NB13-1 & 13-2- Schizophrenia Spectrum & Other Psychotic Disorders and DLA

Question 1

List the psychotic disorders we need to know. What does the term psychotic mean?

Answer 1

• Schizophrenia
• Schizophreniform Disorder
• Brief Psychotic Disorder
• Delusional Disorder
• Schizoaffective Disorder

The term “psychotic” implies a break from reality in thinking and/or perceptions, which is what all of these disorders have in common

Question 2

List the psychotic symptom domains and indicate which ones are considered “CORE” domain symptoms.

Answer 2

1-3 are considered CORE domain symptoms

1. Delusions
2. Hallucinations
3. Disorganized Speech
4. Disorganized/Catatonic Behavior
5. Negative Symptoms

Question 3

Define what a “delusion” is. What are the major delusional themes commonly seen?

Answer 3

A delusion is a fixed belief that is not amenable to change, even in light of conflicting evidence. Major themes are:

• Delusions of grandeur
• Delusions of persecution (paranoid)
• Delusions of control (external force controlling)
• Delusions of reference (belief that an outside action [ie - television show] refers directly to the person
• Thought broadcasting delusion (thoughts being transmitted to others)

Question 4

Describe what disorganized speech is and give the major examples of it.

Answer 4

Speech/Thinking that lacks the normal, logical connections between thoughts.

• Tangentiality - going off on tangents
• Flight of ideas - extreme tangentiality
• Derailment - going off on tangents that have no connection to the previous topic
• Clang Association - word association based on rhyming
• Word Salad - no meaningful relationship between words

Question 5

What other terms are used to describe the “disorganized speech” symptom?

Answer 5

Formal thought disorder

Loose associations in speech/thinking

Question 6

How can you usually distinguish between disorganized and post-stroke aphasias?

Answer 6

With post-stroke aphasias, there will usually be phonemic/paraphasic errors (additions/deletions/mispronunciations of syllables). In psychotic patients, pronunciation is usually fine but the connections between the words is illogical.

Question 7

Describe what disorganized/catatonic behavior is and give major examples of it.

Answer 7

Disorganized Behavior is non goal oriented behavior which often presents as an inability to take care of daily living activities or as having an inappropriated mood/affect

Catatonic Behavior is characterized as multiple motor/behavioral abnormalities that reflect diminished reactivity to the environment. Common examples of this are posturing, waxy flexibility, stereotypies (repetitive movement), non-responsiveness, mutism

Question 8

What does the term “negative symptoms” mean and what are the negative symptoms?

Answer 8

The negative symptom domain contains those symptoms that represent a lack of normal behavior or emotion.

• Diminished emotional expression both verbally and nonverbally
• Avolition - decrease in self-initiated purposeful activities
• Alogia - diminished speech output
• Anhedonia
• Asociality - disinterest in social interactions

Question 9

What are considered to be positive symptoms? Which psychotic symptom domains are considered to be positive symptoms?

Answer 9

Thought, behaviors, or perceptions that are distorted or in excess of normal function. These include the following psychotic symptom domains:

• Delusions
• Hallucinations
• Disorganized Speech
• Grossly Disorganized or Catatonic Behavior

Question 10

List the diagnostic criteria for schizophrenia.

Answer 10

The patient experiences an “active phase” for at least one month and has at least one persistent psychotic symptom for at least 6 months. An “active phase” is having at least two psychotic symptoms with at least one of them being a core symptom (delusions, hallucinations, or disorganized speech)

Question 11

Describe the phases of schizophrenia that are usually seen.

Answer 11

1. Prodromal Phase - psychotic symptoms begin to be apparent, but not enough to constitute an active phase (usually negative symptoms). This phase is included in the 6 month schizophrenia timeline
2. Active Phase - must be at least a month
3. Residual Phase - similar to prodromal phase but occurs after the active phase. Also included in the schizophrenia timeline

Question 12

Answer 12

C

Question 13

List the schizophrenia subtypes we need to know.

Answer 13

The DSM no longer subtypes schizophrenia except to specify “with catatonia.”

Question 14

What is an important differential to consider before diagnosing schizophrenia?

Answer 14

Substance induced psychosis

Question 15

Describe the primary theory of what causes schizophrenic symptoms.

Answer 15

Dopamine Hypothesis - overactivity of mesolimbic dopaminergic neurons (ventral tegmental area to basal forebrain) often causes positive symptoms. Underactivity of the mesocortical dopaminergic neurons (ventral tegmental area to prefrontal cortex) often causes negative symptoms. Activity of the nigrostriatal dopaminergic neurons are also involved. This hypothesis is often considered insufficient because other NTs are often dysregulated as well

Question 16

What neurostructural, neurofunctional, and neurocognitive changes are often seen in schizophrenics?

Answer 16

Neurostructural Changes - ventriculomegaly (enlarged lateral ventricales), cortical and hippocampal atrophy, decreased thalamic volume

Neurofunctional Changes - hypofrontality (decreased prefrontal metabolism, as seen in a PET scan)

Neurocognitive Effects - impairment in multiple areas including attention, memory, and executive functions (processes that have to do with managing oneself and one’s resources in order to achieve a goal)

Question 17

Describe the etiology of schizophrenia

Answer 17

A brain lesion, typically caused by genetics or obstetric issues, occurs during early development. Usually, effects of the lesion aren’t seen until later in development when those areas of the brain mature and become more used.

Effects of lesion can also be influenced by environmental factors.

Question 18

What percentage of the population is affected by schizophrenia and when does onset usually occur?

Answer 18

Approximately 1% of the population is affected

Schizophrenia symptoms will usually first appear in the late teens in men and early twenties in women.

Question 19

What features are commonly associated with schizophrenia?

Answer 19

• low socioeconomic status (due to inability to hold a job)
• Nicotine addiction
• Suicide Risk and Aggressive tendencies due to command hallucinations or paranoid delusions

Question 20

List the prognostic indicators for schizophrenia and what they mean

Answer 20

Question 21

What are the signs that a neurodevelopmental lesion has occurred?

Answer 21

• Hippocampal cellular disorganization
• Increased neurological soft-signs (decreased sensory functioning and motor coordination)
• Increased minor physical anomalies

Question 22

What are the risks of developing schizophrenia?

Answer 22

• General Population - ~1%
• 1st degree relative with disorder - ~15%
• MZ twin with disorder - ~50%

Question 23

Answer 23

D

Question 24

Answer 24

D

Question 25

What are the treatment options for schizophrenia? List them in order of effectiveness.

Answer 25

1. Antipsychotics - atypical class preferrable to traditional class
2. Supportive interventions such as vocational rehabilitation, individual psychotherapy, and family education
3. Electroconvulsive Therapy (ECT) is really only used for medication-refractory schizophrenia, especially with the catatonic type

Psychosurgery is NO longer performed for schizophrenia

Question 26

What are antipsychotic medications AKA? What do these drugs all have in common?

Answer 26

Neuroleptics or major tranquilizers

They all antagonize D₂ dopamine receptors but some do this more potently/selectively than others and some block other receptors as well

Question 27

What are the most prominent traditional antipsychotics? What are there mechanisms of action, effects, and side effects?

Answer 27

Chlorpromazine (Thorazine) and haloperidol (Haldol) are the most prominent.

MOA - D₂ antagonist

Effect - improves positive symptoms

Side Effects - extrapyramidal symptoms (EPS) caused by nigrostriatal D₂ blockade. Neuroleptic malignant syndrome (NMS) can also develop. All antipsychotics can also cause weight gain, sedation, and sexual dysfunction

Question 28

What are extrapyramidal symptoms and when do they usually develop?

Answer 28

Drug induced movement disorders usually caused by a nigrostriatal blockage.

• Dystonia - sustained muscle contrractions; develop within a week
• Parkinsonism - develop within the first few months
• Akathisia - excessive movements due to “inner restlessness”, develop within the first few months
• Tardive Dyskinesia - repetitive, involuntary, purposeless movements, often of the face and extremities; develop after long-term (yrs) use

Question 29

What is NMS?

Answer 29

Neuroleptic malignant syndrome is characterized by tachycardia, hypertension, rapid breathing, fever, extreme rigidity, delirium, or death. It usually occurs within the first two weeks of starting (or increasing dosage) traditional antipsychotics is probably caused by a precipitous drop in DA, affecting hypothalamic functioning

Question 30

List the most prominent atypical antipsychotics in the order that they would be prescribed. What are thes drugs MOAs, effects, and side effects?

Answer 30

1. Risperidone (Risperdal) and Olanzapine (Zyprexa)
2. Clozaril (clozapine), the most effective but has a 1-2% agranulocytosis risk requiring constant patient monitoring

All of these drugs act by antagonising D_{2, 3, 4} and 5-HT_2A receptors

Effect - improve positive and negative symptoms (which is why these are preferrable to traditional antipsychotics)

Side Effects - still have a risk for developing EPS but less so than tranditional antipsychotics. All antipsychotics can also cause weight gain, sedation, and sexual dysfunction

Question 31

What are the diagnostic criteria for schizophreniform disorder?

Answer 31

Same as schizophrenia but less than 6 months. Still requires at least 1 month of an active phase

Question 32

What are the diagnostic criteria for Brief Psychotic Disorder? How is this disorder specified?

Answer 32

At least one core psychotic symptom (delusions, hallucinations, or disorganized speech) episode lasting less than one month with the patient returning to full premorbid functioning.

Specifiers can be added based on the trigger of the episode (ie - with marked stressor or without marked stressor)

Question 33

Answer 33

B

Question 34

What if the duration was over two months?

Answer 34

C

If the duration was over two months, the answer would be D

Question 35

What are the diagnostic criteria for delusional disorder? List and describe the disorder subtypes as well.

Answer 35

The presence of a delusion, and no other psychotic symptom or functional impairment, for at least one month. Delusion could be the result of sustained interaction with another delusional person (formerly shared psychotic disorder)

• Persecutory type - belief of malevolent treatment
• Grandiose Type
• Erotomanic Type - belief of somebody loving them
• Jealous Type - belief of infidelity by partner
• Somatic Type - belief involving bodily functions/sensations
• Unspecified Type - none of the above

Specify whether the delusion is Bizarre (not possible) or Non-Bizarre

Question 36

How is a delusional disorder typically treated?

Answer 36

With antipsychotics, reality testing, and separation from the cause of the delusion (if an identifiable cause can be found).

Question 37

What are the differential diagnoses for delusional disorder somatic type?

Answer 37

Body dysmorphic disorder with absent insight. In BDD, delusion is appearance-related

Illness anxiety disorder. In IAD, the patient is concerned about health but not delusional

Question 38

What are the diagnostic criteria for schizoaffective disorder? What are the subtypes?

Answer 38

• Active phase of schizophrenia occurs concurrently with a major mood episode (MDE or manic) and
• Active phase lasts at least two weeks without mood sxs and
• Mood sxs are present for the majority of the total duration of symptomatic periods of illness

Subtypes - depressive type if just depression is experienced and bipolar type if just mania or both mania and depression are experienced

Question 39

Answer 39

D

Question 40

Answer 40

C