Diagnoses I Flashcards
Time requirement for
(a) scz
(b) brief psychotic d/o
(c) schizophreniform
(d) schizoaffective
(e) delusional d/o
Time requirement
(a) scz: 6+ mo of symptoms for illness. 2+ symptoms present for at leats 1 mo. 6 mo including prodrome or residual period
(b) brief psychotic d/o: at least 1 day, return to fxn w/in 1 mo
(c) schizophreniform: 1-6 mo
(d) schizoaffective: 2 weeks of positive symptoms (delusions/hallucinations) w/o mood symptoms
(e) delusional d/o: 1+ mo
Percent of scz pts that
(a) attempt suicide
(b) complete suicide
(c) M:F
Scz genetic component
(d) monozygotic twins
(e) first degree relatives
Scz
(a) 50% attempt suicide
(b) 15% complete suicide
(c) M = F (men have worse prognosis)
Genetics
(d) 50% incidence btwn monozygotic twins
(e) 10% incidence btwn first degree relatives
Neurotransmitter etiology of scz
(a) DA
(b) 5HT
(c) NE
Scz etiology
(a) Increased DA in limbic system => positive symptoms
(b) Increased 5HT in prefrontal cortex => negative symptoms
(c) Decreased NE => anhedonia
Brain image findings of scz
- *Ventricular enlargement
- cortical atrophy
- hypoactivity of frontal lobes on PET scan
Prognosis of pts w/ schizophreniform
- 1/3 recover
- 2/3 progress to schizophrenia
Tx for
(a) delusional d/o
(b) schizophreniform
(c) schizoaffective
(d) brief psychotic d/o
Tx
(a) delusional d/o- low dose antipsychotic
(b) schizophreniform- 3-6 mo. antipsychotics + supportive psychotherapy
(c) schizoaffective- concurrent antipsychotics + antidepressants
(d) brief hospitalization, supportive psychotherapy, short course of antipsychotics
What is pseudocyesis
Physiologic signs and symptoms of pregnancy in absence of pregnancy-cultural psychosis/common delusion
What is folie-a-deux?
Literally means “a madness shared by 2”-when delusions/hallucinations are transmitted from one to another
Age of onset for scz
Before 45 yoa
M: 15-25
F: 25-35
Lifetime prevalence of
(a) scz
(b) delusional d/o
(c) schizoaffective
Life prevalence of
(a) scz: 1-1.5%
(b) delusional d/o: .03%
(c) schizoaffective: less than 1%
Scz vs. schizoaffective
(a) link?
(b) prognosis
(c) tx
(d) time course
(e) features
Schizophrenia vs. schizoaffective
(a) Schizoaffective has no clear link to scz, but 6–80% of schizoaffective pts will progress to scz
(b) Schizoaffective has a better prognosis
(c) Scz- first line is atypicals, schizoaffective- use both antipsychotics + antidepressants
(d) Scz at least 6 mo, schizoaffective: at least 2 weeks of positive symptoms and no mood symptoms in absence of psychotic sx
Differentiate scz and delusional d/o
Delusional d/o: only delusions (no other symptoms) and function is NOT impaired
Differentiate the subtypes of scz
(a) disorganized
(b) paranoid
(c) catatonic
(d) residual
(e) undifferentiated
Subtypes of scz
(a) Disorganized: prominent disorganized speech, inappropriate affect,
- characterized by disorganized speech and flat/inappropriate affect
- NOT catatonic. Early onset
(b) Paranoid: preoccupied w/ particular delusion.
- characterized by delusions and AH
- NO: disorganized speech, catatonia, inappropriate affect. Later onset
(c) Catatonic- motor immobility, excessive motoric activity, rigidity, echolalia, echopraxia. Rarest
(d) Residual- absence of (+) symptoms for some time, but still have negative symptoms
- prominent negative symptoms
(e) Undifferentiated- NOS
Which subtype of scz is
(a) early onset
(b) late onset
(c) rarest
Subtype of scz
(a) early onset = disorganized
(b) later onset = paranoid
(c) rarest = catatonia
Prognosis of brief psychotic disorder
50-80% have no further psychiatric problems
-very rare diagnosis
Dx: pt meets scz criteria for btwn 1 day to 1 month
Differentiate
(a) thought insertion
(b) broadcasting
(c) thoughts of reference
Differentiate
(a) thought insertion- think others are putting thoughts in your head
(b) broadcasting- others can hear your thoughts
(c) thoughts of reference- from tv/radio, things are related to pt
What d/o are the following types of hallucinations associated with
(a) auditory
(b) visual
(c) tactile
(d) olfactory
Hallucinations
(a) Auditory- most commonly exhibited in schizophrenic pts
(b) Visual- less common in scz. May accompany drug intoxication, drug/alcohol withdrawal, or delirium
(c) Tactile- drug abuse or EtOH withdrawal
(d) Olfactory- common in seizures, usually an aura associated w/ epilepsy
ADHD
(a) Prevalence
(b) Gender difference
(c) Most common comorbidity
(d) Hormonal mechanism
(e) Prevalence of symptoms continuing into adulthood
ADHD
(a) 5-7% school aged children
(b) Boys > Girls (3-5:1)
(c) 2/3 comorbid w/ CD/ODD. 25% risk of ASPD
(d) Dysregulation of NE
(e) 60% have symptoms into adulthood
Age of onset for ADHD
Symptoms have to be present before age 7.
-onset may be as early as age 3
Signs of ADHD in
(a) Preschool
(b) Elementary
(c) Adolescents
(d) Adults
Signs of ADHD
(a) Preschool- temper tantrums
(b) Elementary- difficult peers/noncompliance
(c) Adolescents- internal sense of restlessness rather than motor
(d) Adults- chronic disorganization
Name the stimulants used to treat ADHD
Stimulants for ADHD
- methylphenidates: Ritalin, Concerta
- dexmethylphenidate: Focalin
- dextroamphetamine: Dexedrine, DextroStat
- dextroamphetamine/amphetamine: Adderall
- Lysine-dextroamphetamine: Vyvanse
Name the non-stimulants used to treat ADHD
Nonstimulants for ADHD
- Atomoxetine (Strattera): NE reuptake inhibitor
- Buspirone (Buspar): 5HT1A partial agonist
- alpha 2 agonists: clonidine, guanfacine
Requirements for diagnosis of ADHD
ADHD diagnosis:
- symptoms present before age 7
- must occur in two settings (ex: home and school)
- Inattention type: 6+ features of inattention for 6+ months
- Hyperactivity/impulsivity: 6+ features
- Mixed = meet criteria for both
Name symptoms of inattention for ADHD
Inattention (6+ features for 6+ months)
- inattention to detail
- difficulty sustaining attention
- does not follow through
- organization fail
- avoids tasks that require sustained effort
- loses things, easily distracted
- doesn’t listen
Name symptoms of the following for ADHD
(a) Hyperactivity
(b) Impulsivity
Hyperactivity/impulsivity (6+)
(a) Hyperactivity
- often leaves seat, runs or climbs
- difficulty playing or leisuring
- often ‘on the go’
- often talks excessively
(b) Impulsively
- often blurts out answers
- often has difficulty awaiting turn
- often interrupts
Tx besides meds for ADHD
- psychotherapy
- parental counseling
Differentiate ODD vs. CD:
(a) time requirement
(b) symptoms
ODD vs. CD
(a) ODD: 4+ symptoms for 6+ months. CD: 3+ for 12+ months
(b) ODD: no violation of basic rights
Percent of
(a) ppl w/ ODD who have ADHD
(b) ppl w/ CD who have ADD
(b) ppl w/ CD that develop ASPD
(a) 50% of ppl w/ ODD have ADHD
(b) 70% of CD have ADHD
(c) 40% of CD kids develop ASPD
List the symptoms of ODD
ODD: (4+ for 6+ months)
- loses temper (angry/resentful)
- argues w/ adults
- defies adults
- deliberately annoys ppl
- blames others for misbehavior
- easily annoyed
- spiteful
Symptoms of CD
Conduct d/o:
- aggression towards ppl/animals
- destruction of property (fire setting)
- deceitfulness or theft
- serious violations of rules
Treatment approach for disruptive d/o
Multimodal tx: school, family, community resources to clearly state and enforce behavioral expectations
Gender disparity in ODD
- before puberty: more common in boys
- after puberty: girls = boys
Gender disparity in CD
12:1 boys:girls
Different symptoms
- boys: high risk of fighting, stealing, fire-setting, vandalism
- girls: high risk of lying, running away, sexually acting out
Do ADHD pts generally have a lower IQ?
No, but ADHD symptoms may make it difficult for pts to sit thru neuropsychological testing long enough to obtain valid assessment
Which ADHD symptoms tend to last into adulthood?
Impulsive > hyperactive
Name the most common comorbidities of ADHD
Over 50% of children w/ ADHD have a comorbid psychiatric d/o
- anxiety d/o
- personality d/o
- conduct d/o (30-50%)
- ODD (30-40%)
Differentiate
(a) delusion
(b) illusion
(c) hallucination
(d) use of neologisms
(a) Delusion = fixed false belief
(b) Illusion = misinterpretation of a present external stimulus
(c) Hallucination = perception in the absence of an external stimulus
(d) Neologism = use of words that have meaning only to the person using them
Most common cause of psychosis in the lelderly
Elderly, medically ill pts presenting w/ psychotic symptoms (hallucinations, confusion, paranoia) should carefully be evaluated for delirium
-delirium much more common in elderly
List some medical conditions that can cause psychosis
(a) CNS disease
(b) Endocrinopathies
(d) Nutritional deficiency
Psychosis secondary to general medical condition
(a) CNS disease: temporal lobe epilepsy, tertiary syphilis, MS, neoplasm, Alzheimers Parkinsons, Huntingtons encephalitis, prior disease
(b) Endocrinopathies: hyper/hypothyroid, Cushings/Addisons, hypopituiatry, hypocalcemia
(c) Vitamin deficiences: B12, folate (folic acid), niacin (B3)
Name some prescription meds that can cause psychosis
Rx that can cause psychosis
- corticosteroids
- antiparkinson agents
- anticonvulasants
- antihistamines
- anticholinergics
- some antihypertensives: beta blockers, digitalis, methyphenidate, flouroquinolones
Then obv substances: EtOH, cocaine, hallucinogens (LSD, Ecstasy), MJ, benzos, PCP
Positive symptoms of scz
Added on top of normal behavior
- hallucinations
- delusions
- disorganized behavior or thought
- disorganized speech
Negative symptoms of scz
Subtracted/missing from normal behavior
- social withdrawal/isolation
- flat/blunted affect
- anhedonia
- apathy
- alogia (poverty of speech): speech blocking, latency of response
Cognitive symptoms of scz
-impairments in attention, executive fxn, and working memory
=> poor work and school performance
Describe the residual phase of scz
3 phases of scz
(1) Prodrome- social isolation and irritability. may have physical complaints or newfound interest in religion or the occult (paranormal)
(2) Psychotic- positive symptoms predominate
(3) Residual- btwn episodes of psychosis. Negative symptoms (flat affect, social withdrawal, odd thinking/behavior) predominate. pts can continue to have hallucinations even w/ tx
Features of scz cataonia type
- stereotyped mov’t
- bizarre posturing
- muscle rigidity
When may only one symptom of scz be enough to meet criteria for teh dx
Only one symptom required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on person’s behaviors or thoughts, or two or more voices conversing w/ each other
Name the 5 A’s of schizophrenia
5 A’s = the negative symptoms
- anhedonia
- affect (flat)
- alogia (poverty of speech)
- avolition (apathy)
- attention (poor)
Which subtype of scz is
(a) often higher functioning
(b) poor functioning type
(c) older age of onset
(d) earlier onset
Subtype of scz
Paranoid type: often higher functioning and older age of onset
Disorganized type: often poor functioning type and early osnet
Do scz have
(a) abstraction
(b) insight into their disease
(c) intact memory
(d) intact orientation
Scz pts
(a) often have concrete understandings of idioms
(b) little or no insight into their disease
(c) intact memory and orientation
Common comorbidity in scz pts
Substance abuse
- 30-50% EtOH
- 15-20% cannabis
- 5-10% cocaine
Monozygotic twin accordance for scz
50%
Describe the mechanism by which cocaine can induce psychosis
Cocaine (and amphetamines) increase dopamine activity => can induce scz-like symptoms
-scz partly related to increased DA in certain neuronal tracts
Nt involvement in scz
(a) DA
(b) 5HT
(c) NE
(d) GABA
(e) glutamate
Nt involvement in scz
(a) Increased DA activity in certain tracks => positive symptoms
(b) Increased 5HT activity
- another reason why atypicals may help
(c) Elevated NE
(d) Decreased GABA
- decreased expression of enzyme used to make GABA in the hippocampus of scz pts
(e) Decreased levels of glutamate receptors- scz pts have fewer NMDA receptors
- correlates w/ psychotic symptoms observed from NMDA antagonists (ex: ketamine)
Percent of scz pts who
(a) Respond to antipsychotics
(b) Attempt suicide
(a) 70% of scz pts improve on antipsychotics
(b) 50% of scz pts attempt suicide
Factors for better prognosis in scz
(a) Onset
(b) Type of symptoms
(c) sex
(d) Time course of onset
Factors associated w/ better prognosis for scz
(a) later onset
(b) Positive symptoms
(c) female sex
(d) acute onset
Name two important Rx meds that can exacerbate psychosis in predisposed pts
Beta blcokers and digoxin
Describe the diagnostic criteria for schizoaffective d/o
- delusions or hallucinations for 2 weeks in absence of mood d/o symptoms
- mood symptoms present for substantial portion of psychotic illness
- meet the criteria for a major depressive, manic, or mixed episode (during which criteria for scz is also met)
Loss of what sense predisposes to psychosis
Deafness
What population is delusional d/o more common in?
- Older pts (> 40 yoa)
- immigrants
- hearing impaired
Prognosis for delusional d/o
Prognosis for delusional d/o
- 50% full recovery
- 20% decreased symptoms
- 30% no change
Treatment for shared psychotic d/o
Shared psychotic d/o = folie a deux = pt develops same delusional symptoms as someone they are in a close relationship w/ (often family members)
Tx = separate pt from source of the shared delusion (usually family member w/ underlying psychotic d/o)
- psychotherapy
- antipsychotics if symptoms not improved 1-2 weeks after separation
Koro
Culture-specific pyschosis
-specific to Asia
= pt believes that his penis is shrinking and will disappear causing his death
Amok
Culture-specific pscyhosis
-Malaysia, Southeast Asia
= sudden unprovoked outbursts of violence of which the person has no recollection
-person often commits suicide afterward
Brain fag
Culture-specific psychosis
-Africa
= headache, fatigue, and visual disturbances in male students
List the prognosis from best to worst
- brief psychotic d/o
- schizophreniform
- scz
- schizoaffective
- mood d/o
Best to worst prognosis:
Mood d/o > brief psychotic d/o > schizoaffective d/o > schizophreniform > scz
Distinguish scz from schizotypal
Schizotypal personality d/o- criteria for true psychosis are not met
- paranoid, odd, or magical beliefs
- eccentric, lack of friends, social anxiety
Distinguish schizotypal from schizoid
Both are socially isolative
Schizotypal: magical thinking, odd beliefs
Schizoid: lack of enjoyment from social interactions
