Esquizofrenia y trastornos psicoticos Flashcards
5.1.
A 21-year-old man is brought to the mental health center by his
father, who states that the patient had been withdrawing from
family and friends over the past 6 months to the point that he
sits in his room all day watching TV. He was fired from his job
3 days ago as a food delivery driver after he sat behind the
wheel of his car in a customer’s driveway for 2 hours until his
father got him on the phone and convinced him to drive home.
The patient and his father are asked to wait in the waiting area
for the first available doctor. The father sits and the patient
stands. Two hours later when the doctor comes, the patient is
standing in the exact same position. The father states that his
son has not said anything for the last 24 hours, but will follow
commands. Vital signs are within normal limits.
Comprehensive metabolic panel, heavy metals, urine drug
screen, lumbar puncture, and head CT are all negative. This
patient is most likely to experience hallucinations of what
sensory modality?
A. Auditory
B. Gustatory
C. Olfactory
D. Tactile
E. Visual
5.1. A. Auditory
The patient is displaying classic symptoms of catatonia, which were
preceded by a several-month history of withdrawing from family and
friends. Given the history, his age, his current presentation, and the
negative extensive medical workup, he most likely has a
schizophrenia spectrum disorder, in which auditory, then visual
hallucinations, are most common by far. Gustatory, olfactory, and
tactile hallucinations, especially in the absence of auditory and or
visual hallucinations, may indicate that further workup is needed.
5.2.
What is the leading cause of premature death in people with
schizophrenia?
A. Suicide
B. Heart disease
C. Homicide
D. Accidents
E. Metabolic syndrome complications
5.2. A. Suicide
Suicide is the leading cause of premature death in people with
schizophrenia, with 5% to 6% dying by suicide, according to the
DSM-5-TR. The biggest risk factor is the presence of a major
depressive episode, with command hallucinations and drug abuse
also playing significant roles. Metabolic syndrome complications can
occur as a result of treatment with second-generation and later
antipsychotics but is not the leading cause of premature death. While
people with schizophrenia are more likely to be the victim of
homicide than to commit an act of homicide, both are much less
common than suicide. Accidents are the leading cause of premature
death in young children, and occur more often in adults with
schizophrenia than in the general population, but are not the leading
cause of premature deaths in adults. Heart disease is the leading
cause of death in the United States for everyone.
5.3.
A 35-year-old woman presents to the outpatient clinic with a
complaint of hearing three voices talk about how bad she is and
“all of the horrible things I’ve done throughout my life” for the
past 4 days. She is distressed because “the voices had gotten
much better for a couple of weeks, and I didn’t feel as down, so
I thought I was finally cured.” She states that she has heard the
voices of and on, more days than not, for the past 10 years and
that she was hospitalized for a suicide attempt 9 years ago. At
the time, “I felt lower than I usually do. I didn’t get out of bed
because I was too tired, even though I slept all day. I didn’t eat
and didn’t want to do anything. The voices were even worse,
then.” She was started on medication, “but I don’t remember
what it was. I never filled the prescription.” She has been
intermittently homeless because she cannot keep a job due to
voices distracting her at work, frequent bouts of depression,
and “I don’t want to be around people anyway.” She makes
poor eye contact, and affect is flat. Mood is “down and
frustrated.” Speech is normal rate, volume, and tone. She
endorses current auditory hallucinations. What is the most
likely diagnosis?
A. Schizophrenia
B. Schizophreniform disorder
C. Major depressive disorder with psychotic features
D. Schizoaffective disorder
E. Brief psychotic disorder
5.3. D. Schizoaffective disorder
The most likely diagnosis is schizoaffective disorder. She reports a
steady baseline of symptoms of schizophrenia, including persistent
auditory hallucinations most days, and displays negative symptoms
of poor eye contact and flat affect. In addition, she has endorsed
enough symptoms to have met criteria for major depressive disorder
in the past, and usually has somewhat of a depressed mood. Though
schizophrenia can have a mood component with it, given that she
meets full criteria for both schizophrenia and depression,
schizoaffective disorder is still the better diagnosis. In major
depressive disorder with psychotic features, once the depression
remits, so should the psychosis, but her psychotic symptoms are
almost ever-present. Schizophreniform disorder lasts less than 6
months. Though the most recent hallucinations have been present
for only 4 days, this is in the context of a 10-year history of
hallucinations.
5.4.
A 50-year-old woman is brought to the emergency department
by law enforcement after being found outside of a local
television news anchor’s house. She states that she went to his
house because she “knows” he loves her, “but he’s too afraid to
let me know,” despite him telling her he is happily married and
taking out a restraining order on her. “I wanted to give him the
opportunity to say he loves me without embarrassing him in
front of other people.” She states that she knew he would be her
husband 3 years ago when she first saw him on TV. She
continues to work as a paralegal, but is afraid now that her job
is in jeopardy due to the trespassing charge. She has been
reprimanded at work because she tells clients about his love for
her. She states that she feels depressed and frustrated because
he “won’t admit the truth.” What is the most likely diagnosis?
A. Schizophrenia
B. Schizoaffective disorder
C. Delusional disorder
D. Schizotypal personality disorder
E. Major depressive disorder with psychotic features
5.4. C. Delusional disorder
What separates delusional disorder from a psychotic disorder such
as schizophrenia or schizoaffective disorder is that the delusion is
nonbizarre, and that there could possibly have been a kernel of truth
at the beginning of the delusion. Also, aside from the impact of the
delusions or its ramifications, function is not markedly impaired.
(It’s
possible
that the TV anchor could be in love with her, vs. being
virtually impossible that aliens are contacting her through the radio.)
Major depressive episodes are episodic, and the psychotic features
would likely be more out of touch with reality. Individuals with
schizotypal personality disorder usually are loners, prefer to keep to
themselves, and have few, if any, close relationships.
5.5.
A 55-year-old man is brought to the emergency department by
his parents, with whom he lives. They state that he attacked
them an hour ago “out of the blue. He’s never done that since
he was first diagnosed with schizophrenia 35 years ago.” They
were all eating lunch together as they do every day at noon,
when the patient suddenly got up and lunged at his father with
a knife. His mother was able to talk him down and convince
him to come to the hospital. The patient states that he has
heard voices talking to each other since before he was
diagnosed, but has never had visual hallucinations. However,
that evening he saw his father “transform into a vampire,” and
felt that he had to stab him through the heart. He is worried
that something similar may happen again, as are his parents.
He has been on a nightly does of olanzapine for the past two
years. What should the next step be in the evaluation and
management of this patient?
A. Administer an intramuscular antipsychotic
B. Consult the hospital psychiatrist
C. Perform a medical workup
D. Admit the patient to an inpatient psychiatric facility
E. Contact the patient’s outpatient psychiatrist
5.5. C. Perform a medical workup
Though it is tempting to assume that the patient’s presenting
problems are due to an exacerbation of schizophrenia, given that he
is displaying new, uncharacteristic behaviors and new psychotic
symptoms (visual vs. auditory hallucinations), a medical workup is
warranted. A long-standing diagnosis of schizophrenia does not
preclude someone from having a medical cause of psychotic
symptoms, such as substance intoxication, infections, metabolic
issues, etc., so the same medical workup should be done as if the
person did not have a schizophrenia diagnosis.
5.6.
A 65-year-old woman is brought to the emergency department
by her son who states that his mother has lived at home alone
since the death of her husband 6 years ago. He reports that she
seemed to adjust well and spent time with friends and family
until about a year ago, when she started to stay more to herself
in the house, and eventually stopped going to all functions. She
used to work as a chef and would cook elaborate meals for
herself that would sustain her for several days. This morning,
she called him to say that all of the food in the house was
poisoned, and that she needed him to bring more. After driving
6 hours to check on her, he found her house to be malodorous,
with mold in the unplugged refrigerator, her hair matted, and
with foul body odor. He notes that she looks like she has lost 30
pounds in the last year. When he presented her with the fresh
food, she exclaimed, “This is poison! You’re trying to poison
me, too!” Temperature is 98.8 F, pulse 104, BP 90/60, and
respirations 16. Physical examination reveals a thin,
malodorous female in no acute distress. UDS is negative.
Comprehensive metabolic profile shows increased sodium.
Urine specific gravity is high. Head CT is negative, as is urine
drug screen. She is started on IV fluids for dehydration. What is
the most appropriate disposition?
A. Discharge to home with a home health aide
B. Discharge to an assisted living facility
C. Discharge to her son’s home
D. Admission to the hospital
E. Discharge to home with a next-day psychiatry ap
5.6. D. Admission to the hospital
The patient is acutely psychotic, and is a danger to herself due to
neglect, as evidenced by poor hygiene so chronic that her hair is
matted, dehydration, and weight loss. Until the psychosis clears and
her baseline can be determined, she needs to be hospitalized for her
own safety, whether on a psychiatric inpatient unit for psychosis or a
medical unit for further workup to determine diagnosis. Given that
she lives alone, if she does not return to presymptomatic functioning,
the family and a social worker should meet to discuss disposition
options, including living with her son, living at an assisted living
facility, or living at home with a home health aide, depending on the
severity of her residual symptoms and efficacy of treatment
5.7.
A 37-year-old woman notices that she has been having
difficulty sitting still at work at her job at a call center and at
home for the last week. She was discharged from an inpatient
psychiatric facility 2 weeks ago with a diagnosis of
schizoaffective disorder. During the 2-week hospitalization, she
was started first on risperidone, which led to lactation, then
was switched to haloperidol. She has no current problem with
neck stiffness, but feels an urge to move her legs and walk
around. Because of her productivity quota at work she does not
get up to walk, but instead crosses and uncrosses her legs
constantly. She has the same problem at night, with the
restlessness interfering with her sleep, so she gets up and walks
around for relief. What medication is the first-line treatment
for these symptoms?
A. Ropinirole
B. Benztropine
C. Propranolol
D. Trihexyphenidyl
E. Valbenazine
5.7. C. Propranolol
The woman is suffering from akathisia, a feeling of restlessness and
needing to move, especially in the legs. This is most often caused by
antipsychotics, usually those of the first generation, such as
haloperidol. Treatment is first to try to decrease or stop the offending
agent. If that is not feasible, then the next is
to use a beta-blocker
such as propranolol. Ropinirole is used for restless legs syndrome.
Though the symptoms are largely the same, they typically occur in
the evening or nighttime, as opposed to all day. Benztropine is used
for the stiffness of extrapyramidal symptoms. Trihexyphenidyl is
used for sialorrhea, and valbenazine for tardive dyskinesia
5.8.
A 35-year-old man complains of finger and tongue movements
that have been getting rapidly worse over the last 3 months.
The movements have been present over the last 10 years, since
he was diagnosed with schizophrenia and started on
fluphenazine. Movements are now to the point that he has
trouble holding a cup to drink. Over the years, the fluphenazine
has been lowered to the most effective dose, which is still
moderately high. He has been through adequate trials of
valbenazine, deutetrabenazine, benztropine, and alprazolam,
all of which were ineffective. An abnormal involuntary
movement scale (AIMS) assessment places the movements in
the severe range. What is the most appropriate treatment for
this patient?
A. Change to haloperidol
B. Attempt a slower and more gradual decrease of
fluphenazine
C. Begin tetrabenazine
D. Change to aripiprazole
E. Change to clozapine
5.8. E. Change to clozapine
The patient is displaying severe tardive dyskinesia, which is not
unexpected given a 10-year history of being on a first-generation
antipsychotic starting at a relatively young age. The treatment of
choice is to decrease the offending agent. However, for him, this
cannot be done without risking an exacerbation. The next treatment
is to change to a second-generation antipsychotic, if possible. Given
the severity of his movements, he needs to change to clozapine, as
that is both a second-generation antipsychotic and is effective in
reducing severe tardive dyskinesia. Given that he has already been
on two vesicular monoamine transport-2 (VMAT-2) inhibitors, and
due to the severity of his movements, it is reasonable to guess that
trying a third (tetrabenazine) also will not be effective. He should not
be changed to another first-generation antipsychotic (haloperidol).
Though aripiprazole is a second-generation antipsychotic, the
severity of the movements again makes clozapine a better choice.
5.9.
A 35-year-old woman is being discharged later in the day from
her second hospitalization due to an acute psychotic episode.
She was brought to the hospital 8 days ago after passersby
called the police because she was yelling at women on the
street, accusing them of sleeping with her husband when he
was a baby. During the initial hospitalization 2 years ago, she
was started on quetiapine and was stable enough that she could
return to work in hotel maintenance. She stopped taking the
medication a year later because “I was doing fine. I didn’t need
it anymore.” She was restarted on the quetiapine during this
hospitalization, and required a 20% higher dosage to regain
stability. During the discharge planning meeting, she asks the
physician, “How long do I have to stay on this drug? I don’t
want to be on medication forever.” How should the physician
respond?
A. “You should stay on the medication for at least 2 years, then
get reassessed to see if you can stop it.”
B. “You should stay on the medication for 1 year, then go back
down to your previous dose.”
C. “You should stay on the medication for at least 5 years, then
get reassessed to see if you can stop it.”
D. “That can be assessed on a regular basis. Perhaps you will
be able to come off of it someday.”
E. “You should stay on the medication indefinitely because
you’re likely to have another episode if you don’t.”
5.9. E. “You should stay on the medication indefinitely
because you’re likely to have another episode if you don’t.”
The patient has now had two acute psychotic episodes with a
diagnosis of schizophrenia. Furthermore, her interepisode
functioning is high enough that she is able to maintain a job. Given
those factors, most experts recommend that consideration be given
for indefinite treatment
5.10.
A 43-year-old man is emergently admitted to an inpatient
psychiatric facility for the fifth time in 12 months after EMS
was called to his parents’ house due to him running naked in
living room and overturning furniture. When told to stop, he
ran outside and started pulling up clumps of grass out of the
lawn. He was first diagnosed with schizophrenia at age 22, and
has been treated with haloperidol, fluphenazine, aripiprazole,
aripiprazole lauroxil, and paliperidone. He is currently on
paliperidone palmitate every month. The previous medications
have either been ineffective or partially effective at maximum
doses. His parents assure the admitting physician that they
made sure he took his oral medication daily, and that they take
him to follow-up appointments. “No medicine has worked for
him for long.” He has mild hypercholesterolemia.
Comprehensive metabolic panel is within normal limits. What
should be the next step in his medication regimen?
A. Augment with an oral first-generation antipsychotic
B. Change to a first-generation long-acting injection
C. Change to clozapine
D. Change to the 3-month formulation of paliperidone
palmitate
E. Augment with a first-generation long-acting injection
5.10. C. Change to clozapine
The patient has adequately tried and failed over four different firstand
second-generation antipsychotics, in both oral and long-acting
injectable forms. Given that his parents are diligent about making
sure he takes his oral medications and taking him to appointments,
clozapine should be the next consideration. Changing to a longeracting
form of a medication he is currently not doing well on is likely
to be just as ineffective, especially since he has already been on both
first-generation antipsychotics that are available as a long-acting
injection. He should try what is considered the most effective
antipsychotic as monotherapy before combining two antipsychotics.
5.11.
Patients who show any improvement on an antipsychotic
should remain on that medication to monitor for further
improvement for at least what length of time?
A. Four weeks
B. Six weeks
C. Three months
D. Six months
E. One year
5.11. C. Three months
An adequate trial of an antipsychotic medication is 4 to 6 weeks at an
adequate dose. If the patient shows improvement, they should
remain on that medication for at least 3 and up to 6 months, as
improvements can continue to occur over that length of time.
5.12.
CT scans of patients with schizophrenia consistently show
what neuroanatomical abnormality?
A. Decreased number of D2 receptors in the caudate
B. Enlarged ventricles
C. Increased white matter in the thalamus
D. Enlarged amygdala
E. Decreased density of D2 receptors in the nucleus
accumbens
5.12. B. Enlarged ventricles
Enlarged third and lateral ventricles are a consistent finding in the
brains of individuals with schizophrenia. Many structures, such as
those of the limbic system (amygdala, hippocampus, and
parahippocampal gyrus) and the thalamus are reduced in size.
However, there is an increase in the D2 receptor density in the
caudate, putamen, and nucleus accumbens.
5.13.
What laboratory test must be monitored in patients taking
clozapine in order for them to continue receiving the
medication?
A. Complete blood count with differential
B. Comprehensive metabolic panel
C. Lipid profile
D. Hemoglobin A1c
E. Liver function tests
5.13. A. Complete blood count with differential
Though rare, the 0.3% incidence of agranulocytosis in patients taking
clozapine is enough to mandate weekly complete blood counts with
differential for the first 6 months, biweekly for the next 6, then
monthly. If one lab draw is missed, the pharmacy will not dispense
the next dose of the medication, and the monitoring schedule resets.
A comprehensive metabolic panel, or at least a basic one, lipid
profile, and A1c are important for monitoring metabolic side effects.
Clozapine is not known to affect the liver
