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Schizophrenia

Self-assessment
Multiple choice questions

1. Concerning the symptoms of schizophrenia:


a. Delusions are often of a persecutory type
b. Tactile hallucinations are common
c. Ideas of reference are common
d. Insight is usually impaired
e. Negative symptoms are strong predictors of
outcome
Multiple choice questions
1. Concerning the symptoms of schizophrenia:
Options Answers
a. Delusions are often of a a. True. They are often
persecutory type bizarre.
b. Tactile hallucinations are b. False. They occur only in
common around 20% of patients;
auditory hallucinations are
common.
c. Ideas of reference are c. True. If they become fixed
common and unshakable, they
become delusions.
Multiple choice questions

1. Concerning the symptoms of schizophrenia:


Options Answers
d. Insight is usually d. True. Some insight may
impaired be retained and this needs
to be assessed for
management.
e. Negative symptoms are e. True. They predict a poor
strong predictors of outcome.
outcome
Multiple choice questions

2. Schizophrenia:
a. Is more common in women
b. Is mainly a disorder of Western culture
c. Has a peak age at onset of 23-28 years
d. Is linked to increased rates of suicide
e. Is mainly caused by stress
Multiple choice questions
2. Schizophrenia:
Options Answers
a. Is more common in a. False. There is an equal
women gender distribution.
b. Is mainly a disorder of b. False. It is seen all over
Western culture the world.

c. Has a peak age at onset c. True.


of 23-28 years
Multiple choice questions

2. Schizophrenia:
Options Answers
d. Is linked to increased d. True. Patients have high
rates of suicide rates of suicide.
e. Is mainly caused by stress e. False. Schizophrenia is
predominantly a brain
disorder.
Multiple choice questions

3. Factors that make recovery from schizophrenia


more difficult include:
a. A stable and supportive family background
b. Continued abuse of illicit drugs
c. Failure to comply with medication
d. A strong family history of schizophrenia
e. Continued abuse of alcohol
Multiple choice questions
3. Factors that make recovery from schizophrenia more
difficult include:
Options Answers
a. A stable and supportive a. False. The family is often the principle
family background source of caregivers.
b. Continued abuse of b. True. Street drug use is an important
illicit drugs precipitating factor and continued use
impairs recovery.
c. Failure to comply with c. True. This is common in those who are
medication erratic in clinic attendance, have no fixed
home or refuse regular treatment.
Multiple choice questions
3. Factors that make recovery from schizophrenia more
difficult include:
Options Answers
d. A strong family history of d. True. Risks are increased
schizophrenia 15-fold in first-degree
relatives.
e. Continued abuse of e. True.
alcohol
Multiple choice questions

4. Good prognostic factors in schizophrenia include:


a. An insidious onset of symptoms
b. Being female
c. An early age at onset (e.g. 14 years of age)
d. Marked negative symptoms
e. Early treatment
Multiple choice questions
4. Good prognostic factors in schizophrenia include:
Options Answers
a. An insidious onset of a. False. This indicates a
symptoms poor prognosis.

b. Being female b. True.

c. An early age at onset (e.g. c. False. Early onset


14 years of age) indicates a poor prognosis.
Multiple choice questions
4. Good prognostic factors in schizophrenia include:
Options Answers
d. Marked negative d. False. These have poor
symptoms prognosis and are difficult to
treat.
e. Early treatment e. True. The eventual
outcome worsens with the
length of time for which
active psychotic symptoms
are untreated.
Multiple choice questions
5. Assertive outreach:
a. Involves a multidisciplinary team
b. Monitors patients with the most mild disorders
in case they become worse
c. Provides close supervision and treatment for
patients with dual diagnosis and challenging
behavior
d. Involves a large patient-to-staff ratio
e. Is of proven efficacy in the UK
Multiple choice questions
5. Assertive outreach:
Options Answers
a. Involves a multidisciplinary a. True. Usually all members of
team the team are familiar with the
patient.
b. Monitors patients with the b. False. It is only for the most
most mild disorders in case they severely ill who are difficult to
become worse keep engaged in services.
c. Provides close supervision and c. True. Dual diagnosis usually
treatment for patients with dual implies patients with
diagnosis and challenging schizophrenia and illicit drug
behavior misuse.
Multiple choice questions
5. Assertive outreach:
Options Answers
d. Involves a large patient- d. False. There is a small
to-staff ratio number of patients per staff
(usually 10:1) as the
treatment is intensive.
e. Is of proven efficacy in e. false. Although evidence
the UK from the USA has indicated
benefit, the results of UK
studies are equivocal.
Case history questions
History 1
Jane had a normal childhood and did well academically
at school. In her second year at university, following the
break-up of a relationship, she developed over the
course of a week auditory hallucinations of voices
talking about her and commenting on what she was
doing. She believed firmly that a university lecturer had
implanted an electronic device in her head that could
control her thoughts.
Case history questions

History 1
After being seen by her GP, she was referred urgently to
mental health services where she was assessed jointly
by a nurse and a psychiatrist. She was admitted to the
day hospital. After routine investigations were normal,
she was treated with haloperidol 5 mg daily. After 3
weeks, her hallucinations had subsided and she
recognized that her beliefs had been mistaken. She
continued to improve over the next month and was able
to return to her studies after a further month.
Case history questions
history 1
Questions:
1. What positive symptoms did Jane have?

2. What is the differential diagnosis?

3. What good prognostic factors are present?


Case history questions
history 1

1. What positive symptoms did Jane have?


Answers: Jane is describing classical passivity
experiences in that she has delusional ideas about
being controlled by an external agency. She also is
experiencing third person auditory hallucinations
and a running commentary.
Case history questions
history 1
2. What is the differential diagnosis?

Answers: The most likely diagnosis is schizophrenia


because of the presence of first rank symptoms and the
absence of any symptoms indicating a manic episode. In
a young person, it is always important to exclude a drug-
induced psychosis, which could mimic schizophrenia.
Other possible diagnoses include other organic factors
that could produce a schizophreniform psychosis.
Case history questions
history 1
3. What good prognostic factors are present?
Answers: Good prognostic factors include the rapid onset
of the condition, precipitated by a life event; the rather
florid symptoms; the evidence for a normal childhood
without evidence of a schizoid premorbid personality; and
the return to normal following the illness without any
negative symptoms ( e.g. blunting of affect, lack of
motivation, etc. )
Case history questions
History 2
Jason's childhood was normal. His paternal uncle was
treated for schizophrenia. He left school with basic
qualifications at age 16. He worked as a forklift truck
driver. From age 18 he used cannabis and
amphetamines regularly. Following his 21st, birthday,
his mother and his friends became concerned that he
spent increasing periods of time in his bedroom. His
mother found pieces of paper in his room with scribbled
messages about the CIA (Central Intelligence Agency)
following him.
Case history questions
History 2
He told a friend that he was being watched because he
had invented a machine that converted air to water. He
refused to see his GP and began to refuse his food
because he believed it was poisoned. He was seen at
home by a psychiatrist, social worker and GP. He did not
wish to be admitted to hospital. After considering
whether involuntary admission was needed, it was
decided to monitor and treat him at home. Physical
investigations were normal. He took chlorpromazine and
improved over the next month but was still concerned
that he might be watched.
Case history questions
History 2
His mother noticed that his self-care was less good than
previously. He suffered stiffness and dry mouth from his
drug treatment and stopped it secretly. His symptoms
returned after 1 month; but he still refused hospital
admission. After taking a small overdose of his tablets,
he was admitted to a psychiatric unit under a section of
the Mental Health Act. After a 6 week admission, he was
discharged back home with regular support visits from a
community psychiatric nurse. He was given a monthly
depot intramuscular injection of fluphenazine
decanoate.
Case history questions
history 2

Questions:
1. What types of delusion did Jason develop?

2. On what grounds was he detained under the


Mental Health Act?
Case history questions
history 2

1. What types of delusion did Jason develop?

Answers: Jason developed persecutory delusions.


Case history questions
history 2
2. On what grounds was he detained under the
Mental Health Act?
Answers: He was admitted under the Mental Health
Act because he had a mental disorder, he was at risk
to himself, he refused to be admitted on a voluntary
basis and there was no other reasonable alternative
to treatment.
Case history questions
History 3
Steven had slightly slower milestones at walking and
talking than his elder siblings. At primary school he was a
timid child with few friends. At secondary school, he was
bullied and for periods refused to attend. At 13, years of
age, he was referred to child mental health services
because of persistent nightmares. He told the assessment
team that he knew his room was haunted and he could
hear murmuring from under his bed. He did not re-attend
the clinic. His schoolteacher noticed that he seemed
distracted and was whispering to himself.
Case history questions
History 3
At age 15 he was reassessed and admitted to an
adolescent mental health unit. He was noticed to be
grimacing and smiling incongruously. His computed
tomographic scan showed slight enlargement of his
lateral ventricles, which was within normal limits. He
complained that his movements were being controlled
by ghosts. A diagnosis of schizophrenia was made. He
commenced low-dose haloperidol, which was changed
to risperidone after he suffered a dystonic reaction.
Case history questions

History 3
His delusions improved but he was still
withdrawn and spoke little. He returned to the
family home with visiting support but was
frightened to return to his bedroom. He left
home unannounced the next week. Three
months later he was found sleeping rough in a
nearby town, dishevelled, emaciated and
muttering to himself. He was re-admitted to a
psychiatric unit for further treatment.
Case history questions
history 3

Questions:
1. What negative symptoms has Steven developed?

2. What poor prognostic factors have been present?


Case history questions
history 3
1. What negative symptoms has Steven developed?

Answers: He showed evidence of lack of self-care,


poor motivation and little spontaneous speech.
Case history questions
history 3
2. What poor prognostic factors have been present?
Answers: He shows evidence of soft neurological
signs during childhood, and insidious onset of the
disease, a very early onset of the disease (age 13),
negative symptoms, poor compliance with
treatment and little insight into his illness.

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