Esquizofrenia

Question 1

What is schizophrenia?

Answer 1

Schizophrenia is a brain disorder that affects how people think, feel, and perceive. The hallmark symptom of schizophrenia is psychosis.

Question 2

História da esquizofrenia. Kraepelin, Bleuler e Schneider.

Answer 2

Kraepelin-Emil Kraepelin : Dementia praecox; doença que tendia a começar relativamente cedo e a produzir um prejuízo pervasivo e persistente em aspectos das funções cognitivas e comportamentais.No início ele considerava a doença, de ter curso crônico e desfecho pobre, porém no decorrer de sua vida profissional, acompanhou uma grande amostra de pacientes e observou que 12,5% se recuperaram. Em conseqüência disto, acabou concordando com Bleuler no sentido de que alguns pacientes podiam se recuperar. Enfatizava os prejuizos cognitivos precoces

Bleuler- Cria o termo Esquizofrenia (gr. Schizo=cindido, phrén=mente); para ele, o sintoma mais importante era a fragmentação na formulação e expressão do pensamento – “afrouxamento de associações”. Identificou os 4 “As” bleurianos (na verdade são 6): associações (dissociações) no processo do pensamento, ambivalência, autismo, afeto embotado, avolição, atenção prejudicada. Enfatiza os sintomas negativos.

Kurt Schneider: Interessado em identificar sintomas patognomônicos, como Bleuler. Ele estabeleceu uma hierarquia de sintomas, de acordo com sua importância para o diagnóstico da esquizofrenia – Sintomas de 1ª Ordem (considerados bastante sugestivo de esquizofrenia) e Sintomas de 2ª Ordem (com menor valor para o diagnóstico da doença). Ele dizia que a presença de sintomas de 1ª Ordem não era obrigatória para o diagnóstico de esquizofrenia. Valorizava os sintomas positivos.

1ª Ordem: Percepção delirante, alucinações auditivas (vozes que fazem comentários e/ou vozes que dialogam entre si), sonorização do pensamento, roubo do pensamento, vivências de influência sobre o pensamento, difusão do pensamento.

2ª Ordem: Outros distúrbios sensoperceptivos, intuição delirante, perplexidade, disposições de ânimo depressivos ou maníacos, vivência de empobrecimento afetivo.

Question 3

quais os quatro domínios de sintomas da esquizofrenia?

Answer 3

Positive symptoms

Negative symptoms

Cognitive symptoms

Mood symptoms

Quais os sintomas positivos mais proeminentes na esquizofrenia?

Psychotic symptoms, such as hallucinations, which are usually auditory; delusions; and disorganized speech and behavior

Quais os sintomas negativos mais proeminentes na esquizofrenia?

Negative symptoms - Decrease in emotional range, poverty of speech, and loss of interests and drive; the person with schizophrenia has tremendous inertia

Quais os sintomas cognitivos mais proeminentes na esquizofrenia?

Cognitive symptoms - Neurocognitive deficits (eg, deficits in working memory and attention and in executive functions, such as the ability to organize and abstract); patients also find it difficult to understand nuances and subtleties of interpersonal cues and relationships

Quais os sintomas de humor mais proeeminentes na esquizofrenia?

Mood symptoms - Patients often seem cheerful or sad in a way that is difficult to understand; they often are depressed

Question 4

What are the DSM-5 criteria for schizophrenia?

Answer 4

Schizophrenia is not associated with any characteristic laboratory results.

Diagnostic criteria

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), to meet the criteria for diagnosis of schizophrenia, the patient must have experienced at least 2 of the following symptoms [1] :

Delusions

Hallucinations

Disorganized speech

Disorganized or catatonic behavior

Negative symptoms

At least 1 of the symptoms must be the presence of delusions, hallucinations, or disorganized speech.

Continuous signs of the disturbance must persist for at least 6 months, during which the patient must experience at least 1 month of active symptoms (or less if successfully treated), with social or occupational deterioration problems occurring over a significant amount of time. These problems must not be attributable to another condition.

The American Psychiatric Association (APA) removed schizophrenia subtypes from the DSM-5 because they did not appear to be helpful for providing better-targeted treatment or predicting treatment response.

Question 5

Qual o papel dos antipsicóticos no tratamento da esquizofrenia?

Answer 5

Antipsychotic medications diminish the positive symptoms of schizophrenia and prevent relapses.Approximately 80% of patients relapse within 1 year if antipsychotic medications are stopped, whereas only 20% relapse if treated. Introduzir e observar efeito terapeutico (remissão dos sintomas alvo, sobretudo os positivos (delírios, conduta alucinatória) e de desorganização) por 4 semanas no máximo.Idealmente duas semanas Avaliado pelo PANSS eles devem ser no máximo leves.Considerar remitido se nível de gravidade se mantiver por PELO MENOS 6 MESES. Se psicose persiste pode aumentar a dose ou trocar o antipsicótico. Associações não tem evidencia de melhor efeito terapêutico e aumenta incidência de efeitos colaterais. As melhores evidências para esquizofrenia refratária a clozapina (super-refratários) é associar ECT ou LAMOTRIGINA ao tratamento, não é interessante adicionar outro anti-psicótico.

Algoritimo IPAP para tratamento da esquizofrenia. É interessante que uma das drogas utilizadas antes da clozapina tenha sido a Olanzapina.

Question 6

Qual epidemiologia da refratariedade na esquizofrenia?

Answer 6

.

Question 7

Qual o antipsicótico mais eficaz no tratamento da esquizofrenia?

Answer 7

Clozapine is the most effective medication but is not recommended as first-line therapy.

Question 8

quais antipsicóticos se mostraram melhores que o haloperidol na melhora de todos os domínios de sintomas da esquizofrenia?

Answer 8

amisulprida, risperidona, olanzapina e clozapina.

no entanto na escolha do antipsicótico devem ser considerados também o perfil de efeitos colaterais ( primeira geração sintomas extrapiramidais segunda geração alterações metabólicas) e razões farmacoeconomicas por exemplo haloperidol é eficaz econômico e tem formulação de depósito.

Question 9

Qual o papel da abordagens psicossociais na esquizofrenia? Quais são as mais estudadaS?

Answer 9

Essenciais. The best-studied psychosocial treatments are social skills training, cognitive-behavioral therapy, cognitive remediation, and social cognition training.

Question 10

Quais são os objetivos do tratamento conjunto da esquizofrenia?

Answer 10

To have few or stable symptoms

Not to be hospitalized

To manage his or her own funds and medications

To be either working or in school at least half-time

Question 11

How does impaired cognition affect patients with schizophrenia?

Answer 11

People with schizophrenia have lower rates of employment, marriage, and independent living compared with other people.

Question 12

Porque os subtipos de esquizofrenia foram removidos do DSM-5?

Answer 12

Schizophrenia subtypes were removed from DSM-5 because they did not appear to help with providing better-targeted treatment or predicting treatment response.

Question 13

Quais as subespecificações devem estar presentes no diagnóstico?

Answer 13

Se primeiro episódio ou múltiplos episódios e se em episódio agudo, remissão parcial ou remissão completa. Ou não especificado. Presença ou ausencia de catatonia. Gravidade dos sintomas (colocar tabela).

Question 14

Which abnormalities are found in schizophrenia?

Answer 14

Anatomic, neurotransmitter, and immune system

Question 15

What are neurologic findings of schizophrenia?

Answer 15

Ventricles are somewhat larger, there is decreased brain volume in medial temporal areas, and changes are seen in the hippocampus. loss of whole-brain volume in both gray and white matter.

Question 16

What is the role of the neurotransmitter system in the pathogenesis of schizophrenia?

Answer 16

Drugs that diminish the firing rates of mesolimbic dopamine D2 neurons are antipsychotic, and drugs that stimulate these neurons (eg, amphetamines) exacerbate psychotic symptoms.Hypodopaminergic activity in the mesocortical system, leading to negative symptoms, and hyperdopaminergic activity in the mesolimbic system, leading to positive symptoms, may coexist.Moreover, the newer antipsychotic drugs block both dopamine D2 and serotonin (5-hydroxytryptamine [5-HT]) receptors.Much research focuses on the N -methyl-D-aspartate (NMDA) subclass of glutamate receptors because NMDA antagonists, such as phencyclidine and ketamine, can lead to psychotic symptoms in healthy subjects. [9, 10] Some researchers consider schizophrenia, in large part, a hypoglutamatergic disorder.

Question 17

What is the role of the immune system in the pathogenesis of schizophrenia?

Answer 17

Overactivation of the immune system (eg, from prenatal infection or postnatal stress) may result in overexpression of inflammatory cytokines and subsequent alteration of brain structure and function. For example, schizophrenic patients have elevated levels of proinflammatory cytokines that activate the kynurenine pathway, by which tryptophan is metabolized into kynurenic and quinolinic acids; these acids regulate NMDA receptor activity and may also be involved in dopamine regulation.

Question 18

Is schizophrenia a genetic disorder?

Answer 18

The risk of schizophrenia in first-degree relatives of persons with schizophrenia is 10%. Concordance for schizophrenia is about 10% for dizygotic twins and 40-50% for monozygotic twins.

Question 19

What is the role of the COMT gene in schizophrenia?

Answer 19

The COMT gene codes for the postsynaptic intracellular enzyme COMT, which is involved in the methylation and degradation of the catecholamine neurotransmitters dopamine, epinephrine, and norepinephrine. The several allelic variants of COMT affect its activity. The valine-valine variant degrades dopamine faster than the valine-methionine variant does; subjects with 2 copies of the methionine allele were less likely to develop psychotic symptoms with cannabis use than were other cannabis-using subjects without that variant.schizophrenia is a disease in which multiple rare genetic variants lead to a common clinical outcome.

Question 20

How much of schizophrenia risk is due to genetic factors?

Answer 20

a meta-analysis of twin studies estimated that genetic factors account for about 50-80% of liability to schizophrenia.

Question 21

Which perinatal factors may increase the risk of developing schizophrenia?

Answer 21

Women who are malnourished or who have certain infectious illnesses during their pregnancy may be at greater risk of giving birth to children who later develop schizophrenia.

Question 22

Does marijuana use increase the risk of developing schizophrenia?

Answer 22

A new study suggests that heavy marijuana use in teenagers aged 15–17 years may hasten the onset of psychosis in those at high risk for developing a psychotic disorder.the onset of psychosis in those who used cannabis from age 15 to 17 years occurred at a mean age of 21.07 years, compared with a mean age of 23.86 years in patients who did not use cannabis during those same teenage years. However, the researchers could not say whether marijuana use may actually cause psychosis to develop early or whether people who have a predilection for earlier onset of psychosis also may be more likely, owing to various factors, to use marijuana.

Question 23

What is the prevalence of schizophrenia?

Answer 23

approximately 1% worldwide. Prevalência: variável dependendo do país estudado •  Brasil: “Psicoses não afetivas”: 1.9% •  Proporção homens/mulheres: 1,4: 1 •  Risco mediano de morbidade durante a vida: 7,2/1000 •  Mortalidade (taxa de mortalidade padronizada): 2,6 •  Risco de suicídio ao longo da vida: 4.9%

Question 24

At what age does onset of schizophrenia usually occur?

Answer 24

Tabela

Question 25

Does the prevalence of schizophrenia differ among racial groups?

Answer 25

no racial differences in the prevalence of schizophrenia have been positively identified.

Question 26

Is schizophrenia more common in men or women?

Answer 26

The prevalence of schizophrenia is about the same in men and women. The onset of schizophrenia is later in women than in men, and the clinical manifestations are less severe. This may be because of the antidopaminergic influence of estrogen.

Question 27

How is the natural history of schizophrenia?

Answer 27

Tabela

Question 28

What factors affect the prognosis of schizophrenia?

Answer 28

The prognosis is guarded. Full recovery is unusual. Early onset of illness, family history of schizophrenia, structural brain abnormalities, and prominent cognitive symptoms are associated with a poor prognosis.

Question 29

What is the socioeconomic impact of schizophrenia?

Answer 29

many patients with schizophrenia also have to cope with the burdens of poverty. These include limited access to medical care, which may lead to poor control of the disease; homelessness; and incarceration, typically for minor offenses.

Question 30

Is the mortality rate increased in patients with schizophrenia?

Answer 30

People with schizophrenia have a 5% lifetime risk of suicide. [55] .Mortalidade (taxa de mortalidade padronizada): 2,6x a população geral(Brasil). Other factors that contribute to increased mortality include lifestyle issues such as cigarette smoking, poor nutrition, and lack of exercise, and perhaps poorer medical care and complications of medications

Question 31

Is breast cancer more common in women with schizophrenia?

Answer 31

Women with schizophrenia may have higher rates of breast cancer than women in the general population.Researchers suggest factors such as obesity, nulliparity, and potentially even increased prolactin levels may raise the risk for breast cancer. Não confirmado.

Question 32

What are the benefits of patient education in schizophrenia?

Answer 32

The nature of schizophrenia makes it a potentially difficult illness for patients to understand. Nevertheless, teaching the patient to understand the importance of medication compliance and of abstinence from alcohol and other drugs of abuse is important.

It is helpful to work with the patient so that both patient and family can learn to recognize early signs of a decompensation (eg, insomnia or increased irritability).education of patients about the nature of their illness and treatment, when added to standard care, led to reductions in rehospitalization and symptoms.

Question 33

What should be the focus of family and medical history in suspected schizophrenia?

Answer 33

Information about the medical and psychiatric history of the family, details about pregnancy and early childhood, history of travel, and history of medications and substance abuse are all important. This information is helpful in ruling out other causes of psychotic symptoms.

Question 34

What personal history may indicate schizophrenia?

Answer 34

patient usually had an unexceptional childhood. In retrospect, family members may describe the person with schizophrenia as a physically clumsy and emotionally aloof child. The child may have been anxious and preferred to play by himself or herself. The child may have been late to learn to walk and may have been a bed wetter.A noticeable change in personality and a decrease in academic, social, and interpersonal functioning often begin during middle-to-late adolescence. Usually, 1–2 years pass between the onset of these vague symptoms and the first visit to a psychiatrist. [60] The first psychotic episode usually occurs between the late teenage years and the mid 30s.

Question 35

What observations on a mental status exam indicate schizophrenia?

Answer 35

On a detailed mental status examination (MSE), the following observations may be made in a severely ill patient with schizophrenia:

The patient may be unduly suspicious of the examiner or be socially awkward

The patient may express a variety of odd beliefs or delusions

The patient often has a flat affect (ie, little range of expressed emotion)

The patient may admit to hallucinations or respond to auditory or visual stimuli that are not apparent to the examiner

The patient may show thought blocking, in which long pauses occur before he or she answers a question

The patient’s speech may be difficult to follow because of the looseness of his or her associations; the sequence of thoughts follows a logic that is clear to the patient but not to the interviewer

The patient has difficulty with abstract thinking, demonstrated by inability to understand common proverbs or idiosyncratic interpretation of them

The speech may be circumstantial (ie, the patient takes a long time and uses many words in answering a question) or tangential (ie, the patient speaks at length but never actually answers the question)

The patient’s thoughts may be disorganized, stereotyped, or perseverative

The patient may make odd movements (which may elated to neuroleptic medication)

The patient may have little insight into his or her problems (ie, anosognosia)

Orientation is usually intact (ie, patients know who and where they are and what time it is)

Persons with schizophrenia may display strange and poorly understood behaviors. These include drinking water to the point of intoxication, staring at themselves in the mirror, performing stereotyped activities, hoarding useless objects, and mutilating themselves. Their wake-sleep cycle may be disturbed.

Question 36

Is substance abuse a common comorbidity of schizophrenia?

Answer 36

Alcohol and drug abuse (especially nicotine) are common in schizophrenia, for reasons that are not entirely clear. For some people, these drugs provide relief from symptoms of the illness or the adverse effects of antipsychotic drugs, and the drive for this relief is strong enough to allow even patients who are impoverished and disorganized to find substances to abuse.

Question 37

Which risks are increased in comorbid substance abuse and schizophrenia?

Answer 37

Comorbid substance abuse occurs in 20–70% of patients with schizophrenia, particularly younger male patients, and is associated with increased hostility, crime, violence, suicidality, noncompliance with medication, homelessness, poor nutrition, and poverty. Drug use and abuse can also increase symptoms. For example, cannabis use has been shown to be associated with an earlier onset of psychosis and to correlate, in a bidirectional way, with an adverse course of psychotic symptoms in persons with schizophrenia. That is, people with more severe psychotic symptoms are more likely to use cannabis, and cannabis, in turn, seems to worsen psychotic symptoms. [62] However, other research has shown that the use of cannabis is associated with better cognitive functioning.

Question 38

Do drug-caused episodes of psychosis increase the risk of developing schizophrenia?

Answer 38

A register-based study of more than 3000 inpatients from Scotland who experienced substance-induced psychoses showed that episodes of psychosis induced from several types of illicit substances are significantly linked to a later clinical diagnosis of schizophrenia.

Question 39

depression and schizophrenia

Answer 39

Many patients with schizophrenia report symptoms of depression. It is unclear whether such depression is an independent problem, part of the schizophrenia, a reaction to the schizophrenia, or a complication of treatment. Addressing this issue is important because of the high rate of suicide in patients with schizophrenia.

One meta-analysis suggested that the addition of antidepressants to antipsychotics might help treat the negative symptoms of chronic schizophrenia, which can be difficult to distinguish from depression.

Suicide attempts are lower in people treated with clozapine than with other antipsychotic agents.

Question 40

anxiety disorders and schizophrenia

Answer 40

Some adverse effects of medications, such as akathisia, may be experienced as anxiety. Anxiety may precede the onset of schizophrenia by several years.Treatment is keyed to the source of the anxiety. Antipsychotics usually relieve anxiety that is part of an acute psychotic episode. fluvoxamine and other selective serotonin reuptake inhibitors (SSRIs) should be used cautiously in patients receiving clozapine; they can raise clozapine blood levels. Benzodiazepines may be helpful but carry their own risks.

Question 41

Are obsessive-compulsive disorder (OCD) and schizophrenia comorbid?

Answer 41

Obsessive-compulsive symptoms are a known adverse effect of some antipsychotic medications, particularly clozapine. Patients with schizophrenia and obsessive-compulsive symptoms tend to do more poorly. There is no clear consensus on how to treat the obsessive-compulsive symptoms.Na USP eles fazem sertralina, começam com 25/50mg /dia.

Question 42

Are patients with schizophrenia at increased risk for violence?

Answer 42

Most people with schizophrenia are not violent. However, a few may act violently, sometimes as a result of command hallucinations or delusions.Violence may be associated with substance abuse. However, the rate of violence in patients with schizophrenia who do not abuse substances is higher than that in people without schizophrenia. Clozapine is sometimes recommended for treatment of patients with schizophrenia who are violent.

Question 43

Which disorders should be considered in the differential diagnoses of schizophrenia?

Answer 43

Disorders to be considered in the differential diagnosis of schizophrenia include the following:

Other psychiatric illnesses (Transtorno do humor, transtorno esquizoafetivo, transtorno, esquizofreniforme, transtorno delirante persistente, TPAT,transtorno de personalidade esquizotípico, esquizóide e paranóide, psicose relacionado ao alcool ou cocaina,)

Anatomic lesions

Metabolic illnesses

Endocrine disorders

Infectious illnesses

Miscellaneous disorders

Vitamin deficiency

Question 44

How is schizophrenia differentiated from bipolar affective disorder (manic-depressive illness)?

Answer 44

Patients with manic-depressive illness predominantly have disturbances in their affect or mood. Psychotic symptoms may be prominent during a mania or depression.

In classic manic-depressive illness, the psychotic symptoms are congruent with mania or depression, and the person has periods of euthymia (normal mood) with no psychotic symptoms between the episodes. However, some patients have periods of psychotic symptoms in the absence of depression or mania. In these cases, schizoaffective disorder is diagnosed.

Question 45

How is schizophrenia differentiated from delusional disorder?

Answer 45

In delusional disorder, the person has a variety of paranoid beliefs, but these beliefs are not bizarre and are not accompanied by any other symptoms of schizophrenia. For example, a person who is functioning well at work but becomes unreasonably convinced that his or her spouse is having an affair has a delusional disorder rather than schizophrenia.

Question 46

How is schizophrenia differentiated from schizotypal personality disorders?

Answer 46

Schizotypal personality disorder is characterized by a pervasive pattern of discomfort in close relationships with others, along with the presence of odd thoughts and behaviors. The oddness in this disorder is not as extreme as that observed in schizophrenia.

In schizoid personality disorder, the person has difficulty and lack of interest in forming close relationships with others and prefers solitary activities. No other symptoms of schizophrenia are present.

Question 47

How is schizophrenia differentiated from paranoid personality disorder?

Answer 47

In disorder, the person is distrustful and suspicious of others. No actual delusions or other symptoms of schizophrenia are present.

Question 48

How is schizophrenia differentiated from brain tumors?

Answer 48

In rare cases, brain tumors may be confused with a psychotic illness. Because brain tumors are potentially lethal but treatable, it is important to consider brain imaging studies for every person with a new onset of a psychotic illness or, perhaps, a marked change in symptoms.

Question 49

How is schizophrenia differentiated from subdural hematomas?

Answer 49

Subdural hematomas can manifest as changes in mental status. Intracranial bleeding should be considered in patients who report head trauma or who, for whatever reason, are not able to provide a clear history. Brain imaging may be appropriate in these cases.

Question 50

How is schizophrenia differentiated from idiopathic calcification of the basal ganglia?

Answer 50

Idiopathic calcification of the basal ganglia is a rare disorder that tends to present as psychosis in patients who become symptomatic early in adulthood; those presenting later in life typically present with dementia and a motor system disorder. Schizophrenialike symptoms may precede the onset of intellectual deterioration and extrapyramidal motor disturbances.