First Aid: Psychotic Disorders Flashcards
What are 3 symptoms that automatically tell you a patient is psychotic?
- Perceptual disturbances (hallucinations)
- Delusional thinking
- Disordered thought process
Sensory perception without an actual external stimulus.
Hallucination
What is the most common type of hallucination exhibited by schizophrenics?
auditory
Which type of hallucination is most commonly seen with drug intoxication?
visual
Which type of hallucination is usually an aura associated with epilepsy?
olfactory
Which type of hallucination is usually secondary to drug abuse or alcohol withdrawal?
tactile
Misinterpretation of an existing sensory stimulus.
illusion
What is a loss of ego boundaries?
Unawareness of where one’s mind and body end and those of others begin
List the 3 major broad categories of medical causes of psychosis.
1) CNS disease
2) Endocrinopathies
3) Nutritional/Vitamin Deficiency States
What are the 3 major nutritional/vitamin deficiency causes of psychosis?
- B12
- Folate
- Niacin
What is psychosis due to heavy metal toxicity grouped under?
Psychosis secondary to medication or substance use
To diagnosis psychosis secondary to a medical condition or medication/substance use, when must the prominent hallucinations or delusions occur?
NOT only during episodes of delirium
Name the positive symptoms of schizophrenia.
- Hallucinations
- Delusions
- Disorganized speech
- Grossly disorganized or catatonic behavior
Name the negative symptoms of schizophrenia.
- Affect (flat/blunted)
- Anhedonia
- Apathy (avolition)
- Attention (poor)
- Alogia (poverty of speech)
What are the DSM-IV stipulations for diagnosing schizophrenia?
- 2 or more of positive/negative symptoms that last for at least 1 month and cause significant social or occupational functional deterioration
- Duration of illness for at least 6 months (including prodromal and residual phases)
- Symptoms not due to medical, neurological or substance-induced disorder
List the 3 phases of schizophrenia.
- Prodromal
- Psychotic
- Residual
What are some s/s of the prodromal phase of schizophrenia?
Decline in functioning preceding the first psychotic episode:
- Social withdrawal
- Irritability
- Psysical complaints
- Newfound interest in religion or the occult
What are some s/s of the psychotic phase of schizophrenia?
- Perceptual disturbances
- Delusions
- Disordered thought process/content
What are some s/s of the residual phase of schizophrenia?
Occurs between episodes of psychosis:
- Flat affect
- Social withdrawal
- Odd thinking or behavior
- May have hallucinations (even with treatment)
Name the 5 subtypes of schizophrenia (DSM-IV).
- Paranoid
- Disorganized
- Catatonic
- Undifferentiated
- Residual
How does a schizophrenic usually respond to proverbs/similarities?
Concrete understanding (no abstraction)
What is the typical level of insight for a schizophrenic patient?
Lack insight into disease
What is the typical age of presentation for schizophrenia?
Males- 20
Females- 30
NOT before 15 or after 45 (usually)
True or false: schizophrenia is more severe in women
FALSE: men have more negative symptoms and may be less able to function in society
Is schizophrenia genetic?
- 12% risk if you have first degree relative
- 40% risk if both parents are affected
What is a common comorbidity affecting 50% of schizophrenics?
Postpsychotic depression
What is the “downward drift hypothesis”?
People suffering from schizophrenia are unable to function well in society and enter lower SES groups
Schizophrenia pathophysiology is thought to be related to what chemical?
increased dopamine activity
What drugs can induce a schizophrenia like episode?
cocaine and amphetamines
What dopamine pathway is thought to be responsible for negative symptoms of schizophrenia?
Prefrontal cortical
What dopamine pathway is thought to be responsible for positive symptoms of schizophrenia?
mesolimbic
Which dopamine pathway is blocked by neuroleptics and causes hyperprolactinemia?
tuberoinfundibular
Which dopamine pathway is blocked by neuroleptics and causes EPS?
nigrostriatal
CT scans of brains of schizophrenia patients show what?
enlargement of ventricles and diffuse cortical atrophy
List the other neurotransmitter abnormalities of schizophrenia?
- Elevated serotonin
- Elevated NE
- Decreased GABA
How does GABA potentially affect schizophrenia?
- Loss of GABAergic neurons in hippocampus
- This possibly indirectly activates DA and NE pathways
List some antipsychotics that antagonize 5-HT as well as DA?
- Risperidone
- Clozapine
What percentage of schizophrenics can function fairly well in society with medication?
20-30%
What factors are associated with better prognosis for schizophrenics?
- Later onset
- Good social support
- Positive symptoms
- Mood symptoms
- Acute onset
- Female sex
- Few relapses
- Good premorbid functioning
What factors are associated with worse prognosis for schizophrenics?
- Early onset
- Poor social support
- Negative symptoms
- Family Hx
- Gradual onset
- Male sex
- Many relapses
- Poor premorbid functioning
What percentage of schizophrenics show significant improvement on medication?
70%
What is another word for neuroleptic?
antipsychotic
List the typical neuroleptics.
- Chlorpromazine (low potency)
- Thioridazine (low potency)
- Trifluoperazine
- Haloperidol
What is the MOA of typical neuroleptics?
Mostly D2 antagonists
List the atypical neuroleptics.
- Risperidone
- Ziprosidone
- Clozapine
- Olanzapine
- Quetiapine
- Aripiprazole
What is the MOA of atypical neuroleptics?
Block DA and 5-HT receptors
How long must you try a neuroleptic before efficacy is determined?
at least 4 weeks
EPS are seen mostly with what type of antipsychotics?
High potency typical neuroleptics
haloperidol, trifluoperazine
List the 3 major EPS.
- Dystonia (spasms)
- Parkinsonism (resting tremor, rigidity, bradykinesia)
- Akathisia (restlessness)
How do you treat EPS?
Antiparkinsonian agents (benzotropine, amantadine), benzodiazepines
Anticholinergic sympoms are seen mostly with what type of antipsychotics?
Low potency typical neuroleptics
chlorpromazine, thioridazine
List the common anticholinergic symptoms of antipsychotics.
- Dry mouth
- Constipation
- BLurred vision
What is the treatment plan for tardive dyskinesia?
Stop offending agent
Substitute atypical neuroleptic
Possible benzos, cholinomimetics, and beta-blockers
Who gets tardive dyskinesia?
-Older women after at least 6 months of medication
What are s/s of NMS?
- Confusion
- High fever
- Elevated BP
- Tachycardia
- “Lead pipe” rigidity
- Sweating
- High CPK
Is NMS an allergic reaction?
NO
List some of the other s/s of antipsychotics.
- Weight gain
- Sedation
- Orthostatic hypotension
- ECG changes
- Hyperprolactinemia
- Dermatologic conditions
- Hyperlipidemia
- Glucose intolerance
Which antipsychotic requires weekly blood draws?
clozapine (agranulocytosis)
Which antipsychotic causes irreversible retinal pigemtnation at high doses?
thioridazine
Which antipsychotic may cause deposits in the lens and corena?
chlorpromazine
Who gets NMS?
men who have recently started medication
What is the prognosis for NMS?
20% mortality
What is the DSM-IV criteria for diagnosing schizophreniform disorder?
Same as schizophrenia but s/s last between 1-6 months rather than >6 months
What is the prognosis for schizophreniform disorder?
- 1/3 recover completely
- 2/3 progress to schizoaffective or schizophrenia
(Mood disorder > brief psychotic disorder > schizoaffective disorder >
schizophreniform disorder > schizophrenia)
How do you treat schizophreniform disorder?
- Hospitalize
- 3-6 months of antipsychotics
- Supportive psychotherapy
What is the DSM-IV criteria for diagnosing schizoaffective disorder?
- Meet criteria for either major depressive episode, manic episode or mixed episode (during which criteria for schizophrenia are also met)
- Have had delusions or hallucinations for 2 weeks in ABSENCE of mood disorder sympoms**
- Have mood sympoms present for substantial portion or psychotic illness
- Symptoms not due to general medical condition or drugs
What is the prognosis for schizoaffective disorder?
- Better than schizophrenia/schizophreniform
- Worse than mood disorder
(Mood disorder > brief psychotic disorder > schizoaffective disorder >
schizophreniform disorder > schizophrenia)
How do you treat schizoaffective disorder?
- Hospitalization
- Supportive psychotherapy
- Antipsychotics (short term control of psychosis)
- Mood stabilizers, antidepressants, or ECT for mania or depression
What is the DSM-IV criteria for diagnosing brief psychotic disorder?
Same as schizophrenia but s/s last
What is more common, brief psychotic disorder or schizophrenia?
schizophrenia
What is the prognosis for brief psychotic disorder?
- 50-80% recovery rate (worse than mood, better than schizoaffective)
- 20-50% later diagnosed with schizophrenia or mood disorder
How do you treat brief psychotic disorder?
- Brief hospitalization
- Supportive psychotherapy
- Course of antipsychotics for psychosis
- Benzos for agitation
Who more commonly gets delusional disorder?
- Older patients (>40)
- Immigrants
- Hearing impaired
What is the DSM-IV criteria for diagnosing delusional disorder?
- Non-bizarre, fixed delusion for at least 1 month
- Does NOT meet criteria for schizophrenia
- Functioning in life is NOT significantly impaired
What type of delusion revolves around love?
erotomanic
What type of delusion is associated with inflated self-worth?
grandiose
What type of delusion is physical?
somatic
What is the prognosis for delusional disorder?
- 50% full recovery
- 20% decreased sympoms
- 30% no change
What is the treatment for delusional disorder?
- Psychotherapy
- Trial of high-potency typical antipsychotic or atypical (usually NOT effective)
What is folie a deux?
shared psychotic disorder
Who gets shared psychotic disorder?
family members (usually)
What is the treatment/prognosis for shared psychotic disorder?
- 20-40% improve upon removal from inducing person
- Psychotherapy
- Antipsychotic meds if symptoms not improved in 1-2 weeks after separation
What is Koro?
Asian belief that pt’s penis is shrinking and will disappear causing death
What is Amok?
Malaysian (SE Asian) people have sudden unprovoked outbursts of violence after-which the person has no recollection
What is Brain fag?
African male students get HA, fatigue and visual disturbances
What is a schizotypical personality?
Person has paranoid, odd or magical beliefs
Eccentric
Lacks friends
Social anxiety
(does not meet criteria for true psychosis)
What is a schizoid personality?
Person is withdrawn
Lacks enjoyment from social interactions
Emotionally restricted
