CHAPTER 6 PSYCH Flashcards
A prototype psychotic illness characterized by
chronic course,
deterioration in social and occupational functions,
and positive (delusion, hallucination) and negative
(flat affect, alogia, avolition) symptoms
Schizophrenia
DSM criteria for Schiz
Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSMIV-
TR) diagnostic criteria
The presence of at least two of five characteristic positive
or negative symptoms for at least 1 month:
delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms
In Shiz
only need one of five if the:
delusions are bizarre or a voice or voices
are keeping running commentary on the person’s behavior or two or more voices are conversing
Other criteria for Schiz
b. Deterioration in social, occupational, and interpersonal
relationships
c. Continuous signs of the disturbance for at least 6 months (can include prodromal or residual symptoms like
amotivation)
d. Schizoaffective disorder and mood disorder with psychotic features have been ruled out
e. Not due to effects of substances or general medical
condition
hallmarks of schizophrenia
Psychotic symptoms
In Schiz:
patients experience a confusion of boundaries between
themselves and the world surrounding them, often called
_______
“a loss of ego boundaries
Postive Sz of Schiz
delusions, hallucinations, bizarre behavior
Negative symptoms of Schiz
blunting of affect, autism, ambivalence, social withdrawal, poverty of speech
MC hallucination
auditory hallucinations are the
most common
Firmly held false beliefs that can be bizarre or nonbizarre
(beliefs unique to certain cultural or religious
groups are not synonymous with delusions)
Delusions
Types of Delusions
Somatic, grandiose, paranoid, religious, nihilistic,
sexual, persecutory, delusions of reference, delusions
of thought (insertion, withdrawal, control,
broadcasting)
Belief that a person closely related to him or her has been replaced by a double
Capgras syndrome
Identifies a familiar person in various other people he or she encounters; even if no physical resemblance, he or she maintains they are psychologically identical
Fregoli synrdrome
Belief that penis is getting smaller and will
disappear
Koro
Self-mutilation driven by delusions
Van Gogh syndrome
Belief that thoughts can be implanted into the brain
Thought insertion
Negative symptoms in Schiz:
_________ speech that is empty or with decreased
spontaneity
Alogia:
Negative symptoms in Schiz:
________: sparsity of emotional reactivity
blunting
Negative symptoms in Schiz:
______unable to initiate or complete goals
Avolition
Other common negative symptoms in Schiz:
anhedonia
(unable to experience pleasure), inability to concentrate
or “attend,” inappropriate affect, poor hygiene
Other Sx associated with Schiz
1) Poor insight into illness
2) Abnormalities of eye movements (increased frequency
of blinking and abnormal saccades during test of
smooth pursuits)
3) Decreased stage IV sleep
4) Loss of normal gracefulness of body movements
Other Sx associated with Schiz
5) Up to 25% may have shown schizoid traits before
schizophrenia developed
6) Tend to be less interested in sexual activity
7) Up to 10% of schizophrenics commit suicide within
first 10 years of their illness
8) Up to 20% of schizophrenics drink excessive amounts
of water, which may lead to chronic hyponatremia
and possible water intoxication
9) Alcohol and drug abuse is common, and schizophrenics
smoke cigarettes three times more than the general
population
Subtypes of Schiz
Paranoid (best prognosis), disorganized, catatonic, undifferentiated, residual
Subtype of Schiz
a) Presence of delusions (often persecutory)
b) Frequent auditory hallucinations
c) Onset of illness (late 20s or 30s) later than for
other subtypes
d) More likely to marry and have children
Paranoid (best outcome)
Subtype of Schiz
a) Display disorganized, nonproductive behaviors
and demonstrate disorganized speech patterns
b) Exhibit flat or inappropriate affect; grimacing is
common
c) Can act silly or childlike and burst out laughing for
no reason
d) Delusions and hallucinations are less organized
and fragmentary
e) Earlier onset
Disorganized (formally called hebephrenic)
Subtype of Schiz
i) Motoric immobility (catalepsy, stupor)
ii) Excessive motor activity
iii) Extreme negativism
iv) Stereotypies, mannerisms, grimacing
v) Echolalia, echopraxia
Catatonic (less commonly seen now than in previous
years
_________ these patients do not satisfy criteria
for any other schizophrenia subtype
Undifferentiated:
these patients
no longer have any major psychotic symptoms but
still exhibit evidence of the illness, with negative
symptoms or at least 2 other odd or eccentric behaviors
or perceptual experiences
Residual
Prognosis of Schizophrenia
Chronic, usually early onset, poor long-term outcome,
devastating illness
Phases of Schizophrenia
Prodromal phase, Active phase, Residual phase
Characterize Prodromal phase of Schizophrenia
often prolonged period of social
withdrawal, delayed developmental milestones, awkward
in motor skills, loss of interest in self-care
Good prognostic factors for Schiz
a. Acute onset, short duration, no previous psychiatric
history, no family history of schizophrenia
b) Mood symptoms present, sensorium clouded
c) No obsessive-compulsive disorder, no
assaultiveness
Good prognostic factors for Schiz
d) Premorbid functioning good, high socioeconomic class e) Married, good psychosexual functioning f) Normal findings on neuroimaging
Poor prognostic factors for Schiz
a) Insidious onset, chronic duration, psychiatric history
present, positive family history of
schizophrenia
b) Mood symptoms absent, sensorium clear
c) Obsessive-compulsive disorder is present,
assaultiveness is present
Poor prognostic factors for Schiz
d. Poor premorbid functioning, low socioeconomic class e) Never married, poor psychosexual functioning f) Structural abnormalities present on neuroimaging
Epidemiology of Schiz
a. Prevalence over lifetime is about 1.0% (no differences
worldwide)
b. Average age at onset: men, _______ years (17-27 years); women, _____ years (17-37 years)
c. Male (M):Female (F) equal frequency
21
27
d. M>F in ________
e. F>M in _______
f. Onset before age 10 and after age 45 are uncommon
severity of illness, negative symptoms, suicide risk
mood comorbidity, better prognosis, better
social functioning
Etiology of Schiz
_______ idea has strong support: the
subject may have genetic predisposition to develop
schizophrenia but does not manifest it unless other factors are encountered (e.g., environmental stressors)
“Two-hit” or “multiple-hit”
In Schiz
Most consistent finding is ______
ventricular enlargement,
especially third and lateral ventricles
In Schiz
Selective reduction in size of :
frontal lobe, basal ganglia,
thalamus, and limbic regions, including the hippocampus
and medial temporal lobe
In Schiz
Increased incidence of
1) Cavum septum pellucidum
2) Partial callosal agenesis
Functional neuroimaging of Schiz
a. __________: negative
symptoms and neurocognitive deficits
b. Positron emission tomographic (PET) studies implicate:
Hypofrontality (frontal and prefrontal cortex)
frontal cortex (orbital, dorsolateral, medial), anterior cingulate gyrus, thalamus, several temporal lobe subregions, and cerebellum
anatomic substrate for visual hallucinations
in schizophrenia:
_________ is responsible for visual recognition
of objects and faces
Inferotemporal cortex
Neuropathology of Schiz
a. Decreased cell density in the _____
b. Displacement of interneurons in _____
dorsomedial nucleus of thalamus
frontal lobe cortex
1) Dopamine-blocking drugs seemed to ________ psychotic symptoms (antipsychotics)
lessen
Five types of dopamine receptors: D1, D2, D3, D4,
D5
a) D1: located in ______ and ________
b) D2: located in _______
c) D3 and D4: high concentration in the____
d) D5: located in _________
cerebral cortex and basal ganglia
striatum
limbic system
thalamus, hippocampus, and
hypothalamus
receptor occupancy of antipsychotic medications
1) ________: D2 receptors (78% receptor occupancy), no
obvious D1 receptors
2) ______: D2 receptors (48%), D1 receptors (38%-
52%),
_______receptors are associated with fewer
extrapyramidal symptoms
Typicals
Atypicals
D1
Mainstay treatments: antipsychotics (D2 receptor blockers
[postsynaptic])
b. Treatment
1) First line, _____ (may improve neurocognitive impairment in schizophrenia
examples are
atypicals
risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprasole (Abilify)
Second line of Tx for Schiz: _____, is atypical, expensive,
and needs monitoring because of the potential
for severe agranulocytosis
clozapine (Clozaril)
Maintenance duration for Schiz
at least 1 to 2 years after the
initial psychotic episode
Electroconvulsive therapy (ECT): schizophrenia does
not typically respond to ECT, but it could be considered
for _______
catatonic schizophrenia
Goal of Psychosocial rehabilitation for Schiz
- Restore the patient’s ability to function in the
community
2) Appropriate/affordable housing, group homes
3) Vocational training
4) Assertive community treatment
In Schizophreniform d/o, Duration of clinical signs and symptoms is less than ______
6
months
In Schizophreniform d/o:
At least two of the following:
delusions, hallucinations,
disorganized speech, disorganized behavior or catatonia,
or negative symptoms
In Schizophreniform d/o:
a. Similar to schizophrenia except for_____
b. ________ fully recover within 6 months
c. 66% usually progress to schizophrenia or schizoaffective
disorder
duration
33%
In Schizophreniform d/o:
Good prognostic factors:
onset of psychosis within _____weeks after change of behavior/functioning,
good premorbid functioning,
______
________
4
positive symptoms,
confusion and disorganization at peak of psychotic symptoms
Prominent mood symptoms and at least 2 weeks of
psychotic symptoms in the absence of mood symptoms
Schizoaffective Disorder
In Schizoaffective Disorder:
a. Uninterrupted period during which a mood disorder
(major depression, mania, or mixed episode) coexists
with symptoms of the _______
b. Must have delusions or hallucinations present for 2
weeks or more in absence of ______
c. Meets criteria for a mood disorder for a substantial periodof time during the illness (active and residual periods)
d. Symptoms not due to substances, medications, or
general medical condition
active phase of schizophrenia.
mood symptoms
Schizoaffective Disorder
Course
a. Prognosis: better than schizophrenia, but worse than
______
b. Suicide risk: ______
major depression
10%
_______ is most effective
but not without risk in Tx of Schizoaffective do
(clozapine
Schizoaffective Disorder
________can worsen illness, selective serotonin reuptake inhibitors (SSRIs), and trazodone can be beneficial for_______
tricyclic antidepressants (TCAs)
mood
component
Characterized by nonbizarre delusions and does not
affect other areas of a patient’s life
Delusional Disorder
Delusional disorder ________ is the relatively
more common delusional disorder
persecutory type
Overview of DSM-IV-TR criteria for delusional disorder
a. Nonbizarre delusions for______ or more months
b. Active-phase symptoms of ______ have not been
met
c. Functioning usually is not impaired, behavior is not odd
d. If present, _______symptoms are brief in relation to period of illness
e. Not caused by substances or general medical condition
1
schizophrenia
mood
Common defense mechanisms for delusional disorder:
denial, reaction formation,
projection
Etiology and pathophysiology of Delusional disorder
a. Not related to schizophrenia or mood disorders
b. Psychosocial stressors may be involved
c. Genetic factors may be important
d. Neurologic injury may precipitate or worsen the disorder
Delusions are nonbizarrre, persistent
Difficult to treat: denial of illness, difficulty with
trust
Prevalence: 0.03%, F>M, onset in middle age
Functioning usually not impaired
Delusional Disorder
Delusional Disorder
________ antipsychotic agent or high-potency
typical antipsychotic agent
1) Usually helps with anxiety and intensity of delusion
2) _____ can be helpful, even apart from depression
3) ______ is helpful for somatic delusional
disorder
atypical
SSRIs
Pimozide (Orap)
- Shorter duration than other psychotic disorders, sudden onset and termination of symptoms
- Is often precipitated by a stressor, may occur without
an apparent antecedent
Brief Psychotic Disorder
Overview of DSM-IV-TR criteria for BPS
a. At least one of the following symptoms for 1 or more
days but less than 1 month:
b. Not a mood disorder with psychotic features, schizoaffective disorder, schizophrenia, substance-induced, or due to general medical condition
delusions, hallucinations,
disorganized speech, grossly disorganized or catatonic
behavior
In BPS
More commonly seen in patients with _____ and _________ disorders
personality (borderline or histrionic) and dissociative
In BPS course is:
Brief, sudden onset of psychosis, with full return to premorbid functioning within a month
In BPS
Factors associated with good prognosis:
sudden onset, short duration, severe stressor, prominent mood symptoms, maintenance of affective reactivity, prominent confusion at peak of psychosis
In BPS
Factors associated with good prognosis:
sudden onset, short duration, severe stressor, prominent mood symptoms, maintenance of affective reactivity, prominent confusion at peak of psychosis
In BPS
______ completely recover, and in the other 20%
to 50% _______ disorder may be
diagnosed
50% to 80%
Schizophrenia or a mood
a. Presence of prominent hallucinations or delusions
b. Evidence points to substance or medication as a cause of symptoms
c. Not better accounted for by other psychotic disorder or
as part of a delirium
Substance-Induced Psychotic Disorder
Work-up for Substance-Induced Psychotic Disorder
1) ________, other stimulants
2) Alcohol, benzodiazepines, barbiturates
3) _______ (lysergic acid diethylamide [LSD],
phencyclidine [PCP], marijuana, mushrooms)
4) ________ (jimson weed, trihexyphenidyl)
5) Medications (glucocorticoids, belladonna alkaloids
Cocaine, amphetamines, ephedrine
Hallucinogens
Anticholinergic agents
a. Psychotic symptoms are present
b. Not enough information to make a specific diagnosis
c. May have contradictory information
Psychotic Disorder Not Otherwise Specified
Types of Mood disorders
major depressive disorder, dysthymicdisorder, bipolar I disorder, bipolar II disorder, cyclothymic disorder, substance-induced mood disorder, mood disorder due to general medical condition, mood disorder not otherwise specified
Characterized by severely depressed mood and/or anhedonia
leading to deterioration and inability to function
socially and occupationally
Major Depressive Disorder
MDD criteria
“SIG E CAPS” (useful mnemonic for depression)
Need five symptoms for 2 weeks, must also have
depressed mood or anhedonia
S—sleep disturbance I—loss of interest G—guilt E—loss of energy C—loss of concentration A—appetite change (gain/loss) P—psychomotor agitation/retardation S—suicidal ideations
MDD
Chronic if full criteria are met for at least _________—
clinically challenging!
2 years
In MDD
Melancholic feature specifier
a) Loss of pleasure in all or almost all activities or lack
of reactivity to usually pleasurable stimuli and
b) At least three of the following:
distinct quality of depressed mood,
mood worse in the morning,
early morning awakening,
marked psychomotor retardation or agitation,
marked anorexia or weight loss, or excessive or inappropriate guilt
In MDD
Atypical feature specifier
a) Mood reactivity: _________
b) At least two of the following:
brightens in response to positive events and
considerable weight gain or increased appetite, hypersomnia, leaden paralysis, long-standing interpersonal rejection sensitivity
In MDD
Catatonic feature specifier:
At least two of the following:
motoric immobility,
excessive motor activity, extreme negativism, peculiarities
of voluntary movement, echolalia or
echopraxia
In MDD
Postpartum onset specifier
a) Onset of episode within _____post partum
b) Can be life-threatening to mother and child
c) High rate of recurrence, _____
d) 1:500 to 1:1,000 births
4 weeks
30% to 50%
In MDD
Longitudinal course specifier
a) With full interepisode recovery
b) Without full interepisode recovery
In MDD
Seasonal pattern specifier
a) _______ between onset of mood disorder
and a particular time of year and
b) __________(or change from depression to
mania or hypomania) also occur at a characteristic
time of year
Temporal relation
Full remissions
In MDD
_________specifier
a) At least four episodes of mood disturbance in 12
months
b) Episodes have either remission or change to opposite
polarity for at least 2 months between episodes
Rapid-cycling
In MDD
Most episodes clear spontaneously within _____ months
6
In MDD
________: the most serious complication
Suicide risk
Suicide in MDD
Females ________suicide more frequently than males Males ______ suicide more frequently than females
attempt
complete
Risk factors for suicide in MDD:
advancing age, feeling hopeless,
psychotic symptoms, severe agitation, substance
abuse, chronic medical illness, living alone
low levels of _______, ______, ____ in the limbic
region may result in depression
serotonin,
norepinephrine (NE), or dopamine
Regulates mood, hunger, sleep, impulsivity, cognition,
pain, sexual responsiveness. What Nt?
Serotonin (5-hydroxytryptamine [5HT])
_________metabolite levels in cerebrospinal fluid are
usually low in suicidal patients
5HT
________ maintains mood, energy, interest, motivation
NE:
______important in motivation, drive, and
pleasure and reward
Dopamine:
in MDD
Family studies: first-degree relatives of patients with
major depressive disorder are ______more likely
than controls to have major depressive disorder
2× to 3×
In MDD
Twin studies_____ concordance rate in monozygotic
and ______% rate in dizygotic twins
: 50%
10% to 25
In MDD
1) Sleep time is usually decreased in patients with major
depressive disorder
2) Patients have shortened______of first rapid eye
movement (REM) period
3) Increased length of ______
latency
first REM period
Disorders associated with depression and mood disorders
1) Cancer (especially _______): 25% of cancer
patients often develop depression
2) Dementia: _______ of patients with Alzheimer’s disease
have depression
3) Seizure disorders: up to 60% of patients with seizure
disorders (especially _________) develop
depression
pancreatic
11%
temporal lobe epilepsy
Movement disorders
a) _____ of Parkinson’s patients can have depression
b) ______ incidence of depression among patients with
Huntington’s disease
c) _______ incidence of depression among patients with
Wilson’s disease
50%
40%
20%
1) _____hemisphere strokes lead to dysphoria
2) ______ hemisphere strokes lead to euphoria
Anterior left
Right
1) Depressed patients may have increased number of
focal signal hyperintensities in the______
2) Patients with major depressive disorder may have
smaller _______ AND _____
white matter
caudate nuclei and frontal lobes
