777 schizophrenia Flashcards
PSYCHOSIS:
symptom state that refers to the presence of reality misinterpretations, disorganized thinking, and lack of awareness regarding true and false reality.
Schizophrenia is Defined by abnormalities in 1 of the following 5 domains
Delusions Hallucinations Disorganized thinking Grossly disorganized or abnormal motor behavior, including catatonia Negative symptoms
Delusions
Fixed false beliefs:
Delusions: Persecutory:
belief that one is going to be hurt, harassed by an individual organization
Delusions: Referential:
belief that certain gestures, comments, environmental cues are directed at oneself
Delusions: Grandiose:
belief that one has exceptional abilities, wealth or fame
Delusions: Erotomanic:
belief that another person is in love with him or her
Delusions: Nihilistic:
belief that a major catastrophe will occur
Delusions: Somatic:
beliefs and preoccupations regarding health and organ function
Delusions defined as bizarre when:
they are clearly implausible and not understandable to same culture peers
Thought withdrawal:
thoughts have been removed by an outside force
Thought insertion:
thoughts have been put into one’s mind
Delusions of control:
one’s body or actions are being manipulated by an outside force
Hallucinations
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:
Disorganized Thinking (Speech)
Formal thought disorder
Inferred from person’s speech
Loose associations/derailment
Tangential speech
Word salad
Must be severe enough to substantially impair effective communication
Grossly Disorganized or Abnormal Behavior
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
Negative Symptoms
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
Schizophrenia
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
Schizophrenia Diagnostic Criteria
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
Schizophrenia Diagnostic Criteria (continued)
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
Schizophrenia Epidemiology
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
Biochemical Factors
Dopamine hypothesis: schizophrenia results from too much dopaminergic activity
Serotonin excess
GABA loss in hippocampus
Anatomical Abnormalities
Ventricular enlargement
Sulci enlargement
Cerebellar atrophy
Decreased frontal lobe size
Positive Symptoms
A. Hallucinations
B. Delusions
C. Illusions
D. Disorganized
Thinking
E. Bizarre behaviorNegative Symptoms
A. Flat affect B. Anhedonia C. Avolition D. Social Isolation E. Diminished Self-Care
Mental Status Exam
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
Thought Disorders found in Schizophrenia: Thought Content
Delusions
Religiosity
Paranoia
Magical thinking
Thought Disorders found in Schizophrenia: Form of Thought
Looseness of associations Neologisms Concrete thinking Clang associations Word salad Circumstantiality Tangentiality Mutism Perseveration
Psychomotor Behavior
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
Suicide Risk
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
Violence/Impulsive Behaviors
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
Comorbidities
Substance related disorders Over 50% with tobacco use disorder Anxiety disorders OCD Weight gain Diabetes Metabolic syndrome Cardiovascular disease Pulmonary disease
Differential Diagnosis
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
Course and Prognosis: Phase 1:
Premorbid personality often indicates social maladjustment, social withdrawal, irritability, antagonistic thoughts and behaviors
Course and Prognosis: Phase 2:
The Prodromal Phase change in premorbid functioning and extends until the onset of frank psychotic symptoms
Course and Prognosis: Phase 3:
Schizophrenia psychotic symptoms are prominent
Course and Prognosis: Phase 4:
Residual Phase characterized by remission and exacerbation, negative symptoms may remain
Course and Prognosis (continued)
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
Treatment
Hospitalization Partial hospitalization day programs Pharmacotherapy ECT Psychosocial Therapies Social skills training Family oriented therapies Case management PACT Group therapy CBT Art therapy
Hospitalization
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)
Pharmacotherapy
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
Typical or First Generation Antipsychotics (FGA’s)
Prolixin (Fluphenazine)
Haldol (Haloperidol)
Thorazine (Chlorpromazine)
Trilafon (Perphenazine)
Atypicals or Second Generation Antipsychotics (SGA’s)
Abilify (Apiprazole) Risperdal (Risperidone) Zyprexa (Olanzapine) Seroquel (Quetiapine) Geodon (Ziprasidone) Clozaril (Clozapine) Invega (Paliperidone)
medication , continued
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
Clozapine (Clozaril)
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
SGA’s Side Effects
All SGA’s share a class warning for causing Weight gain Dyslipidemia Type II Diabetes Accelerated cardiovascular disease
Metabolic Syndrome with SGA’s
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
Side Effects of Typical Antipsychotics
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
Medications Used to Counteract EPS Symptoms
Amantadine (Symmetrel) Benztropine (Cogentin) Diphenhydramine (Benadryl) Trihexyphenidel (Artane) Propranolol (Inderal)
Tardive Dyskinesia
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
Psychiatric Disorders with Psychotic Symptoms
Major Depression with Psychotic Features Bipolar Disorder, Manic Episode Schizoaffective Disorder Delusional Disorders Personality Disorders: Paranoid, Schizotypal & Borderline Personality Disorder
Substances Associated with Psychosis
Anxiolytics Cocaine Methamphetamine Ketamine MDMA Designer drugs Alcohol Cannabis Hallucinogens Phencyclidine Inhalants Sedatives Hypnotics
Medications Associated with Psychosis
Anesthetics Analgesics Anticholinergic agents Anticonvulsants Antihistamines Antihypertensive and cardiovascular medications Antimicrobials Antiparkinsonians Chemotherapeutic agents Corticosteroids GI meds Muscle relaxants Nonsteriodal antiinflammatories Phenylephrine Pseudoephedrine Disulfram
Toxins Associated with Psychosis
Anticholinesterase Organophosphate insecticides Sarin Carbon monoxide Volatile substances: fuel, paint
Psychoeducation
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
Other DSM Psychotic Disorders
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
