Psychosis Flashcards
What percentage refractory?
25%
What percentage functional remission?
12-15%
Most common delusion?
Persecutory
How long for delusional disorder?
1 month
Other name for erotomania delusion?
Clérambeault
Other name for jealousy delusion?
Othello
Delusional disorder specifiers?
With bizarre content
Severity (0-4, 5-point scale)
Course (after 1 year, first episode, multiple episodes, continuous, unspecified)
Delusional disorder epidemiology?
Prevalence 0.2%
M=F for most part
Onset around 40yo
What is NOT a risk factor for delusional disorder?
DEPRESSION
Delusional disorder is not a risk for developing what?
SCHIZOPHRENIA
Stable diagnosis, 50% remission, 30% no change
How long for brief psychotic disorder?
24 hours to 1 month
Only need ONE symptom (at least delusion, hallucination or disorganized speech)
Brief psychotic disorder specifiers?
With marked stressors
Without marked stressors
With postpartum onset (max 4 weeks PP)
With catatonia
Brief psychotic disorder epidemiology?
Prevalence 9% of first episode psychosis
2F : 1M
More in developing countries
Onset in mid 30s
Brief psychotic disorder prognosis?
50% will have a final diagnosis of something chronic (like schizophrenia or mood d/o)
How long for schizophreniform?
1 month at least but less than 6 months
At least TWO symptoms
No need for functional decline
Schizophreniform specifiers?
With good prognostic features = at least TWO of
- prominent psychotic symptoms within 4 weeks of first noticeable change in behaviour
- confusion or perplexity
- good pre-morbid functioning
- absence of blunted or flat affect
Without good prognostic features
With catatonia
Schizophreniform epidemiology?
Prevalence 0.3-0.7% similar to schizophrenia
Common in DEVELOPING countries
5M : 1F
Higher likelihood of a family history of mood disorder vs. schizophrenia
Schizophreniform prognosis?
1/3 remain with schizophreniform
2/3 eventually schizophrenia or schizoaffective
RESPOND QUICKER TO RX than schizophrenia
Higher risk of schizophrenia in relatives if dx
How long for schizophrenia?
At least 1 month and more than 6 months (including prodromal and residual phases)
At least TWO symptoms
Marked decrease level of functioning
Most common predictor of non-adherence to treatment?
Anosognosia (symptoms NOT coping strategy)
Schizophrenia specifiers?
Course (after 1 year)
With catatonia
Early onset = 18 years old
Very early onset = 13 years old
Schizophrenia epidemiology?
Prevalence 0.3-0.7% Higher INCIDENCE in men Prevalence M = F Mid to late 20s for FEP Late teens and mid-30s for symptom emergence
Which symptoms are more closely related to prognosis in schizophrenia?
Negative symptoms
Schizophrenia risk factors?
Male gender
Winter birth
Urban environment
Hypoxia at birth, perinatal complications
Advanced paternal age (>60yo in K&S)
Migration (2nd generation > 1st generation)
** MOST INDIVIDUALS WITH SCHIZOPHRENIA HAVE NO FAMILY HISTORY**
Suicide in schizophrenia?
5-6% complete 20% attempt Young males with substance use Following discharge from hospital Depression MOST SIGNIFICANT Unemployed NEGATIVE SYMPTOMS ARE PROTECTIVE CLOZAPINE IS PROTECTIVE
Criteria for schizoaffective disorder?
Major mood episode concurrent with criterion A of schizophrenia.
Psychotic sx in absence of mood episode for at least 2 WEEKS.
Mood sx present for majority of total duration of illness
No need for functional decline or to r/o ASD
Schizoaffective disorder specifiers?
Depressive type
Bipolar type
With catatonia
Course (after 1 year)
Schizoaffective disorder symptoms compared to schizophrenia?
Less negative symptoms
Less anosognosia
Better prognosis overall, but not as good as pure mood disorder
Schizoaffective disorder gene?
DISC1 gene on 1q42
Schizoaffective disorder epidemiology?
Prevalence 0.3% (1/3 as likely as schizophrenia)
F > M
Early adulthood age of onset
Suicide in schizoaffective disorder?
5%
Higher risk with depressed type and North Americans
What percentage of FEP is substance-induced?
7-25%
Alcohol-induced hallucinations are generally what kind?
Auditory
What to rule out if olfactory hallucinations?
Temporal lobe epilepsy
Most common psychosis due to medical condition?
Post-ictal psychosis in 2%-7.8% epilepsy patients
What are the other-specified schizophrenia spectrum disorders?
Persistent auditory hallucinations
Delusions with significant overlapping mood episodes
Attenuated psychosis syndrome
Delusional symptoms in partner of individual with delusional disorder
Catatonia most common with?
Mood disorders (25-50%, bipolar especially)
Less with schizophrenia (10%)
Need to r/o NMS
How many patients with schizophrenia have catatonia?
35%
Types of catatonia?
- Malignant
- Stuperous
- Excited
NMS presents with malignant and stuperous
Mania presents with excited
Periodic catatonia presents with stuperous and excited
Cannabis and psychosis
Association ++ at younger than 15yo
Earlier disease onset by 2.7-6.9 years
2-3x increased risk for schizophrenia but inverse NOT TRUE (adolescent psychosis does not increase cannabis use risk)
Schizophrenia and physical co-morbidities
Cigarettes, CAD, DM2, HIV, Hep C
Life expectancy decreased by 10-20 years!
LOWER RISK OF RHEUMATOID ARTHRITIS
Schizophrenia and psychiatric co-morbidities
Substance use 44-47%
Anxiety 50%
Mood disorder 50%
PTSD
Schizophrenia and elderly
Less positive symptoms
20% have no active symptoms over 65yo
Respond WELL to antipsychotics
Need smaller doses
Bleuler
Associational disturbances
Affective disturbance
Autism
Ambivalence
Secondary symptoms of hallucinations, mood changes, delusions and perplexity
Schneider first rank symptoms?
Auditory hallucinations (audible thoughts, arguing voice, commentating voice)
Broadcasting of thoughts (insertion, withdrawal)
Control of thoughts (forced feelings/impulses, forced actions, passivity experiences)
Delusional perception
Negative symptoms?
Anhedonia Asociability Alogia Avolition Decreased emotional expression
NOT APATHY (don’t have loss of concern)
Hallucination outside normal perceptual field (such as seeing behind your back)
Extracampine hallucination
Fantom mirror
Autoscopic
in depression
Don’t see self in mirror
Negative autoscopic
Image persists despite stimulus gone
Palinopsia
in LSD, trauma, migraine, epilepsy
Seeing small people or animals
Lilliputian
delirium tremens, LBD
Perceiving shapes (such as in clouds)
Pareidolia
Mixed up sense (seeing doors)
Synesthesia
Altered internal state (such as “brain on fire”)
Cenesthetic hallucination
Imposter syndrome (hypo identification)
Capgras
Stranger is a loved one (hyper identification)
Fregoli
Other created physically similar
Subjective double
Inanimated double
Doppleganger
Others interchange physically and psychologically
Intermetamorphosis
Places have been duplicated
Reduplicative paramnesia
People living in house
Phantom boarder syndrome
Nihilistic delusion
Cottard
Schizophrenia heritability?
80%
Multi loci gene with incomplete penetrance
22q11 = PRODH (Di George) 1-2% of schizophrenia but 25x increased risk in those with Di George 22q1 = COMT
9 linkage sites: 1q, 5p, 6p, 8p, 10p, 13p, 15q, 22q
Pyknic type (short, stalky) = good Aesthenic/athletic types = bad
Genetic risk if MZ twin
47%
Genetic risk if both parents
40%
Genetic risk if DZ twin
12%
Genetic risk if 1 parent
12% (or 6% in KS)
Genetic risk if sibling
8%
Di George characteristics
22q11
Nasal voice, long narrow face, narrow palpebral fissures, flat cheeks, proeminent nose, small ears, small mouth, learning d/o, ++ otitis, cardiac malformation, hypocalcemia, platelet dysfunction
Genetics of negative symptoms in schizophrenia?
Mutations in DTNBP1 + NEUREGLIN1
Ultra high risk psychosis groups?
- 1st degree relative or significant decrease in functioning in last year
- Attenuated positive symptoms (MOST COMMON)
- Brief and intermittent positive symptoms
Ultra high risk group conversion to psychosis?
10-18% / year
35% / 10 years
73% have co-morbidity
DEPRESSION most common
What should be monitored at all check-ins (baseline, 1 month, 3 months, annually?)
BMI/weight
EPS
What should be monitored only as clinically indicated?
Prolactin
Dopamine signaling in schizophrenia?
Phasic INCREASES
Tonic DECREASES
Neuropsychiatry and schizophrenia
White matter loss STABLE
Grey matter loss PROGRESSES
Cognitive deficits often precede diagnosis
Become more severe with 1st episode then stable
Decreased dendritic arborization and spines
Neuropathology and schizophrenia
INCREASED lateral ventricles (80%)
INCREASED 3rd ventricle
INCREASED basal ganglion
INCREASED asymmetry
HYPOFRONTALITY on functional imaging (decreased frontal metabolism)
DECREASED thalamus DECREASED cerebellum DECREASED temporal, frontal, occipital lobes DECREASED amygdala DECREASED hippocampus
ATROPHY = poor prognostic sign
Acute intermittent porphyria
Abdominal pain, psychosis, polyneuropathy
Increased urinary aminolevulinic acid (while symptomatic)
Treat with IV hemin
Which neurotransmitter has a possible role in anhedonia?
Norepinephrine
Positive symptom circuit?
Anterior cingulate basal ganglia thalami-cortical circuit
Negative symptom circuit?
Dorsolateral-prefrontal
Correlate with decrease DA1 receptor concentration in prefrontal cortex
EEG in psychosis
Abnormal in 15-25%
Worst prognosis if abnormal in FEP
Similar to complex partial epilepsy picture
Eye movements in schizophrenia
Decreased smooth visual pursuit
Disinhibition of saccadic movements
Endocrinology and schizophrenia
Abnormal dexamethasone suppression test which predicts poor outcome
Decreased concentrations of LH and FSH
luted release of prolactin and HG or GRH/TRH
Percentage of post-psychotic depressive disorder?
25%
Increased suicide risk
LAI trial?
6 weeks post achieving steady state
Clozapine trial?
8-12 weeks
More than 400mg or Clozapine level more than 1100nm/L
CATIE trial findings?
SGA = FGA except Zyprexa which was mildly superior but had high incidence of metabolic syndrome
Relapse?
15-23% per year if treated vs. 79% if untreated
Clozapine response rate?
30-60%
Treatment resistance?
At least 2 moderate + symptoms OR at least 1 severe + symptom after trial of 2 different APs
Clozapine resistance tx?
NOT Tegretol (agranulocytosis risk) NOT Gabapentin
Metabolic syndrome?
Abdominal obesity (WC 80cm women or 94cm men) + 2 others
- Trigs > 1.7mol/L
- Hypertension >130/85mmHg
- HDL <1.3 mol/L
- Fasting glucose > 5.6mmol/L
Mesocortical
Negative symptoms
Hypoactivity
D1 receptors
Motivation and cognition
Mesolimbic
Positive symptoms
Memory, emotional behaviours
Reward pathway
D2 receptors
Tuberoinfundibular
Decreased dopamine secretion by hypothalamus with decreased inhibition of prolactin aka indirect prolactin increase
DOPAMINE INHIBITS PROLACTIN
Serotonin and dopamine?
SEROTONIN INHIBITS DOPAMINE
D2 blockade percentages?
68% = efficacy 72% = prolactin increase 80% = EPS
Clozapine = 38-68%
Clozapine and Quetiapine most loose binding
Haldol, paliperidone and risperidone higher blockade
Abilify
5HT1a partial agonist 5HT2a antagonism CYP 2D6 and 3A4 Least QT prolongation No effect or even decreases prolactin
Anticholinergic APs
Clozapine > Zyprexa > Seroquel > Abilify > Risperdal
Least risk NMS
Tx with Physostigmine
DOPAMINE INHIBITS CHOLINERGIC ACTIVITY
Low potency APs have higher anticholinergic activity
EPS risk factors?
High potency APs
Women
Elderly
Symptoms can last 2 weeks to 3 months after stopping AP
Akathisia
Middle aged women most at risk
Risk factors include iron deficiency, caffeine, SSRIs, anxiety, co-morbid mood d/o
Beta-blocker
ANTICHOLINERGIC NOT HELPFUL
Indications for B-blocker use?
Akathisia Performance anxiety Tremor due to Lithium Alcohol withdrawal Aggressive/violent especially secondary TBI
Acute dystonia
Risk factors include young man, hypocalcemia, hypothyroidism, hypoparathyroidism, recent cocaine use
Treat with anticholinergic, benzo SL or Benadryl IM
BETA BLOCKERS NOT HELPFUL
Most frequent TD symptom?
Peri-oral
TD
Rarely in first 6 months of treatment
Decreased by sleep, movement of affected areas, voluntarily
ANTICHOLINERGIC MAY WORSEN
Clozapine CBC monitoring?
CBC weekly x 6 months
every 2 weeks x 6 months
every month afterwards
Which anticholinergic may cause depression?
Tetrabenazine
Which meds can cause agranulocytosis?
Clozapine
Tegretol
Seroquel
Mirtazapine
Predictor sign of seizures?
Myoclonus
Missed Sustenna injection?
Less than 6 weeks, give dose
Less than 6 months, give loading dose again
More than 6 months, start over
Missed Abilify Maintena?
More than 6 weeks, need to supplement with PO again (usually have to supplement with PO Abilify x 2 weeks when starting)
Missed Risperdal Consta?
If missed 2nd dose or more than 6 weeks, need PO supplementation again (usually have to supplement with PO Risperdal x 3 weeks when starting)
Side effect frequency?
- Parkinsonism
- Dystonia
- Akathisia (most common in another source??)
- TD
NMS criteria
0.01-0.02% Fever Rigidity Tachycardia Autonomic dysfunction Altered mental state Elevated CK, LFTs, WBC
NMS risk factors
Young male (compared to elderly women for almost all other side effects except for acute dystonia) Neurological dysfunction Dehydration Exhaustion Agitation Fast administration/titration
NMS treatment
Dantrolene
Bromocriptine
Amantadine
Which receptors mediate weight gain?
5HT2C
H1
Alpha 1
Black box warning for SGA?
Increased stroke risk in dementia-related psychosis
Which antipsychotic can cause cataracts?
Quetiapine
Which cognitive task is most affected in schizophrenia?
Processing speed
Perseveration is common in which illnesses?
SCHIZOPHRENIA Organic causes (delirium)
Genes of negative symptoms?
DTNBP1
Neureglin 1
Who coined the term “schizophrenia”?
Bleuler
Who coined the term “dementia praecox”?
Kraepelin
