Psychosis and Schizophrenia

Question 1

“Normal” psychotic experiences

Answer 1

a. Transient hallucinations—visual and tactile
i. Caused by stress or anxiety
b. Hypnogogic hallucinations (false perception experienced while falling off to sleep)
c. Hypnopomic hallucinations (false perceptions upon awakening)
d. Loosening of associations and illogical thinking decrease considerably after age 6 or 7.

Question 2

most common causes of psychosis in children

Answer 2

a. Mood and anxiety are the most common cause of psychotic symptoms in children and adolescnets.
b. Can occur in the context of drug use and alcohol abuse, seizure disorders, metabolic illnesses, CNS tumors and infections, and delirium.

Question 3

Epidemiology of schizophrenia

Answer 3

a. Fewer than 1 in 10,000 children will develop schizophrenia.—peak incidence of 1% among adults.
b. About 4% of all cases preent prior to age 15.
c. Average onset is 18-25 years for men and 23-35 for women.
d. Peak in incidence after 40 years of age—10% of female cases.
e. More women diagnosed with a mood disorder and men with schizo.

Question 4

The 4 As of schizophrenia

Answer 4

4. The 4 As of schizophrenia
   a. Affective blunting
   b. Loosening of associations (speech characterized by shifting between topics that are only minimally related to one another—cognitive disorganization)
   c. Autism
   d. Ambivalence or indecisiveness

Question 5

Positive symptoms

Answer 5

i. Paranoid delusions
ii. Hallucinations.
iii. Disorganized speech
iv. Grossly disorganized or catatonic behavior

Question 6

Negative symptoms

Answer 6

i. Affective blunting
ii. Poverty of thought and speech or alogia
iii. Difficulty initiating goal-directed behavior or avolition
iv. anhedonia
v. asociality

Question 7

Schizoaffective Disorder vs schizophrenia vs psychotic mood disorders

Answer 7

Schizophrenia:

Two (or more) of the following:

i. Delusions
ii. Hallucinations
iii. Disorganized speech (e.g., frequent derailment or incoherence)
iv. Grossly disorganized or catatonic behavior
v. Negative symptoms (i.e., diminished emotional expression or avolition).

At least one symptom must be (1), (2), or (3)

Social/occupational dysfunction

Duration: Continuous signs of the disturbance persist for at least 6 months

Schizoaffective Disorder:

• An uninterrupted period of illness during which, at some time, there is a major mood episode (major depressive or manic) concurrent with symptoms that meet criterion A for schizophrenia
• During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
• Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual periods of the illness.

Question 8

Neuroimaging studies and gray matter changes in adolescent schizophrenia

Answer 8

a. MRI brain scans reveal the same neurological changes observed in adults—abnormally enlarged ventricles (decreased brain volume)→ children lose about 4 -5 times as much cortical gray matter as do normal teens. The gray matter loss progressively engulfs the brain from back to front, beginning in parietal structures involved in visuospatial and associative thinking and eventually moving forward to temporal and dorsolateral prefrontal cortices involved in sensorimotor and visual function. The loss of tissue in these areas corresponds directly to clinical impairments, mirroring the neuromotor, auditory, visual search, and executive functioning deficits found in schizos.
b. Reduced cell size and total neurons in the basal ganglia.
c. Reduced amygdala, hippocampal, and parahippocampal volume.
d. Reduced prefrontal activity, thalamic abnormalities, and a reduction in the size of cerebellar vermis.

Question 9

Prognostic indicators for schizophrenia

Answer 9

Good:

1. Acute onset
2. Short duration of illness
3. Lack of prior psychiatric history
4. Presence of affective symptoms, confusion, or mood symptoms
5. Good premorbid adjustment
6. Steady work history
7. Marriage
8. Older age at onset
9. Female

Bad:

10. Insidious onset
11. Long duration of illness
12. Psychiatric history
13. Poor insight
14. OC symptoms
15. History of violence
16. Premorbid personality disorder
17. Poor work history
18. Celibacy
19. Young age at onset
20. Family history

Question 10

Differential diagnosis of schizophrenia

Answer 10

a. Schizoaffective disorder, bipolar disorder, and MDD can all present with psychosis

Schizophrenia and schizoaffective disorder
Bipolar Disorder 
Depression
Pervasive Developmental Disorders 
Anxiety (particularly OCD)
PTSD
Substance Abuse
Medication Induced