32 - Schizophrenia Flashcards
What are the diagnoses in Schizophrenia spectrum and other psychotic disorders?
Diagnoses
- Schizophrenia
- Psychotic Disorders
- Schizotypal(personality) Disorders
What is the definition of Schizophrenia?
Abnormalities in 1 or More of 5 Domains
- Delusions
- Hallucinations
- Disorganized Thinking and/or Speech
- Grossly Disorganized or Abnormal Motor Behavior including Catatonia
- Negative Symptoms
Define delusions
Delusions: fixed beliefs that are not amenable to change in light of conflicting evidence
Define persecutory delusions
When you are harmed or harassed by a delusion
Define referential delusions
When gestures, comments or environmental cues seem to be directed at oneself
Define grandiose delusions
When individual believes they have exceptional abilities, wealth or fame
Define erotomanic delusions
When the individual believes falsely that another person is in love with them
Define nihilistic delusions
Delusions that involve a conviction that a major catastrophe will occur
Define somatic delusions
Delusions that involve preoccupation regarding health and organ function
Define hallucinations
Perception-like experiences that occur without an external stimuli
- Vivid and clear
- Full force
- Impact normal perceptions
- Not under voluntary control
Define auditory hallucinations
Usually voices, familiar or not, distinct from the individual’s own thoughts
Define disorganized thinking (speech)
- A diagnosis inferred from the individual’s speech
- It must impair communication
- It is a less severe
impairment that occurs in prodromal and residual phase of schizophrenia
What are the different types of disorganized thinking?
- Derailment or loose associations (switching from topic to topic)
- Tangentiality (answers to questions are unrelated to the question)
- Incoherence or “word salad” (resembles receptive aphasia)
What types of grossly disorganized or abnormal motor behavior do we see in schizophrenia?
- May manifest in a variety of ways from childlike “silliness” to unpredictable agitation
- The old definition used to just be catatonia (stiffness or other sign), but now it is expanded
- Problems may be noted in any goal directed behavior
What are negative symptoms?
These symptoms account for the morbidity of schizophrenia, but are less prominent in other psychotic disorders
- Diminished emotional expression
- Avolution
- Alogia
- Anhedonia
- Asociality
Describe diminished emotional expression
- Reductions in the expression of emotions in the face, eye contact and intonation of speech
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Describe avolution
Decrease in motivated self initiated purposeful activities
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Describe alogia
Diminished speech output
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Describe anhedonia
Decreased ability to experience pleasure from positive sminuli or degradation in the recollection of pleasure previously experienced
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Describe asociality
Lack of interest in social interactions
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What are schizotypal disorders?
A pervasive pattern of social and interpersonal deficits marked by…
- Discomfort or inability to have close relationships
- Cognitive and perceptual distorions
- Eccentricities of behavior
This begins in adulthood and is present in a variety of contexts
Must have all of these…
- Ideas of reference
- Odd beliefs or magical thinking
- Unusual perceptual experiences including body illusions
- Odd thinking or speech
- Suspicious or paranoid ideation
More common in males***
When do we see schizotypal disorders?
- They do NOT occur during the course of other conditions such as schizophrenia, bipolar or depressive disorder
- Even when psychoses occur during this conditions, it is not considered schizotypal disorder
- It is NOT part of autism spectrum
I CAN be premorbid to schizophrenia and in this case, it should be stated as such
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What is delusional disorder?
The presence of 1 or more delusions with a duration of ONE MONTH
KNOW ONE MONTH ***
What is the prevalence of delusional disorders?
- Most frequent subtype is persecutory (belief that one is being conspired against) ***
- Jealous type is more common in males than females ***
- No major gender differences in frequency overall
What is brief psychotic disorder?
- Presence of delusions, hallucinations, disorganized speech, catatonic behavior
- Presence of at least ONE DAY, but not more than ONE MONTH with the eventual return to premorbid functioning **
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What is the prevalence of brief psychotic disorder?
- May account for 9% of the first onset psychosis in the US
- Those with time frames of 1-6 months as opposed to 1 month are found more in developing countries ***
- 2x more common in females than males
What is schizophreniform disorder?
When two or more of the following symptoms are present for a significant time during a ONE MONTH period ***
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized movement (catatonia)
- Negative symptoms (diminished emotional expression or avolition)
Note: Episode lasts at least ONE MONTH, but less than SIX MONTHS ***
What is the long-term outcome of those who develop schizophreniform disorder
1/3 recover in 6 months
2/3 go on to have schizophrenia or schizoaffective disorder
Define schizophrenia
Two or more of the following present for a significant time during a 1 month period
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized behavior (catatonia)
- Negative symptoms
Continuous signs of disturbance must persist for at least 6 months with 1 month of active symptoms ***
What are the associated features supporting the diagnosis of schizophrenia?
MOST EMPHASIZED SLIDE ***
ALL IN RED…
- Lack of insight into their illness (anosognosia) and this is a symptom, not a coping strategy
- Similar to lack of awareness of neurological deficits following brain damage (anosognosia)
- This predicts non-adherence to treatment and proper outcomes
KNOW THIS ***
They don’t get it because they CAN’T get it ***
What is the prevalence of schizophrenia?
Lifetime prevalence is 0.3% to 0.7% with variation by race. country, origin
Describe the difference in disease course between males and females
Males
- Onset in early-mid 20s
- Poorer premorbid adjustment
- Lower education
- More structural brain abnormalities
- More negative symptoms
- More cognitive impairment
- Poorer outocmes
- Limited social contacts, do not typically marry
Females
- Later onset (late 20s), lower incidence
- Fewer brain abnormalities
- Less cognitive impairment
- Better outcomes
- Only 25% develop before the age of 30
- Symptoms more affect laden
- More psychotic symptoms
- Symptoms worsen later in life
- Greater tendency for late onset after age 40
What is schizoafective disorder?
- Uninterupted period of illness during which there is a major mood episode (major depressive or manic mood) concurrent with criteria for schizophrenia
** Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness **
What is the prevalence of schizoaffective disorder?
- 1/3 as common as schizophrenia
- Lifetime prevalence of 0.3%
- Higher in females
What is one cause of psychotic disorders?
Substances and medications ***
There is a whole list of drugs that cause problems ***
How common are substance/medication induced psychotic disorders?
7-25% of individuals with the first episode of psychosis are reported to have the substance/medication induced type
Describe psychotic disorder due to another medical disorder
Associated with the diagnosis of one of the following…
- Neurological conditions
- Endocrine conditions
- Metabolic conditions
Which type of medical disorders leading to psychotic disorders have an increased rate of suicide associated with their diagnosis?
Neurological conditions ***
Neoplasm, cerebrovascular disease, Huntington’s, MS, epilepsy, auditory or visual nerve injury, deafness, migraine, CNS infection
What is the prevalence of psychotic disorder due to another medical disorder?
- Lifetime prevalence is 0.21% to 0.54%
- When stratified by age in those older than 65, it is as high as 0.74%
Describe the comorbidities seen in psychotic disorder due to another medical disorder
If psychotic and older than 80, the medical condition is a major neurocognitive disorder (dementia)
What is catatonia?
Clinical picture is dominated by 3 or more of the following
- Stupor (not relate to the environment)
- Catalepsy (passive induction of posture against gravity)
- Waxy Flexibility (slight even resistance to positioning)
- Mutism (very little to no verbal response)
- Negativism (opposition or no response to external stimuli)
- Posturing (spontaneous and active maintenance of a posture against gravity)
- Mannerism (odd, circumstantial caricature of normal actions)
- Stereotypy (repetitive, abnormal, frequent non-goal directed movement)
- Agitation not influenced by external stimuli
- Grimacing
- Echolalia (mimic speech)
- Echopraxia (mimic movements)
What is the main theory for the development of schizophrenia?
Glutamate theory ***
- Altered receptor densities and subunit composition in hippocampus and prefrontal cortex
What are the histopathological changes we see in schizophrenia?
KNOW THIS ***
- Decreased volume of hippocampus, thalamus, temporal and prefrontal cortex
- Decreased total gray matter volume
- Cyto-architectural abnormalities
- Absence of gliosis-suggests developmental abnormality
- Evidence of abnormal cell migration in hippocampus and frontal cortex
- Caudate volume decreased in neuroleptic naïve; increased with neuroleptic exposure
- Evidence of decreased synaptic connectivity
What are the neuroimaging changes we see in schizophrenia?
KNOW THIS ***
Neuroimaging changes:
- Lateral and third ventricle are enlarged
- Bilateral (L>R), approximately 10% volume reduction
- If present at time of diagnosis this may progress to poor outcome patient
- Larger ventricles in affected discordant monozygotic twins
What are the functional brain imaging changes we see in schizophrenia?
KNOW THIS ***
Functional Brain Imaging:
- Hypofrontality at rest in chronic patients may correlate with negative symptoms
- Consistent failure to activate prefrontal cortex during performance of cognitive task (deficit syndrome)
- Temporal lobe activity increased at baseline-impaired activation in response to memory task
What are the neuropsycholigical functioning changes we see in schizophrenia?
Neuropsychological Functioning:
- Deficits in attention, memory, executive functioning
- Cognitive deficits present at the time of diagnosis may progress
- Cognitive deficits predict the level of functioning
What are the acute treatment options for psychosocial disorders?
- Containment, reduce stimulation, develop alliance
- Avoid medication side effects and involve patients in medication selection
- Educate and support family and significant others
Medication is NOT the answer all the time –> 75% is meds, the rest is other things
What are the long term treatment options for psychosocial disorders?
Evidence based practices
- Assertive Community Treatment
- Integrated Treatment for Co-occurring Disorders
- Supported Employment
Illness Management and Recovery
- Family Psycho-education
- Permanent Supportive Housing*** (#1)
- Med TEAM (Medication Treatment, Evaluation and Management)
- Consumer-Operated Services
- Interventions for Disruptive Behavior Disorders
- Treatment of Depression in Older Adults
- Supported Education
What is assertive community treatment?
- Teach them everything (cleaning, banking, check meds)
- Decreases hospitalizations
- Outcome = decreases medical complications (better follow through and patient compliance)
What is the number one evidence based practice in the long term treatment of psychosocial disorders?
Permanent supportive housing ***
Describe violence in schizophrenics
Homicide rate may be increased by 10 fold but still less than 1% of the population
Describe victimization in schizophrenics
As a group they are more frequently victimized than other individuals
Describe suicide in schizophrenics
- Suicide risk is 10-15 % (20% with schizophrenia) with the highest risk the first 5 years of illness
- 5-6% of those with Schizophrenia/ Schizoaffective disorder die by suicide
KNOW SUICIDE ***
