Clinical Approach to Psychotic Disorders

Question 1

What is the onset of schizophrenia?

What are some precipitating factors?

What confers a 6x increased risk?

Answer 1

Late adolescence and early adulthood.

Psychosocial stressors, trauma, drug and EtOH abuse.

Cannabis use increases risk 6x!

Question 2

Which symptoms confer a better prognosis for schizophrenia? Which are more common?

Which symptoms/features confer a worse prognosis?

Answer 2

“Positive symptoms” - delusions, hallucinations, disorganized speech, repetitive movements.

“Negative symptoms” - inability to show emotions, apathy, difficulties talking, and withdrawing from social situations and relationships.

• poor cognitive performance
• younger onset
• poor premorbid functioning
• insidious onset
• *more common

Question 3

What are the prodromal signs and symptoms of schizophrenia?

Answer 3

Possible schizoid or schizotypal personalities

Few close friends in childhood

Minimal social activity

Question 4

Which type of twin has an increased concordance rate for schizophrenia (40-50% vs. 10-15%)?

Why?

Answer 4

Monozygotic twins > Dizygotic twins

Monozygotic twins share 100% of DNA, while Dizygotic twins share only 50%.

Question 5

What is a potential etiology of schizophrenia?

Genes from what drive the interaction between polygenic risk scores and the possible etiology?

Answer 5

Early-life complications (ELC) during pregnancy, labor, delivery and early neonatal life increase risk 1.5-2x (this is greater than any common genetic variant).

Genes highly and differentially expressed in placenta drive the interaction between polygenic risk scores and ELCs on schizophrenia risk.

Question 6

Prenatal exposure to _____ during the ____________ appears to increase risk of developing schizophrenia by 7x.

What is associated with a 3x increased risk?

Answer 6

Prenatal exposure to influenza virus during the 1st trimester of pregnancy appears to increase risk of developing schizophrenia by 7x.

URI during any time in pregnancy was associated with a 3x increased risk of schizophrenia by age 47 y/o.

Question 7

What is the neurophysiological basis for schizophrenia?

Where else is this process seen?

Which area of the brain is seen to be overactive in schizophrenia patients?

Which hormone might be elevated or depressed?

Answer 7

The “revised dopamine hypothesis” proposes hyperactive dopamine transmission in the mesolimbic areas and hypoactive dopamine transmission in the prefrontal cortex in schizophrenia patients.

Dopamine dysregulation is also observed in brain regions including the amygdala and prefrontal cortex, which are important for emotional processing.

Overactive dopamine system in the hippocampus.

Cortisol levels might be high or low.

Question 8

What types of hallucinations are most common in schizophrenia?

Answer 8

Auditory Hallucinations: usually experienced as voices, whether familiar or unfamiliar. They are perceived as distinct from their own thoughts.

Question 9

Which kind of hallucinations are not indicative of psychosis?

Answer 9

Hypnagogic: hallucinations that occur while falling asleep.

Hypnopompic: hallucinations that occur while waking up.

Question 10

What is another name for Disorganized Thinking (Speech)?

What are a few types?

Answer 10

“Formal thought disorder”

Tangentiality
Derailment or loose associations
Incoherence or “word salad”

Question 11

Avolution =

Alogia =

Answer 11

Avolution = decrease in motivated self-initiated purposeful activities.

Alogia = diminished speech output.

Question 12

What are the 6 diagnostic criteria for schizophrenia?

Answer 12

A. At least 2 of the following for most of 1 month, with at least 1 of the first 3 symptoms:

• delusions
• hallucinations
• disorganized speech
• **
• grossly disorganized or catatonic behavior
• negative symptoms

B. Adult - most of the time after onset of symptoms the level of functioning is far below what it was prior to onset.
Child or adolescent - failure to achieve expected level of functioning.

C. Continuous signs of the disturbance persist for at least 6 months. - must include at least 1 month of symptoms from Criterion A - may include periods of prodromal or residual symptoms

D. Schizoaffective disorder or mood disorders with psychotic features have been ruled out

E. Not due to substance abuse, a medication effect, or another medical condition

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Question 13

Schizophrenia - Catatonic type is dominated by at least 2 of the following:

Answer 13

• Motoric immobility as evidenced by catalepsy or stupor
• Excessive motor activity (apparently purposeless and not influenced by external stimuli)
• Extreme negativism or mutism
• Peculiarities of voluntary movement such as posturing, stereotyped movements, prominent mannerisms or prominent grimacing
• Echolalia or echopraxia (meaningless repetition of words, or movement)

Question 14

What is the leading cause of death in schizophrenia?

Answer 14

Suicide - 5-6% will commit suicide, with 20-50% attempting suicide at some point.

Question 15

What’s on the DDx for schizophrenia?

Answer 15

Organic mental disorders (Neurocognitive disorders)

• delirium: acute medical illness, with psychotic symptoms.
• dementias: usually mimic negative symptoms of schizophrenia.

Neuropsychiatric manifestations of autoimmune disorders

Mood disorders

Question 16

What treatment is indicated in the following phases/scenarios of schizophrenia?

Acute psychosis

Stabilization phase

Maintenance phase

Poor responders

Answer 16

Acute psychosis: hospitalization if needed for patient safety and to get stabilized; IM injections of Haldol, fluphenazine, lorazepam.

Stabilization phase: consider converting to newer, atypical (SGA) antipsychotics.

Maintenance phase: keep patients free from symptoms while avoiding incapacitation side-effects (i.e. maintenance).

Poor responders: relapses in patients whose schizophrenia was once controlled but no longer respond; non-compliance is a common occurence.

Question 17

What has been found to make schizophrenia symptoms worse?

Answer 17

Insight oriented group and individual psychotherapy modalities have been found to make symptoms worse.

Question 18

What drug class is used for Catatonic disorder?

Answer 18

Benzodiazepines

Question 19

What 5 criteria must be met to render a diagnosis of Delusional disorder?

Answer 19

A. The presence of one (or more) delusions with a duration of 1 month or longer.

B. Criterion A for schizophrenia has never been met.

C. Apart from the impact of the delusion, functioning is not impaired, and behavior is not obviously bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.

E. Not caused by the direct effects of a substance or a general medical condition.

Question 20

What are the 3 diagnostic criteria for Brief Psychotic disorder?

Answer 20

A. Presence of one (or more) of the following symptoms. At least one of these must be met:

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

B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.

C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Question 21

What 4 criteria must be met to render a diagnosis of Schizophreniform disorder?

Answer 21

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be met:

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

B. An episode of the disorder lasts at least 1 month but less than 6 months.

C. Schizoaffective disorder or mood disorders with psychotic features have been ruled out

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Question 22

What 4 criteria must be met to render a diagnosis of Schizoaffective disorder?

Answer 22

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1: Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Question 23

What 5 features are needed for a diagnosis of Substance/Medication-induced Psychotic Disorder?

Answer 23

A. Presence of one or both of the following symptoms:

1. Delusions
2. Hallucinations

B. There is evidence from the history, physical examination, or laboratory findings of both:

1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by a psychotic disorder that is not substance/medication-induced. Such evidence of an independent psychotic disorder could include the following: - symptoms precede onset of substance/medication use - symptoms persist for about 1 month after cessation of withdrawal or intoxication - or there is evidence of a non-substance/medication-induced psychotic disorder

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 24

What are the 5 diagnostic criteria of Psychotic Disorder Due to Another Medical Condition?

Answer 24

A. Prominent hallucinations or delusions.

B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

C. The disturbance is not better explained by another mental disorder.

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 25

Define: Delusions with significant overlapping mood episodes

Answer 25

Persistent delusions with periods of overlapping mood episodes that are present for a substantial portion of the delusional disturbance.

Question 26

Define: Attenuated psychosis syndrome

Answer 26

Psychotic-like symptoms that are below a threshold for full psychosis (e.g., the symptoms are less severe and more transient, and insight is relatively maintained).

Question 27

What are the timelines for the following:

Schizophrenia

Schizophreniform

Brief psychotic disorder

Answer 27

Schizophrenia: > 6 mo.

Schizophreniform: 1-6 mo.

Brief psychotic disorder: < 1 mo.

Question 28

In short, what defines the following:

Schizoid

Schizotypal

Schizophrenia

Schizoaffective

Answer 28

Schizoid = very introverted and voluntarily withdraws from social interactions

Schizotypal = Schizoid symptoms + magical thinking and odd behavior

Schizophrenia = Schizotypal + Psychosis

Schizoaffective = Schizophrenia + Mood Disorder