Psychosis ( I and II) Flashcards
Define schizophrenia.
- Psychiatric syndrome that includes impaired reality testing, hallucinations, and delusions
- Heterogeneous etiologies => mesocorticolimbic circuit dysregulation
- More likely to make conclusions on little information
- Dysjunction in conclusion making
What are the 5 symptom clusters associated with schizophrenia?
- Positive symptoms
- Disorganization
- Negative symptoms
- Cognitive deficits
- Mood symptoms => if this is prominent then considered schizoaffective
[Each symptom cluster emphasis may represent a different neuropathology]
What are the criteria for schizophrenia?
CATEGORY A SYMPTOMS
2 or more of the following symptoms for at least 1 month:
1. *Delusions
2. *Hallucinations
3. *Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative sxs
- At least one of the starred symptoms needs to be present
What social/occupational dysfunction is associated with schizophrenia?
CATEGORY B SYMPTOMS
Dysfunction at:
- Work, school, interpersonal, or self-care functioning are markedly below level prior to onset
What is the duration criteria for schizophrenia (check in DSM V)?
CATEGORY C SYMPTOMS
6 months of continuous symptoms
How do we differentiate schizophrenia from a mood disorder/schizoaffective?
CATEGORY D
Schizophrenia=> brief or no mood episodes
How is schizophrenia differentiated from autism spectrum?
CATEGORY F
Schizophrenia => prominent hallucinations or delusions
What are the negative symptoms associated with schizophrenia?
Social indifference
Lack of motivation
Emotional constriction
Self-neglect
What cognitive symptoms are associated with schizophrenia?
Impaired memory, concentration Difficulty filtering Motor planning Executive function - Sorting tasks - Problem solving Impaired insight Disorientation
What are the diagnostics for schizophreniform disorder (heading towards schizophrenia)?
Criteria A, D, E for SCZ are met
Duration 1-6 months
- Watch out for:
- Good prognostic features: <4 week program, good premorbid function, no flat affect
- Poor prognostic features: catatonia
What are Category E symptoms in schizophrenia?
- Substance abuse
- Underlying medical issue
What are the diagnostics of an acute psychotic disorder
1 or more of for 1 day-1 month (full return to premorbid fxn):
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
What should be noted in acute psychotic disorders?
- Presence of stressors
- Postpartum onset
- Catatonia
What are the criteria fro schizoaffective disorder?
- Major depressive, manic or mixed episodes concurrent with criterion A for SCZ
- Delusions or hallucinations for 2+ weeks in the absence of mood symptoms
- Mood symptoms present for majority of total duration
- Substance/general medical exclusion
What are the 2 subtypes of schizoaffective disorder?
1) Bipolar type
2) Depressive type
What are the criteria fro a delusional disorder?
*More likely to be dangerous to plan significant harmful actions
A)One or more delusions, 1+ month
B) Criterion A for SCZ never met
- If hallucinations, not prominent and related
C) Functioning/behavior not markedly impaired
D) Mood episodes«_space;delusional periods
E) Substance/general medical exclusion
What are the criteria of schizotypal disorder?
At least 5 of the below:
1) Ideas of reference
2) Odd beliefs that influence behavior
3) Unusual perceptual experience
4) Odd thinking and speech
5) Suspiciousness or paranoia
6) Inappropriate or constricted affect
7) Behavior or appearance odd or peculiar
8) Lack of close friends
9) Excessive social anxiety
- Biologic markers are similar to schizophrenia (rather than affective disorder)
What are the criteria for attenuated psychosis syndrome (the prodromal period)?
1+ in attenuated form, intact reality testing:
- Delusions
- Hallucinations
- Disorganized speech
> once/week for past month
Begun or worsened past year
Distressing and disabling
Criteria for psychotic disorder never met
What is the prevalence of schizophrenia (including schizoaffective disorder)?
~1%
What factors influence the prevalence of schizophrenia?
- Increased risk in lower SES groups, childhood trauma
- Increased risk with environmental insults:
- First trimester exposure to famine, epidemic, summer, perinatal trauma, anoxia
What is the typical onset of schizophrenia?
Teens to 20s
What is the treatment response to schizophrenia relapse?
Schizophrenic relapse tends to lead to poorer response to treatment
What is the association between time before treatment and treatment response?
Longer duration of untreated psychosis associated with poorer treatment response
What are key gender differences in schizophrenia?
- Later onset, better premorbid function in women
- Better medication response in women (at least to FGAs)
- Estrogen has neuroprotective effects and inhibits D2 receptors
Describe the course of schizophrenia.
PRODOMAL PHASE: social, cognitive deficits may precede active phase by many years
FIRST EPISODE: highly treatment responsive
ACTIVE PHASE: full syndrome, typically 3-4 decades (teens or 20’s to 50’s)
RESIDUAL PHASE: ~1/3 remission, ~1/3 attenuation of symptoms in older years
What complications are associated with schizophrenia?
- Homelessness: ~50% of homeless have severe mental illness
- Unemployment, underemployment
- Under-education (cessation/break from education)
- Impaired relationships
- Family discord
- Suicide (20-40% attempt, 10% complete)
- Violence (though not increased when stable)
What drug reduces the risk of suicide and violence?
Clozapine
By how much is the lifespan shortened due to schizophrenia?
10-30 years shortened
- Shortest in untreated
What factors contribute to lowered life expectancy in schizophrenics?
- Tobacco use
- Chronic medical conditions (COPD, DM-2, poor self care)
- Suicide
- Medication effects (Neuroleptic Malignant Syndrome, long QT, metabolic)
What is the correlation between substance use disorder and schizophrenia?
Substance abuse disorders are associated with a 50% lifetime risk of schizophrenia
- 25% of SUD patients have schizophrenia
How does schizophrenia increase the risk of substance use disorder?
Schizophrenia increases the risk of substance use disorder 3-5 times
What are complications of substance use?
- Earlier onset of Schizophrenia
- Higher relapse, hospitalization rates
- Treatment non-compliance
- Poorer medication response
- Increased risk for violence
- Increased risk for HIV, hepatitis
- Greater brain volume loss over 5 yrs
What are the complications associated with tobacco use?
- 70-90% people with schizophrenia smoke
- Nicotine administration - reduce cognitive deficits
- Lung disease significantly elevated
What are the neuroanatomic findings in schizophrenia?
- Cerebral atrophy ~5% loss
- Reduced volume of structures (caudate, hippocampus)
- Poor organization of cortical layers
- Histologic evidence of disordered neuronal migration, connection and atrophy
What are the functional brain abnormalities associated with schizophrenia?
- Diffuse cerebral dysfunction, particularly prefrontal + medial temporal
- fMRI deficits in PFC and hippocampus during specific tasks
What are the neurochemical brain abnormalities associated with schizophrenia?
- Dopamine hyperactivity in mesolimbic tract
- Dopamine hypoactivity in mesocortical
- Glutamate NMDA
- Serotonin, GABA, norepinephrine, ACh
What is the major hypothesis regarding schizophrenic pathophysiology?
Pathophysiology of schizophrenia is associated with impaired dopamine neurotransmission
What are the 4 main dopaminergic pathways
1) Mesolimbic
2) Mesocortical
3) Nigrostriatal
4) Tuberoinfundibular
Describe the mesolimbic pathway
The mesolimbic pathway originates from the midbrain ventral tegmental area and innervates the ventral striatum (nucleus accumbens), olfactory tubercle, and parts of the limbic system.
- Overactivity => positive symptoms of schizophrenia
Describe the mesocortical pathway
The mesocortical pathway also originates from the midbrain ventral tegmental area and innervates areas of the frontal cortex. It has been implicated in aspects of learning and memory.
- Reduction in dopamine activity => negative/cognitive symptoms of schizophrenia
Describe the Nigrostriatal pathway
The nigrostriatal pathway is involved in control of movement.
Describe the Tuberoinfundibular pathway
The tuberoinfundibular pathway projects from the hypothalamus to the anterior pituitary gland and controls prolactin secretion
What is the risk of schizophrenia with an affected parent?
5%
What is the risk of schizophrenia amongst an siblings, with an affected sibling?
10% in siblings, children
What is the risk of schizophrenia amongst identical twins?
50%
What is the general genetic risk of schizophrenia?
~1%
What circuits are affected in genetic schizophrenia?
Regulation of Prefrontal Cortex circuits and interplay of dopamine, glutamate, and GABA
What is the relationship between schizophrenia and NMDA antagonists?
NMDA antagonists replicate symptoms of schizophrenia
- PCP and ketamine
What is the major role of NMDA glutamate receptors?
NMDA glutamate receptors mediate neuronal cell death, pruning
- dysregulation may lead to apoptosis
What stressors trigger the onset of schizophrenia?
Hormonal changes Social stressors Drug use Traumatic brain injury Sleep deprivation
What are the 5 major forms of treatment for schizophrenia?
1) Antipsychotic medications
2) Psychotherapy
- CBT, metacognitive
3) Clinical case management
- Assertive Community Tx
4) Psychosocial rehabilitation
- Cognitive remediation, supported employment
5) Peer support
What are first generation antipsychotics (FGAs)?
First Generation Antipsychotics (FGAs):
D2 antagonists
- eg: chlorpromazine, haloperidol
What are second generation antipsychotics (SGAs)?
2nd Generation Antipsychotics (SGAs):
D2, 5HT2 antagonists:
- eg: clozapine, “atypical antipsychotic”
Gen 2.1:
D2 partial agonist
- eg: aripiprazole
What do antipsychotic meds reduce?
Reduce psychotic symptoms, agitation, and disorganization
- prevent relapse into acute symptoms
How are antipsychotic meds limited?
- Reduce the risk of relapse (10-20% remission rates)
- Limited improvement in negative and cognitive symptoms
What are illness management and recovery skills in schizophrenia (4)?
1) Social Skills Training
2) Early warning signs & intervention plan
3) Peer support & mentoring
4) Exercise & lifestyle
What are the evidence based practices in treating/managing schizophrenia (6) ?
1) Illness management & recovery skills
2) Supported employment
3) Family psychoeducation
4) Assertive community treatment
5) Integrated dual disorders treatment
6) Standardized pharmacological treatment
What should be considered in supported employment for schizophrenic patients?
1) Place - train sequence
2) Competitive employment
3) Integrated community settings
4) Individual Placement & Support
What are the benefits of supported employment?
- Shifts target to maximal function
- Negative & cognitive symptoms
- Side effects
- Assist with managing stress
- Rich response data
- Work as adjunctive treatment strategy
What is the 2nd most effective management practice in preventing relapse in schizophrenic patients?
Family collaboration [Support Education Harness family resources Provide skills Extension of treatment team]
What are the key aspects of integrated dual disorders treatment (schizophrenia + substance use disorder)?
- Co-occurring substance use disorder
- Integrated treatment team
- Addiction treatment staff
- Simultaneous treatment of both disorders
- Motivational development
- Harm reduction
- Eliminates suppression of substance abuse treatment response
