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Ministry of Health of Ukraine Bukovynian State Medical University




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Ministry of Health of Ukraine

Bukovynian State Medical University


“Approved”

on the methodical meeting

of the Department of neurology, psychiatry

and medical psychology nm. S.M.Savenko

“____” ___________ 2009 (Report № __).

Chief of the Department

_______________________

Professor V.M. Pashkovsky


Methodical INSTRUCTION

for 4-th year students of medical faculty №2

(the speciality “medical affair”)

for independent work during preparing to practical class


Theme 24-25: schizophrenia. basic hypotheses of pathogenesis. clinical forms and types of motion. treatment of the patients with schizophrenia.


MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY


Topical module 6. Polyetiological mental disorders.


Сhernivtsi, 2009


1. Actuality of theme:

Schizophrenia is a chronic, severe, and disabling mental disorder that affects approximately 1 percent of the population at some point in their lifetime. The disorder often develops earlier in men, usually in the late teens or early twenties, while women typically develop the disorder in their twenties and early thirties. People with schizophrenia often experience hallucinations (usually hearing voices not heard by others) or delusions (believing that other people are reading their minds, controlling their thoughts, or plotting to harm them). Persons with schizophrenia usually have disturbed interpersonal relationships.  They are often fearful and withdrawn, with disorganized speech and behaviour.  Treatment almost always includes medications.  Newer medications are more effective than older ones and have fewer side effects.


2. Duration of practical classes - 4 hours.


3. ^ EDUCATIONAL PURPOSE

3.1. To know:

  1. The definition of schizophrenia.

  2. Etiology and pathogenesis of schizophrenia.

  3. Clinical manifestations of schizophrenia.

  4. The kinds of flowing of schizophrenia.

  5. Classification of the forms of schizophrenia.

  6. Clinical manifestations of heboid schizophrenia.

  7. Clinical manifestations of simple schizophrenia.

  8. Clinical manifestations of catatonic schizophrenia.

  9. Clinical manifestations of paranoid schizophrenia.

  10. The types of remission of schizophrenia.

  11. Clinical manifestations of schizoaffective disorder.

  12. Clinical manifestations of schizotypal disorder.

  13. Clinical manifestations of delusional disorder.

  14. Diagnosis of schizophrenia.

  15. Treatment of patients on schizophrenia.


3.2. Able:

  1. To reveal basic symptoms of schizophrenia.

  2. To diagnose debut of schizophrenia.

  3. To diagnose nuclear forms of schizophrenia.

  4. To determine the types of flowing of schizophrenia.

  5. To determine the types of remission of schizophrenia.

  6. To diagnose schizoaffective and schizotypal disorders.

  7. To reveal chronic delusional disorder.

  8. To treatment of patients on schizophrenia.

  9. To organize rehabilitative measures of patients on schizophrenia.


3.3. To capture practical skills:

  1. To collect anamnesis in patients on schizophrenia.

  2. To collect family anamnesis.

  3. To diagnose the disorders of thinking of patients on schizophrenia.

  4. To diagnose the emotional disorders of patients on schizophrenia.

  5. To diagnose the disorders of behaviour of patients on schizophrenia.

  6. To diagnose nuclear forms of schizophrenia.

  7. To conduct differential diagnosis of schizophrenia.

  8. To prescribe a treatment of patients on schizophrenia.

  9. To prescribe rehabilitative measures of patients on schizophrenia.

  10. To conduct prophylactic and psychohygienic work with patients on schizophrenia and their families.



^ 4. INTERSUBJECT INTEGRATION (base level of preparation).


Names of previous disciplines

Skills are got


1. Normal and pathologic physiology.


2. General psychology.


3. Medical psychology.


4. Medical genetic.


1. To know physiology and pathologic physiology of thinking, emotion and will activity, types of HNA.

2. To know and determine psychological features thinking, emotion and behaviour of human.

3. To describe state of thinking, emotional, will activity of different types of personality.

4.To possess of methods examination genetic diseases of human.


5. Advices to students.


5.1. ^ CONTENTS OF THEME.

Etiology. The etiology of schizophrenia is not understood com­pletely, but there are several theories concerning the probable cas­ual factors of this disorder. The majority of authors agree that it is an illness with hereditary predisposition. Schizophrenia sometimes develops in people with organic brain damage. In many cases it starts after some additional harmful influence, which acts as a trig­ger mechanism and precipitates the onset of the disorder. Such harmful factors include psychological trauma, psychoactive sub­stances abuse, in rare cases - physical illness, overstrain or child delivery. In many cases, though, schizophrenia develops in the ab­sence of any obvious trigger factors. Sometimes the patients have specific pre-morbid personality features, like lack of close social relationships, reserve, and emotional coldness.

Suggested factors in the etiology of schizophrenia: I.Predisposing (genetic, social circumstances). II. Precipitating (trigger) - acute life stress. III. Maintaining (chronic life stress, family emotional reactions).

GENETICS. Evidence for inheritance. Schizophrenia is more common in the families of schizophrenic patients than in the general population (where the lifetime risk is a little less than 1%). Thus among the siblings of schizophrenics the risk is about 14%; among the chil­dren of one schizophrenic parent it is about 13%, and among the children of two schizophrenic parents it is about 37%. Twin stu­dies indicate that a major part of this familial loading is likely to be due to genetic rather than to environmental factors. The strik­ing finding is that among monozygotic twins the concordance rate (the frequency of schizophrenia in the sibling of the affected twin) is consistently higher (about 50%) than among dizygotic twins (about 17%). Adoption studies confirm the importance of genetic factors: the likelihood of developing schizophrenia in children who have been separated at birth from a schizophrenic parent and brought up by non-schizophrenic adoptive parents is no less than that in children brought up by their own schizophrenic parent.

Although twin studies point to genetic factors, they indicate that environmental factors are also important, for even among identi­cal twins half the siblings do not develop schizophrenia. The na­ture of these environmental factors will be considered later; at this stage the mode and mechanism of inheritance of the genetic fac­tors will be considered briefly.

The mode of inheritance. The mode could be monogenic (that is caused by a single gene), polygenic (that is caused by the cu­mulative effect of several genes), or heterogeneous (that is schizophrenia could be not one disorder but several, each caused by a different gene or genes). Despite much research, it is not known which of these modes of inheritance operates in schizophrenia.

^ Two main mechanisms have been sug­gested: disordered brain biochemistry and abnormal brain devel­opment.


Disordered brain biochemistry. Disordered brain biochemistry has been suggested for three reasons; first, many genetic disorders are caused by this mechanism; second, the response of some schiz­ophrenic symptoms to antipsychotic drugs suggests that they have a biochemical basis; third, the abuse of amphetamine, a drug which increases dopamine functions, can induce a disorder like schizophre­nia. A disorder of dopamine transmission has been suggested, main­ly because effective antipsychotic drugs reduce dopaminergic func­tion in the brain. Despite extensive research, there is still no con­vincing evidence that disordered activity of dopaminergic systems is the cause of schizophrenia.

Abnormal brain development (organic brain damage). It has recently been suggested that abnormal brain development is a cause of some cases of schizophrenia. Several strands of evidence sug­gest that some kind of disorder of brain development could be im­portant in the etiology of schizophrenia, but the ideas are specu­lative. First, “soft signs” (neurological signs which do not point to a local lesion in the brain) have been reported in adults with schiz­ophrenia, suggesting a neurological abnormality of some kind. Sec­ond, schizophrenics are more likely than other people to have a history of obstetric complications, and these could have caused brain damage.

It has been suggested that there may be two groups of schizo­phrenics. In the first group, the disorder begins before the mid-twenties, with mainly negative symptoms, minor neurological ab­normalities, evidence of temporal lobe abnormality, and a chronic course. The second group has mainly positive symptoms of schiz­ophrenia, no neurological abnormalities, and a more benign course. These ideas are stimulating new research, but as yet there is not enough evidence to be certain whether there are two such groups.

Environmental factors. Environmental factors can predispose to the development of schizophrenia, precipitate the onset, provoke relapse after initial recovery, and maintain the disorder in persist­ing cases.

Predisposing factors: it has been suggested that adverse living conditions contribute to etiology, since rates of schizophrenia are higher among people living in areas of social deprivation. Howev­er, this association could arise because people who are developing schizophrenia tend to be ineffective socially and therefore move into socially deprived residential areas (“social drift”). Schizophre­nia is more frequent among people of low social class and this as­sociation could be explained similarly: either life in a lower social class environment is stressful, or people who are developing schiz­ophrenia tend to move into jobs that are of lower social class.

The important precipitating (trigger) factors of schizophrenia are stressful events occurring shortly before the onset of the disorder. Maintaining factors include chronic family stress, particularly strongly expressed feelings among family members (“high emotional expression”, often referred to as “high EE”). Some schizophrenics are highly aroused (as judged by physiological measures). It has been suggested that social withdrawal is a protective mechanism to reduce arousal, and that strongly expressed feelings within the family provoke relapse by increasing arousal.

Finally it has been suggested that inconsistent forms of child-rearing predispose to schizophrenia, but such ideas are not support­ed by evidence. Unfortunately they have had the consequence of engendering unjustified guilt in some parents.

Epidemiology. The annual incidence of schizophrenia is between 0.1 and 0.5 per 1,000 of the population, with the highest rates be­ing among young men and women aged between 35 and 39 years. The point prevalence of schizophrenia is between 2.5 and 5.3 per thousand (substantially higher than the incidence because some cases become chronic). The lifetime risk of developing schizophre­nia is about 1 in 100 (7.0-9.0 per thousand).


The types of debut of schizophrenia:

I. Acute beginning of disease:

1. Maniac-like debut.

2. Depressive debut.

3. Delirious debut.

4. Epileptic form debut.


II. Gradually beginning of disease:

1. Affective willing impoverishing of person.

2. Anti social debut.

3. Mannered-bizarrerie debut

4. Psychoasthenic debut.

5. Neurosthenic (astheno-hypochondrical) debut

6. Hysteric debut

7. Hallucination-delusion debut.

These above mentioned kinds of debut may be connected each with other.


Schizophrenia







The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. The most important psychopathological phenomena include thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussing the patient in the third person; thought disorders and negative symptoms.

The course of schizophrenic disorders can be either continuous, or episodic with progressive or stable deficit, or there can be one or more episodes with complete or incomplete remission. The diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedate the affective disturbance. Nor should schizophrenia be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal. Similar disorders developing in the presence of epilepsy or other brain disease should be classified under F06.2, and those induced by psychoactive substances under F10-F19 with common fourth character .5.

F20.0




Paranoid schizophrenia







Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances. Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.







Paraphrenic schizophrenia

F20.1




Hebephrenic schizophrenia







A form of schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate, thought is disorganized, and speech is incoherent. There is a tendency to social isolation. Usually the prognosis is poor because of the rapid development of “negative” symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults.

F20.2




Catatonic schizophrenia







Catatonic schizophrenia is dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods. Episodes of violent excitement may be a striking feature of the condition. The catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic hallucinations.







Catatonic stupor
Schizophrenic: catalepsy, catatonia , flexibilitas cerea

F20.3




Undifferentiated schizophrenia







Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes in F20.0-F20.2, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics.







Atypical schizophrenia

F20.4




Post-schizophrenic depression







A depressive episode, which may be prolonged arising in the aftermath of a schizophrenic illness. Some schizophrenic symptoms, either “positive” or “negative”, must still be present but they no longer dominate the clinical picture. These depressive states are associated with an increased risk of suicide. If the patient no longer has any schizophrenic symptoms, a depressive episode should be diagnosed (F32.-). If schizophrenic symptoms are still florid and prominent, the diagnosis should remain that of the appropriate schizophrenic subtype (F20.0-F20.3).

F20.5




Residual schizophrenia







A chronic stage in the development of a schizophrenic illness in which there has been a clear progression from an early stage to a later stage characterized by long- term, though not necessarily irreversible, “negative” symptoms, e.g. psychomotor slowing; underactivity; blunting of affect; passivity and lack of initiative; poverty of quantity or content of speech; poor nonverbal communication by facial expression, eye contact, voice modulation and posture; poor self-care and social performance.

F20.6




Simple schizophrenia







A disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. The characteristic negative features of residual schizophrenia (e.g. blunting of affect and loss of volition) develop without being preceded by any overt psychotic symptoms.

F21




Schizotypal disorder







A disorder characterized by eccentric behaviour and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies occur at any stage. The symptoms may include a cold or inappropriate affect; anhedonia; odd or eccentric behaviour; a tendency to social withdrawal; paranoid or bizarre ideas not amounting to true delusions; obsessive ruminations; thought disorder and perceptual disturbances; occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation. There is no definite onset and evolution and course are usually those of a personality disorder.







Latent schizophrenic reaction
Schizophrenia:
· borderline
· latent
· prepsychotic
· prodromal
· pseudoneurotic
· pseudopsychopathic
Schizotypal personality disorder

F22




Persistent delusional disorders







Includes a variety of disorders in which long-standing delusions constitute the only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic or affective. Delusional disorders that have lasted for less than a few months should be classified, at least temporarily, under F23.-.

F22.0




Delusional disorder







A disorder characterized by the development either of a single delusion or of a set of related delusions that are usually persistent and sometimes lifelong. The content of the delusion or delusions is very variable. Clear and persistent auditory hallucinations (voices), schizophrenic symptoms such as delusions of control and marked blunting of affect, and definite evidence of brain disease are all incompatible with this diagnosis. However, the presence of occasional or transitory auditory hallucinations, particularly in elderly patients, does not rule out this diagnosis, provided that they are not typically schizophrenic and form only a small part of the overall clinical picture.







Paranoia
Paranoid:
· psychosis
· state
Paraphrenia (late)
Sensitiver Beziehungswahn

F23




Acute and transient psychotic disorders







A heterogeneous group of disorders characterized by the acute onset of psychotic symptoms such as delusions, hallucinations, and perceptual disturbances, and by the severe disruption of ordinary behaviour. Acute onset is defined as a crescendo development of a clearly abnormal clinical picture in about two weeks or less. For these disorders there is no evidence of organic causation. Perplexity and puzzlement are often present but disorientation for time, place and person is not persistent or severe enough to justify a diagnosis of organically caused delirium (F05.-). Complete recovery usually occurs within a few months, often within a few weeks or even days. If the disorder persists, a change in classification will be necessary. The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.

F24




Induced delusional disorder







A delusional disorder shared by two or more people with close emotional links. Only one of the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s) and usually disappear when the people are separated.







Folie а deux
Induced:
· paranoid disorder
· psychotic disorder




F25




Schizoaffective disorders







Episodic disorders in which both affective and schizophrenic symptoms are prominent but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes. Other conditions in which affective symptoms are superimposed on a pre-existing schizophrenic illness, or co-exist or alternate with persistent delusional disorders of other kinds, are classified under F20-F29. Mood-incongruent psychotic symptoms in affective disorders do not justify a diagnosis of schizoaffective disorder.

F25.0




Schizoaffective disorder, manic type







A disorder in which both schizophrenic and manic symptoms are prominent so that the episode of illness does not justify a diagnosis of either schizophrenia or a manic episode. This category should be used for both a single episode and a recurrent disorder in which the majority of episodes are schizoaffective, manic type.







Schizoaffective psychosis, manic type
Schizophreniform psychosis, manic type

F25.1




Schizoaffective disorder, depressive type







A disorder in which both schizophrenic and depressive symptoms are prominent so that the episode of illness does not justify a diagnosis of either schizophrenia or a depressive episode. This category should be used for both a single episode and a recurrent disorder in which the majority of episodes are schizoaffective, depressive type.

F25.2




Schizoaffective disorder, mixed type







Cyclic schizophrenia
Mixed schizophrenic and affective psychosis

^ Types of flowing of schizophrenia:

I. Chronic flowing – continuous-progredient type. It develops during many years and finishes specific dementia.

II. Fits-like progredient type – with acute fits and periods remission. Result in defect of personality.

III. Fits-like type (reccurent) - with acute fits (flashes, as maniac and depressive phase) and periods remission after its. Result in defect of personality. Defect of personality is insignificant.

IV. Constant (stationary) – flowing of disease is unchanged during years.


^ Types of remission of schizophrenia:

I. Complete (remission A) – total disappear positive symptoms and preserves insignificant negative symptoms.

II. Incomplete (remission B) – significant lowering positive symptoms and preserves temperate negative symptoms (work ability is limited).

III. Incomplete (remission C) - temperate lowering positive symptoms, significant defect of personality (work ability is total lost).

IV. Partially (remission D) – lowering of acuity flowing of disease (patients need in treatment).

Treatment

The treatment of schizophrenia can be divided into that for the acute illness and that for chronic disability. In both, the best re­sults are obtained when drugs and social treatment are combined. This account first describes the methods and then explains how they are employed in everyday practice.

^ Antipsychotic drugs

Treatment of acute schizophrenia. Antipsychotic drugs have an immediate sedative effect, followed by an effect on symptoms (par­ticularly hallucinations and delusions). The second effect may take up to 3 weeks to develop fully. The various antipsychotic drugs do not differ in therapeutic effectiveness but have different side-effects. Hence it is seldom appropriate to change a drug that has been taken in full dose without undue side-effects because another drug is unlikely to be more effective. However, it is appropriate to change a drug when side-effects prevent full dosage. For an acutely ill patient, treatment usually begins with .chlorpromazine 100 mg three times a day or an equivalent dose of another com­pound; if there is no response the dose can be increased, but sel­dom exceeds 900 mg of chlorpromazine a day; information should be checked with the manufacturer’s literature or a work of refer­ence. When large doses are given, an anticholinergic drug is often required to prevent the development of acute dystonic reactions, akathisia, or parkinsonian effects.

Treatment after the Acute Phase. Many controlled trials have shown that continued oral or depot medication generally prevents relapse. However, some patients remain well without drugs, whilst other relapse despite continuing medication. Unfortunately it is not possible to predict which patients will benefit from continuing drug treatment, and the clinician has to decide by reducing the drugs cautiously when the patient has been free from symptoms for sev­eral months, or by increasing them carefully if there has been no response to ordinary doses.

Since long-continued antipsychotic medication may lead to irre­versible dyskinesias, it is important to avoid unnecessary treatment by reducing dosage cautiously from time to time, increasing it again if symptoms return. Since anticholinergic drugs may increase the likelihood of dyskinesia, they should not be prescribed routinely but only if there are troublesome extrapyramidal side-effects. Many pa­tients fail to take oral medication regularly over long periods, and therefore depot injections are generally more effective.

Antidepressants. As explained already, depressive symptoms are common among patients with schizophrenia. When the symptoms are severe, antidepressant medication can be given, though with less confidence of success than in depressive disorder. Antidepres­sants are indicated also in schizoaffective disorder. Lithium is ben­eficial for schizoaffective disorder, particularly when there is a mix­ture of schizophrenic and manic symptoms. (Lithium is not of val­ue for schizophrenia.)

^ Electro-convulsive therapy. The principal indications for ECT in schizophrenia are (a) when there are severe depressive symptoms accompanying schizophre­nia, and (b) in the rare cases of catatonic stupor. ECT is often rap­idly effective in both these conditions, ECT may also be effective in acute episodes of schizophrenia, even without severe depression or stupor, but it is seldom used because drug treatment is simpler and equally beneficial.

Social treatment and rehabilitation. Much of the skill in treating schizophrenia is in arranging an environment that is optimally stimulating. With insufficient stimulation negative symptoms increase; with too much stimulation po­sitive symptoms become more pronounced. To achieve the desired balance, attention has to be given to the patient's accommodation his work, and his leisure activities. As explained above, strong emo­tional reactions by relatives are a potent form of stress; therefore an effort should be made to reduce such reactions with family counselling. If this effort is unsuccessful, the patient may choose to live in a hostel, a group home, or lodgings. A homeless patient may also live in such accommodation. Similar attention needs to be given to finding suitable work (if necessary in sheltered sur­roundings) and suitable leisure activities for the patient.

As mentioned above, social measures also include support for relatives who may themselves be stressed.

Psychotherapy. Counselling for the patient and relatives is an essential part of treatment. Dynamic psychotherapy has not been shown to be effective, however, and is not part of the treatment for schizophrenia.


^ 5.2. Theoretic QUESTIONS:

  1. The definition of schizophrenia.

  2. Etiology of schizophrenia.

  3. Pathogenesis of schizophrenia.

  4. Basic clinical manifestations of schizophrenia.

  5. The types of debut of schizophrenia.

  6. Classification of the forms of schizophrenia.

  7. Clinical manifestations of heboid schizophrenia.

  8. Clinical manifestations of simple schizophrenia.

  9. Clinical manifestations of catatonic schizophrenia.

  10. Clinical manifestations of paranoid schizophrenia.

  11. The kinds of flowing of schizophrenia.

  12. The types of remission of schizophrenia.

  13. Clinical manifestations of schizoaffective disorder.

  14. Clinical manifestations of schizotypal disorder.

  15. Clinical manifestations of delusional disorder.

  16. Diagnosis of schizophrenia.

  17. The methods of treatment of patients on schizophrenia.

  18. Urgent help at hallucination-delusion excitement.

  19. Urgent help at heboid excitement.

  20. Urgent help at catatonic excitement.

  21. Supporting therapy of patients on schizophrenia.

  22. Rehabilitative measures of patients on schizophrenia.



5.4. Material for self-contrrol.


A. Questions of self-controls:

1. The definition of schizophrenia.

2. Etiology of schizophrenia.

3. Pathogenesis of schizophrenia.

  1. Basic clinical manifestations of schizophrenia.

5. The types of debut of schizophrenia.

6. Classification of the forms of schizophrenia.

  1. Clinical manifestations of heboid schizophrenia.

  2. Clinical manifestations of simple schizophrenia.

  3. Clinical manifestations of catatonic schizophrenia.

  4. Clinical manifestations of paranoid schizophrenia.

  5. The kinds of flowing of schizophrenia.

  6. The types of remission of schizophrenia.

  7. Clinical manifestations of schizoaffective disorder.

  8. Clinical manifestations of schizotypal disorder.

  9. Clinical manifestations of delusional disorder.

  10. Diagnosis of schizophrenia.

17. The methods of treatment of patients on schizophrenia.

18. Urgent help at hallucination-delusion excitement.

19. Urgent help at heboid excitement.

20. Urgent help at catatonic excitement.

21. Supporting therapy of patients on schizophrenia.

  1. Rehabilitative measures of patients on schizophrenia.


B. TESTS:

1. What is most probably reason for beginnings of schizophrenia?

A. Inheritance

B. External factors

C. Endocrine disoders

D. Infection-allergic factors

E. Products of decay of carbons metabolism

2. What syndrome is specific for schizophrenia?

A. Depressive state

B. Maniac state

C. Kandinski-Clerambault’s syndrome

D. Dysphoric state

E. Amnestic disorientation


3. Next signs are specific of catatonic form of schizophrenia, except:

A. Dupre’s symptoms

B. Maniac ideas

C. Waxen flexibility

D. Negativism

E. Autism


4. Next signs are specific of paranoid form of schizophrenia, except:

A. Persecutory delirium

B. Kandinski-Clerambault’s syndrome

C. Pseudo hallucination

D. Psychical automatism

E. Mutism


5. Next signs are presence about emotional stupidity, except:

A. Indifference to myself and surrounding people

B. Emotional coolness to relatives

C. Decreasing of intensive activity

D. Decreasing of energetic potential

E. Melancholic delusion


6. Specific signs are presence about abulia, except:

A. Lowering of libido

B. Loosing of impulse to action

C. Agoraphobia

D. Loosing of physical and psychical activity

E. Lowering interest to environment


7. Next nuclear form of schizophrenia there are all, except alone:

A. Simple

B. Heboid

C. Hypertoxic

D. Paranoid

E. Catatonic

8. Next disoders of psychical function are specific of schizophrenia, except:

A. Thinking

B. Emotion

C. Will

D. Memory

E. Speech


9. Schizophrenia has next basic symptoms, except:

A. Emotional stupidity

B. Euphoria

C. Paralogic thinking

D. Abulia

E. Intra psychical ataxia


10. What is basic syndrome of schizophrenia:

A. Senestopathia

B. Intra psychical ataxia

C. Amentia

D. Metamorphopsia

E. Confabulation


11. Next signs are specific of paranoid form of schizophrenia, except alone:

A. Non systematized delusions

B. Kandinski-Clerambault’s syndrome

C. Psychical automatism

D. Atactic incoherence of speech

E. Amential confusion


12. Terminal state of schizophrenia is characterized by:

A. Apato-abulic syndrome

B. Paranoid delirium

C. Paraphrenic delirium

D. Confabulations

E. Obsessive states


13. Schizophrenia has next signs, except:

A. Progressing

B. Intra psychical ataxia

C. Estrangement from reality

D. Paramnesia

E. Ambivalents of fillings


14. What is philosophizing judgement:

A. Rapidity of thought

B. Echo of thoughts

C. Disposition to futile judgements

D. Symptom of “deja vu”

E. Echo mnesia


15. Heboid (hebephrenic) form of schizophrenia is characterized by:

A. Emotional lability

B. Mutism and negativism

C. Slowing of movements

D. Frolicsome, incongruous behaviour

E. Amnesia


16. Next signs are specific of catatonic form of schizophrenia, except alone:

A. Mutism

B. Stupour

C. Waxen flexibility

D. Impulsive actions

E. Imbecility


17. Next signs are specific of simple form of schizophrenia, except alone:

A. Improverishing of psychical life

B. Autism

C. Blunting of affect and loss of volition

D. Symbolic thinking

E. Non-malignant flowing


18. Simple form of schizophrenia does begin?

A. in 14-20 years

B. in 8-13 years

C. in 21-34 years

D. in 35-40 years

E. after 100 years


19. What is basic method of treatment of patients with schizophrenia?

A. Hormone therapy

B. Insulin comatose therapy

C. Convulsion therapy

D. Psychopharmacologic therapy

E. Psychotherapy


20. What medicines are using in patients with paranoid form of schizophrenia?

A. Haloperidol

B. Zoloft

C. Cipramil

D. Amitriptilin

E. Meliril


21. Next medicines are used in patients with schizophrenia, except:

A. Clopicsol

B. Risperidon

C. Zipreksa

D. Fluanksol

E. Fluoksitin


22. All medicines are atypical anti psychotic means, except:

A. Zipreksa

B. Rispolept

C. Solian

D. Clopicsol

E. Etaperasin

^ C. Situational tasks

1. A 27-year-old man was hospitalized to the psychiatric hospital for the 4-th time during 2 years. He hears voices commenting on his actions, has delusions of persecution (is sure that the Mafia wants to kill him). After a course of treatment with neuroleptics is discharged from hospital with the diagnosis of schizophrenia, state of remission. The secondary prevention of the relapses of schizophrenia requires:

A. Participation in a self-help group

B. Long-term hospitalization

C. Supportive treatment with neuroleptics of prolonged action

D. Psychiatric observation

E. Psychoanalytic treatment


2. A patient is 16 y.o. In the last year his behaviour has gradually changed: he secluded himself, was not interested in communication with friends, in learning. He became indifferent towards relatives, motivelessly rude, was speaking or laughing to himself. He answers the questions formally correctly, laconically. Considers he to be absolutely healthy but a little tired, says, he's thinking about writing a book "Projection of humanity on the plane of Universe". He always has a copy-book with which is full of a great many of the same daggers. What is the most probable diagnosis?

A. Schizophrenia

B. Schizoid personality disorder

C. Pick's disease

D. Depressive disorder

E. Autistic personality disorder


3. The observed patient’s movements are retarded, she answers no questions. Sometimes she spontaneously stays in strange postures. It is possible to set [form] her body and limbs into different positions artificially. If the psychiatrist lifts her arm or leg, so that she remains standing on the other leg, the patient can stay in such a position for quite a long time. Name the probable disorder.

A. Catatonic stupor, shizophrenia

B. Depressive stupor, bipolar disorder

C. Apathetic stupor, shizophrenia

D. Psychogenic stupor, stress disorder

E. Dissociative stupor, dissociative psychosis


4. The patient complains that all the police forces in the country are after him, and there are many “spies” in the department. He states that certain persecutors aim at taking away his money and remove him from his position at work. His awareness is not disturbed. The orientation in space and time is normal. His insight is impaired, the patient is sure he is sane. The behaviour corresponds to his thoughts and experiences; the patient demands justice, writes letters to different official bodies, asking to defend him from the ac­tions of the “spies”.

Name the probable form of shizophrenia:

A. Simple

B. Heboid

C. Hypertoxic

D. Paranoid

E. Catatonic

5. The patient was brought to the reception department of a psychiatric hos­pital by policemen. At the reception department the patient is tense and angry. He states that his neighbour has established in his flat an apparatus, with which he records all the patient’s thoughts and inserts his own thoughts into his head. Sometimes with the help of special equipment the neighbour broadcasts pro­grams, in which offends the patient in different ways. Recently the neighbour made the patient walk in the wrong direction, use obscene language in public, and produced artificial cheerfulness in him. The patient attacked his neigh­bour and tried to stab him with a knife. Name the probable syndrome:

A. Fregoly syndrome

B. Da Casta’s syndrome

C. Cotard’s syndrome

D. Syndrome of intermetamorphose

E. Clerambault-Kandinsky syndrome


6. A male teenager (15 years old) with a normal level of intelligence and no conduct disorders before the age of 14, is characterized by rudeness, neg­ativism, perverted emotional reactions and drives with antisocial tendencies. His attitude to others, especially members of his family, is often cruel, he seems to enjoy hurting people. At school he sometimes bites or pinches girls painfully, and says that he does this because he “likes them”. He often of­fends and beats his grandmother and mother, when they “irritate” him. Name the form of shizophrenia:

A. Simple

B. Heboid

C. Hypertoxic

D. Paranoid

E. Catatonic


7. A female patient, 42 years old, is disabled (invalid of 2-nd group) owing to her mental disorder. At the inpatient department of a psychiatric hospital spends most of her time in bed, talking to herself. The patient ex­plained, that she was hearing “voices” of a big group of people, who “at­tached” themselves to her head with the help of complicated equipment. These people’s brains were joined with her brain into a kind of system, so she is able to exchange thoughts with them and follow their instructions. These phenomena change her mood, suppress her will and “turn her into a robot”. The patient is sure that other people know her thoughts. What medicine is not using in this case?

A. Clopicsol

B. Risperidon

C. Zipreksa

D. Fluanksol

E. Fluoksitin


8. Patient S., male, 52 years old, an actor by profession, during a re­hearsal suddenly began to bite others and fool about: he ran around the stage, made faces, laughed loudly, tore the decorations, recited senseless rhymes, which he made up himself, then jumped down into the orchestra pit. Didn’t let anyone come near him, was aggressive and used dirty language when peo­ple tried to stop or catch him. Before anyone could stop him, the patient sud­denly ran out into the street shouting, “Art for the masses!” Name the probable syndrome:

A. Maniacal excitation

B. Catatonic excitation

C. Hysterical excitation

D. Agitated depression

E. Hebephrenic excitation


9. A patient wrote an official letter to the police bodies: “Please defend me against a group of bandits. They have secretly inserted a radio transmit­ter in my brain, and with it put bad thoughts into my head. They have cov­ered all my feelings with a glass lid. Intending to control me, the move my tongue and make me say rude and dirty words, fill my head with their con­versations. I have changed, and now feel myself like a robot”. Can’t be dis­suaded. Name the syndromal diagnosis:

A. Clerambault-Kandinsky syndrome

B. Paranoid syndrome

C. Paraphrenic syndrome

D. Paranoiac syndrome

E. Cotard’s syndrome


^ 6. RECOMMENDED LITERATURE IS:

6.1. Basic:

  1. Clinical Psychiatry from Synopsis of Psychiatry by H.I.Kaplan, B.J.Sadock. – New York: Williams @ Wilkins. – 1997.

  2. Psychiatry. Course of lectures. – Odessa: The Odessa State Medical University. – 2005. – 336 p.

  3. Lectures.

  4. Internet resource.

6.2. Additional:

  1. Морозов Т.В., Шумский Н.Г. Введение в клиническую психиатрию. – Н.Новгород: Изд-во НГМА, 1998.

  2. Попов Ю.В., Вид В.Д. Современная клиническая психиатрия. – М., 1997.

  3. Сонник Г.Т. Психіатрія: Підручник / Г.Т.Сонник, О.К.Напрєєнко, А.М.Скрипніков. – К.: Здоров’я, 2006.     


Prepared by assistant S.D.Savka


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