🔑 Key Learning
- Schizophrenia is a chronic psychotic disorder characterised by hallucinations, delusions, and disordered thought
- First-rank symptoms (Schneider’s criteria) are highly suggestive of schizophrenia
- Management includes antipsychotics, CBT, and family support
- Clozapine is reserved for treatment-resistant cases
- Specific named delusional syndromes may feature in MCQs
🧠 Overview
- A psychotic disorder involving disruption of perception, thought, and affect
- Symptoms may be continuous or relapsing-remitting
⚠️ Risk Factors (Ranked by Risk Ratio)
- Family history – RR 8
- Ethnicity – highest risk in Afro-Caribbean populations – RR 5
- Migration – RR 3
- Cannabis use – RR 1.5
👀 Clinical Features
Schneider’s First-Rank Symptoms
-
Auditory hallucinations:
- Voices in the third person
- Thought echo or running commentary
-
Disorders of thought:
- Thought insertion – the belief that one’s thoughts have been planted by another
- Thought withdrawal – the belief that one’s thoughts are being ‘stolen’
- Thought broadcast – the belief that one’s thoughts are being broadcast to others
-
Passivity phenomena:
- Feeling that actions/sensations are being externally controlled
-
Delusional perception:
- Assigning delusional meaning to a normal sensory experience
- e.g. “It is windy today, so I will score 100% in this exam”
Other Features
- Social withdrawal and isolation
- Apathy and flat affect
- Catatonia or abnormal posturing
💊 Management
First-line
-
Oral antipsychotic (first or second generation) + psychosocial support:
- CBT
- Family intervention
- Art therapy
Preferred antipsychotics (second generation / atypical):
Atypical (2nd gen) antipsychotics are often preferred due to lower risk of EPSEs.
- Olanzapine
- Risperidone
- Aripiprazole
- Quetiapine
- Amisulpride
Clozapine
- Reserved for treatment-resistant schizophrenia
- Indicated if no response to ≥2 antipsychotics over 6–8 weeks
-
Adverse effects:
- Agranulocytosis: requires regular FBC monitoring
- Constipation
- Hypersalivation: treat with hyoscine butylbromide
🧩 Named Delusional Syndromes
| Syndrome | Description |
|---|---|
| Cotard Syndrome | Belief that one is dead or body part is missing |
| De Clérambault Syndrome | Belief that a celebrity/idol is in love with the patient |
| Delusional Parasitosis | Fixed belief of being infested with insects or parasites |
| Othello Syndrome | Pathological jealousy; belief that partner is cheating without evidence |
| Folie à deux | Shared delusion between two closely connected individuals |
| Capgras Delusion | Belief that a familiar person has been replaced by an impostor |
| Fregoli Syndrome | Belief that different people are actually the same person in disguise |
👁️ Charles-Bonnet Syndrome
- Visual or auditory hallucinations in patients with visual impairment
- Preserved lucid consciousness and insight
-
Common in:
- ARMD
- Glaucoma
- Cataracts
- Key feature: patients know the hallucinations are not real
📝 Exam Clues & Clinchers
- Third-person auditory hallucinations + thought broadcast → first-rank symptoms → schizophrenia
- Thought insertion + delusional perception → first-rank symptoms → schizophrenia
-
Longstanding schizophrenia + poor response 2+ antipsychotics → consider clozapine
- Monitor FBC for agranulocytosis
- Hallucinations + visual impairment + intact insight → Charles-Bonnet Syndrome
- Fixed belief of infestation → delusional parasitosis
- Delusion of being dead → Cotard syndrome
- Shared delusion between relatives → folie à deux