First Aid for the Psychiatry Clerkship - "Psychotic Disorders"

Question 1

Define delusions.

Answer 1

Delusions are fixed, false beliefs that remain despite evidence to the contrary and cannot be accounted for by the cultural background of the individual.

Question 2

Delusions are sometimes classified as bizarre or non-bizarre. What’s the difference?

Answer 2

• Non-bizarre delusions are unlikely but at least plausible. For instance, someone saying “the neighbors are reading my mail!” is a little weird but at least feasible.
• Bizarre delusions are those that are completely implausible. An example of this would be “Martians are broadcasting my thoughts on secret radio stations.”

Clinically, non-bizarre delusions are typical of delusional disorders and bizarre delusions are typical of schizophrenia.

Question 3

What are some common themes of delusions?

Answer 3

• Ideas of reference (thinking everything is about you)
• Persecution/paranoia
• Grandiosity
• Hyperreligiosity
• Somatic delusions (thinking you have a disease that you don’t)
• Delusions of guilt (“I am responsible for Ebola!”)
• Delusions of control (“Someone is putting thoughts in my head!”)

Question 4

What is the difference between an illusion and a hallucination?

Answer 4

• An illusion is when you mistake one stimulus for another. For instance, seeing a stick and thinking it’s a snake is an illusion.
• A hallucination has no basis in external stimuli. So seeing a snake floating in the clear blue sky is a hallucination.

Question 5

First Aid breaks down the medical causes of psychosis into what four categories?

Answer 5

• CNS issues (e.g., Parkinson’s, prion disease, dementia, encephalitis, Huntington’s)
• Endocrinopathies (e.g., hyper- and hypocalcemia, thyroid dysfunction, Cushing’s)
• Metabolic/nutritional disorders (e.g., hypoglycemia, B1 deficiency, niacin deficiency)
• Other (e.g., connective tissue disease)

Question 6

The symptoms of schizophrenia are broken into what three categories?

Answer 6

• Positive symptoms: hallucinations, delusions, disorganized speech, bizarre behavior
• Negative symptoms: flat affect, anhedonia, apathy
• Cognitive symptoms: memory impairment, difficulty paying attention

Question 7

Schizophrenia usually proceeds through what three phases?

Answer 7

1) . Prodromal: decline in function
2) . Psychotic: perceptual disturbances
3) . Residual: social withdrawal and negative symptoms

Question 8

Give the DSM-V criteria for a diagnosis of schizophrenia.

Answer 8

•At least two of the following symptoms with at least one of the two from the first three things (that must be present for a month or more):
- Hallucinations
- Delusions
- Disorganized speech
- Grossly disorganized speech or behavior
- Negative symptoms (flat affect, anhedonia, social withdrawal)
•The above must cause distress or impairment of social function
•Not due to a substance taken
•Going on for at least six months

Question 9

List the five negative symptoms seen in schizophrenia.

Answer 9

Think of the A's: 
•Apathy
• Anhedonia
•Affect (flat) 
•Attention (poor) 
•Alogia (aka, paucity of speech)

Question 10

What is the prevalence of schizophrenia?

Answer 10

About 1:200 people

Question 11

What is the monozygotic concordance rate of schizophrenia?

Answer 11

50%

Interestingly, if both parents have schizophrenia, then the risk of inheritance is about 40%.

Question 12

Men tend to present with schizophrenia _________________, compared to women.

Answer 12

earlier (around 20) with more negative symptoms

Question 13

What is the “downward drift” theory of schizophrenia?

Answer 13

Schizophrenia is more common in lower SES populations. It is postulated that people with schizophrenia are less able to hold down jobs and therefore end up poorer.

Question 14

The dopamine hypothesis states that schizophrenia is caused by increased dopaminergic activity in the ______________ cortex and decreased dopaminergic activity in the _____________ cortex.

Answer 14

mesolimbic; prefrontal cortical

Question 15

Antipsychotics often block the _____________ pathway which leads to Parkinsonian symptoms.

Answer 15

nigrostriatal

Question 16

Other than dopamine, what neurotransmitter is thought to be elevated in schizophrenia?

Answer 16

Serotonin (hence, second-generation antipsychotics block serotonin, too)

Question 17

Schizophrenic patients have been shown to have decreased levels of what neurotransmitter receptor?

Answer 17

NMDA

It’s thought that this is why NMDA antagonists can cause psychosis.

Question 18

With medication, about ________ percent of people with schizophrenia can function well in society.

Answer 18

20-30

Many (40% - 60%) still can’t function in society with medications.

Question 19

Head CTs of patients with schizophrenia may show _______________.

Answer 19

ventricle enlargement and cortical atrophy

Question 20

Those with __________ schizophrenic symptoms tend to have a better prognosis.

Answer 20

positive

Other factors that correlate with better prognosis include good social support, later onset, female gender, few relapses, and good premorbid functioning.

Question 21

The typical antipsychotics are better at treating ___________ symptoms.

Answer 21

positive

Question 22

True or false: second-generation antipsychotics typically become effective in one week.

Answer 22

False. SGAs need to be given for up to four weeks to reach maximum efficacy.

Question 23

In addition to medication, _____________ can help those with schizophrenia funciton normally in society.

Answer 23

behavioral therapy

Question 24

Why is diphenhydramine given to treat extrapyramidal symptoms?

Answer 24

Diphenhydramine has anticholinergic properties and functions like trihexyphenidyl and benztropine.

Question 25

In addition to ziprasidone, _______________ is a weight-neutral SGA.

Answer 25

aripiprazole

Question 26

Vitamin ____ has some ability to treat tardive dyskinesia.

Answer 26

E

Question 27

The cumulative risk of developing tardive dyskinesia is _______ per year.

Answer 27

5%

Taking antipsychotics for twenty years will almost always lead to TD.

Question 28

Why is schizophreniform disorder clinically useful?

Answer 28

One-third of patients who meet the criteria for schizophrenia within the last six months will actually recover completely.

Question 29

What factors predict a worse outcome in schizophrenia?

Answer 29

• Gradual onset
• Family history
• Male gender
• Early onset
• Poor social support
• Negative symptoms
• Many relapses
• Substance use

Question 30

Brief psychotic disorders are cases in which the patient meets criteria for schizophrenia but resolve within one month. What can cause this?

Answer 30

• Bereavement
• Sexual assault
• Many other things

Question 31

What are the diagnostic criteria for delusion disorders?

Answer 31

• One or more delusions for at least one month
• No impairment of life
• Criteria for schizophrenia not met
• Usually non-bizarre delusions

Question 32

With treatment, what percent of people with delusional disorder will fully recover?

Answer 32

More than half

Question 33

How are delusional disorders treated?

Answer 33

Antipsychotics are often used, although the evidence for their use is somewhat lacking. Group therapy can be helpful, but sometimes patients’ insight is so poor that they cannot be helped.