Psychosis Flashcards
Schizphrenia Background Info:
Lifetime prevalence: __ - __%
Gender: Male ___ Women (affects ___% of people in total)
Disease Course: more severe in men as men have more negative symptoms.
Genetics: strong genetic predisposition (50% concordance among monozygotic twins, 40% inheritance if both parents have schizophrenia, 12% inheritance if one 1st degree relative has schizophrenia)
Avg. age of onset: ___ for men, up to ___ for women.
Disease rarely presents before __ or after __ y/o. ~50% of psychiatric beds ~ 15% of all treated mental illness
Costs to Society: ~ 30 billion/yr 2.5% of total health care cost 9th leading cause of disability worldwide
Suicide: ___% attempt, __% complete
Schizophrenia Background Info:
Lifetime prevalence: .05 - 1%
Gender: Male = Women (affects 1% of people in total)
Disease Course: more severe in men as men have more negative symptoms.
Genetics: strong genetic predisposition (50% concordance among monozygotic twins, 40% inheritance if both parents have schizophrenia, 12% inheritance if one 1st degree relative has schizophrenia)
Avg. age of onset: 18 for men, up to 25 for women.
Disease rarely presents before 18 or after 45 y/o. ~50% of psychiatric beds ~ 15% of all treated mental illness
Costs to Society: ~ 30 billion/yr 2.5% of total health care cost 9th leading cause of disability worldwide
Suicide: 50% attempt, 10% complete
Longitudinal Course of Schizophrenia:
Age 0-15: __ __
16-20: Prodromal –> __ symptoms
21-40: ____ symptoms, ___
41-60: Burn out phase –> negative/cognitive symptoms, non-responsive to Rx
Longitudinal Course of Schizophrenia:
Age 0-15: normal function
16-20: Prodromal –> subtle symptoms
21-40: chaotic symptoms, dysfunction
41-60: Burn out phase –> negative/cognitive symptoms, non-responsive to Rx
Prognosis of Schizophrenia:
Approximately ___% recover
- Approximately __% stay the same
- Approximately ___% do poorly with negative symptoms worsening over time
Prognosis of Schizophrenia:
Approximately 10% recover
- Approximately 20% stay the same
- Approximately 70% do poorly with negative symptoms worsening over time
- The ___-____ model posits that a biological predisposition toward developing schizophrenia is inherited genetically, and that this vulnerability interacts with ___ challenges (the concordance rate in monozygotic twins, ~48%, is nearly 3x that in dizygotic twins).
- O____, birth and early ____ complications, ____ of birth (e.g., during spring and early winter months)
Other etiologies: - exposure to___
- drug use
- ____life events
- The stress-diathesis model posits that a biological predisposition toward developing schizophrenia is inherited genetically, and that this vulnerability interacts with environmental challenges (the concordance rate in monozygotic twins, ~48%, is nearly 3x that in dizygotic twins).
- Obsterics, birth and early childhood complications, season of birth (e.g., during spring and early winter months)
Other etiologies: - exposure to infections
- drug use
- stressful life events
Presentation of Schizophrenia:
DHS(t) B(i)N Characteristic Symptoms
2 or more, each present for a significant proportion of the time for 1 month (or less if treated):
- ____
- ____
- Disorganized ____
- Grossly disorganized or catatonic ____
- _____ symptoms (flat affect, apathy, alogia, or avolition)
Dx: Must have:
- Continuous signs of disturbance persist for at least ___ months
- __/___ Dysfuntions
Must rule out:
- ____ and mood disroders
- Substance and general med conditions
Presentation of Schizophrenia:
DHS(t) B(i)N Characteristic Symptoms
2 or more, each present for a significant proportion of the time for 1 month (or less if treated):
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (flat affect, apathy, alogia, or avolition)
Dx: Must have:
- Continuous signs of disturbance persist for at least 6 months
- Social/Occupational Dysfuntions
Must rule out:
- Schizoaffective and mood disroders
- Substance and general med conditions
- *Schiznophrenic Delusions:**
- Defined as a ____ belief based on ____ inference about external reality that is firmly held, despite what most everyone else believes, and despite what constitutes incontrovertible and obvious proof of evidenced to the contrary - Always keep in mind cultural norms
Types of Delusions:
_____ - delusions resolve around love
____ - inflated self-worth
_____ - delusions of unfaithfulness
___ - physical delusions
____ - delusions of being persecuted
____ - more than 1 delusion
Abnormal belief (delusions):
- Paranoia
- Thought ___ - put into his/her mind by an external force.
- Thought ___ – thoughts removed by outside force.
- Thought ___ - thoughts are transmitted to others.
- *Schiznophrenic Delusions:**
- Defined as a false belief based on incorrect inference about external reality that is firmly held, despite what most everyone else believes, and despite what constitutes incontrovertible and obvious proof of evidenced to the contrary - Always keep in mind cultural norms
Types of Delusions:
- *Erogotmatic** - delusions resolve around love
- *Grandiose** - inflated self-worth
- *Jealous** - delusions of unfaithfulness
- *Somatic** - physical delusions
- *Percusatory**- delusions of being persecuted
- *Mixed** - more than 1 delusion
Abnormal belief (delusions):
- Paranoia
- Thought insertion - put into his/her mind by an external force.
- Thought withdrawal – thoughts removed by outside force.
- Thought broadcast - thoughts are transmitted to others.
- *Disorganized Speech in Schiznophrenia:**
- Primary impairment ____ processing (similar to ___)
- Impaired language ___
- *Disorganized Speech in Schiznophrenia:**
- Primary impairment linguistic processing (similar to aphasia)
- Impaired language comprehension
Disorganized or Catatonic Behavior in Schizophrenia
- Lack of ___ awareness
- ____ thinking
- ____ impairment
- Vulnerable to ___
- Poor monitoring, disruption in establishing, maintaining and changing set
- Impaired ___ memory
Disorganized or Catatonic Behavior in Schizophrenia
- Lack of social awareness
- Disorganized thinking
- Cognitive impairment
- Vulnerable to distraction
- Poor monitoring, disruption in establishing, maintaining and changing set
- Impaired working memory
The Negative Symptoms of Schizophrenia (The 5 A’s)
- A___-a____: Recreation, sex, intimacy, friendship
- ____: Social inattentiveness
- ___ ____ : Facial expression, eye contact, vocal inflection, inappropriate affect
- ____: Poverty of speech/content of speech, blocking
- ___-____: Poor self care, loss of persistence in school/work
The Negative Symptoms of Schizophrenia (The 5 A’s)
- Anhedonia-asociality: Recreation, sex, intimacy, friendship
- Attention: Social inattentiveness
- Affetive Flattening : Facial expression, eye contact, vocal inflection, inappropriate affect
- Alogia: Poverty of speech/content of speech, blocking
- Avolution-apathy: Poor self care, loss of persistence in school/work
Suggested Medical Assessment to Rule Out Medical Causes of Schizophrenia
- Check __ and __ history
- PE w/ focused ___ exam
- CBC, blood urea, electrolytes, nitrogen, vit. __ and ___ levels
- Check l___ and t___
- Check for H__, tertiary ____
- Head ___ (stroke? Parkinson’s?)
- Electroencephalogram, ceruloplasmin, CXR, LP
Suggested Medical Assessment to Rule Out Medical Causes of Schizophrenia
- Check medical and family history
- PE w/ focused neuro exam
- CBC, blood urea, electrolytes, nitrogen, vit. B and CK levels
- Check liver, thyroid
- Check for HIV, tertiary syphillis
- Head imaging (stroke? Parkinson’s?)
- Electroencephalogram, ceruloplasmin, CXR, LP
Dopamine Hypothesis of Schizophrenia
- proposed that schizophrenia is due to an excess of ___ activity in ____ brain areas, the nucleus ___, __ __, lateral ___, and ____ tubercle (e.g., mesolimbic dopamine hyperactivity).
- based on evidence that chronic administration of the stimulant __-____ produced a psychosis that resembles paranoid schizophrenia.
- d-Amphetamine and cocaine increases the release of ___ and ___ and inhibits their reuptake.
- isomers of d-amphetamine with different effects on the availability of NE and DA in rodents were used to show that increased locomotor activity, which correlates best with psychosis in humans, is due to an increased release of __ rather than ___.
Schizophrenia is though to result primarily from an excess in ____ signaling in the ___ (connecting the midbrain to the limbic system) and ___ (connecting the midbrain to the frontal cortex) pathways of the brain
- *Dopamine Pathways:**
1. ___ tract (This pathway transmits dopamine from the substantia nigra pars compacta (SNc) to the caudate nucleus and putamen. Important for motor functioning)
- ___ tract (This pathway transmits dopamine from the ventral tegmental area (VTA) to the nucleus accumbens. The VTA is located in the midbrain, and the nucleus accumbens is in the ventral striatum. Important for reward related function)
- ____ tract (This pathway transmits dopamine from the VTA to the prefrontal cortex. The “meso” prefix in “mesocortical” refers to the VTA, which is located in the midbrain, and “cortical” refers to the cortex. Important for exec. functioning)
- _____ tract (activity of this pathway inhibits the release of prolactin.)
Why are these pathways important?
- They are not isolated to one part of the brain. They ___ the entire brain, which affects the brain in all levels. It is a whole brain issue
Dopamine Hypothesis of Schizophrenia
- proposed that schizophrenia is due to an excess of DA activity in limbic brain areas, the nucleus accumbens, stria terminalis, lateral septum, and olfactory tubercle (e.g., mesolimbic dopamine hyperactivity).
- based on evidence that chronic administration of the stimulant d-amphetamine produced a psychosis that resembles paranoid schizophrenia.
- d-Amphetamine and cocaine increases the release of DA and NE and inhibits their reuptake.
- isomers of d-amphetamine with different effects on the availability of NE and DA in rodents were used to show that increased locomotor activity, which correlates best with psychosis in humans, is due to an increased release of DA rather than **NE
Schizophrenia is though to result primarily from an excess in dopaminergic signaling in the mesolimbic (connecting the midbrain to the limbic system) and mesocortical (connecting the midbrain to the frontal cortex) pathways of the brain**
- *Dopamine Pathways:**
1. Nigrostriatal tract
- Mesolimbic tract
- Mesocortical tract
4.Tuberoinfundibular tract
Why are these pathways important?
- They are not isolated to one part of the brain. They cross the entire brain, which affects the brain in all levels. It is a whole brain issue
Structural Changes In Schizophrenia
- *Decreased Size:**
1. ___ ___ cortex changes [DLPFC]) (important for executive functions, such as working memory, cognitive flexibility, planning, inhibition, and abstract reasoning. However, the DLPFC is not exclusively responsible for the executivefunctions.)
- ___ ___ lobe, especially the hippocampus changes. (important for long term memory)
- ___ ___ cortex (Many studies attribute specific
functions such as error detection, anticipation of tasks, attention, motivation, and modulation of emotional responses to this area) - ___ ___ gyrus (This area has been involved in the perception of emotions in facial stimuli. Furthermore, it is an essential structure involved in auditory processing, as well as in the function of language in individuals who may have an impaired vocabulary, or are developing a sense of language. It has been discovered to be an important structure in the pathway consisting of the amygdala and prefrontal cortex, which are all involved in social cognition processes)
- *Increased Size:**
1. __ and ___ ventricles
Structural Changes In Schizophrenia
- *Decreased Size:**
1. Dorsolateral prefrontal cortex changes [DLPFC]).
2. Medial temporal lobe, especially the hippocampus changes.
3. Anterior cingulate cortex
4. Superior temporal gyrus (STG) - *Increased Size:**
1. Lateral and third ventricles
Treatment for Schizophrenia:
Anti-psychotics - all block ___
- Typical (or 1st gen.) antipsychotics: good at treating ___ symptoms, but not so much the ___ ones:
Chloe and Hal threw out their trifle which hit Perry, the flute player (6)
- ____ (low pot.)
- ____ (high pot.)
- _____ (low pot.)
- ___, ____ and ____ (high pot.)
Side Effects: ____ Syndrome (biggest problem with first generation anti-psychotics)
- ___—a subjective feeling of restlessness
- Acute ___ reactions—abrupt onset muscular spasms of the neck, eyes, trunk, extremities*
- ___—stiffness, tremor, impaired gait
*Chronic dopamine blockade can lead to ___ ___, a movement disorder that may occur following long-term treatment with antipsychotic medications. Movements may include ___ and ___ movements, such as __ smacking, sucking and puckering as well as facial grimacing irregular movements of the limbs, particularly choreoathetoid-like movements of the fingers and toes and slow, writhing movements of the trunk. It is __ disabling and often irreversible.
Note: drugs with ___ potency are less likely to cause EPS, but are more likely to cause ___side effects such as drowsiness, and hypotension. Conversely, drugs with ___ potency cause more EPS. Why is that?
Treatment for Schizophrenia:
Anti-psychotics - all block dopamine
- Typical (or 1st gen.) antipsychotics: good at treating posititve symptoms, but not so much the negative ones:
Chloe and Hal threw out their trifle which hit Perry, the flute player (6)
- Chlorpromazine (low pot.)
- Haloperidol (high pot.)
- Thiorizadine (low pot.)
- Trifluoperazine, Perphenazine and Fluphenazine (high pot.)
Side Effects: Extrapyramidal Syndrome (biggest problem with first generation anti-psychotics)
- Akathisia—a subjective feeling of restlessness
- Acute dystonic reactions—abrupt onset muscular spasms of the neck, eyes, trunk, extremities*
- Parkinsonism—stiffness, tremor, impaired gait
*Chronic dopamine blockade can lead to tardive dyskinesia a movement disorder that may occur following long-term treatment with antipsychotic medications. Movements may include mouth and tongue movements, such as lip smacking, sucking and puckering as well as facial grimacing irregular movements of the limbs, particularly choreoathetoid-like movements of the fingers and toes and slow, writhing movements of the trunk. It is mildly disabling and often irreversible.
Note: drugs with low potency are less likely to cause EPS, but are more likely to cause autonomic side effects such as drowsiness, and hypotension (b/c you have to give more for it to work and as a result it hits H1 (drowsiness) and alpha-1 (hypotension) receptors. Conversely, drugs with high potency cause more EPS but cause less autonomic syndomes because you can adminsiter it in low doses, which do not block H1, alpha-1 and muscarinic receptors. **Why is that?
The drugs that have lower potency (more drug required to hit therapeutic levels of D2 receptor blockade), are less likely to cause EPS but are more likely to cause autonomic side effevts such as drowsiness and hypotension because the higher doses cause blocking of the H1 and a1 receptors (normally, alpha-1 causes vasoconstriction). Conversely, the drugs that have higher potentcy are more likely to cause EPS but are less likely to cause autonomic side effects. Think of it this way, a higher potency drug can be administered in lower doses, and therefore there is a lower chance of inadvenrtantly blocking H1, alpha1 and muscarinic receptors.**
Atypical aka SECOND GENERATION Medications for Schizophrenia:
- Blocks___ and ____(5HT2A), ___ and ___ receptors
- somewhat less effective than typical antipsychs at treating ____. symptoms, but better at treating ___ symptoms.
Note: blocking H1 can cause sleepiness, weight gain, metab. syndromes that blocking alpha-1
- vaso____, ___tension
The atypical schizophrenic medications include:
An ORC named ZAQ
1. ___
2. ___
3. ____
4. _____
5. ____
6. _____
Atypical aka SECOND GENERATION Medications for Schizophrenia:
- Blocks D2 and Serotonin (5HT2A), alpha-1 and H1 receptors
- somewhat less effective than typical antipsychs at treating positive symptoms, but better at treating negative symptoms.
Note: blocking H1 can cause sleepiness, weight gain, metab. syndromes that blocking alpha-1
- vasodilation, hypotension
The atypical schizophrenic medications include:
An ORC named ZAQ
1. Olanzepine
2. Risperidone
3. Clozapine
4. Ziprasidone
5. Aripiprazole
6. Quetiapine
Uniqueness of Clozapine
The good:
- Effective in ____% of treatment-resistant patients at 6 weeks
- Blocks __ to ___% of D2 receptors
- Minimal EPS and risk of __ __ (b/c low potency)
- Prevents ___
- Stabilizes ___
- Improves ___ and hypo___
- Reduces ___ and aggression
- Reduces suicidality
- Possibly reduces cigarette smoking and substance abuse
The bad:
- Horrific side effects in ___ ____. Because of ___ (rate 1/250) it is second line after ___ antipsychotics have failed.
Uniqueness of Clozapine
The good:
- Effective in 30% of treatment-resistant patients at 6 weeks
- Blocks 40 to 60% of D2 receptors
- Minimal EPS and risk of tardive dyskinesia (b/c low potency)
- Prevents relapse
- Stabilizes mood
- Improves polydipsia and hyponatremia
- Reduces hostility and aggression
- Reduces suicidality
- Possibly reduces cigarette smoking and substance abuse
The bad:
- Horrific side effects in bone marrow. Because of agranulocytosis (rate 1/250) it is second line after two antipsychotics have failed.
