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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
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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 They are often fearful and withdrawn, with disorganized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.
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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
1. Normal and pathologic physiology.
2. General psychology.
3. Medical psychology.
4. Medical genetic.
Skills are got
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.
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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.
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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
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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
F23
F24
F25
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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
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.
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 à deux
Induced:
· paranoid disorder
· psychotic disorder
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.
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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
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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.
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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.
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
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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
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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
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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
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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
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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