Schizophrenia

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55 Schizophrenia

Fiona Hynes, Graham Murray

	T	F
1. Birth injury affects the age of onset of schizophrenia.
2. Schizophrenia is more common in those of Afro-Caribbean origin.
3. In expressed emotion, hostility is more detrimental than derogatory comments.
4. Both negative and positive symptoms lead to expressed emotion by carers.
5. The Camberwell Family Interview is a semi-structured interview to assess the level of expressed emotion.
6. Neuregulin 1 gene is implicated in the aetiology of schizophrenia.
7. Genes involved in myelination are implicated in the aetiology of schizophrenia.
8. The dysbindin gene is associated with schizophrenia.
9. In schizophrenia the gene for tau protein is abnormal.
10. 5% of elderly schizophrenics have a family history of schizophrenia in their first-degree relatives.
11. Having a relative with the disease is the largest single risk factor for schizophrenia.
12. In monozygotic twins discordant for schizophrenia, the risk of schizophrenia in their offspring is equal.
13. Oneiroid state was described by Mayer-Gross.
14. Somatization is an important factor in persistent delusional disorder.
15. Delusional disorder is associated with passivity phenomena.
16. Persistent delusional disorder is associated with persistent hallucinations.
17. There is no association between late onset schizophrenia and paranoid personality disorder.
18. The hippocampus is smaller in schizophrenia.
19. The information gating process is dysfunctional in schizophrenia.
20. The negative symptoms of schizophrenia are related to hypofunction of the pre-frontal cortex.
21. Schizophreniform psychosis associated with temporal lobe epilepsy occurs most commonly shortly after seizures.
22. In schizophrenia, intensive case management is more effective than standard care in preventing readmissions.
23. Schneiderian first-rank symptoms predict outcome in schizophrenia.
24. The mode of onset predicts prognosis in schizophrenia.
25. Expressed emotion can affect the outcome of most psychiatric disorders.

ANSWERS

1. Birth injury affects the age of onset of schizophrenia.

True: Perinatal complications have been associated with increased risk, earlier age of onset, negative symptoms and poorer prognosis of schizophrenia. The onset of schizophrenia tends to be earlier in males and in those with a positive family history, obstetric complications in gestation and delivery, especially, those that increase the risk of hypoxia, premorbid cognitive and behavioural deficits, low IQ, cannabis abuse, minor physical anomalies and deviances in brain structure (McKenna 2006, p. 128; Murray et al 1997, p. 295; Sadock & Sadock 2005, p. 1390).

2. Schizophrenia is more common in those of Afro-Caribbean origin.

True: Both Caribbean-born and UK-born Afro-Caribbeans have higher rates of schizophrenia compared to their white neighbours (Gelder et al 2000, p. 602; p. Stein & Wilkinson 1998, p. 326).

3. In expressed emotion, hostility is more detrimental than derogatory comments.

False: Expressed emotion includes critical comments, hostility, emotional overinvolvement, positive remarks and warmth. The levels of each component and their relative contributions vary across cultures. The first three are the most predictive of relapse. Further specification has not been possible (Gelder et al 2000, p. 626; Stein & Wilkinson 1998, p. 365).

4. Both negative and positive symptoms lead to expressed emotion by carers.

True: The carers of patients with schizophrenia are concerned about the negative symptoms, e.g. social withdrawal, lack of interaction, lack of interests, self-neglect, and the positive symptoms, e.g. disturbed or inappropriate behaviour and threats of violence. They can lead to expressed emotion and hence worsen the symptoms (Gelder et al 2006, p. 296).

5. The Camberwell Family Interview is a semi-structured interview to assess the level of expressed emotion.

True: The Camberwell Family Interview is a semi-structured, standardized interview to assess expressed emotion. The items are critical comments, hostility, emotional overinvolvment, warmth and positive comments. The interview is carried out with a relative and recorded on audiotape. Ratings are based on content and vocal tone (Stein & Wilkinson 1998, p. 364).

6. Neuregulin 1 gene is implicated in the aetiology of schizophrenia.

True: Abnormal glutamate neurotransmission is implicated in the aetiology of schizophrenia. An exon from the neuregulin 1 gene of chromosome 8p, called NRG1, is expressed in CNS synapses and plays a role in the expression and activation of neurotransmitter receptors, including glutamate receptors.

The Icelandic studies implicate NRG1 in the aetiology of schizophrenia. They found a core haplotype in 7.5% of the general population and in 15.4% of patients with schizophrenia. This would account for a 9% increase in risk for siblings of an affected individual. However, no single nucleotide polymorphism was associated with schizophrenia as significantly as the haplotype. This suggests that none of the identified variants were functional polymorphisms (Gelder et al 2006, p. 284; Sadock & Sadock 2005, p. 265).

7. Genes involved in myelination are implicated in the aetiology of schizophrenia.

True: Brains of patients with schizophrenia and bipolar disorders show downregulation of key oligodendrocytes and myelination genes, including transcription factors that regulate these genes, compared with control brains (Gelder et al 2006, p. 280; Wright et al 2005, p. 254).

8. The dysbindin gene is associated with schizophrenia.

True: There is an association between a single nucleotide polymorphism within the gene DTNBP1 encoding dysbindin (dystrobrevin binding protein) located on chromosome 6p22 and schizophrenia. Dysbindin is found both presynaptically and postsynaptically in a variety of neuron populations both cortically and subcortically. Dysbindin is involved in synaptic functioning and signalling. Reduced dysbindin expression has been seen in the dorsolateral prefrontal cortex, hippocampal formation and cingulate gyrus of patients with schizophrenia (Gelder et al 2006, p. 280; Wright et al 2005, p. 254).

9. In schizophrenia the gene for tau protein is abnormal.

False: Increased cerebrospinal fluid tau protein levels are considered a marker of neurodegenerative processes such as Alzheimer’s disease. The more pronounced cognitive decline in older schizophrenic patients has been hypothesized to indicate a higher risk of developing Alzheimer’s disease. However, no significant differences in cerebrospinal fluid total tau and phospho-tau levels between patients with schizophrenia and controls have been found (Schonknecht et al 2003).

10. 5% of elderly schizophrenics have a family history of schizophrenia in their first-degree relatives.

False: The genetic contribution to schizophrenia decreases with increasing age of onset. A positive family history of schizophrenia is commoner in those whose illness starts in early life or middle age. Recent studies have found no increased risk of schizophrenia in the first-degree relatives of patients with late onset schizophrenia-like psychosis. This suggests that schizophrenia-like psychoses with onset in late life are not genetically associated with schizophrenia (Butler & Pitt 1998, p. 156; Gelder et al 2006, p. 514; Johnstone et al 2004, p. 643).

11. Having a relative with the disease is the largest single risk factor for schizophrenia.

True: The most powerful risk factor for schizophrenia is having a relative afflicted with the disorder. The prevalence of schizophrenia in the general population is approximately 0.85%. The lifetime risk of developing schizophrenia in relatives of patients with schizophrenia is: parents = 5%; siblings = 10%; children = 14%; children if both parents ill = 46% (Gelder et al 2000, p. 599; Gelder et al 2006, p. 281; Stein & Wilkinson 1998, p. 329).

12. In monozygotic twins discordant for schizophrenia, the risk of schizophrenia in their offspring is equal.

True: This is because the unaffected twin has the same genetic susceptibility for developing schizophrenia as the affected twin, but for some reason the susceptibility was not expressed (Gelder et al 2006, p. 282).

13. Oneiroid state was described by Mayer-Gross.

True: Mayer-Gross proposed an organic cause for schizophrenia and introduced the term oneiroid states (Oneiroide Erlebnisform) in 1924. He described it as consisting of acute psychotic symptoms with no organic features. The patient experiences narrowing of consciousness and scenic hallucinations. It can occur in schizophrenia and in intensive care patients who have to be totally passive and dependent on others. The atmosphere is perceived as strange and dream-like. The contents of oneiroid states are often remembered.

However, Ladislas von Meduna described oneirophrenia in 1939 as a syndrome of endocrine origin characterized by acute confusion, dream-like quality of perceptions (hence the term oneirophrenia), anxiety, delusions, visual hallucinations and complete recovery (Gelder et al 2000, pp. 69, 645; McKenna 2006, p. 287; Sadock & Sadock 2005, p. 1514).

14. Somatization is an important factor in persistent delusional disorder.

False: Delusional disorder is characterized by a single set of delusions or a set of related delusions, which are usually persistent and sometimes lifelong. The content of the delusions involves situations that occur in real life such as being followed, poisoned, infected, loved at a distance, deceived by spouse or lover, or having a disease (DSM-IV 1994, p. 296; ICD-10 1992, p. 97).

15. Delusional disorder is associated with passivity phenomena.

False: Delusional disorder is characterized by a single set of delusions or a set of related delusions, which are usually persistent and sometimes lifelong. The content of the delusions involves situations that occur in real life such as being followed, poisoned, infected, loved at a distance, deceived by spouse or lover, or having a disease. Unlike in schizophrenia, the delusions are non-bizarre (DSM-IV 1994, p. 296; ICD-10 1992, p. 97).

16. Persistent delusional disorder is associated with persistent hallucinations.

False: Delusional disorder is characterized by a single set of delusions or a set of related delusions, which are non-bizarre, usually persistent and sometimes lifelong. Tactile or olfactory hallucinations may be present if they are related to the delusional theme. Clear, prominent and persistent auditory hallucinations and delusions of control are incompatible with the diagnosis (DSM-IV 1994, p. 296; ICD-10 1992, p. 97).

17. There is no association between late onset schizophrenia and paranoid personality disorder.

False: Lifelong paranoid or schizoid personality traits are found in 45% of patients with late onset schizophrenia (Gelder et al 2006, p. 514; Johnstone et al 2004, p. 644).

18. The hippocampus is smaller in schizophrenia.

True: Patients with schizophrenia have ventricular enlargement and small but significant reductions in brain weight and volume. There is volume loss in several areas including the hippocampus, prefrontal cortex and temporal cortex (Gelder et al 2006, p. 287; Stein & Wilkinson 1998, p. 344).

19. The information gating process is dysfunctional in schizophrenia.

True: When two sounds are delivered 0.5 seconds apart, normal individuals have a significantly decreased response to the second sound. A full response to the second sound occurs only if it is delayed 0.8 seconds. Thus, the two sounds of the pair are perceived quite differently, solely as a function of the time interval between them. This elementary form of habituation is called sensory gating.

The response to sound is measured using the P50 component of the auditory evoked potential. P50 is the positive wave that occurs 50 ms after the stimulus. Compared to the first sound, the amplitude of the P50 to the second sound is diminished by at least 50% in normals due to sensory gating. This inhibition of the P50 to the second sound, which is a measure of sensory gating, is impaired in most patients with schizophrenia. This may result in their inability to ignore irrelevant stimuli, resulting in feeling flooded with stimuli. They may cope by withdrawing and avoiding contact with others (Sadock & Sadock 2005, p. 1448).

20. The negative symptoms of schizophrenia are related to hypofunction of the pre-frontal cortex.

True: There is evidence from PET, SPECT and fMRI studies to suggest that the negative symptoms of schizophrenia are related to hypofunction of the dorsolateral prefrontal cortex. The hypofrontality may worsen with the duration of illness (Gelder et al 2000, p. 607; Gelder et al 2006, p. 287; Sadock & Sadock 2005, p. 1396).

21. Schizophreniform psychosis associated with temporal lobe epilepsy occurs most commonly shortly after seizures.

False: There are two types of psychoses associated with epilepsy:

1. The transient post-ictal psychosis usually starts 2–72 hours after the seizure and lasts 3–4 days. This is often associated with grandiosity, religious and mystical features.

2. Most epilepsy patients with a schizophreniform psychosis have a chronic interictal illness with no known direct relationship to ictal discharges or seizure events. The psychotic symptoms may worsen with increase in seizure frequency or anticonvulsant withdrawal. In a few, the psychosis may worsen on control of seizures. The terms alternating psychosis and forced paradoxical normalization refer to this antagonism between psychosis and seizures or EEG discharges (Johnstone et al 2004, p. 353; Mitchell 2004, p. 119; Sadock & Sadock 2005, p. 382; Yudofsky & Hales 2002, p. 683).

22. In schizophrenia, intensive case management is more effective than standard care in preventing readmissions.

False: No significant difference was found between intensive and standard case management in a 2-year follow-up study (Byford et al 2000).

23. Schneiderian first-rank symptoms predict outcome in schizophrenia.

False: First-rank symptoms are not predictors of outcome. Factors associated with good outcome include: acute onset, major precipitants, confusion or perplexity, prominent affective symptoms, female gender, good premorbid social adjustment, having no family history of schizophrenia and having a family history of affective disorder (Gelder et al 2006, p. 295; Johnstone et al 2004, p. 406; Stein & Wilkinson 1998, p. 305).

24. The mode of onset predicts prognosis in schizophrenia.

True: Acute onset, precipitating factors, older age of onset, and affective disturbance are associated with good prognosis (Gelder et al 2006, p. 295; Johnstone et al 2004, p. 406; Stein & Wilkinson 1998, p. 305).

25. Expressed emotion can affect the outcome of most psychiatric disorders.

True: Expressed emotion has been shown to predict outcome in schizophrenia, mood disorders, eating disorders and alcoholism (Johnstone et al 2004, p. 404).

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