Lecture 5: Clinical Features of Schizophrenia Flashcards

1
Q

September 11

A

Jeannette Dagam, DO

Psychiatrist

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2
Q

Diagnostic Criteria: A

A

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

  1. Delusions
  2. Hallucinations
  3. Disorganized speech (e.g. frequent derailment or
    incoherence)
  4. Grossly disorganized or catatonic behavior
  5. Negative symptoms (i.e. diminished emotional expression or avolition)
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3
Q

Diagnostic Criteria: B

A

For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood
or adolescence, there is a failure to achieve expected level of interpersonal, academic or occupational functioning).

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4
Q

Diagnostic Criteria: C

A

Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by 2 or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

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5
Q

Diagnostic Criteria: D

A

Schizoaffective disorder and depressive disorder in bipolar
disorder with psychotic features have been ruled out because either
1: no major depressive or manic episodes have occurred
concurrently with active-phase symptoms, or
2: they have been present
for a minority of the total duration of the active and residual periods of the illness

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6
Q

Diagnostic Criteria: E

A

The disturbance is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication) or another medical condition

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7
Q

Diagnostic Criteria: F

A

If there is a history of autism spectrum disorder or a
communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia are also present for at least 1 month (or less if successfully treated)

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8
Q

Positive Symptoms

A

Delusions
Hallucinations
Disorganized speech
Disorganized behavior

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9
Q

Negative Symptoms

A

Affective Flattening – reduction in range and intensity of
emotional expression, including facial expression, voice tone, eye contact, and body language

Alogia – poverty of speech, the lessening of speech fluency and productivity

Avolition – reduction, difficulty or inability to initiate and persist
in goal-directed behavior; is often mistaken as disinterest or
depression

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10
Q

Prevalence, Development and

Course

A

Lifetime prevalence approximately 0.3%-0.7%

Onset prior to adolescence is rare

Psychotic features typically emerge between the late teens and mid-30s

Peak age of onset is early to mid 20s for males and late 20s for females

Earlier age of onset is traditionally seen as a worse predictor for prognosis

Age of onset is likely related to gender, with males having worse premorbid adjustment, lower educational achievement, more prominent negative symptoms and cognitive impairment, and in general worse outcomes

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11
Q

Development and Course continued…

A

Psychotic symptoms tend to diminish over the life course, perhaps in association with normal age-related declines in dopamine activity.

The essential features of schizophrenia are the same in childhood, but it’s more difficult to make the diagnosis. In children, delusions and hallucinations may be less elaborate than in adults and visual hallucinations are more common and need to be distinguished from normal fantasy play.

Late onset cases (after 40 years) are overrepresented in females.
Often the course is characterized by a predominance of psychotic
symptoms with preservation of affect and social functioning

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12
Q

Familial Clustering of Schizophrenia

A

80%-85% of persons with schizophrenia have NO
1st-degree relatives with schizophrenia

60% of persons with schizophrenia have NO 1st or
2nd degree relatives with schizophrenia

Nevertheless, family studies consistently show increased risk in relatives of probands

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13
Q

HISTORY OF PRESENT

ILLNESS

A

49-yr-old single African American female presented
to a local psychiatric emergency room with her sister
for worsening paranoid delusions that her phone is
bugged, people are following her, that her ex-fiance is trying to kill her, referential delusions of death threats in license plates and AH of music/ex-fiance

Paranoia has resulted in insomnia, decreased food/
water intake, decreased attention to activities of daily living, missed work without calling in

Paranoia has intensified over the last several days but
per family reports, the patient has had an insidious onset of paranoia for the past year

Patient suspected her fiancé at the time of cheating, so she began tape-recording him at night because she believed he was revealing whom he was cheating with. When she played the recordings for her family, all
that was audible was his snoring but she was convinced she was hearing incriminating information.

Complicating factors in obtaining a better history of
onset/quality of symptoms:
a) patient refused to sign a release of information for ex-fiance
b) patient had been living alone since her fiance moved out

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14
Q

HOSPITAL COURSE

of that crazy lady

A

Upon evaluation by the treatment team, patient was
extremely paranoid/delusional that staff were trying to gas her by manipulating the light switches. Walked around with a napkin over her nose claiming to smell the gas

Paranoid that her ex would send people to find and hurt her on the unit

Auditory hallucinations of voices saying they were going to shoot her through the heart

Patient was observed to be distracted by her hallucinations at times. Also endorsed paranoia that the food was tainted.

Initially, very paranoid about starting medications but
agreed to start Geodon (patient was already morbidly obese, so
neuroleptic-induced weight gain was a concern).

Geodon was gradually titrated up with good tolerability but the patient continued to be delusional, irritable, reading her Bible and rebuking the
medications and staff. Believed that demons were controlling her

Prolixin was added to the patient’s regimen with the hope of hastening her recovery

Patient eventually began sleeping better, became less paranoid, isolated less, was eating adequately and began to report that she felt the medication was helping

The patient’s insight also improved, gradually able to entertain the notion that her fears may be originating from within her

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15
Q

FOLLOW-UP AFTER
DISCHARGE

(of that crazy lady)

A

Patient developed some side affects to the Prolixin which was tapered as an outpatient and eventually dc’ed.

The patient reported doing well on the Geodon –acknowledging that she had been hospitalized for mental illness, denied many previous paranoid thoughts, and reunited with her ex-fiance.

However, the pt still required assistance from family
regarding medication administration and had not yet
been able to return to work.

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16
Q

Later Onset Schizophrenia

A

More likely to have been married but nonetheless
more socially isolated and impaired when contrasted
with general population

Presentation more likely to include persecutory
delusions and hallucinations and less likely disorganized and negative symptoms

Often there is a predominance of positive symptoms w/ preservation of affect and social functioning

17
Q

Good Prognostic Indicators

A

Later onset means better premorbid functioning

Women with schizophrenia tend to express more affective symptomatology, paranoid delusions, and hallucinations, whereas men tend to express more negative symptoms
(flat affect, avolition, social withdrawal)

In general, women have been found to have a better prognosis as defined by number of hospitalizations, lengths of hospital stays, overall duration of illness, time to relapse, response to neuroleptics, and social and work functioning

Gender advantage lessens with age

18
Q

The Role of Estrogens in

Schizophrenia

A

Estrogen, like all gonadal steroids, are fat soluble –easily entering nerve cells and binding to specific receptor proteins either within the cell nucleus or in the cellular cytoplasm

Mechanism of estrogen’s actions is through gene
expression but it may also act directly on neurotransmitter systems.

Estrogens are known to modulate the dopamine system.

Estrogens stimulate nerve growth factors and enhance neuronal survival

Long-term studies (15+ years after illness onset) globally do not support outcome differences between men and women

However at 2, 5, and 10 years into the illness, most research shows that women as a group doing significantly better than men

This ‘doing better’ during the first decade may be more
related to premorbid competence, decreased substance abuse, and compliance with treatment than to hormones (although such behaviors may be hormone-dependent to some extent)

19
Q

Estrogens, Age, and

Schizophrenia

A

It is thought that the initiation of cyclical hormone fluxes in women may serve as a protective function against the development of adolescent psychosis

This is reinforced by the bimodal age of onset peak in
women – the 2nd peak being in the early to mid 40s, a time when estrogen levels are falling

Also supportive of the protective effects of estrogen
is how the severity of illness in women approximates that of men in later years after the onset of menopause

20
Q

When the role of Estrogen does

not seem to confer an Advantage

A

Studies have confirmed the absence of gender effect on the age of onset for patients with familial schizophrenia

There is a trend toward decreasing familial risk for
schizophrenia with increasing age of onset

Data indicate that women with a positive family history of schizophrenia do not have the reported delay in age of onset, suggesting the effect of
estrogen cannot play its protective role in the presence of genetic factors

21
Q

Overview of Post Mortem Findings

A

Reduced brain size and weight in some, not all, studies

Tissue reduction and neuronal disarray in many regions

Limbic system most extensively involved

Possible involvement of cortex, corpus callosum, basal ganglia

Generally, absence of gliosis

22
Q

gliosis

A

an increase in the size and number of astrocytes of the brain.

Excessive proliferation of the neuroglia.

Gliosis is a process leading to scars in the central nervous system that involves the production of a dense fibrous network of neuroglia (supporting cells) in areas of damage. Gliosis is a prominent feature of many diseases of the central nervous system, including multiple sclerosis and stroke. After a stroke, neurons die and disappear with replacement gliosis.

23
Q

Brain Size, Volume, and Weight

A

Compared to controls matched for age & sex, many studies
find no differences.

But…Some studies find:
5% to 8% reduction in weight
4%-5% reduction in anterior-posterior length

Neuroleptic drug effects may be present

Adults with schizophrenia have head (skull) circumference
similar to controls

Infants who meet criteria for schizophrenia in adulthood have
slightly reduced head circumference (in early infancy)

Conclusion: more evidence for focal than generalized
abnormalities

24
Q

Ventricular Enlargement

A

Compared to age- and sex-matched controls, 15%-20% of patients with schizophrenia show mild to moderate increase in size of lateral ventricles, inferior (temporal) horns, and 3rd ventricle (but not the 4th)

Enlargement of 3rd ventricle generally found more
frequently and to a greater degree

Enlargement is bilateral, symmetric, and diffuse

Ventricle-to-brain ratio (VBR) is abnormally high in about 20% of patients

25
Q

Limbic System Abnormalities

A

Reduced volume in the:
amygdala
hippocampus
parahippocampal gyrus

Decreased counts of pyramidal neurons in hippocampus

Disarray of pyramidal neuron alignment in hippocampus

26
Q

Cortical Abnormalities

A

Abnormally widened sulci seen in 10% -15% of patients with schizophrenia (not correlated
with ventricular enlargement)

Some studies report reduced gyral width, thickness of cortical mantle, and density of cortical neurons in frontal & temporal lobe regions

27
Q

Thalamic Abnormalities

A

Many studies find decreased tissue volume; some find increased glia

Brain imaging studies implicate thalamic dysfunction

Treatment with neuroleptics or atypical antipsychotics leads to increased thalamic volume (approaching controls), compared to untreated patients

28
Q

Neuropsychological Abnormalities in Schizophrenia

A

Reduced IQ

Attention deficits

Memory deficits

Impairment of executive function

29
Q

Attention Deficits in Schizophrenia

A

Patients with schizophrenia show many deficits on tasks requiring sustained attention, vigilance, and freedom from distractibility

Predictability does not help

Reaction times and error rates are consistently greater than in control groups

30
Q

Memory Deficits in Schizophrenia

A

Both recognition memory and recall are impaired

Impairment affects both verbal & visual information

Episodic (as oppose to fact, or semantic, memory) memory is most greatly affected

NOT affected: Immediate memory (registration) and procedural memory (motor
skills)

31
Q

Executive Function Impairment in Schizophrenia

A

Similar to frontal lobe syndromes

Significant impairment in cognitive flexibility, planning, and problem-solving

32
Q

Treatment

A

Pharmacologic interventions

Address co-morbidities

  • Psychiatric
  • Physical

Recovery focused interventions

  • Modified Cognitive Behavioral Therapy
  • Social skills training
  • Vocational rehabilitation
  • Family education