777 schizophrenia

Question 1

PSYCHOSIS:

Answer 1

symptom state that refers to the presence of reality misinterpretations, disorganized thinking, and lack of awareness regarding true and false reality.

Question 2

Schizophrenia is Defined by abnormalities in 1 of the following 5 domains

Answer 2

Delusions
Hallucinations
Disorganized thinking
Grossly disorganized or abnormal motor behavior, including catatonia
Negative symptoms

Question 3

Delusions

Answer 3

Fixed false beliefs:

Question 4

Delusions: Persecutory:

Answer 4

belief that one is going to be hurt, harassed by an individual organization

Question 5

Delusions: Referential:

Answer 5

belief that certain gestures, comments, environmental cues are directed at oneself

Question 6

Delusions: Grandiose:

Answer 6

belief that one has exceptional abilities, wealth or fame

Question 7

Delusions: Erotomanic:

Answer 7

belief that another person is in love with him or her

Question 8

Delusions: Nihilistic:

Answer 8

belief that a major catastrophe will occur

Question 9

Delusions: Somatic:

Answer 9

beliefs and preoccupations regarding health and organ function

Question 10

Delusions defined as bizarre when:

Answer 10

they are clearly implausible and not understandable to same culture peers

Question 11

Thought withdrawal:

Answer 11

thoughts have been removed by an outside force

Question 12

Thought insertion:

Answer 12

thoughts have been put into one’s mind

Question 13

Delusions of control:

Answer 13

one’s body or actions are being manipulated by an outside force

Question 14

Hallucinations

Answer 14

Perception like experiences that occur without an external stimulus
Vivid, clear with the full-force and impact of normal perceptions
Not under voluntary control
Occur in any sensory modality: auditory, visual, olfactory, tactile, gustatory
Auditory most common:

Question 15

Disorganized Thinking (Speech)

Answer 15

Formal thought disorder

Inferred from person’s speech

Loose associations/derailment

Tangential speech

Word salad

Must be severe enough to substantially impair effective communication

Question 16

Grossly Disorganized or Abnormal Behavior

Answer 16

Catatonic: marked decrease in reactivity to the environment

Range from resistance to instructions to complete lack of verbal or motor responses (mutism, stupor)

Catatonic excitement: excessive motor activity without a purpose/cause

Usually associated with schizophrenia

Can be present in Bipolar Disorder, MDD and some medical conditions

Question 17

Negative Symptoms

Answer 17

Associated with schizophrenia
Diminished emotional expression
Avolition: lack of motivation
Alogia: inability to speak
Anhedonia: lack of pleasure
Asociality	
Account for a substantial portion of the morbidity associated with schizophrenia

Question 18

Schizophrenia

Answer 18

Clinical syndrome of variable but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior

Estimated to account for approximately 2.5 percent of all health care costs

Not a homogeneous disorder with a single cause

WHO one of the 10 leading causes of disability

Question 19

Schizophrenia Diagnostic Criteria

Answer 19

Criteria A. Two or more of the following, present for a significant amount of time during a one month period, at least one of the symptoms must be 1, 2 or 3

1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms

Question 20

Schizophrenia Diagnostic Criteria (continued)

Answer 20

Criteria B. Level of functioning in one or more major area such as work, interpersonal relations, or self care is markedly below the level achieved prior to onset

Criteria C. Continuous signs persist for at least 6 months, must include one month of Criteria A

Criteria D. Schizoaffective disorder and bipolar disorder have been ruled out

Criteria E. Disturbance not attributable to physiological effects of a substance or another medical condition

In autism spectrum or communication disorders, the additional diagnosis of schizophrenia is made if delusions and hallucinations are present

Question 21

Schizophrenia Epidemiology

Answer 21

Lifetime prevalence in the US is 1%
Higher incidence in urban areas of industrialized nations
Found in all societies and geographic areas
Only about ½ of all patients with schizophrenia obtain treatment
Equally prevalent in men and women
Onset earlier in men
Peak age of onset 10-25 years in men, 25-35 years for women
1st degree biological relatives of persons with schizophrenia have a 10 times greater risk for developing the disease
Persons with schizophrenia have a higher mortality rate
80% of patients have significant concurrent medical illnesses
More likely to have been born in winter and early spring
Prenatal exposure to influenza
Substance abuse common co-morbidity and associated with poorer function
90% of persons with schizophrenia may be dependent on nicotine
Patients with schizophrenia account for 15-45% of the homeless population in US
Occupy 50% of all psychiatric inpatient beds

Question 22

Biochemical Factors

Answer 22

Dopamine hypothesis: schizophrenia results from too much dopaminergic activity
Serotonin excess
GABA loss in hippocampus

Question 23

Anatomical Abnormalities

Answer 23

Ventricular enlargement
Sulci enlargement
Cerebellar atrophy
Decreased frontal lobe size

Question 24

Positive Symptoms

Answer 24

A. Hallucinations
B. Delusions
C. Illusions
D. Disorganized
     Thinking 
E. Bizarre behavior

Question 25

Negative Symptoms

Answer 25

``` A. Flat affect B. Anhedonia C. Avolition D. Social Isolation E. Diminished Self-Care ```

Question 26

Mental Status Exam

Answer 26

Appearance: ranges from disheveled, screaming, agitated to obsessively groomed, completely silent and immobile Affect: reduced emotional responsiveness or overly active, inappropriate, flat Mood: depressed, anxious, anhedonic Perceptual disturbances: hallucinations Thought disorders Impulsiveness, violence, suicide and homicide Orientation usually oriented to time place and person Memory: usually intact Cognitive impairment: subtle cognitive dysfunction in attention, executive functioning, working memory, episodic memory Judgment and insight: poor insight

Question 27

Thought Disorders found in Schizophrenia: Thought Content

Answer 27

Delusions Religiosity Paranoia Magical thinking

Question 28

Thought Disorders found in Schizophrenia: Form of Thought

Answer 28

``` Looseness of associations Neologisms Concrete thinking Clang associations Word salad Circumstantiality Tangentiality Mutism Perseveration ```

Question 29

Psychomotor Behavior

Answer 29

Anergia: lack of energy Waxy flexibility: person maintains the body position into which they were placed also called catalepsy Posturing: strange, fixed and bizarre bodily positions, also known as catatonic posturing Pacing and rocking

Question 30

Suicide Risk

Answer 30

5 - 6% of individuals with schizophrenia die from suicide 20% attempt suicide on 1 or more occasions Many have significant suicidal ideation May be related to command hallucinations Suicide risk remains high over the entire course of the illness Young males with co-morbid substance abuse at particular risk Suicide risk heightened with unemployment, feelings of hopelessness, depression, period after psychosis and hospitalization

Question 31

Violence/Impulsive Behaviors

Answer 31

Increased potential for violence in untreated schizophrenia Persecutory delusions Previous episodes of violence Persons with schizophrenia no more likely to commit homicide than the general public Assess for hx of violent behavior Dangerous behaviors while hospitalized Command hallucinations

Question 32

Comorbidities

Answer 32

``` Substance related disorders Over 50% with tobacco use disorder Anxiety disorders OCD Weight gain Diabetes Metabolic syndrome Cardiovascular disease Pulmonary disease ```

Question 33

Differential Diagnosis

Answer 33

``` Temporal lobe Epilepsy, Parkinsonism Tumor, Stroke, brain trauma, TBI Infectious encephalitis, neuro-syphilis and AIDS Autoimmune e.g. Systemic Lupus Alzheimer’s, Huntington’s Drug Induced: Stimulants: amphetamines, cocaine Hallucinogens Withdrawal from etoh, barbiturates and anticholinergics ```

Question 34

Course and Prognosis: Phase 1:

Answer 34

Premorbid personality often indicates social maladjustment, social withdrawal, irritability, antagonistic thoughts and behaviors

Question 35

Course and Prognosis: Phase 2:

Answer 35

The Prodromal Phase change in premorbid functioning and extends until the onset of frank psychotic symptoms

Question 36

Course and Prognosis: Phase 3:

Answer 36

Schizophrenia psychotic symptoms are prominent

Question 37

Course and Prognosis: Phase 4:

Answer 37

Residual Phase characterized by remission and exacerbation, negative symptoms may remain

Question 38

Course and Prognosis (continued)

Answer 38

Course includes remission and exacerbation 5-10 years after 1st psych hospitalization 50% of patients have poor outcome with repeated hospitalizations 20-30% of individuals with schizophrenia able to live somewhat normal lives 20-30% moderate symptoms 40-60% significantly impaired

Question 39

Treatment

Answer 39

``` Hospitalization Partial hospitalization day programs Pharmacotherapy ECT Psychosocial Therapies Social skills training Family oriented therapies Case management PACT Group therapy CBT Art therapy ```

Question 40

Hospitalization

Answer 40

Acute psychosis Suicidal ideation Homicidal ideation Threatening behavior Grossly disorganized or inappropriate behavior Severe agitation Inability to care for self Treatment of acute psychosis focuses on safety and alleviating the most severe symptoms May use IM antipsychotics combined with benzodiazepine, most commonly Lorazepam (Ativan)

Question 41

Pharmacotherapy

Answer 41

First generation antipsychotics or typical antipsychotics (FGA) Associated with immediate and long term motor problems Second generation antipsychotics or atypical antipsychotics (SGA) Less likely to cause EPS and TD Equally effective SGA’s more widely used Symptom reduction usually in 1-2 weeks 50% of patients respond, 25% partial and 25% no response Goal is reduction in positive symptoms

Question 42

Typical or First Generation Antipsychotics (FGA’s)

Answer 42

Prolixin (Fluphenazine) Haldol (Haloperidol) Thorazine (Chlorpromazine) Trilafon (Perphenazine)

Question 43

Atypicals or Second Generation Antipsychotics (SGA’s)

Answer 43

``` Abilify (Apiprazole) Risperdal (Risperidone) Zyprexa (Olanzapine) Seroquel (Quetiapine) Geodon (Ziprasidone) Clozaril (Clozapine) Invega (Paliperidone) ```

Question 44

medication , continued

Answer 44

``` Titrate slowly Goal is reduction in positive symptoms Before initiation of medication baseline weight and BMI, vital signs, fasting plasma glucose and lipid profile Treatment for 1 year after remission Lifelong treatment in patients with primary psychotic disorders Black box warning in the elderly Clozapine special category ```

Question 45

Clozapine (Clozaril)

Answer 45

First effective antipsychotic with low EPS Patients who have failed standard therapies Associated with substantial risk of agranulocytosis Assess for infection (sore throat, fever) report immediately Risk for myocarditis Needs close monitoring of WBC First 6 months weekly Second 6 months bi-monthly Maintenance monthly Slow titration up to 300mg/QD

Question 46

SGA’s Side Effects

Answer 46

``` All SGA’s share a class warning for causing Weight gain Dyslipidemia Type II Diabetes Accelerated cardiovascular disease ```

Question 47

Metabolic Syndrome with SGA’s

Answer 47

Cluster of metabolic abnormalities associated with obesity and that contribute to an increased risk of Type II Diabetes Diagnosed when the patient has 3 or more of the following symptoms Abdominal obesity High triglyceride level Low HDL cholesterol level Hypertension Elevated blood glucose level Before initiation of treatment with SGA’s Baseline weight and BMI, vital signs, fasting plasma glucose and lipid profile Every three months for first 6 months Every 6 months thereafter

Question 48

Side Effects of Typical Antipsychotics

Answer 48

``` EPS: Extra Pyramidal Side Effects Cogwheeling Dystonia Akathesia Tardive dyskinesia (TD) Parkinsonianism ``` Neuroleptic Malignant Syndrome (NMS): potentially life threatening: muscle rigidity, autonomic dysregulation, fever, leukocytosis, increase in serum creatinine, acute confusion Orthostatic hypotension

Question 49

Medications Used to Counteract EPS Symptoms

Answer 49

``` Amantadine (Symmetrel) Benztropine (Cogentin) Diphenhydramine (Benadryl) Trihexyphenidel (Artane) Propranolol (Inderal) ```

Question 50

Tardive Dyskinesia

Answer 50

Syndrome characterized by abnormal involuntary movements of the patient’s face, mouth, trunk or limbs (choreoathetoid movements) Affects 20 – 30% of patients treated with antipsychotics particularly the FGA’s Monitor for symptoms using the AIMS Scale

Question 51

Psychiatric Disorders with Psychotic Symptoms

Answer 51

``` Major Depression with Psychotic Features Bipolar Disorder, Manic Episode Schizoaffective Disorder Delusional Disorders Personality Disorders: Paranoid, Schizotypal & Borderline Personality Disorder ```

Question 52

Substances Associated with Psychosis

Answer 52

``` Anxiolytics Cocaine Methamphetamine Ketamine MDMA Designer drugs Alcohol Cannabis Hallucinogens Phencyclidine Inhalants Sedatives Hypnotics ```

Question 53

Medications Associated with Psychosis

Answer 53

``` Anesthetics Analgesics Anticholinergic agents Anticonvulsants Antihistamines Antihypertensive and cardiovascular medications Antimicrobials Antiparkinsonians Chemotherapeutic agents Corticosteroids GI meds Muscle relaxants Nonsteriodal antiinflammatories Phenylephrine Pseudoephedrine Disulfram ```

Question 54

Toxins Associated with Psychosis

Answer 54

``` Anticholinesterase Organophosphate insecticides Sarin Carbon monoxide Volatile substances: fuel, paint ```

Question 55

Psychoeducation

Answer 55

``` Nature of the illness Symptoms Coping mechanisms Course of the illness Management of the illness Connection b/w stress and symptom exacerbation Medication side effects Importance of medication adherence Importance of diligent monitoring of medication adherence When to alert health care provider Emergency plans ``` ``` Support services Financial assistance Legal assistance Caregiver support groups NAMI Club house model Respite care Home health care ```

Question 56

Other DSM Psychotic Disorders

Answer 56

Delusional Disorder Brief Psychotic Disorder Substance/Medication Induced Psychotic Disorder Psychotic Disorder Due to Another Medical Condition Catatonic Disorder due to Another Medical Condition Schizophreniform Disorder Schizoaffective Disorder Unspecified Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder