergers syndrome.

Bleuler (1911) described the four A's, symptoms he considered were characteristic of
schizophrenia
Ambivalence: simultaneous, contradictory thinking.
Autism: preoccupation with internal stimuli.
Inappropriate Affect: external manifestations of mood.
Loosening of Associations: illogical or fragmented thought processes.

Epidemiology of schizophrenia
Incidence (the number of new cases of schizophrenia diagnosed each year): 15-20 per 100,000 per
year.
Prevalence (estimated population of people who are living with schizophrenia at any given time):
0.5-1%.
Mean age at onset: males = 22 years, females = 26 years.
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Gender: males > females (1.5:1).
Note: schizophrenia was previously thought to be equally common in males and females.

Aetiology of schizophrenia
Biological factors
o Genetics
A wealth of evidence supports a strong genetic contribution.
Multiple genes of small effect.
The heritability of schizophrenia is 80%.
Relationship to person with schizophrenia Risk of developing schizophrenia
No relative affected 1%
First cousins 2%
Uncles/aunts 2%
Nephews/nieces 4%
Grandchildren 5%
Parent 6%
Siblings 10%
Children of one affected parent 13%
Children of two affected parents 46%
Fraternal twin 17%
Identical twin 48%
Susceptibility genes:
D-amino acid oxidase activator (DAOA, also known as G72).
Dysbindin.
Neuroregulin.
Zinc finger protein 804A (i.e. ZNF804A).
Susceptibility chromosomal abnormalities:
Disrupted in schizophrenia 1 (DISC1).
Microdeletion of chromosome 22q11 (velo-cardio-facial syndrome) increases the risk
of development of schizophrenia.
o Neurochemistry
Dopamine (DA) hypothesis
Postulates that schizophrenia is due to excess dopamine within the mesolimbic
system. This theory is based on:
Amphetamine, a DA agonist, produces positive symptoms similar to
schizophrenia.
Levodopa increases DA concentrations and produces positive symptoms of
schizophrenia.
Dopamine agonists worsen psychotic symptoms.
Disulfiram inhibits DA metabolism and worsens schizophrenia.
Of the and isomers of flupenthixol, only the isomer helps people with acute
schizophrenia.
~ Cis-flupenthixol ( isomer) is a DA antagonist and is clinically effective.
~ Trans-flupenthixol ( flupenthixol) does not have DA antagonist activity and is
clinically ineffective.
Note: dopamine levels are not increased in urine or tears.
Serotonin (5HT) hypothesis
Postulates that schizophrenia is due to serotonin over-activity. This theory is based
on:
LSD, a 5HT agonist, produces positive symptoms similar to schizophrenia.
The newer antipsychotics act by blocking the 5HT receptors, e.g. olanzapine is a
5HT
2A
receptor antagonist.
Glutamate hypothesis
Glutamate stimulates NMDA receptors.
Phencyclidine (angel dust) produces both positive and negative symptoms by
blocking NMDA receptors.
o Neurodevelopmental hypothesis
Schizophrenia is more common among people born in the winter and spring than among
those born in the summer (more common between January and April in the northern
hemisphere, and between July and September in the southern hemisphere).
Note: one possible reason that researchers believe may explain this seasonality of schizophrenia risk is
the association between winter/spring births and sunlight exposure. A lack of sunlight (for example,
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during the shorter days of winter) can lead to vitamin D deficiency, which scientists believe could alter
the development of a child's brain in the mothers uterus and after birth. The timing may also reflect
seasonal exposure to viral infections.
Prenatal exposure to infection (such as influenza), malnutrition or stress, are associated
with an increased risk of schizophrenia.
Obstetric complications (e.g. birth asphyxia) are associated with an increased risk of
schizophrenia.
Non-right handedness (i.e. left handedness or mixed handedness) is associated with an
increased risk of schizophrenia.
Note: a link has been found between the left-handed gene LRRTM1 and the predisposition to develop
psychotic illness such as schizophrenia. It has been postulated that the genetic mechanism underlying
normal left hemispheric dominance is altered in schizophrenia.
Note: several studies have reported increased non-right-handedness in healthy relatives of patients
with schizophrenia suggesting a genetic cause for decreased cerebral dominance in schizophrenia.
Increased rates of minor physical abnormalities.
People who develop schizophrenia show abnormalities in their development that precedes
disease onset.
Cognitive development
Children who later develop schizophrenia as adults have been shown to be
distinguished by their peers by lower educational test scores.
Increased risk for developing schizophrenia has been shown to be associated
with reduced IQ.
Motor development
Children who later develop schizophrenia as adults have been shown to be
distinguished by their peers by delayed motor milestones and have been shown
to perform poorly in sports and handicrafts compared to normal peers.
Abnormalities of motor development may be reflected in the excess of
neurological soft signs (i.e. minor neurological signs indicating non-specific
cerebral dysfunction, e.g. poor motor coordination, sensory perceptual
difficulties and difficulties in sequencing of complex motor tasks).
Social and interpersonal adjustment
Children who later develop schizophrenia have been shown to have poorer peer
relationships than controls.
Premorbid symptomatology
Children who later develop schizophrenia have been shown to have a high risk
of developing schizophrenia as adults if they reported experiencing one or more
of the following:
~ Believing that other people could read their mind.
~Experiencing messages that have been sent to them by the television or the
radio.
~ Believing that people have been spying on them.
~ Hearing voices that other people cannot hear.
o Organic factors
Positive association
Increased risk in people with:
~ Chronic temporal lobe epilepsy.
~ Huntingtons chorea.
~ Traumatic brain injury.
Negative association
There is a negative association between rheumatoid arthritis and schizophrenia.
o Substance misuse
Adolescent cannabis use is associated with an increased risk of developing schizophrenia.
A functional polymorphism in the catechol-o-methyltransferase (COMT) gene
moderates the influence of adolescent cannabis use on developing adult psychosis.
Carriers of the COMT valine 158 allele are more likely to exhibit psychotic
symptoms and to develop schizophrenia if they use cannabis.
The use of stimulants such as amphetamine and hallucinogens such as ketamine,
phencyclidine (PCP) and lysergic acid diethylamide (LSD) can mimic symptoms of
schizophrenia.

Psychological factors
o Life events
Childhood trauma is associated with an increased risk of developing schizophrenia.
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Recalled sexual abuse is associated with an increased risk of developing schizophrenia.
Separation from a parent for six months before the age of five years is associated with
increased risk of developing schizophrenia.
Compared to normal controls, people with schizophrenia may have more life-events
particularly clustered in the three weeks preceding relapse or admission.

Social factors
o Employment status
Unemployed.
o Living situation
Urban > rural increased risk with increasing number of years (before age 20 years)
residence in urban areas.
o Socio-economic group
Increased risk in lower socio-economic groups (i.e. IV and V).
Social drift hypothesis - affected individuals drift down the socio-economic scale as
a consequence of their illness (both premorbidly and after illness onset).
Social causation hypothesis/breeder hypothesis - stresses related to socioeconomic
deprivation are risk-increasing or inducing factors for the development of
schizophrenia.
o Premorbid characteristics
People with schizophrenia often live alone, are unmarried and have few friends. These
patterns frequently began before the illness.
o Migration
Increased risk among migrants, e.g. Afro-Caribbean migrants in UK. The risk persists into
second generation migrants.

Brain abnormalities
Abnormal smooth pursuit eye movements (paroxysmal saccadic eye movements) in 50-80% of
patients and their relatives.
Structural brain imaging
o Ventricle to brain ratio is greater than controls.
o Enlargement of the cerebral ventricles.
o Cortical volume loss
The greatest reductions are in the temporal lobe, especially the medial temporal lobe.
Volume loss affects grey matter more than white matter.
Widening of sulci.
o Functional brain imaging
Functional dysconnectivity between frontal and temporal lobes.
o Post mortem studies
The brains of people with schizophrenia are lighter (decrease in brain weight) and smaller
(reduction in anterior-posterior length) than controls.
Reduction in neuronal population in the temporal lobes, possibly on the left.
Reversed planum temporale asymmetry.

Males versus females
Males are more likely than females to have:
o More obstetric complications.
o Poorer premorbid adjustment.
o More structural brain abnormalities (which are associated with cognitive decline).
o Negative symptoms.
o Worse prognosis.
Men are less likely than females to:
o Get married.
Fertility rates in females with schizophrenia are reduced by about 25% compared to the general
population.

Risk of suicide
2%.
Note: the widely held view that 10-15% of people with schizophrenia die from suicide

is misleading
because it refers to proportionate mortality,

not lifetime risk. Nevertheless, there is a substantial
increase

in risk of suicide compared with the general population.
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Note: the risk of suicide is increased in the period following discharge from hospital. High IQ and
good insight are associated with higher suicide risk in schizophrenia.

Prognosis
Overall prognosis
o 1/3 good prognosis.
o 1/3 intermediate prognosis.
o 1/3 poor prognosis.
The prognosis is more favourable in less developed countries (the reasons are not fully
understood).
Prominent affective symptoms are a predictor of good prognosis.
Predictors of poor prognosis
o Male gender.
o Single.
o Separated, widowed or divorced.
o History of obstetric complications.
o Low IQ.
o Insidious onset.
o Younger age of onset.
o Low premorbid functioning.
o Longer duration of untreated psychosis.
o Negative symptoms predominate over positive symptoms.
o Substance misuse.
o Ventricular enlargement.
o Poor response to medication.
o Family history of schizophrenia.
o Misuse of alcohol and/or illicit substances.
o High expressed emotion.
Note: high expressed emotion is a predictor of symptomatic relapse following discharge from hospital.
Those people from families with high expressed emotion relapse more frequently than those who are
from families without high expressed emotion. Components of high expressed emotion are critical
comments, hostility and emotional over-involvement.
Note: the risk of relapse is increased in people who misuse alcohol and/or illicit substances.
Note: there is an increased risk of bipolar affective disorder in families of people with schizophrenia
and vice versa.
Note: the rate of cigarette smoking in people with schizophrenia is higher than that of the general
population. Those people with schizophrenia who smoke do so at heavier rates than the general
population.

2. Schizotypal disorder

ICD-10 criteria
A disorder characterised by eccentric behaviour and anomalies of thinking and affect which
resemble those seen in schizophrenia, although no definite and characteristic schizophrenic
anomalies have occurred at any stage.
Occasionally schizotypal disorder evolves into overt schizophrenia.
It is more common in individuals related to people with schizophrenia and is believed to be part of
the genetic spectrum of schizophrenia.
Note: although the ICD-10 diagnostic criteria for schizotypal disorder differ in detail from the DSM-IV
criteria for schizotypal personality disorder, they define essentially the same condition. ICD-10 does
not consider the disorder to be a personality disorder (unlike DSM-IV) and it classifies it with
schizophrenia, schizotypal and delusional disorders.

3. Persistent delusional disorders

A 30 year old man has a five year history of believing that he is being followed by the FBI and that his
life is under threat. He denied a history of auditory hallucinations and other symptoms of
schizophrenia.

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ICD-10 criteria
This group includes a variety of disorders in which long-standing delusions constitute the only, or
the most conspicuous, clinical characteristic and which cannot be classified as organic,
schizophrenic or affective. One example is Ekboms syndrome (see Chapter 20).

Subtypes
A. Delusional disorder
o Delusions constitute the most conspicuous or the only clinical characteristic.
o They must be present for at least three months and be clearly personal rather than subcultural.
o There must be no evidence of brain disease, no or only occasional auditory hallucinations, and
no history of schizophrenic symptoms (delusions of control, thought broadcasting etc.).
B. Other persistent delusional disorders
o Residual category for persistent delusional disorders that do not meet the criteria for
delusional disorder.

4. Acute and transient psychotic disorders

A 40 year old teacher was under significant stress at work after he was promoted to headmaster two
weeks previous. Following his promotion, he described a one week history of auditory hallucinations
and believing that the students in the school were poisoning his food. He resigned from the job as
headmaster and reported that within two days, he no longer experienced auditory hallucinations and
ceased to believe that the students wanted to harm him.

ICD-10 criteria
Acute onset
o A change from a state without psychotic features to a clearly abnormal psychotic state within a
period of two weeks or less.
Typical symptoms
o Rapidly changing and variable state called a polymorphic state.
o The presence of typical schizophrenic symptoms.
Associated acute stress
o The first psychotic symptoms occur within about two weeks of one or more events that would
be regarded as stressful to most people in similar circumstances, within the culture of the
person concerned.
Complete recovery usually occurs within a few months, often within a few weeks or even days.

Subtypes
A. Acute polymorphic psychotic disorder without symptoms of schizophrenia
Acute onset.
Several types of hallucination or delusion, changing in both type and intensity from day to day
or within the same day.
Varying emotional state.
In spite of the variety of symptoms, none should be present with sufficient consistency to
fulfill the criteria for schizophrenia or for manic or depressive episode.
B. Acute polymorphic psychotic disorder with symptoms of schizophrenia
Acute onset.
Several types of hallucination or delusion, changing in both type and intensity from day to day
or within the same day.
Varying emotional state.
Symptoms that fulfill the criteria for schizophrenia must have been present for the majority of
the time since the establishment of an obviously psychotic clinical picture.
C. Acute schizophrenia-like psychotic disorder
Acute onset.
Symptoms that fulfill the criteria for schizophrenia must have been present for the majority of
the time since the establishment of an obviously psychotic clinical picture.
Criteria for acute polymorphic psychotic disorder are not fulfilled.
If the schizophrenic symptoms last for more than one month, the diagnosis should be changed
to schizophrenia.
D. Other acute predominantly delusional psychotic disorders
Acute onset.
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Delusions or hallucinations must have been present for the majority of the time since the
establishment of an obviously psychotic state.
Criteria for neither schizophrenia nor acute polymorphic psychotic disorder are fulfilled.
If delusions persist for more than three months, the diagnosis should be changed to persistent
delusional disorder.
If only hallucinations persist for more than three months, the diagnosis should be changed to
other non-organic psychotic disorder.

5. Induced delusional disorder

Two sisters live together and have a close relationship. One sister has a history of believing that the
FBI were following her and wanted to harm her. Her sister, who does not have a history of mental
illness, reported that over the past month she too believes that the FBI are a threat to her.

ICD-10 criteria
A rare delusional disorder shared by two or occasionally more people with close emotional links.
Only one person suffers from a genuine psychotic disorder; the delusions are induced in the
other(s) and usually disappear when the people are separated.
Almost invariably, the people concerned have an unusually close relationship and are isolated from
others by language, culture or geography.
The individual in whom the delusions are induced is usually dependent on or subservient to the
person with the genuine psychosis.
Note: this condition includes folie a deux (see Chapter 20 on other psychiatric syndromes).

6. Schizoaffective disorder

A 32 year old woman presented with a one month history of believing that she is being followed by the
FBI, in addition to a reduction in her sleep, appetite and energy level.

ICD-10 criteria
Episodic disorders in which both affective and schizophrenic symptoms are prominent within the
same episode of the illness, preferably spontaneously but at least within a few days of each other.
The episode of illness does not meet the criteria for either schizophrenia or depressive or manic
episodes.

Subtypes
A. Schizoaffective disorder, manic type
A disorder in which schizophrenic and manic symptoms are both prominent in the same
episode of illness.
B. Schizoaffective disorder, depressive type
A disorder in which schizophrenic and depressive symptoms are both prominent in the same
episode of illness.
C. Schizoaffective disorder, mixed type
Disorders in which symptoms of schizophrenia coexist with those of a mixed bipolar affective
disorder.

Epidemiology
Males = females.
Prevalence of schizophrenia is not increased in schizoaffective families but the prevalence of mood
disorders is increased.

Management
Antipsychotics used in combination with lithium or an antidepressant.

Prognosis
Intermediate between schizophrenia and affective disorder, i.e. a better prognosis than people with
schizophrenia and a worse prognosis than people with affective disorders.
Schizoaffective disorder, manic type has a better prognosis than schizoaffective disorder,
depressive type.

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MCQs Chapter 18

Question 1: Which ONE of the following statements regarding schizophrenia is TRUE?
A. The prodromal period of schizophrenia typically consists of positive symptoms which are
followed by negative symptoms.
B. Diagnostic symptoms should be present for at least two weeks in order to fulfil the ICD-10
criteria for schizophrenia.
C. Catatonic schizophrenia is more common in developing than developed countries.
D. Paranoid schizophrenia, the commonest type of schizophrenia, is characterised by prominent
disorganisation of speech and behaviour.
E. Hebephrenic schizophrenia has a better prognosis than paranoid schizophrenia.

Question 2: Which ONE of the following statements regarding schizophrenia is TRUE?
A. Neologisms are words that only have meaning to the person who uses them.
B. The age of onset of paranoid schizophrenia tends to be earlier than catatonic schizophrenia.
C. Simple schizophrenia is characterised by positive symptoms in the absence of negative
symptoms.
D. Hebephrenic schizophrenia has prominent positive symptoms.
E. Post-schizophrenic depression is characterised by the presence of depressive symptoms after
all of the symptoms of schizophrenia have subsided.

Question 3: Which ONE of the following is NOT a first rank symptom of schizophrenia?
A. Third person auditory hallucinations.
B. Thought broadcasting.
C. Running commentary.
D. Somatic hallucinations.
E. Made actions.

Question 4: Which ONE of the following regarding first rank symptoms of schizophrenia is
TRUE?
A. First rank symptoms are heritable.
B. Perplexity is not a first rank symptom of schizophrenia.
C. First rank symptoms are characteristic of schizophrenia.
D. In echo de la pensee, the patient hears the echo of his thoughts in the form of a voice at the
same time as the thought.
E. First rank symptoms are of good prognostic value.

Question 5: Which ONE of the following is NOT a negative symptom of schizophrenia?
A. Affective blunting.
B. Lack of interest in social contact.
C. Hallucinations.
D. Anhedonia.
E. Lack of motivation.

Question 6: Which ONE of the following is NOT classified under Type 1 schizophrenia?
A. Absent neurological signs.
B. Good response to antipsychotics.
C. Acute schizophrenia.
D. Good premorbid functioning.
E. Negative symptoms.

151
Question 7: Which ONE of the following is LEAST LIKELY to be a differential diagnosis of
negative symptoms of schizophrenia?
A. Cannabis excess.
B. Environmental over-stimulation.
C. Alzheimers disease.
D. Depression.
E. Aspergers syndrome.

Question 8: Which ONE of the following is NOT one of the As of schizophrenia, as described
by Bleuler?
A. Autism.
B. Ambivalence.
C. Loosening of associations.
D. Apathy.
E. Inappropriate affect.

Question 9: Which ONE of the following statements regarding the epidemiology of schizophrenia
is TRUE?
A. The mean age of onset of schizophrenia is most commonly in middle age.
B. The mean age of onset of schizophrenia is less in females than males.
C. The incidence of schizophrenia is 0.5-1%.
D. Schizophrenia is slightly more common in females than males.
E. The prevalence of schizophrenia is approximately 1%.

Question 10: Which ONE of the following statements regarding the aetiology of schizophrenia is
LEAST LIKELY?
A. Macrodeletion of chromosome 22q11 (velo-cardio-facial syndrome) increases the risk of
developing schizophrenia.
B. The heritability of schizophrenia is 80%.
C. Dopamine antagonists improve psychotic symptoms.
D. Left-handedness is associated with an increased risk of developing schizophrenia.
E. Low IQ, childhood trauma and recalled sexual abuse are all associated with an increased risk
of developing schizophrenia.

Question 11: Which ONE of the following statements regarding brain abnormalities in
schizophrenia is FALSE?
A. Increased ventricle to brain ratio compared to controls.
B. Cortical volume reduction is greater in white matter than grey matter.
C. Reversed planum temporale asymmetry.
D. Widening of sulci.
E. Cortical volume loss is most pronounced in the temporal lobe.

Question 12: Which ONE of the following characteristics is MORE APPLICABLE to males than
females with schizophrenia?
A. More likely to marry.
B. Better premorbid functioning.
C. Less structural brain abnormalities.
D. Worse prognosis.
E. Less likely to have a history of obstetric complications.

152
Question 13: Which ONE of the following is a GOOD prognostic factor for schizophrenia?
A. Single.
B. Prominent negative symptoms.
C. Acute prognosis.
D. Male gender.
E. Younger age at onset.

Question 14: Which ONE of the following statements regarding schizoaffective disorder is
TRUE?
A. Two subtypes exist manic type and depressive type.
B. The prevalence of schizophrenia is increased in families with schizoaffective disorder.
C. Affective and schizophrenic symptoms are prominent within different episodes of illness.
D. The condition is more common in females than males.
E. Manic subtype as a better prognosis than the depressive subtype.

Questions 15-19:
A. Children of one affected parent
B. No relative affected
C. Parent
D. Identical twin
E. First cousin
F. Fraternal twin
G. Sibling
H. Children of two affected parents
I. Nephew
J. Grandchild
For each of the percentage risks of developing schizophrenia below, choose the single most likely
relationship to the person with schizophrenia from the above list of options. Each option may be used
once, more than once or not at all.
15. 1%
16. 10%
17. 48%
18. 5%
19. 13%

153
MCQ answers Chapter 18

1. C
2. A
3. D
4. B
5. C
6. E
7. B
8. D
9. E
10. A
11. B
12. D
13. C
14. E
15. B
16. G
17. D
18. J
19. A

154
Chapter 19

Management of schizophrenia

155
Chapter 19: Management of schizophrenia

1. Biological management.
2. Psychological management.
3. Social management.

1. Biological management of schizophrenia
(Reference: Maudsley Guidelines, 10
th
edition)
Introduction
Antipsychotics (also known as neuroleptics) are effective both in the acute and maintenance
treatment of schizophrenia and other psychotic disorders.
For people with newly diagnosed schizophrenia, offer oral antipsychotic medication. Provide
information and discuss the benefits and side effect profile of each drug with the patient.
The lowest possible dose should be used. For each patient, the dose should be titrated up to the
lowest known to be effective.
For the majority of people, the use of a single antipsychotic is recommended.
Combination of antipsychotics should only be used when the response to a single antipsychotic
(including clozapine) has been shown to be inadequate.
Discuss the use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs
with the patient and carer if appropriate. Discuss their possible interference with the therapeutic
effects of prescribed medication and psychological treatments.
Those receiving antipsychotics should undergo close monitoring of physical health including blood
pressure, pulse, ECG, plasma glucose and plasma lipids.

156
Treatment algorithm for schizophrenia (Maudsley Guidelines, 10
th
edition)

Efficacy
Further to the publication of The Clinical Antipsychotic Trials of Intervention Effectiveness

(CATIE)

Study and The Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study
(CUtLASS), the World Psychiatric Association reviewed the evidence relating to the relative
efficacy of 51 typical antipsychotics which are also known as first generation antipsychotics
(FGAs) and 11 atypical antipsychotics which are also known as second generation antipsychotics
(SGAs) and concluded that, if differences of extrapyramidal side effects (EPSEs) could be
minimised (by careful dosing) and anticholinergic use avoided, there is no convincing evidence to
support the advantage for SGAs over FGAs.
As a class, SGAs may have a lower propensity for EPSEs but this is offset by a higher propensity
for metabolic side effects.
SGAs may be superior to FGAs in treating negative symptoms. Both FGAs and SGAs treat
positive symptoms.
Either agree the choice of antipsychotic with the
patient and/or carer, or if not possible:
start a SGA

Titrate if necessary to a minimum effective dose

Adjust the dose according to response and
tolerability

Assess over 6-8 weeks

Effective Not effective Not tolerated or poor
compliance

Continue at
the dose
which is
established as
effective
Change the drug and follow the above process.
Consider the use of either a SGA or FGA
If poor compliance is
related to poor tolerability,
discuss with the patient and
change the drug

If poor compliance is
related to other factors,
consider a depot
antipsychotic or
compliance therapy
Not effective

Clozapine
157
FGAs still play an important role in schizophrenia and offer an alternative to SGAs when SGAs
are poorly tolerated or where FGAs are preferred by the patients themselves.
Clozapine has superior efficacy in the treatment of schizophrenia over other antipsychotics.

Key points that patients should know
Antipsychotics do not cure schizophrenia. They treat symptoms in the same way that insulin treats
diabetes.
After a first episode of schizophrenia, patients are likely to benefit from treatment with
antipsychotics for up to five years.
More established illness requires continued maintenance with antipsychotics.
Antipsychotics should not be stopped suddenly.
Many antipsychotic medications are available. Different medications suit different people.
Perceived side effects should always be discussed so that the best tolerated medication can be
found.
Family interventions and CBT increase the chance of staying well.
Prodromal symptoms (or relapse signatures) vary between patients but include insomnia, agitation,
irritability, depression and anxiety, or overvalued ideation.

Types of antipsychotics
Class of agent Group Example
Typical (first generation
antipsychotics, FGAs)

Phenothiazine Chlorpromazine
Promazine
Trifluoperazine
Fluphenazine (depot)
Butyrophenone Haloperidol
Thioxanthene Flupenthixol (depot)
Note: flupenthixol has some
antidepressant effects
Zuclopenthixol (depot)
Benzamide Sulpride
Diphenylbutylpiperidine Pimozide
Atypical (second generation
antipsychotics, SGAs)

Substituted benzamide Amisulpride
Thienobenzodiazepine Olanzapine
Dibenzothiazepine Quetiapine
Benzizoxazole Risperidone
Paliperidone (the main active
metabolite of risperidone which
itself is an atypical antipsychotic)
Phenylindole derivative Sertindole
Dibenzodiazepine Clozapine
Atypical antipsychotic (or
third generation antipsychotic)
Aripiprazole
Note: the threshold for antipsychotic efficacy is more than 65% D
2
receptor occupancy. D
2
receptor
threshold applies to all antipsychotics (i.e. typicals or atypicals).
Note: the threshold for raised prolactin is more than 72% of D
2
receptor occupancy.
Note: blocking more than 78% of D
2
receptors produces EPSEs. This applies to both typicals and
atypicals.
Note: high 5-HT
2A
antagonism is not protective against EPSEs.

Effects of D
2
antagonism
Mesolimbic pathway: antipsychotic efficacy is mediated by antagonism of D
2
receptors in the
limbic striatum.
Mesocortical pathway: deterioration in cognitive function.
Nigrostriatal pathway: parkinsonism and other EPSEs.
Tuberoinfundibular pathway: hyperprolactinaemia.

Compliance
Poor compliance is particularly a problem with schizophrenia.
The risk of relapse in two years in someone with schizophrenia who stops their prescribed
medication is approximately 75%.
158
Factors associated with compliance in schizophrenia:
o Attitudes.
o Insight.
o Side effects of medications.
o The presence of negative symptoms.
o Psychosocial support network.
o Ease of access to care.

Benefits of antipsychotics
Antipsychotics may be able to affect the natural course of schizophrenia.
o Repeated relapse of illness is associated with decline. Prevention of relapse by using
antipsychotics may improve outcome.
o Longer duration of untreated psychosis is associated with poorer outcome.
Antipsychotics may be neuroprotective.

Side effects of antipsychotics
Sedation
o Greatest risk greatest with chlorpromazine (the most sedative of the phenothiazines),
clozapine and olanzapine.
Impaired glucose tolerance and diabetes
o Greatest risk with phenothiazines, clozapine and olanzapine.
o Oral glucose tolerance or fasting blood glucose should be measured before starting
antipsychotic treatment and during treatment.
Dyslipidaemia
o Increases the risk of cardiovascular disease.
o Greatest risk is with phenothiazines, clozapine and olanzapine.
o Lipids should be measured before starting antipsychotic treatment and during treatment.
Weight gain
o Clozapine > olanzapine > quetiapine > risperidone > amisulpride.
o Aripiprazole is weight neutral and may be associated with weight loss.
o When weight gain occurs, switching to medications with a lower risk of weight gain can be
done. Alternatively, aripiprazole can be added to existing treatment. Furthermore, dietary
advice can be given.
Metabolic syndrome
o Olanzapine is associated with the development of the metabolic syndrome, i.e.
hyperinsulinaemia, low glucose tolerance, dyslipidaemia, hypertension and obesity.
Reduced seizure threshold
o Clozapine carries the greatest risk.
Hypertension and QTc prolongation
o Clozapine carries the greatest risk of hypertension.
o Pimozide and sertindole carry the greatest risk of QTc prolongation.
Postural hypotension
o Mediated through adrenergic
1
blockade.
o Increased risk when phenothiazines are prescribed for the elderly.
o Chlorpromazine, clozapine, risperidone and quetiapine all have affinity for
1
receptors,
making dose titration necessary.
Hyperprolactinaemia
o Dopamine inhibits prolactin release therefore dopamine antagonists increase prolactin levels.
o Hyperprolactinaemia produces galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism,
sexual dysfunction and an increased risk of osteoporosis.
o Most plasma elevation occurs with risperidone, amisulpride and sulpride.
o For most people with symptomatic hyperprolactinaemia, a switch to a non-prolactin elevating
medication is the first choice. An alternative is to add aripiprazole to the existing treatment.
Anticholinergic side effects
o Dry mouth, blurred vision, constipation.
o Antipsychotics with potent anticholinergic side effects should not be given to people who
have closed angle glaucoma.
Photosensitivity
o Chlorpromazine: sunburn can be a problem.
Peripheral oedema (e.g. ankle oedema)
o Occurs in 3% of people prescribed olanzapine.

159
Sexual dysfunction
o Reported as a side effect of all antipsychotics.
o All effects are reversible.
o Antipsychotics decrease dopaminergic transmission which can decrease libido and can also
increase prolactin levels which also reduce libido.
Neuroleptic malignant syndrome (NMS)
o A rare, but life-threatening, idiosyncratic reaction to antipsychotic medication.
o Although potent antipsychotics (e.g. haloperidol, fluphenazine) are more frequently associated
with NMS, all antipsychotic agents, typical or atypical, may precipitate the syndrome.
o Mood stabilisers (lithium, carbamazepine) and antidepressants (SSRIs, TCAs, MAOIs) have
also been implicated in NMS, as has withdrawal from antiparkinsonian agents.
o Mortality rate is up to 20%.
Death usually results from respiratory failure, cardiovascular collapse, myoglobinuric
renal failure, arrhythmias or diffuse intravascular coagulation.
o Signs/symptoms
Hyperthermia (temperature above 38
0
C).
Fluctuating consciousness.
Generalised rigidity (lead pipe).
Autonomic instability (tachycardia, tachypnoea, fluctuating blood pressure, diaphoresis,
sialorrhea).
Increased creatinine phosphokinase (CPK) or urinary myoglobin level.
Leukocytosis.
Metabolic acidosis.
o Investigations
Vital signs (pulse, blood pressure, temperature).
FBC.
RFT.
LFT.
Serum CPK.
o Management
Stop any agents thought to be causative (especially antipsychotics).
Monitor vital signs.
Benzodiazepines (e.g. lorazepam).
Supportive measures, e.g. rehydration, oxygen, correct volume depletion/hypotension
with IV fluids, decrease temperature (e.g. cooling blankets, antipyretics, cooled IV fluids,
ice packs).
Reverse dopamine blockade: bromocriptine (a dopamine agonist).
Reduce rigidity: dantrolene (a muscle relaxant).
If rhabdomyolysis occurs: hydration and alkalinisation of the urine using IV sodium
bicarbonate to prevent renal failure.
o Restarting antipsychotics
Stop antipsychotics for at least five days.
Begin with a small dose and increase gradually while monitoring vital signs and CPK.
Consider using a different antipsychotic (e.g. quetiapine or clozapine).
Extrapyramidal side effects (EPSEs)
Dystonia Parkinsonism/pseudoparkinso
nism
Akathisia Tardive dyskinesia
Signs and
symptoms
Sustained involuntary
muscular spasms which
are often painful
Cervical dystonia
(torticollis): neck
twists and turns to
one side. In
addition, the head
may be pulled
forward or
backward
Opisthotonus:
arching of the back
Blepharospasm:
involuntary,
forcible closure of
Tremor
Rigidity
Bradykinesia

A movement disorder
characterised by a
feeling of unpleasant
inner restlessness and a
compelling need to be
in constant motion, e.g.
Rocking while
standing or sitting
Lifting the feet as
if marching on the
spot
Crossing and
uncrossing the legs
while sitting
People with akathisia
are unable to sit or keep
Repetitive, involuntary,
purposeless movements
Grimacing
Tongue protrusion
Lip smacking
Puckering and
pursing of the lips
Rapid eye blinking
Rapid movements of
the extremities may
also occur (upper
extremities affected >
lower extremities)

160
the eyelids
Oculogyric crisis:
upward deviation
of the eyes
still, complain of
restlessness, fidget,
rock from foot to foot
and pace
Prevalence Approximately
10%
More common in:
o Young males
o Neuroleptic
nave
o Use of high
potency drugs
(e.g.
haloperidol)
Approximately 20%
More common in:
o Elderly females
o Those with pre-existing
neurological damage
(head injury, stroke,
etc)
Approximately
25%
Approximately 5%
More common in:
o Elderly females
o Presence of
organic brain
illness, alcohol
dependency,
affective illness,
diabetes and
intellectual
disability
o Those who had
acute EPSEs
early in
treatment
o Concomitant
anticholinergic
treatment
Treatment
options
Anticholinergics (e.g.
procyclidine, biperiden)
Dose reduction
Change to an atypical
antipsychotic
Anticholinergics (e.g.
procyclidine, biperiden)
Reduce
antipsychotic dose
Change to an
atypical
Propanolol, or
clonazepam, or
cyproheptadine
(antihistamine), or
mirtazapine, or
trazodone, or
mianserin, or
clonidine
Note: anticholinergics
are generally unhelpful
Stop anticholinergics
Decrease
antipsychotic dose
Note: dose reduction may
initially worsen tardive
dyskinesia
Change to an atypical
Clozapine

Note: a family history of a primary movement disorder (Parkinsons disease, dystonia, tremor) is a risk
factor for development of EPSEs.
Note: tardive dyskinesia can occur in people with psychosis who have never taken antipsychotics.

Clozapine

Introduction
Patients on clozapine must be registered with an approved monitoring system, i.e. Clozapine
Patient Monitoring Service (CPMS) or Zaponex Treatment Access System (ZTAS). Each patient
prescribed clozapine receives a unique CPMS number.
Initiation of clozapine is done either as an inpatient or where appropriate facilities exist for
monitoring (e.g. at a day hospital).
A normal leukocyte count (WBC > 3,500/mm
3
,

neutrophils > 2,000/mm
3
) must precede treatment
initiation.
FBCs must be repeated (and results sent to CPMS) at weekly intervals for 18 weeks (when the risk
of neutropenia/agranulocytosis is greatest) and then fortnightly until one year. Blood monitoring
continues monthly after one year of treatment.
Dose of clozapine should be titrated up slowly. Need for close monitoring of vital signs on
initiation because of hypotensive effect.
If the patient has not received clozapine for 48 hours or longer, clozapine should be restarted at the
starting dose and re-titrated upwards.
Response to clozapine occurs in 30-60% of people with treatment resistant schizophrenia.
40-70% of people with treatment resistant schizophrenia are also clozapine resistant.
Clozapine reduces suicidality, hostility, aggression and both positive and negative symptoms.
Clozapine does not increase prolactin release in humans.
161
Indications
Treatment resistant schizophrenia (main indication).
Tardive dyskinesia.
Psychosis in Parkinsons disease.
Huntingtons psychosis.
Resistant mania.

NICE Guidelines
Clozapine should be used in treatment resistant schizophrenia when there has been a lack of a
satisfactory clinical improvement despite the sequential use of the recommended doses for six to
eight weeks of at least two antipsychotics at least one of which should be an atypical.

Baseline investigations (before commencing clozapine)
Bloods: FBC, fasting cholesterol, lipids and glucose level.
ECG.
Chest X ray.
Weight.

Plasma level measurements
Plasma levels of clozapine, norclozapine and the clozapine to norclozapine ratio can be measured
after three weeks of starting clozapine and at intervals during treatment.
o Norclozapine is the active metabolite of clozapine.
o Norclozapine has a longer half life than clozapine.
o Mean clozapine to norclozapine ratio is 1.33 across dose ranges.
> 3 suggests the sample was not at the trough stage.
< 0.5 suggests poor compliance.
Clozapine plasma levels are reduced in:
o Males.
o Younger patients.
o Smokers.
Clozapine plasma levels are increased in:
o Asians.
In those not responding to clozapine, the dose should be adjusted to give a clozapine plasma level
in the range 350-500ug/l. Those not tolerating clozapine may benefit from a reduction to a dose
giving a plasma level within this range.

Sites of action
Dopamine receptors
o Low affinity for D
2
receptors compared to typical antipsychotics.
o Affinity for D
4
receptors is approximately 10 times greater than for D
2
receptors.
o Also binds to D
1
, D
3
and D
5
receptors.
Serotonin receptors
o Affinity for 5-HT receptors.
Adrenergic receptors
o Affinity for
1
and
2
receptors.
Muscarinic receptors.

Main side effects
Side effect Management
Agranulocytosis (incidence 0.8%) or
neutropenia (incidence 3%)
Note: agranulocytosis:
Females > males
Older individuals > younger
individuals
Asians > Caucasians
Stop clozapine
Admit to hospital
Sedation Reduce the morning dose
Weight gain Diet
Exercise
Constipation High fibre diet
Laxatives
162
Hypersalivation Hyoscine hydrobromide (Kwells)
Carry a cloth to absorb the saliva
Use an extra pillow at night
Hypotension Stand up slowly
Reduce the dose
Slow down the rate of increase
Hypertension Reduce the dose
Medication (e.g. atenolol) may be needed
Tachycardia Reduce the dose
Nausea Anti-emetic
Fever Anti-pyretic
Check FBC
Seizures After a seizure, withhold clozapine for one day, re-start at a
reduced dose and give sodium valproate
Exacerbate OCD symptoms Addition of an SSRI

Additional side effects
Haematological
o Eosinophilia
o Thrombocytopenia
Nervous system
o Dizziness/vertigo
o Headache
o Tremor
o Syncope
o Delirium
Cardiovascular
o Myocarditis
o Cardiomyopathy
Gastrointestinal
o Transient moderate asymptomatic elevations in liver function tests
o Pancreatitis
Genitourinary
o Urinary incontinence/nocturnal enuresis
o Urinary urgency/frequency
o Urinary retention
Endocrine
o Increased risk of developing hyperglycemia and/or diabetes mellitus
Respiratory
o Pneumonia

Clozapine augmentation
Clozapine augmentation can be used in cases of inadequate response to clozapine.
Suggested options for augmenting clozapine:
o Add haloperidol.
o Add amisulpride.
o Add sulpride.
o Add risperidone.
o Add aripiprazole.
o Add omega-3 triglycerides.

Antipsychotic depot injections

Introduction
Antipsychotics can be given as a long-acting depot injection injected into a large muscle (usually
the gluteus maximus), allowing for sustained release over one to four weeks.
Depot injections reduce relapse rates of schizophrenia.

163
Indications
Poor compliance with oral treatment.
Failure to respond to oral medication.
Memory problems or other factors interfering with the ability to take medication regularly.

Differences between depots
Typical antipsychotic depots
o Zluclopenthixol deconate (Clopixol)
Consider for aggressive and agitated patients.
o Flupenthixol deconate (Depixol)
Consider for depressed patients (mood elevating?).
o Haloperidol deconate (Haldol)
Consider for prophylaxis of manic episode.
Increased risk of EPSEs.
o Fluphenazine deconate (Modecate)
Avoid in depression (associated with depressed mood).
Increased risk of EPSEs.
o Pipotiazine palmitate (Piportil)
Consider when EPSEs are problematic as it possibly has a low risk of EPSEs.
Atypical antipsychotic depots
o Olanzapine pamoate.
o Risperidone consta.
o Paliperidone palmitate.

Specific side effects
Pain/swelling at the injection site, rarely abscess, nerve palsies.
Side effects as for oral medication may take two to three days to emerge and may persist for weeks
after discontinuation.

2. Psychological management of schizophrenia
(Reference: NICE Guideline 82 schizophrenia, March 2009)

Psychoeducation for the patient and family. Psychoeducation provides information about the
disorder and its treatment to patients and their family members. It is supposed that increased
knowledge enables people with schizophrenia to cope more effectively with their illness.
Offer cognitive behavioural therapy (CBT) to all patients with schizophrenia. This can be started
either during the acute phase or later, including in inpatient settings.
o CBT is based on the hypothesis that psychotic symptoms such as delusions and hallucinations
stem from misinterpretations and irrational attributions caused by self-monitoring deficits.
o CBT seeks to help patients rationally appraise their experiences of disease symptoms and how
they respond to them, thereby reducing symptoms and preventing relapse.
Offer family intervention to all families of people with schizophrenia who live with or are in
close contact with the patient. This can be started either during the acute phase or later, including
in inpatient settings. Family intervention may be particularly useful for families of people with
schizophrenia who have:
o Recently relapsed or are at risk of relapse.
o Persisting symptoms.
Consider offering art therapies to all people with schizophrenia, particularly for the alleviation of
negative symptoms. This can be started either during the acute phase or later, including in inpatient
settings.
Do not routinely offer counselling and supportive psychotherapy (as specific interventions) to
people with schizophrenia. However, take patient preferences into account, especially if other
more efficacious psychological treatments, such as CBT, family intervention and art therapies, are
not available locally.
Cognitive remediation: a substantial proportion of patients with schizophrenia have impaired
cognition, particularly in the domains of psychomotor speed, attention, working memory and
executive function, verbal learning and social cognition. Several cognitive remediation approaches
involve compensation strategies to organise information, use of environmental aids such as
reminders and prompts, and a range of techniques to enhance executive function and social
cognition.
164
For people with schizophrenia whose illness has not responded adequately to biological or
psychological management
Review the diagnosis.
Establish that there has been adherence to antipsychotic medication, prescribed at an adequate dose
and for the correct duration (i.e. compliance?).
Review engagement with and use of psychological treatments.
o If family intervention has been undertaken, suggest CBT. If CBT has been undertaken,
suggest family intervention for people in close contact with their families
Consider other causes of non-response, such as co-morbid substance misuse (including alcohol),
the concurrent use of other prescribed medication or physical illness.
3. Social management of schizophrenia
Alcohol/substance misuse counselling
o Alcoholics Anonymous (AA): for people who have an alcohol problem.
o Al Anon: for the families of people who have an alcohol problem.
o Al Teen: for teenage children of people who have an alcohol problem.
o Narcotics Anonymous (NA): for people who have a substance misuse problem.
Social work input to assist with employment opportunities and supported accommodation if
needed.
Occupational therapy input to improve skills.
Social skills training
o Improves day to day living skills by focusing on components of social competence such as
self-care, basic conversation, vocational skills and recreation.
o Teaches people about the verbal as well as non-verbal behaviours involved in social
interactions, so that they can determine how to act appropriately in the company of other
people in a variety of different situations.
Clubhouses: programme of support and opportunities for people with severe and persistent mental
illness. Clubhouse participants are called members. There are no therapists or psychiatrists on
staff. Programmes are administered through the joint efforts of both clubhouse members and staff.
o Clubhouses offer an employment programme designed to integrate interested members back
into employment in the community.
o Clubhouses also offer housing support and placement, financial planning, evening and
weekend social programmes, continuing education support.
Vocational and rehabilitation training
o Supported employment involves individually tailored job placement, rapid job search and
provision of ongoing job support.
o Eve Holdings: provides programmes in a wide range of career options.
o Daughters of Charity: offers horticultural and catering vocational training programmes.
o National Learning Network: provides programmes in a wide range of career options.
Befriending: isolation is a common problem for people suffering from mental illness. Befriending
is a relationship between a volunteer befriender and a befriendee which operates within a structural
framework. This is usually a time limited relationship which enables a person to widen their own
social network, increase independence and make informed choices, so enabling them to live life to
the full.
Domestic violence support
o Womens Aid: provides information and support to women and children who are being
physically, emotionally and sexually abused in their own home.
o M.O.V.E (Men Overcome Violence): works with men who have been violent or abusive
towards their partners by helping them to take responsibility for their violence and changing
their attitudes and behaviours.
o Refuges for women and children.
Rape crisis counselling
o Rape Crisis Centre.
o Laragh Counselling for adult victims of childhood sexual abuse.
Support groups
o Mental Health Ireland: provides care, support and friendship for the mentally ill, in addition to
a Caring for Carers Programme.
o Grow: helps recovery in those who have suffered from mental illness.
o Shine: a support and patient advocacy organisation for schizophrenia.
165
Patient advocacy: the Irish Advocacy Network provides a peer advocacy service with people who
have personal experience of mental health difficulties who have achieved a sufficient level of
recovery.

166
MCQs Chapter 19

Question 1: Which ONE of the following associations relating to the effects of D
2
antagonism is
FALSE?
A. Nigrostriatal pathway parkinsonism.
B. Mesolimbic pathway antipsychotic efficacy.
C. Mesoinfundibular pathway extrapyramidal side effects.
D. Tuberoinfundibular pathway hyperprolactinaemia.
E. Mesocortical pathway deterioration in cognitive function.

Question 2: Which ONE of the following statements regarding the side effects of antipsychotics is
TRUE?
A. Olanzapine has the greatest potential for weight gain of all of the antipsychotic medications.
B. Haloperidol is more sedative than olanzapine.
C. Peripheral oedema occurs in 10% of people prescribed olanzapine.
D. Chlorpromazine has the greatest potential for reducing the seizure threshold.
E. Aripiprazole is not associated with weight gain.

Question 3: Which ONE of the following statements regarding the neuroleptic malignant
syndrome is TRUE?
A. Alkalinisation of the urine is a useful strategy in the case of rhabdomyolysis.
B. Association with hypothermia.
C. Bromocriptine is a dopamine antagonist which is a useful agent for reversing the dopamine
blockade.
D. Mortality, which is up to 20%, usually results from diaphragmatic spasm.
E. Associated with metabolic alkalosis.

Question 4: Which ONE of the following associations regarding extrapyramidal side effects is
FALSE?
A. Parkinsonism most common in elderly females.
B. Akathesia prevalence of approximately 25%.
C. Dystonia most common in young males.
D. Tardive dyskinesia most common in elderly males.
E. Dystonia and parkinsonism treatment with anticholinergics.

Question 5: Which ONE of the following statements regarding clozapine is FALSE?
A. Clozapine levels are lower in males than females.
B. Clozapine reduces suicidality.
C. Clozapine increases human prolactin levels.
D. The risk of agranulocytosis is greatest in the first 18 weeks of treatment.
E. Norclozapine has a longer half life than clozapine.

Question 6: Which ONE of the following side effects is MOST LIKELY associated with
clozapine?
A. Weight loss.
B. Worsening of symptoms of obsessive compulsive disorder.
C. Diarrhoea.
D. Bradycardia.
E. Hyposalivation.

167
Questions 7-11: Types of antipsychotics
A. Thioxanthene
B. Diphenylbutylpiperidine
C. Dibenzothiazepine
D. Phenothiazine
E. Dibenzodiazepine
F. Thienobenzodiazepine
G. Benzizoxazole
H. Benzamide
I. Substituted benzamide
J. Butyrophenone
For each of the antipsychotics below, choose the single most likely group from the above list of
options. Each option may be used once, more than once or not at all.
7. Olanzapine
8. Haloperidol
9. Quetiapine
10. Clozapine
11. Amisulpride

168

1. C
2. E
3. A
4. D
5. C
6. B
7. F
8. J
9. C
10. E
11. I

169
Chapter 20

Other psychiatric syndromes

170
Chapter 20: Other psychiatric syndromes

Important conditions
1. Psychotic conditions
A. Delusional misidentification syndrome.
i. Capgras syndrome (illusion of doubles).
ii. Fregoli syndrome.
iii. Intermetamorphosis.
iv. Syndrome of subjective doubles.
B. Lycanthropy.
C. Cotards syndrome.
D. Folie a deux (induced psychosis).
E. Ekboms syndrome (delusional parasitosis, delusion of infestation).
F. Erotomania (De Clerambaults syndrome).
G. Morbid jealousy (Othello syndrome).
2. Non-psychotic conditions
A. Couvade syndrome.
B. Charles Bonnet syndrome.
C. Gansers syndrome (syndrome of approximate answers).
D. Diogenes syndrome (senile squalor syndrome).
E. Munchausen syndrome.
F. Munchausen syndrome by proxy.

1. Psychotic conditions

Management consists of treatment of the underlying disorder, e.g. treatment with an antipsychotic (e.g.
olanzapine or risperidone) or an antidepressant (e.g. SSRI).

A. Delusional misidentification syndrome
An umbrella term for a group of delusional disorders that involve a belief that the identity of a
person, object or place has been altered.
This syndrome is usually considered to include four main variants:
i. Capgras syndrome (illusion of doubles)
o Capgras syndrome scenario
A woman insists that her husband is not her real husband but someone disguised
as him.
o Features of the condition
The most common type of delusional misidentification syndrome.
Not an illusion but a delusional disorder in which the person believes that a close
relative or a spouse has been replaced by an exact double.
Usually associated with affective disorders or schizophrenia, but can occur with
organic disorders.
Females > males.
ii. Fregoli syndrome
o Fregoli syndrome scenario
A woman is convinced that her boyfriend often changes his appearance to that of
other people (look-alikes) in order to follow her.
The delusional belief that one or more familiar persons, usually persecutors
following the patient, repeatedly change their appearance and are actually a
single person in disguise.
Usually associated with schizophrenia but can occur with affective or organic
disorders.
iii. Intermetamorphosis
o Intermetamorphosis scenario
A woman is convinced that people swap identities with one another. She denies
that they change their physical appearance.
The belief that people in the environment swap identities with each other while
maintaining the same appearance.
171
iv. Syndrome of subjective doubles
o Syndrome of subjective doubles scenario
A woman believes there is a double of herself who undertakes actions specific to
that person which do not mirror her own activities.
A person believes there is a doppelganger or double of himself carrying out
independent actions.

B. Lycanthropy
Lycanthropy scenario
o A man believes that he has been transformed into a wolf.
o The delusional belief that the patient has been transformed into an animal who behaves
accordingly.
o Reported cases have included the belief of transformation into a wolf, dog, cat, horse,
hyena, tiger, bird, frog or a bee.

C. Cotards syndrome
Cotards syndrome scenario
o A man believes that his skin is rotting and that he is already dead.
o A nihilistic delusion in which the person holds a delusional belief that they are dead, do
not exist, are putrefying or have lost their blood or internal organs.
o Generally occurs in patients suffering from depression with psychotic features but it can
also occur in patients suffering from schizophrenia or organic mental conditions (e.g.
general paralysis, epilepsy).
o Females > males.
o Middle aged/older people > younger people.

D. Folie a deux (induced psychosis)
Folie a deux scenario
o Two sisters live together and have a close relationship. One sister has a history of
believing that the FBI are following her and want to harm her. Her sister, who does not
have a history of mental illness, reported that over the past month she too believes that
the FBI are a threat to her.
o A delusional belief is transmitted from one individual to another.
o Most commonly diagnosed when the two or more individuals concerned live in close
proximity and may be socially or physically isolated and have little interaction with other
people.
o Most common relationship between the two people is sisters.
Note: distribution of the relationships in Western countries differs from those indicated by Japanese
data, in which mother-child and spousal combinations are the most common.
o Most common type of delusion is persecutory.
o Most common subtype of folie a deux is folie impose in which the dominant person
initially forms a delusional belief during a psychotic episode and imposes it on another
person or persons with the assumption that the secondary person might not have become
deluded if left to his own devices.
o Delusions of the recipient disappear after separation or admission to hospital.

E. Ekboms syndrome (delusional parasitosis, delusion of infestation)
Ekboms syndrome scenario
o A man believes that his skin is infested with parasites.
o The person believes that their skin and/or eyes are colonised by parasites.
o People with delusional parasitosis are likely to ask for help not from psychiatrists but
from dermatologists, veterinarians, pest control specialists or entomologists.
o Females > males.
o Middle aged/older people > younger people.

172
F. Erotomania (De Clerambaults syndrome)
Erotomania scenario
o A young woman is convinced that a famous singer is deeply in love with her. She writes
him daily love letter, attends all of his concerts and has bought night-vision glasses so
that she can more clearly detect his loving glances towards her as she watches him
through his bedroom window.
o The person believes that someone, usually of a higher social or professional status, is in
love with them.
o They may make repeated contact with that person.
o This condition is associated with the risk of violence to the victim when repeated attempts
by the patient to make contact with the victim are turned down. Violence can be directed
towards the love object, as well as towards people perceived by the subject as rivals or
people thought to be in the way of the relationship.
o Usually associated with paranoid schizophrenia. Also associated with affective disorders
or organic disorders.
o Management consists of treatment of any underlying disorder. However, the pure form
(i.e. not associated with any other disorder) is very resistant to physical treatment and
psychotherapy.
o Females > males.

G. Morbid jealousy (Othello syndrome)
Morbid jealousy scenario
o A man is convinced that his wife is having an extra-marital affair. He follows her to and
from work and interrogates her about her work activities when she returns home. He has
become increasingly more violent towards her and repeatedly demands that she should
confess to the affair. She denies that she has never had an affair.
Introduction
o Morbid jealousy differs from normal jealousy in its intensity or rationality.
o Morbid jealousy is a disorder in which an individual believes that their partner is, or will
be, sexually unfaithful.
o Morbid jealousy can occur when a partner is in fact being unfaithful, provided that the
evidence for the infidelity is incorrect and there is an excessive or irrational response to
such evidence.
Aetiology
o Chronic alcohol dependence.
o Addiction to substances other than alcohol (e.g. morphine, cocaine and amphetamines).
o Organic brain disorders (e.g. Alzheimers disease, endocrine disturbances, cerebral
tumours, Parkinsons disease, Huntingtons chorea and tertiary syphilis).
o Schizophrenia.
o Neurotic disorders.
o Mood (affective) disorders.
o Personality disorders.
o Pathological jealousy may present as the only delusion in delusional disorder or may
present as obsessive compulsive neurosis.
Psychopathology
o Normative life crises.
o Jealous predisposition.
o Impotence.
o Real or imaginary hypophallism.
o The projection of homoerotic or heteroerotic impulses.
o Being significantly older than ones partner.
Clinical characteristics
o Jealous subject
Frequently accusing their partner of infidelity and looking for evidence of infidelity.
Scrutinising the telephone records and postal correspondence of their partner and
finding confirmation of the infidelity in innocent phrases and events.
A car parked opposite the house could be interpreted as belonging to the lover of the
unfaithful partner.
If a partner arrives home slightly later than usual from work or shopping, it is
assumed that infidelity has taken place.
Any new interests are assumed to have come from activities with the new lover.
173
Subjects may claim that the ring of a telephone contains a special message from a
lover.
Morbidly jealous individuals may become enraged if their partner becomes pregnant
due to the belief that a rival lover is the father of the unborn child.
Subjects may insist that their partner submits to a home-made lie detector test or
undergoes hypnosis in order to uncover the truth regarding their infidelity.
Subjects may examine bed linen and underwear for seminal stains and even the
genitals of their partner for additional evidence, as well as setting traps, innocent
findings from which are interpreted as definite proof of infidelity.
Excessive sexual demands are often made to exhaust the partner from engaging in
infidelity. It can be perceived as evidence of infidelity if the accused does not agree
to these excessive demands.
The partner may be prevented from wearing particular clothes, jewellery or make-up
which would be deemed by the subject to attract suitors. Additional activities in
pursuit of evidence of infidelity include stalking the partner or hiring a private
detective.
o Effects on the partner
Often reduce contact with, or even avoid, members of the affected individuals
gender, or situations in which these imagined rivals may be encountered.
The partner may feel that by falsely confessing that infidelity had in fact occurred
would reduce the accusations of the jealous subject and result in peace. This
however, tends to have the opposite effect and often serves to worsen the situation.
Partners of aggressively jealous subjects may develop a range of symptoms including
feelings of helplessness, isolation, extreme passivity, anxiety and depression. Some
may abuse prescription drugs and alcohol.
Epidemiology
o Prevalence: unknown but thought to be less than 1% of the population.
o Males > females.
Risk
o Homicide.
o Domestic violence.
o Suicide.
o Morbid jealousy has a high rate of recurrence and can reoccur when the subject with
morbid jealousy enters a new relationship with a new partner.
Management
o Hospitalisation if there are any suicidal or homicidal indicators.
o Geographical separation of the partners may be all that is effective in morbid jealousy
which is refractory to treatment.
o Treatment of any primary psychiatric illness.
o Antipsychotics should be used in subjects suffering from psychotic illnesses.
o Cognitive behavioural therapy.
o Insight-oriented therapy.
Prognosis
o Poor prognosis.

2. Non-psychotic conditions

A. Couvade syndrome
Couvade syndrome scenario
o A young man presents with a history of nausea in the morning and a distended abdomen
of three months duration. His wife is three months pregnant.
o Experiencing symptoms resembling pregnancy (e.g. minor weight gain, morning nausea,
abdominal swelling and/or spasms, food cravings, hormonal changes disturbed sleep
patterns), in a man whose female partner is pregnant.
o In more extreme cases, the symptoms can include labour pains, postpartum depression
and nosebleeds.
o Tends to present in the third or ninth month of the females pregnancy.
o Some people attribute the symptoms of Couvade syndrome to jealousy of the womans
ability to give birth, while others maintain that the symptoms result from male guilt over
impregnating the woman, or the husband regarding the wife as a competitor that he must
try to outperform.
174
o Increased estradiol and decreased testosterone has been found in the blood and saliva of
men with Couvade syndrome versus controls.
Management
o Psychoeducation regarding the condition.
o Reassurance.

B. Charles Bonnet syndrome
Charles Bonnet syndrome scenario
o A man with deteriorating vision described the emergence of vivid hallucinations of
dancing children.
o The core features are the occurrence of well formed, vivid and elaborate visual
hallucinations in a partially sighted person who has insight into the unreality of what he is
seeing.
o There should not be features which might lead to an alternative explanation for the
hallucinations such as psychosis, dementia or intoxication.
o The syndrome occurs most commonly in elderly people, probably because of the
prevalence of visual impairment in this group.
o The common conditions leading to the syndrome are age related macular degeneration,
glaucoma and cataract.
o It is important to keep in mind that Charles Bonnet syndrome is not a psychotic condition.
The hallucinations are not a sign of any form of mental illness. They are a normal
response of the brain to the loss of vision.
o A difference between the hallucinations which people with mental health problems and
people with Charles Bonnet Syndrome have is that in Charles Bonnet syndrome, people
quickly learn that the hallucinations are not real.
o Many people who experience this condition report that their hallucinations are positive
and even pleasant, such as colourful flowers or dancing children. Others find the
hallucinations more troubling because they are intrusive and interfere with their
remaining vision or because the images can be alarming or even frightening.
o The duration of the hallucinations varies from person to person. In some people they last
only seconds, others experience them for much longer periods of minutes or even hours. It
is unusual for the visual hallucinations to be continuous. In nearly everyone, the
hallucinations disappear within about 18 months as the brain becomes accustomed to the
sight loss. If there is subsequent sudden deterioration in vision, the visual hallucinations
may return.
Management
o There is no definitive treatment for the condition. Reassurance and explanation that the
visions are benign and do not signify mental illness has a powerful therapeutic effect.
Note: visual hallucinations can occur in blind or partially sighted people.
Note: auditory hallucinations can occur in deaf or hearing impaired individuals.

C. Gansers syndrome (syndrome of approximate answers)
Gansers syndrome scenario
o The police arrested a man for breach of the peace. When asked how many legs a table
has, he answered five.
o Approximate answers, e.g.
Doctor: how many legs does a table have?
Patient: five.
o Clouding of consciousness.
o True hallucinations or pseudohallucinations.
o Conversion symptoms.
o Usually sudden in onset and, like malingering, seems to arise in response to an
opportunity for personal gain or the avoidance of some responsibility.
o The condition is usually self limiting with amnesia for the episode.
Males > females.
Gansers syndrome is sometimes called prison psychosis because it was first observed in
prisoners.
Management
o Gansers syndrome resolves spontaneously in the absence of specific treatment once the
stress that triggered the episode has settled.
175
o Supportive psychotherapy and monitoring for safety and a return of symptoms are the
main elements of treatment.
o Medication usually is not used, unless the person also suffers from depression, anxiety,
or a personality disorder.

D. Diogenes syndrome (senile squalor syndrome)
Diogenes syndrome scenario
o The daughter of an elderly woman expressed concern that her mothers house is in a
filthy condition and full of items including rubbish, rotting food, newspapers and
cardboard boxes. It has become extremely difficult to manoeuvre around the house due to
the large accumulation of items which have no practical use and constitute a fire hazard.
o Extreme self-neglect, domestic squalor, social withdrawal, excessive hoarding
(syllogomania) and lack of concern about ones living conditions.
o Hoarding of rubbish or objects, usually of no practical use in ones home and domestic
squalor.
o Affected homes can become fire hazards.
o Infestations can occur (e.g. with mice, rats, cockroaches, maggots, bed bugs).
o Associated with ill health and unsafe home situations.
o Associated with dementia, frontal lobe impairment without dementia, obsessive
compulsive disorder, depression, delusional disorder, substance abuse, personality
disorder, intellectual disability and physical illness.
o The disorder is not specific to a certain socioeconomic status and is equally prevalent
among men and women in the age range of 60-90 years.
o Most affected individuals are single or widowed, living alone and their decline tends to be
lengthy in duration.
o Some patients have a prior psychiatric history. Non-compliance with treatment and
follow-up are almost universal.
Management
o The main obstacle to helping affected people is their reluctance to seek help and their
resistance to medical intervention when it is offered.
o Day care and community care are the main lines of management rather than hospital
admission.
o Consider the use of SSRIs to treat the compulsive hoarding behaviours.
o Atypical antipsychotics may be considered when paranoid symptoms are present.
o Prevent additional clutter in the home environment, establish a cleaning plan, discard
objects and organise the living space.

E. Munchausen syndrome
Munchausen syndrome scenario
o A woman presented to the Emergency Department with a self-reported history of
haematuria. A urine sample was taken from her in the Emergency Department. No
organic cause was detected. On further examination, fresh cuts were noted on two of her
finger tips.
o A type of factitious disorder in which a person intentionally fakes, simulates, worsens or
self-induces an injury or illness for the main purpose of being treated like a medical
patient.
o Gastrointestinal symptoms or haemoptysis are the most common presentations.
o These people are sometimes eager to undergo invasive medical interventions. They are
also known to move from doctor to doctor, hospital to hospital, or town to town to find a
new audience, once they have exhausted the workup and treatment options available in a
given medical setting.
o When Munchausens syndrome is suspected, the doctor should review the patients
medical records and search for possible inconsistencies between what is documented and
what the patient has told them. They should also try to get in touch with family or friends
of the patient to find out whether the patients claims about their medical history are true.
o The medical team can also check blood and urine samples for traces of substances which
would suggest they were deliberately ingested or injected and could explain their
symptoms.
o The patients hospital room may be searched for materials that the person may have
injected into themselves or for hidden medications or substances. However, this
procedure has ethical considerations of its own.
176
o Males > females.
Management
o Need to limit behaviour - hospital registry of such patients.
o Treating a patient with Munchausen syndrome can be extremely challenging. Most of
these patients will deny ever having had such a problem and will most likely be
uncooperative, making it hard to get them to adhere to treatment plans.
o If the patient will remain in therapy, cognitive behavioural therapy should be considered.
o If medications are prescribed, they will be for the treatment of other mental disorders that
are also present, such as anxiety or depression.
Note: Munchausen syndrome is a factitious disorder not a fictitious disorder.

F. Munchausen syndrome by proxy
Munchausen syndrome by proxy scenario
o A woman presented to the Emergency Department with her eight year old daughter. The
mother stated that she was very concerned about the raised areas on her daughters right
arm. Irregularly shaped blister-like areas were observed. A needle mark was noted on the
childs arm. A swab of the region showed evidence of faecal material.
o A type of factitious disorder characterised by a pattern of behaviour in which someone,
usually a mother, induces physical ailments upon another person, usually her child.
o The mother attempts to gain attention and recognition for herself by putting on the public
faade of a dedicated and loving mother. However, when alone with her child she will
subject them to abuse, both physical and emotional, as she tries to deliberately make them
sick.
o A form of child abuse.
o The mother may have a nursing or medical background, have her own history of
Munchausen syndrome, have a history of marital discord, deny deception, lack the usual
parental concern and have suicidal ideation or attempt suicide before or after discovery of
the syndrome.
o The mother may thrive in the medical environment and enjoy the attention and care she
receives from the health care staff. She may have a history of frequent use of Emergency
Departments and ambulances.
o Females > males.
Management
o Child protection the case should be reported to a child protection social worker.
o Successful psychotherapy for perpetrators is difficult to achieve. Firstly, the mothers
denial is often so strong that she may not admit to the act. Secondly, it is difficult to gain
access to the emotional life of patients who enact rather than verbalise their feelings.
o If the perpetrator will remain in therapy, cognitive behavioural therapy should be
considered.
o If medications are prescribed for the perpetrator, they will be for the treatment of other
mental disorders that are also present, such as anxiety or depression.
Note: Munchausen syndrome by proxy is a factitious disorder not a fictitious disorder.

177
MCQs Chapter 20

Question 1: Which ONE of the following statements is TRUE?
A. The commonest type of delusion in folie a deux is a delusion of reference.
B. Cotards syndrome is associated with psychotic depression.
C. Fregoli syndrome is the commonest type of delusional misidentification syndrome.
D. Ekboms syndrome tends to occur in people in their 20s or 30s.
E. Erotomania has the same gender distribution as Othello syndrome.

Question 2: Which ONE of the following statements regarding Othello syndrome is FALSE?
A. Associated with a poor prognosis.
B. Associated with impotence and personality disorders.
C. Does not occur when a partner is being sexually unfaithful.
D. More common in males than females.
E. Has a high rate of recurrence.

Question 3: Which ONE of the following statements is TRUE?
A. The hallucinations in Charles Bonnet syndrome tend to be poorly formed.
B. Couvade syndrome is peaks in the second month of pregnancy.
C. Diogenes syndrome is associated with the hoarding of useful objects.
D. Munchausen syndrome has a different gender distribution to Gansers syndrome.
E. Gansers syndrome is associated with a clouding of consciousness.

Questions 4-8: Uncommon psychiatric syndromes
A. Lycanthropy
B. De Clerambaults syndrome
C. Fregoli syndrome
D. Couvade syndrome
E. Folie a deux
F. Capgras syndrome
G. Charles Bonnet syndrome
H. Othello syndrome
I. Cotards syndrome
J. Diogenes syndrome
For each of the scenarios below, choose the single most likely diagnosis from the above list of options.
Each option may be used once, more than once or not at all.
4. A 32 year old woman is in love with Hugh Grant, despite the fact that they have never
personally met one another. She is convinced that he loves her from the way he looked over
his shoulder in his latest film. She has been arrested on several occasions for trying to gain
access to studios that have been filming him in scenes for his various films in order to
proclaim her love. She is becoming increasingly more annoyed that her love letters and
telephone calls to the studios have not been answered by Hugh Grant.
5. A man physically assaults his partner and insists that she confess to her affair. The partner
denies than any affair took place.
6. I am able to detect some slight difference in look or gesture or intonation of voice in my
relatives, and this is enough to confirm my belief that they are impersonators.
7. A 25 year old man barks like a dog and walks around on all four limbs due to his belief that
he is a dog.
8. A man develops labour pains at the same time that his wife goes into labour.

178

1. B
2. C
3. E
4. B
5. H
6. F
7. A
8. D

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