Common Comorbidities Flashcards
What is clinical heterogeneity?
There are many variations in the clinical presentation of patients with schizophrenia:
This is referred to as “clinical heterogeneity”
- Virtually no two patients with schizophrenia present with the same constellation of symptoms
- Even in the same patient, symptoms can change over time and there is A LOT of
interplay between different symptoms
In addition, however, a diagnosis of schizophrenia often comes with variation in other psychiatric symptom domains. I.e.:
- Affective Symptoms
- Anxiety Symptoms
- Substance abuse
What does comorbidity mean?
The simultaneous presence of two or more diseases in one patient
What does psychiatric comorbidities mean?
In many cases, the severity of these “additional” symptoms are severe
enough to warrant their own diagnosis
- In fact, most people with schizophrenia ALSO meet criteria for other
psychiatric disorders. We refer to this as “Psychiatric Comorbidity” - Comorbidity: The simultaneous presence of two or more diseases in one patient
What are the most common psychiatric comorbidities?
Affective Disorders
Anxiety Disorders
Substance Use Disorders
How does comorbidities make a complex diagnoses more complicated??
Comorbidities make a complex diagnosis even MORE complicated because the symptoms often feed off of each
other. I.e.:
- Changes in the severity of negative symptoms might contribute to
variation in symptoms of depressed mood - Changes in the severity of paranoid delusions might contribute to
variation in symptoms of anxiety - Changes in the severity of auditory hallucinations might contribute
to variation substance use
How common are psychiatric comorbidities? What accounts for high rates of comorbidity?
Psychiatric Comorbidity among patients with schizophrenia are so
common that that is has been suggested that they might be integral to
the diagnosis!
However, there are several possibilities that might account for the high
rates of comorbidity. Specifically, they might be considered:
- To have, by chance, co-occurred with schizophrenia
- To have manifested ‘‘secondary’’ to the core disorder, schizophrenia
- To have manifested because schizophrenia is more common in this core disorder
- To be a consequence of some underlying shared liability to both sets of
disorder
What are the most common affective disorders?
More than half of patients with schizophrenia endorse affective symptoms
Identifying the prevalence of affective “disorders” is not really possible
- This is due to the treatment of co-occurring affective symptoms by the DSM
- DSM-5: Other specified mood disorder…
The prevalence of comorbid major depressive episodes has been extensively studied
- 28.6% of patients with schizophrenia would meet criteria
Manic and hypomanic episodes are WAY more difficult to estimate…
- Rough estimates range from 5% - 30%
What are the most common anxiety disorders?
Panic Disorder (PD)
- 25% prevalence of panic attacks and a 15% prevalence of PD in patients with
schizophrenia vs. 2.0%–5.1% in the general population
Post traumatic Stress Disorder
- Trauma histories are common in patients with schizophrenia, and childhood trauma is a
risk factor for psychosis
- 29% prevalence of PTSD in patients with schizophrenia, compared with a 7.8% in the
general population
Social Phobia
- 30% prevalence in patients with schizophrenia vs. 7% of the general population
Obsessive Compulsive Disorder (OCD)
- 25% prevalence of obsessive-compulsive symptoms and a 23% prevalence of OCD in
patients with schizophrenia vs 2.5% in the general population
- Several lines of evidence suggest that patients with both schizophrenia and OCD may
represent a ‘‘schizo-obsessive’’ subtype of schizophrenia…
What are the key features of a schizo-obsessive subtype?
-Co-occurrence of Schizophrenia and OCS/OCD
- Individuals exhibit prominent obsessive-compulsive symptoms that interfere with daily life including
- Intrusive thoughts
- Compulsions or Ritualistic behaviors
- Early Onset and Poorer Prognosis
- Some studies suggest an earlier onset of schizophrenia in patients with significant OCS.
- Higher rates of cognitive impairment, lower insight, and greater resistance to treatment.
- Unique Symptom Presentation including:
- Higher levels of anxiety and distress compared to typical schizophrenia
- Obsessions may focus on delusions or psychotic content, making differential diagnosis challenging
- Greater cognitive inflexibility and difficulties in decision-making
What are the neurobiological and genetic links of a schizo-obsessive subtype?
Possible shared genetic or neurobiological mechanisms between schizophrenia and OCD including:
- Alterations in the dopaminergic and serotonergic systems
- Dysfunctions in the fronto-striatal circuitry, which is implicated in both schizophrenia and OCD
What are the treatment challenges for a schizo-obsessive subtype?
Antipsychotic medications, especially second-generation antipsychotics, can sometimes induce or worsen OCS
Selective serotonin reuptake inhibitors (SSRIs), commonly used for OCD, may exacerbate psychotic symptoms
Cognitive-behavioral therapy (CBT) adapted for psychotic and obsessive-compulsive symptoms may be beneficial
What are the clinical implications with a schizo-obsessive subtype?
Proper assessment is crucial, as obsessive-compulsive symptoms can be mistaken for negative symptoms or thought
disorder in schizophrenia
Personalized treatment strategies, including medication adjustments and psychotherapy, may improve outcomes
True or False: More research is needed to determine if schizo-obsessive disorder should be classified as a distinct schizophrenia subtype
TRUE
What is the relationship between substance use disorders and schizophrenia?
The abuse of alcohol and/or illicit drugs by patients with
schizophrenia seems to be ‘‘the rule rather than the exception”
Roughly half of patients with schizophrenia meet criteria for a
substance use disorder at some point
Males more than females
Patients with SUD typically have an earlier age of onset of
schizophrenia
What are the most common types of substance use disorders?
Opioids and Hallucinogen Use Disorders
- 27.5% prevalence vs. ~1% in the general population
Cannabis Use Disorders
- 26.2% prevalence vs. 5.7% in the general population
Alcohol Use Disorders
- 24.3% prevalence vs. 7.5% in the general population
Stimulant Use Disorder
- 7.3% prevalence vs. 0.2% in the general population
What is the relationship between comorbidities and outcomes?
In virtually every instance, the presence of comorbid
psychiatric diagnoses in individuals with schizophrenia are
associated with:
- Worse long-term outcomes
- Increased likelihood of psychotic relapse
- Increased risk for suicide
- More difficulty with medication
- Adverse effects due to more medication
- Increased likelihood of medication non-compliance, particularly with substance use disorders
What medical comorbidities do patients with schizophrenia have? What about general illnesses?
Patients with schizophrenia have a range of common medical comorbidities including:
- cardiovascular diseases
- diabetes
- obesity
- sexual dysfunction
- Many of these medical problems may be related to the effects of antipsychotic drugs….
However, patients with schizophrenia also have a much higher rate of preventable risk factors
for medical illnesses relative to the general population including:
- smoking
- high alcohol consumption
- poor diet
- lack of exercise
What percent of deaths do medical comorbidities account for?
60%
