"Psychotic Disorders" — Practice

Question 1

Prominent visual hallucinations in a newly psychotic patient most strongly suggest

Accepted Answer

B

Question 2

Clozapine is indicated after failure of

Accepted Answer

B

Question 3

A 19-year-old is brought with three days of agitation, visual hallucinations of insects, and disorientation worse at night. He is febrile. Most likely diagnosis and approach?

Accepted Answer

This is delirium until proved otherwise, not a first episode of schizophrenia.

Four features point away from a primary psychotic illness: prominent visual rather than auditory hallucinations, disorientation, fluctuation with worsening at night, and fever indicating a physical cause. Schizophrenia occurs in clear consciousness with preserved orientation.

Management is to search for the cause with full examination, blood count, cultures, glucose, electrolytes, renal and liver function, toxicology and, where indicated, imaging and lumbar puncture, while treating agitation with the minimum necessary sedation. Admitting him to a psychiatric bed on an antipsychotic without investigation risks missing a treatable and potentially fatal illness.

Question 4

A 22-year-old has two years of declining function, has stopped attending college, sits alone and speaks little, with no hallucinations or delusions. His family call him lazy. Interpret.

Accepted Answer

This is likely the negative symptom syndrome of schizophrenia, comprising avolition, alogia, blunted affect and asociality, possibly preceded by an unnoticed or brief positive phase.

The interpretation matters because negative symptoms are routinely attributed to laziness or poor character, which delays diagnosis by years and damages the family relationship.

The clinical task is to distinguish primary negative symptoms from their mimics: depression, which carries pervasive low mood, guilt and hopelessness; antipsychotic-induced parkinsonism, which adds bradykinesia and rigidity; and understimulation from an impoverished environment.

The prognostic implication is significant. Prominent negative symptoms and insidious onset both predict worse outcome, and antipsychotics do relatively little for them, so psychosocial intervention and supported employment carry proportionally greater weight.

Question 5

A 45-year-old has believed for three years that a colleague is stealing his research. He works normally, has no hallucinations, and functions well otherwise. Diagnosis, and why is it easily missed?

Accepted Answer

Delusional disorder, characterised by a single circumscribed delusional system with preserved functioning outside it.

It is missed because the patient does not look unwell. There is no thought disorder, no hallucination, no self-neglect and no functional decline, so the belief is often taken at face value, particularly where it concerns something plausible such as workplace conflict or infidelity.

These patients typically come to attention through occupational or legal routes, after complaints, litigation or confrontation, rather than by seeking psychiatric help, because they locate the problem outside themselves.

Assessment requires careful separation of a delusion from a justified belief, sometimes needing collateral evidence, and treatment is difficult because insight is absent and engagement is poor.

Question 6

A patient with a mood disorder becomes mute and immobile, holding limbs in odd positions when placed there, and repeating the examiner's words. The team plans haloperidol. Comment.

Accepted Answer

This is catatonia, with mutism, immobility, waxy flexibility and echolalia, and haloperidol is the wrong choice.

Catatonia is a psychomotor syndrome rather than a subtype of schizophrenia, and it occurs more often in mood disorders and organic illness than in schizophrenia, which fits this patient. Antipsychotics may worsen it and can precipitate malignant catatonia, a life-threatening state with fever and autonomic instability that closely resembles neuroleptic malignant syndrome.

The correct step is a lorazepam challenge, which is both diagnostic and therapeutic, since catatonia typically responds dramatically to benzodiazepines. Where benzodiazepines fail or the patient is deteriorating, electroconvulsive therapy is highly effective.

Alongside this, organic causes must be excluded and the underlying mood disorder treated, with attention to hydration, nutrition and thromboprophylaxis given the immobility.

Question 7

A patient has failed adequate trials of two antipsychotics over two years. The team plans a third. Comment.

Accepted Answer

The plan is defensible only if the previous trials were genuinely inadequate. Failure of two adequate trials, each at a therapeutic dose for sufficient duration with confirmed adherence, defines treatment resistance and is the indication for clozapine.

Clozapine is the only antipsychotic with established superiority in this situation and additionally reduces suicide risk. A third conventional trial has a low probability of response and postpones the only intervention likely to work, and delay itself reduces the eventual chance of response.

Before starting clozapine, adherence should be verified, since apparent resistance is frequently covert non-adherence, and a long-acting injectable is a reasonable way to establish this. Substance use, particularly cannabis, and inadequate dosing should be excluded for the same reason.

The counterargument that clozapine is burdensome is real but is usually given too much weight relative to the cost of continued active psychosis.

Question 8

A family are highly critical of a young man with schizophrenia, telling him repeatedly to make more effort. He has relapsed twice this year despite taking medication. What is the relevance?

Accepted Answer

This is high expressed emotion, comprising criticism, hostility and emotional overinvolvement, and it predicts relapse independently of medication adherence.

The relevance is therapeutic rather than merely descriptive. Family intervention that reduces expressed emotion, by providing education about the illness, reframing negative symptoms as illness rather than character, teaching communication and problem-solving, and supporting the carers themselves, has been shown to reduce relapse rates substantially.

It also reframes the family's frustration accurately. Criticism of avolition assumes the patient could try harder if he chose to, and understanding avolition as a symptom removes both the accusation and the guilt that follows it.

Practically, this patient needs family intervention alongside optimised medication. Treating medication as the only variable leaves the strongest modifiable predictor of relapse untouched, which is why he is relapsing despite adherence.

Question 9

A patient asks why his identical twin has schizophrenia and he does not, since they share the same genes. How would you explain this?

Accepted Answer

The observation is accurate and is one of the most informative facts in psychiatric genetics. Concordance for schizophrenia in monozygotic twins is around fifty per cent, not a hundred, despite identical genomes.

The explanation is that genes confer vulnerability rather than destiny. Risk is roughly one per cent in the general population, about ten per cent with an affected first-degree relative, and around fifty per cent in an identical twin, so genetic loading clearly matters, but something further is required for illness to emerge.

The neurodevelopmental model supplies the framework. Early insults to brain development, including obstetric complications and maternal infection, produce circuits that function adequately in childhood and fail when demand increases in adolescence and early adulthood. Later exposures then act on that vulnerability, with cannabis carrying the strongest evidence, particularly with early and high-potency use, alongside urban upbringing and migration.

Even identical twins differ in intrauterine environment, obstetric experience, drug exposure, life events and epigenetic modification, and it is that divergence rather than their genes that explains the difference between them.

Practice — "Psychotic Disorders"

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