Psychotic Disorders Flashcards
Idea of reference
Delusion that cues in the external environment are uniquely related to the individual (i.e. The TV characters are talking directly to me…)
What are the two types of delusions of control?
Thought broadcasting: belief that ones thoughts can be heard by others
Thought insertion: belief that others are placing thoughts in ones head
What is a somatic delusion?
Belief that one is infected with a disease or has a certain illness
What are the 6 types of delusions?
- Persecution/ Paranoid
- Ideas of reference
- Control (thought broadcasting/ insertion)
- Grandeur
- Guilt
- Somatic
What is an “illusion” ?
Misinterpretation of sensory stimulus i.e. mistaking a shadow for a cat
List 4 types of hallucinations; with which pathology are they each commonly associated?
- Auditory: schizophrenia
- Visual: intoxication/ withdrawals, delirium, LBD
- Olfactory: epileptic aura
- Tactile: drugs/ ETOH
List 4 medical causes of psychosis:
- CNS disease: CVD, MS, neoplasm, Alzheimers, PD, Huntington’s, Tertiary syphilis…)
- Endodrinopathies: Cushing’s/ Addison’s, Hypo/hyperthyroid, Hypocalcemia, Hypopituitarism)
- Nutritional/ Vitamin deficiency: B12, folate, niacin
- Connective Tissue Disease: SLE, temporal arteritis, porphyria
What are the 3 DSM 5 criteria for psychotic disorder due to another medical condition (not primary psych issue)?
- Hallucinations or Delusions
- Episodes occur outside context of delirium
- History, physical exam, lab data to support alt. dx
What are the 4 DSM 5 criteria for substance/medication induced psychotic disorder?
- Hallucinations or Delusions
- Episodes occur outside context of delirium
- History, physical exam, lab data to support med/sub
- Not better accounted for by psychotic disorder that is NOT sub/ med induced
Which labs should be run with a suspected dx of psychotic disorder? (4)
- TSH
- B12
- RPR
- Urine/ serum drug screen
What are the DSM 5 diagnostic criteria for schizophrenia?
2+ of the following for at least 1 month: **At least 1 of them must be 1, 2, or 3 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized/ catatonic bx 5, Negative sx
Additionally:
- Pt mus exhibit functional deterioration
- Illness must persist for 6+ MOS
- Sx can’t be explained my medical/substance
What are the three phases of schizophrenia manifestation, and what are the characteristics of each?
- Prodromal- decline in fxn; social withdrawal, etc.
- Psychotic- perceptual disturbances
- Residual- mild perceptual disturbance, social withdrawal, negative sx.
What are the three types of symptoms associated with schizophrenia?
- Positive sx
- Negative sx
- Cognitive sx
5 A’s of Schizophrenia Negative Sx:
- Anhedonia
- Affect (flat)
- Alogia (poverty of speech)
- Avolition (apathy)
- Attention (poor)
What are three cognitive abilities are compromised in schizophrenia?
How does this manifest clinically?
- Attention
- Executive fxn
- Working memory (typically procedural memory and orientation are intact)
**Pts may have decline in work or school performance
What are the DSM 5 criteria for brief psychotic disorder?
How common is the dx?
With what is it commonly associated?
Same as schizophrenia, but for 1 day-1 month duration sx
- *Patients must have full return to premorbid level of fxn within one month
- *RARE dx
- *Commonly occurs in response to extreme stress: bereavement, sexual assault, etc.
What are the DSM 5 criteria for schizophreniform disorder?
Same as schizophrenia but for 1-6 months
What is post-psychotic depression?
Major depressive episode following resolution of psychotic sx in schizophrenic or psychotic patient
_______ commonly occurs comorbidly with schizophrenia:
Substance use; most common substances in order are:
Nicotine –> ETOH –> Cannabis –> Cocaine
What is the downward drift hypothesis associated with schizophrenia?
Schizophrenic patients have difficulty holding jobs/ functioning in society–> more common in patients wof lower SES
People born during what time of year have a higher risk of developing schizophrenia?
Winter and early spring–possibly associated with second trimester flu infection
What is the lifetime prevalence of schizophrenia?
0.3-0.7%
What are the two dopaminergic pathways implicated in schizophrenia?
- Mesolimbic: ^^^ DA –> positive symptoms
- Prefrontal cortical: LOW DA–> negative symptoms
Which two dopaminergic pathways are incidentally blocked by antipsychotics–> ADRs?
Tubuloinfundibular: ^^^ prolactin–> sex probs/ moobs
Nigrostriatal: EPS
In addition to DA, 4 other neurotransmitters are implicated in the development of schizophrenia.
What are these NTs?
Which are high and which are low?
What evidence supports the relevance of each imbalance to schizophrenia manifestation?
- 5HT: HIGH–blocked by some atypical antipsychotics
- NE: HIGH–decreases with long term antipsychotic use
- GABA: LOW–decreased enzyme required for production in hippocampus
- GLUTAMATE: LOW– less NMDA receptors (supported by NMDA blocker/ Ketamine induced psychosis)
List 7 factors associated with BETTER prognosis for schizophrenia:
- LATER or ACUTE onset
- Good social support
- Positive sx
- Mood sx
- FEMALE gender
- FEWER relapses
- High premorbid functioning
List 8 factors associated with WORSE prognosis for schizophrenia:
- EARLY or INDOLENT onset
- Poor social support
- Negative sx
- Family hx (high genetic link)
- MALE gender
- MANY relapses
- LOW premorbid functioning
- Comorbid substance use
What is seen on neuroimaging in a schizophrenic patient? (2)
- enlarged ventricles
- diffuse cortical atrophy
First generation (typical) antipsychotics:
- Receptor target
- Best for treating which sx?
- ADRs? (3)
- Mostly D2 antagonists
- Positive sx (little effect on negative sx)
- EPS, Neuroleptic malignant syndrome, Tardive dyskinesia
Second generation (atypical) antipsychotics:
- Receptor target (3)
- Best for treating which sx?
- ADRs?
- Antagonist at 5HT2, D4 (more) and D2
- Positive and negative sx; no documented diff bw typicals in terms of efficacy…
- LESS EPS, MORE METABOLIC SYNDROMES
How long should atypicals be taken to determine whether or not they are effective?
At least 4 weeks
What is the deal with Clozapine?
- Patients must fail multiple antipsychotics before taking
- ^^^ risk agranulocytosis
List 4 examples of EPS ADRs?
- dystonia (spasms of face, tongue, neck)
- parkinsonism (resting tremor, bradykinesia)
- akathisia (restlessness)
- tardive dyskinsia
How do we treat EPS ADRs? (3)
- anticholinergics (benztropine, iphenhydramien)
- BDZs+ Beta blockers for akathisia
Which drugs classes cause the worst anticholinergic ADRs (2)? What are 4 examples of these ADRs?
- Low potency typical antipsychotics + Atypicals
- Dry mouth, constipation, blurry vision, hyperthermia
Which drug classes cause metabolic syndromes?
Which two antipsychotics are “weight neutral”?
How do we manage patients on these drugs?
- Second generation antipsychotics
- Aripiperazole, Ziprasidone
- Monitor BP, sugar, lipids// encourage smoking cessation
What are the treatments for Tardive Dyskinesia (4)
Which population gets this most frequently?
- Discontinue offending agent (typically a typical)
- BDZs
- Botox
- Vitamin E
Most commonly occurs in older women after at least 6 mos of treatment with medication
High potency typical antipsychotics have a predilection to cause what two types of ADRs?
- EPS
- Neuroleptic malignant syndrome
What are the characteristic manifestations of neuroleptic malignant syndrome? (5)
Which drugs most commonly cause this?
- Altered mental status
- Lead pipe rigidity
- ^^^ CPK
- Leucocytosis
- Metabolic acidosis
**Most commonly associated with HIGH IV/IM dosing of HIGH POTENCY TYPICAL neuroleptics
Which antipsychotic is associated with retinal pigmentation at high doses?
Thioridazine
Which antipsychotic is associated with pigmented deposits in lens and cornea?
Chlorpromazine
What are three additional ADRs associated with neuroleptic use?
- QTc interval prolongation
- Hematologic (cytopenias)
- Dermatologic conditions (rashes, photosensitivity)
How many patients progress from schizophreniform disorder –> schizophrenia or schizoaffective disorder?
How many experience complete recovery?
What does treatment entail?
2/3 of all patients; 1/3 experience complete recovery
Tx: hospitalization, 6 mos antipsychotic tx, psychotherapy
DSM 5 Diagnostic criteria for Schizoaffective Disorder (4):
- MDD (2 weeks) or Manic episode (1 week) + psychotic sx consistent with schizophrenia simultaneously
- 2 weeks psychosis sans mood disturbance
- Mood disturbance present throughout majority illness
- Sx NOT due to medical condition/ drugs
Poor prognostic factors associated with Schizoaffective Disorder (5):
- Poor premorbid adjustment
- Early and indolent onset
- Predominantly psychotic sx
- Long course
- Family hx of schizophrenia
Delusional disorders most commonly occur in what population?
- Age
- 3 types of ppl at risk
- 40+ yoa
- Immigrants
- Hearing impaired
- Pts with family hx of schizophrenia
DSM 5 Diagnostic criteria for Delusional Disorder (3):
- 1+ delusions for AT LEAST 1 mos
- DOES NOT meet diagnostic criteria for schizophrenia
- Daily functioning NOT SIGNIFICANTLY IMPAIRED
Describe the character of Delusional Disorder delusions vs. Schizophrenic delusions (2):
- Nonbizarre
- Daily functioning NOT impaired
7 Subclasses of delusional disorder:
- ergomatic type–that another person is in love w them
- grandiose type–having great talent
- somatic type
- persecutory type
- jealous type–unfaithfulness
- mixed type– more than one of above
- unspecified type
Rank the psychotic disorders in order from best to worst prognosis (4):
- Mood disorder with psychotic features
- Schizoaffective disorder
- Schizophreniform disorder
- Schizophrenia
Describe the findings in Schizotypical personality disorder: (4)
- Paranoid, odd/ magical beliefs
- Eccentric and lacking friends
- Social anxiety
- No psychosis
Describe the findings in Schizoid personality disorder: (3)
- Solitary activities
- Does not enjoy social interaction
- No psychosis
