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Psychotic Disorders Flashcards

1
Q

Schizophrenia patients develop illness at what age range? (Males vs females)

A

18-25 males

21-30 females

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2
Q

Schizophrenia patients have trouble with?

A

Thinking clearly

They often don’t want to take their meds becasue they don’t have insight into their illness

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3
Q

DSM criteria for scizophrenia

A

two or more each present during a 1 month period. at least one must be the first 3
delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms (diminished emotional expression)
must have deterioration in function
signs of disturbance last for 6 months
rule out schizoaffective, depressive, and bipolar or other condition/medication
If ASD, must have hallucinations or delusions for >1 month

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4
Q

Positive symptoms of schizophrenia

A

hallucinations, delusions, disorganized thought, disorganized behavior (would notice if on a bus)
delusions: fixed false beliefs regardless of evidence
hallucinations- perception experience without stimulus. schizo typically auditory

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5
Q

Types of delusions

A

(beliefs by the schizophrenic patient)
grandiose, nihilistic (death), persecutory (being treated wrongfully), somatic (organs have stopped functioning), sexual (other people think they are a rapist or prostitute), religious

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6
Q

Qualities of disorganized though

A

tangentiality, circumstantiality, word salad, perseveration, loose associations, clanging (rhyming everything), neologisms (make up new words), blocking (stop talking mid sentence).
non goal directed behavior (silliness to unpredictable agitation)

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7
Q

Negative symptoms of schizophrenia

A

diminished emotional expression, avolition (lose ability to imitate goal directed behavior)
reduced speech, poor grooming, limited eye contact, less emotional responsiveness, reduced interest, reduced social drive

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8
Q

Mental status Exam findings in schizophrenia

A

appearance/behavior- disheveled, poor hygiene
speech- increased latency, monotone
affect- constructed, blunted or flat
thought process and content- disorganized, thought blocking, poverty of though, hallucinations, thought insertion, though broadcasting
judgement- poor
insight- lack of

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9
Q

Worldwide prevalence of schizo is ____

(Strong/Weak) genetic predisposition

A

0.5-1%
strong. concordance with monozygotic, strong inheritance if both parents schizo
multiple hit hypothesis (genetic predisposition + other risk factors)
Risk factors: paternal age, season of birth (winter), birth complications, urban birth, migration, cannabis use, trauma

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10
Q

In schizophrenia patients, what comes first: negative symptoms or positive

A

negative comes first. positive symptoms tend to diminish over life course

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11
Q

Drugs that enhance _____ transmission to limbic system lead to or worsening psychotic symptoms

A

dopamine. drugs that block dopamine D2 receptors are used to treat psychotic symptoms
don’t let patients do cocaine or meth

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12
Q

What brain pathway leads to the positive symptoms of schizophrenia?

A

mesolimbic hyperactivity pathway

ventral tegmentum->nucleus accumbens

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13
Q

What brain pathway leads to the negative and cognitive symptoms of schizophrenia?

A 
mesocortical underactivity
(ventral tegmental-> DA to dorsal lateral PFC and ventral medial PFC)
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14
Q

Dopamine pathways that are involved with schizophrenia

A

mesolimbic (pos), mesocortical (neg), nigrostriatal (EPS (movement problems) when blocked by antipsychotics), tuberoinfundibulnar (hyperprolactinemia when antipsychotics)

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15
Q

Pathophysiology role of glutamate NMDA receptors in schizophrenia

A 
NMDA hypofunction-> increased symptoms-> mesolimbic and mesocortical paths
NMDA antagonists (PCP and ketamine)-> schizolike symptoms in health and exacerbate preexisting symptoms in pts with schizophrenia.
These interact with dopamine pathways
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16
Q

Besides NMDA and dopamine, what are other neurotransmitters involved in schizophrenia

A

5ht: increased. some antipsychotics block 5-HT2a
GABA: decreased activity in schizo
Ach: decreased-> smaller density of muscarinic and nicotinic receptors

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17
Q

How many patients with schizophrenia attempt and die by suicide

A

⅓, 1/10

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18
Q

What is associated with better prognosis with schizophrenia

A

later onset, social support, mood symptoms, female, good premorbid functioning, no FH, no SU (many schizophrenic patients either increase or decrease psychosis with substances)

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19
Q

Medical causes of Psychosis (there are 9 here)

A

substance use, withdrawal, medication induced, infections, metabolic and endocrine disorders, tumor stroke brain trauma, temporal lobe epilepsy, autoimmune disorder, toxic illness

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20
Q

What are 4 other psychiatric disorders that schizophrenia must be distinguished from (other things that should be on the differential)

A

schizoaffective, mood disorder, delusional disorder, personality disorder
(should also look into schizophreniform disorder, brief psychotic disorder, factitious disorder with psych symptoms, malingering)

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21
Q

Treatments for schizophrenia

A

pharmacotherapy (treat aggressively), ECT, CBT, transcranial magnetic stimulation), community treatment, psychosocial and vocational rehab, family therapy, appropriate housing

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22
Q

Name the psych disorder
uninterrupted period of illness with a major mood episode, delusions or hallucinations for 2 or more weeks w/o mood episode, mood episode must be majority of active duration
not attributable to substance

A

DSM criteria for schizo affective disorder

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23
Q

Schizoaffective disorder prognosis and treatment

A

Prog: better than schizophrenia, worse than mood disorder
Treatment: target mood and psychotic symptoms (one drug: second gen antipsychotic). first gen used for psychotic symptoms. mood stabilizers/antidepressants often needed. combo drug and non drug treatments

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24
Q

Name the disorder
one or more delusions with >1month duration
does not have schizophrenia
behavior is not bizarre or odd
could have manic or depressive but must be brief
not attributable to any other medical condition

A

DSM criteria for delusions disorder

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25
Name the disorder based on epidemiology, age, prevalence etc: 0.2%, persecutory type is most common, no gender differences. onset middle to late adult life. familial relationship with schizo. generally employed and self supporting
Delusional Disorder
26
Delusional disorder medications
antipsychotics but response poor (lower anxiety but still delusions) SSRIs Relationship building-> then gently challenge delusional beliefs
27
``` Name the psychotic disorder psychotic symptoms last >1 day, <1 month others ruled out 2x as common in women, hospitalization may be helpful antipsychotics helpful if agitated ```
Brief psychotic disorder
28
Typical schizophrenia but >1month and <6 months, ruled out other med conditions. if symptoms last more than 6 months, changed diagnosis
Schizophreniform disorder
29
Thought process that wanders from the point but does eventually get to the point
circumstantial thought process
30
Blocking/partial agonist the D2 receptors in the mesolimbic pathway relieves the ________ symptoms of schizophrenia, but may _______ the negative symptoms from mesocortical
positive worsen -this may lead to aboral movements from nigrostriatal (extrapyramidal side effects)
31
D2 receptor activity is how you treat schizophrenia but there might be effects at _______ and ______ that might cause what?
nigrostriatal- EPS. treat with anticholinergic medications (d2 block->up Act release) tuberinfundibular- block d2->up prolactin release->sexual dysfunction, gynecomastia, dysmenorrhea, amenorrhea
32
What effect do the 5HT2A receptors have in schizophrenia? 5HT2A antagonism has decreased risk of ______ and _____
downstream effect on glutamate-> reduce DA in mesolimbic. | EPS and prolactinemia
33
What is the difference between typical and atypical antipsychotics?
typical has little to no 5HT2A receptor antagonism. atypical has potent 5HT2A receptor antagonism
34
Response to antipsychotics should happen within ____ hours. However, __________ are associated with negative attitude and poor responses
48 hours | dysphoria, anxiety, akathisia-> pts do not like this and this will make them upset and not take their meds
35
What are some goals for 7 days out from starting antipsychotics for schizophrenia?
decrease agitation, hostility, combativeness, anxiety normalize sleep and eating -> titrate to good dose
36
What are some goals for 2-3 weeks out from starting antipsychotics for schizophrenia?
improve symptoms, increase socialization, self care and mood. If no response then week 2 then change meds
37
Following remission of 1st episode of schizophrenia, treatment should be continued for ______
18 months. | antipsychotics are largely palliative and not curative (not all symptoms resolve)
38
What are the most commonly used typical antipsychotics (there are 3 here)
haloperidol (haldol) fluphenazine (prolix) chlorpromazine (thorazine)
39
What are the most commonly used atypical antipsychotics? (I used 7 ._.)
``` clozapine (clozaril) olanzapine (zyprexa) risperidone (risperdal) paliperidone (Invega) quetiapine (Seroquel) ziprasidone (geodon) aripiprazole (Abilify) ```
40
Treatment of naive individuals with first break schizophrenia, what am I prescribing?
Aripiprizole, risperidone, Ziprasidone | These three have the lowest risk of causing adverse effects
41
Clozapine should be considered for individuals with schizophrenia ONLY if
The patient is have suicidal symptoms or there have been two antipsychotics that have already been tried this is the BEST antipsychotic we have, reserved for treatment resistant schizophrenia
42
Poor patient adherence for antipsychotics for schizophrenia should suggest usage of ____
long acting injectable! (2 weeks-6 months) | This can actually be offered at any time
43
Typical antipsychotics MOA is _______. ___% blockade is what produces the antipsychotic effect.
non-selective D2 receptor antagonist (basically no 5HT2) | 65%
44
Typical antipsychotics treat ______ symptoms of schizophrenia, but there is a high risk of _____ and ______
positive | extrapyramidal side effects, hyperprolactinemia (these cause typical be chosen less)
45
Atypical antipsychotics MOA is ____.
High 5HT2 receptor antagonism + D2 receptor antagonist. | modulation or partial agonist at D2 receptors
46
% of D2 antagonism for atypical-> rank how much antagonism
risperidone > olanzapine > quetiapine > clozapine | Aripiprazole = D2 partial agonist
47
Atypical antipsychotics treat the positive symptoms of schizophrenia with a lower risk of EPS and hyperprolactinemia but there might be __________
metanbolic adverse effects (weight gain, diabetes, dyslipidemia) ESPECIALLY for clozapine (AEs improve over months)
48
Antipsychotics are ______ (cross BBB) and are metabolized by ______
highly lipophilic | CYP450. 2D6 and 3A4-> drug drug I's
49
What are two antipsychotics that could be taken with food to increase absorption? Which one is given sublingually?
lurasidone, ziprasidone | asenapine
50
What 3 antipsychotics that are available as a short acting injectable?
haloperidol, olanzapine, ziprasidone
51
What are 6 antipsychotics that are available as a long acting injectable?
haloperidol, fluphenazine, risperidone, aripiprazole, paliperidone, olanzapine (every 2 weeks)
52
Which antipsychotic has a black box warning for post injection delirium/sedation syndrome?
olazapine | must monitor for 3 hrs
53
Which DA tracts do the typical antipsychotics hit?
ALL-> mesolimbic, msocortical, nigrostriatal, tuberoinfundibular best benefit is 65% block
54
For typical antipsychotics, what is the difference between haloperidol + fluphenazine and chlorpromazine? (think MOA)
Haloperidol and fluphenazine-> block D2 receptors only | Chlorpromazine block D2 + hist-1 + α-1 + muscarinic (more AEs= sedation, hypotension, anticholinergic)
55
Do atypical antipsychotics treat negative cognitive symptoms?
not enough evidence to say these are effective for negative symptoms
56
Most atypical bind to D2, transiently block, then _______ from D2 R's
rapidly disassociate. blockage caries by the atypical + dose risperidone > olanzapine > quetiapine > clozapine The rapid dissociation causes fewer AEs
57
Which atypical is a D2 partial agonist? (blocking excess DA)
aripiprazole (also caripraszine and brexpiprazole) does not block or bind + disassociate like other atypical-> less EPS and hyperprolactinemia
58
At high doses (>6mg), ______ can act like a typical antipsychotic (good D2 block) and cause _____ and _____
Risperidone EPS and hyperprolactinemia clinical dose <6mg
59
Clozapine and quetiapine MOA have _____ and ______ and there is a low risk of EPS and hyperprolactinemia
low D2 antagonist (40% block) | 5HT2a receptor antagonism (low doses)
60
If an atypical antipsychotic hits 5HT2C receptors what happens? Histamine 1? α1? muscarinic?
5HT2C: weight gain histamine- weight gain + sedation (quetiapine, clozapine, *olanzapine*) α1- hypotension (quetiapine, clozapine) muscarinic- anticholinergic (olanzapine, clozapine->bowel regime)
61
A risk factor for typical antipsychotics is _______, seen within 24-96 hours post antipsychotic initiation. What does this look like?
Dystonia onset of muscle spams (tonic contractions) Most commonly in head, neck, jaw, mouth, and eyes (back arching, upward deviation of eyes, tongue protruding, lock jaw)
62
How to treat dystonia that you might get from typical antipsychotics?
IV/IM anticholinergives (benztropine =cogentin) +/- benzodiazepine (lorazepam
63
What does akathisia mean? If untreated, what are the risks?
Katherine is cancelled party (inner restlessness, compulsion to move-> cannot be still-> pacing, shifting, shuffling, tapping feet, march in place) Violence + suicide
64
What to do if patient has akathisia when they start an antipsychotic?
``` switch to different antipsychotic (typical>atypical) decrease dose give benzodiazepine (rapid relief) propranolol (sustained relief) NO anticholinergics ```
65
Can you see pseudoparkinsonism in antipsychotics?
Uhm, yes duh bradykinesia, pill rolling tremor, cogwheel rigidity, postural abnormalities. To treat, switch, add oral anticholinergic
66
What can be seen months after antipsychotic treatments? why?
Tardive dyskinesias chronic block D2->up regulation + hypersensitive D2 receptors->can't reset when discontinued med. imbalance indirect and direct. damage to striata cholinergic interneurons longer on antipsychotic -> increased risk baseline AIMS assessment
67
What does tardive dyskinesia look like?
orofacial movements (lipsmacking, chewing, eye linking, jaw movement, tongue movement grimacing)->limb and truncal (twisting, toe tap, pelvic thrusting, rocking, swaying) irreversible, hyperkinetic, involuntary worsen with dress
68
How to treat tardive dyskinesia caused by antipsychotics?
``` VMAT inhibitors (decrease presynaptic DA-> block repacking) valbenazine + deutrabenazine switching to another antipsychotics or anticholinergics will not help ```
69
_____ is disruption of central thermoregulatory process in hypothalamus and/or muscle contraction, which is an AE of antipsychotics. Low incidence, high morbidity/mortality. typical are higher risk
Neuroleptic malignant syndrome. | presents: altered mental status, autonomic instability, lead pipe righty, fever
70
Treatment for neuroleptic malignant syndrome
stop antipsychotic, start again after symptoms resolve/choose another meds: bromocriptine (D2 agonist), dantrolene (skeletal muscle relaxant) given em blankets
71
What happens with chronic hyperprolactinemia? How to treat?
decreased bone mineral density ->fractures -> osteoporosis | switch to atypical, lower dose, add on partial d2 agonist (aripiprazole)
72
Antipsychotics are a risk factor for developing ________ (other health conditions)
T2DM, dyslipidemia, CV disease | many develop DM w/in 6mo treat
73
Antipsychotics with the highest risk for metabolic adverse effects
clozapine, olanzapine
74
Antipsychotics with the lowest risk for metabolic adverse effects
aripiprazole, ziprasidone, lurasidone
75
How to treat the metabolic adverse effects from antipsychotics?
switch to low risk atypical or a typical, diet + exercise, metformin for clozapine or olanzapine
76
Αlpha-1 antagonism from antipsychotics cause ______ and there is an increased risk with ___ and ___
orthostatic hypotension | clozapine and quetiapine (tolerance overtime)
77
Antipsychotics can block delayed K-+ rectifier channel during repolarization which might cause _______. Also, all can prolong QTc, highest risk from____
``` ventricular arrhtymias (torsades de pointes) IV haloperidol Other risk factors: hypoK, hypoMg, QTc prolong meds ```
78
Anticholinergic adverse effect from antipsychotics are from antagonism at ______, cause _____, and there is an increased risk with _______
muscarinic dry mouth, urinary retention, blurred vision, constipation, tachycardia, cog slowing clozapine, olanzapine, chorpromazine
79
Sedation is an adverse effect from antipsychotics that antagonizes ____. 4 medications that have biggest risk?
histamine-1 | clozapine, olanzapine, quetiapine, chlorpromazine. Tolerance overtime
80
All antipsychotics lower _______, with ______ with increased risk
seizure threshold chlorpromazine + clozapine Treat with decrease dose or change. don't need anticonvulsant
81
Neutropenia is a risk from ____. Should be stopped when absolute neutrophil count <500
clozapine. (might be from BM effect or antibodies to WBC) | MUST have baseline ANC and check throughout treatment

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