ICL 9.1: Psychotic Disorders & Schizophrenia

Question 1

what is psychosis?

Answer 1

a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality

Question 2

which psychiatric disorders have psychosis?**

Answer 2

1. brief psychotic disorder
2. schizophreniform disorder
3. schizophrenia and schizoaffective disorder
4. delusional disorder
5. mood disorder with psychotic features

Question 3

what is brief psychotic disorder?**

Answer 3

lasts 1 day to 1 month

must have at least 1 symptom with return to premorbid level of functioning:
1. delusions

2. hallucinations
3. disorganized speech/behavior/catatonia

Question 4

what is schizophreniform disorder?**

Answer 4

lasts 1 to 6 months

must have at least 2 symptoms present for a significant portion of time during at least 1 month

1. delusions
2. hallucinations
3. disorganized speech/behavior/catatonia/negative symptoms

Question 5

what is schizophrenia and schizoaffective disorder?**

Answer 5

lasts for over 6 months

schizophrenia is the same as schizophreniform so must have at least 2 symptoms present for a significant portion of time together during at least 1 month = delusions, hallucinations, disorganized speech/behavior/catatonia –> but may include prodromal period that’s anywhere from 1 month-6 months where they have a lot of negative symptoms

schizoaffective disorder is when there are psychotic symptoms for 2 weeks between mood episodes (can be bipolar type or depressed type)

Question 6

what is delusional disorder?**

Answer 6

lasts for over 6 months

must have at least 1 delusion

functioning is NOT impaired and behavior is NOT obviously bizarre or odd; with all the other psychotic disorders there is impairment or functioning and behavior!

Question 7

what is mood disorder with psychotic features?**

Answer 7

lasts for more than 1 or 2 weeks –> so these people will have psychotic symptoms when they’re concurrently experiencing mood symptoms

1. major depressive disorder: at least 5 symptoms of SIGECAPS, must have depressed mood or anhedonia as one
   (lasts 2 weeks)
2. bipolar I disorder: at least 3 symptoms if you’re a euphoric manic or 4 symptoms of if you’re an angry manic of DIGFAST (last 1 week for mania)

Question 8

how can you differentiate between bipolar i disorder with psychotic symptoms and schizoaffective disorder bipolar type?

Answer 8

schizoaffective disorder bipolar type is when there are just psychotic symptoms for 2 weeks between mood episodes

bipolar disorder with psychosis is when there’s psychotic symptoms specifically when you’re in a manic or depressed state but not all the time

you have to look at the time course and the history and what you’ll see with a bipolar I disorder is that they only have psychotic symptoms when they’re in a high or low –> also tends to be mood congruent psychosis so if they’re manic and euphoric then you have a special power to spread love and you’re awesome

if they always have psychotic symptoms and 2 weeks of just psychotic baseline without any mood symptoms whatsoever ever then they have schizoaffective disorder –> tends to be mood incongruent psychosis during highs/lower and more in line with your baseline delusions so during your mania/depression you’re still going to think aliens are coming like you always do, maybe you’ll just be extra worried about them during the high/low

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Question 9

what is paranoid personality disorder?

Answer 9

pervasive feelings of distrust; they have a baseline constant paranoia

might lack delusions but the patient still feels that people are acting maliciously and cannot be trusted

might believe in conspiracy theories or feel that he is the target of ill will; these patients are often litigious and unhappy

usually there is no evidence of overt psychosis or a break from reality

antipsychotics might be helpful if the patient is willing to take them

Question 10

how do you differentiate between schizophrenia and paranoid personality disorder?

Answer 10

people who have schizophrenia who are grossly psychotic with paranoid delusions can look like PPD

but PPD is chronic and sustainable and doesn’t have the gross psychosis with negative symptoms like catatonia

so if they’re always paranoid that’s more in line with PPD

Question 11

what is delusional disorder?

Answer 11

persistent false beliefs of persecution

delusions are often about finances or marital fidelity

the beliefs might appear possible but are not based on fact; hallucinations do not usually occur and the delusions are never bizzare

no impairment in functioning!**

Question 12

what is schizophrenia?

Answer 12

patients are quite disturbed; they often have bizarre persecutory delusions that are unlikely to be possible

auditory hallucinations are common

negative and positive symptoms

treatment with antipsychotic medications is often successful but poor insight causes compliance issues

Question 13

what is the schizo spectrum?

Answer 13

1. schizoid
2. schizotypal
3. schizophrenia
4. schizoaffective

Question 14

what is schizoid?

Answer 14

introverted, voluntarily withdraws from social interactions, avoid intimacy, indifferent to praise or criticism, restricted emotions, loss of interest

Cluster A Personality Disorder

part of the schizo spectrum

Question 15

what is schizotypal?

Answer 15

schizoid type symptoms plus magical thinking and odd behavior, cognitive and perceptual distortions, ideas of reference, eccentric

has the closest genetic link to schizophrenia

ex. crazy cat lady or the tarot card reader

Cluster A Personality Disorder

part of the schizo spectrum

Question 16

how common is schizophrenia and what populations are more likely to have it?**

Answer 16

schizophrenia occurs throughout the world (1% prevalence), and at similar rates in ethnic groups around the world

the incidence (the number of new cases annually) is about 1.5 per 10,000 people

men are diagnosed with schizophrenia more than women and tend to have a worse prognosis

usual age of onset is early adulthood (although earlier range in men compared to women) –> 18-25 years for men and 25-35 years for women

Question 17

what causes factor into schizophrenia?

Answer 17

1. nature
2. prenatal complciations (3rd trimester specifically which damages neuronal synapses)
3. nurture
4. substance use (marajuana specifically is horrible and effects synaptic pruning)
5. psycho-social issues and stress
6. dopamine and glutamate hypotheses

basically we don’t know….there’s a ton of stuff that we think factors into it

honestly go listen, like around 1 hr 5 minutes super interesting

Question 18

whats the inflammatory hypothesis of schizophrenia?

Answer 18

untreated psychosis and depression causes an inflammatory cascade which can contribute to neurofibrillary tangles which contribute to alzheimers

Question 19

which 2 dopamine pathways are relevant to schizophrenia symptoms?

Answer 19

1. overactive mesolimbic pathway = positive symptoms

ventral tegmental area –> nucleus accumbens

2. mesocortical pathway dysfunction = negative and cognitive symptoms

ventral tegmental area –> cortex

Question 20

what are the structural brain abnormalities seen in schizophrenic patients?

Answer 20

1. enlarged ventricles
2. decreased volume

smaller prefrontal cortex and hippocampus

intellect and social cognition deteriorates as grey matter mass declines

3. reduced symmetry in temporal, frontal and occipital lobes

Question 21

what are the connectivity brain abnormalities seen in schizophrenic patients?

Answer 21

1. abnormal neuronal connectivity and synaptic signaling
2. altered dopaminergic and glutamatergic neurotransmission

disruption of large-scale networks between prefrontal cortex and other parts of the limbic system affects memory, leads to hallucinations, and cognitive dysmetria (difficulty in prioritizing, processing, coordinating, and responding to information)

damage to neurons which result in disruption to networks and structural change is brought about epigenetically through the contribution of microglia (small amoeboid cells) involved in neuronal and synaptic pruning and damage

Question 22

what is the DSM5 criteria for schizophrenia?**

Answer 22

A. two or more of the following, each present for a significant portion of time during a 1 month period (or less if treated); at least one of these must be 1, 2 or 3:

1. delusions
2. hallucinations
3. disorganized speech (derailment, incoherence)
4. grossly disorganized or catatonic behavior
5. negative symptoms

B. for a significant portion of time, the level of functioning in one or more areas of life (work, interpersonal relationships, self-care) is markedly below normal levels

C. continuous signs of the disturbance persist for at least 6 months (of which at least 1 month must have “active” criterion A symptom), and may include periods or prodromal or residual symptoms

D. Ruled out schizoaffective disorder and bipolar disorder

E. not due to substance or other medical condition

F. can have a diagnosis of autism, but must still meet full criteria for schizophrenia

Question 23

what are the positive symptoms of schizophrenia?

Answer 23

1. delusions
2. hallucinations
3. distortions in language or communication
4. disorganized speech
5. disorganized behavior
6. catatonic behavior
7. agitation

Question 24

what are the negative symptoms of schizophrenia?

Answer 24

1. alogia
2. affective blunting
3. asociality
4. anhedonia
5. avolition
6. attentional impairment
7. poor memory, planning
8. poor decision making

Question 25

what are loose associations?

Answer 25

continual shifting from topic to topic without any apparent or logical connection between thoughts

positive symptom of schizophrenia

Question 26

what are neologisms?

Answer 26

new, seemingly meaningless words that are formed by combining words

positive symptom of schizophrenia

Question 27

what is anhedonia?

Answer 27

inability to feel pleasure; lack of interest or enjoyment in activities or relationships

negative symptom of schizophrenia

Question 28

what is avolition?

Answer 28

inability or lack of energy to engage in routine (e.g., personal hygiene) and/or goal-directed (e.g., work, school) activities

negative symptom of schizophrenia

Question 29

what is alogia?*

Answer 29

lack of meaningful speech, which may take several forms, including poverty of speech (reduced amount of speech) or poverty of content of speech (little information is conveyed; vague, repetitive)

negative symptom of schizophrenia

Question 30

what is asociality?

Answer 30

impairments in social relationships; few friends, poor social skills, little interest in being with other people

negative symptom of schizophrenia

Question 31

what is flat affect?

Answer 31

flat outward expression (no emotional response), toneless voice

negative symptom of schizophrenia

Question 32

what is clang associations?

Answer 32

when words are said together that rhyme. Example would be ““I said the bread and read the shed and fed Ned at the head”

positive symptom of schizophrenia

Question 33

what is word salad?

Answer 33

when words are spoken together that are not connected at all.

example would be “Horse paper handbags skipping forests play together”

positive symptom of schizophrenia

Question 34

what are the 3 things that go into the treatment of schizophrenia?

Answer 34

1. biological

prevention of brain damage, medication adherence, sobriety

2. psychological

coping skills, cognitive enhancement therapy, cognitive behavioral therapy, assertive community treatment

medications don’t take positive symptoms down to 0% so you have to find ways to fight them when they do pop up

CEH focuses on the negative symptoms of schizophrenia like attention and thought processing via computer games to work on attention and strengthen neuronal pathways

CBT to challenge hallucinations or delusions

3. social

functioning at home, work, school and with friends, avoidance of legal system

Question 35

what’s the difference between remission and recovery?

Answer 35

remission = 50% improvement in symptoms

recovery = full improvement in symptoms

Question 36

how does schizophrenia present as increased aging?

Answer 36

CNS:dilated ventricles, reduced brain volume and gray matter volume; hypofrontality, neurocognitive deficits such as executive functioning, working memory, and attention; neurophysiologic (low amplitudes on evoked potentials)

Musculoskeletal system:abnormalities in muscle fibers; altered nerve conduction velocity; reduced bone density

Skin:aging skin

Eyes:increased rate of cataracts (not caused by medications); degradation in motion discrimination

Endocrine system:abnormal gonadal hormones; low estrogen; low androgen; thyroid dysfunction, elevated cortisol

Metabolism:increased rates of obesity; glucose dysregulation even before antipsychotic treatment; increased insulin resistance; abnormal glucose tolerance; reduced insulin-like growth factor-1 levels

Immune system:increased pro-inflammatory cytokines (interleukin [IL]-1B, IL-6, IL-3, IL-4, IL-10, IL-13, tumor necrosis factor-Symbol Stdα) and decrease in anti-inflammatory cytokines (IL-2, interferon [INF]-Symbol Stdα, INF-Symbol Stdγ) and vitamin D

Cardiovascular:systolic hypertension, increased pulse pressure

Oxidative stress and mitochondrial dysfunction:increase in reactive oxygen species in brain tissue and increased DNA and RNA oxidation markers

Telomere dynamics:significantly higher rates of telomere loss.

Question 37

what are the comorbidities associated with schizophrenia?

Answer 37

1. infectious diseases

8x higher HIV and 4x higher HepC prevalence

2. psychiatric disorders

depression, panic disorder, suicidality, PTSD, OCD

3. substance use

tobacco, cannabis, alcohol

4. metabolic syndrome

2x increased prevalence of DM2, dyslipidemia, HPT, obesity

Question 38

what are the stages of schizophrenia?

Answer 38

1. premorbid = no or few symptoms
2. prodromal = attenuated symptoms aka light symptoms like magical thinking or ideas of reference
3. syndromal = deterioration, psychotic symptoms present
4. chronic or residual = psychotic symptoms, negative symptoms, cognitive symptoms, functional disability

each episode creates a new baseline for most people so that’s why prevention of psychotic episodes is SO important!

Question 39

how do you recover from schizophrenia?

Answer 39

even though there are degrees to recovery, it IS possible to recovery from schizophrenia! this is why getting treatment at the first psychotic episode is so important

recovery includes 4 processes:
1. finding hope

2. re-establishign identity
3. taking responsibility for recovery
4. finding meaning and getting on with life

Question 40

what are good prognostic factors of schizophrenia?

Answer 40

1. later age at onset of symptoms
2. good social support
3. mood symptoms (more schizoaffective symptoms)
4. acute onset
5. female sex
6. few relapses
7. no history of substance use

Question 41

what are the benefits of psychotherapy for schizophrenic patients?

Answer 41

1. prevents crisis visits and hospitalizations
2. improves long-term medication and treatment adherence
3. enhances the therapeutic alliance
4. focuses on solving practical problems with activity-oriented therapies

CBT, CET; may include vocational rehabilitation and social skills training to help the patient correctly perceive and respond to social situations

Question 42

what are the goals of psychosocial treatments?

Answer 42

1. set realistic expectations
2. discover adaptive strategies
3. stay active in treatment in the face of a chronic illness
4. create a benign and supportive environment for the patient and caregivers