Psychotic Disorders

Schizophrenia

•    First-rank (Schneiderian) symptoms:

o    Auditory hallucinations (e.g., third-person "running commentary")

o    Thought insertion, withdrawal, broadcasting

o    Passivity phenomena (delusions of control)

o    Delusional perception (ordinary perception given bizarre significance)

•    Positive symptoms:

o    Hallucinations, delusions, disorganised thought and behaviour

•    Negative symptoms:

o    Apathy, alogia (poverty of speech), anhedonia, affective flattening, social withdrawal

•    Epidemiology:

o    Lifetime prevalence ≈1%

o    Onset: young adulthood (men ~20s, women ~late 20s)

•    Neuroimaging:

o    Enlarged lateral and third ventricles

o    Reduced cortical grey matter, especially temporal lobes

•    Prognostic factors:

o    Better: acute onset, precipitating stressor, good premorbid function, predominantly positive symptoms, female sex

o    Worse: insidious onset, negative symptoms, early onset, family history

Other psychotic disorders

•    Schizoaffective disorder:

o    Both mood disorder (depressive or manic) and schizophrenia criteria met during the same episode

o    Must have ≥2 weeks of psychotic symptoms alone (without mood symptoms)

•    Delusional disorder:

o    Persistent non-bizarre delusions (e.g., persecutory, grandiose, erotomanic) >3 months

o    Minimal functional impairment; hallucinations rare

•    Brief psychotic disorder:

o    Sudden onset psychosis <1 month

o    Often linked to severe stress

•    Substance/medication-induced psychosis:

o    Drugs: amphetamines, cocaine, steroids, LSD, cannabis

o    Consider in sudden onset or atypical features

Treatment

•    Antipsychotics:

o    Typical (first-generation):

    E.g., haloperidol, chlorpromazine

    More extrapyramidal side effects (EPS): acute dystonia, akathisia, parkinsonism, tardive dyskinesia

    Neuroleptic malignant syndrome (NMS): rigidity, fever, autonomic instability, raised CK; stop drug, give dantrolene

o    Atypical (second-generation):

    E.g., risperidone, olanzapine, quetiapine

    Less EPS, more metabolic syndrome risk (weight gain, diabetes, dyslipidaemia)

    Risperidone: hyperprolactinaemia

    Quetiapine: sedation

o    Clozapine:

    Indicated for treatment-resistant schizophrenia (failure of ≥2 antipsychotics)

    Agranulocytosis risk → regular FBC monitoring

    Other risks: myocarditis, seizures, sialorrhoea

•    Psychosocial interventions:

o    CBT for psychosis

o    Family therapy

o    Supported employment

Extra Revision Pearls

•    EPS management:

o    Acute dystonia: benztropine or procyclidine

o    Akathisia: beta-blockers (e.g., propranolol)

o    Tardive dyskinesia: switch to clozapine

•    Depot preparations: used to improve adherence

•    Substance misuse: strong association with worse outcomes (especially cannabis)

•    Schizophrenia risk factors:

o    Genetic (monozygotic twin concordance ~50%)

o    Urban upbringing

o    Obstetric complications