Psychotic Disorders Flashcards
Overview
I. Psychosis is generally defined to mean “loss of contact with reality” and can involve firmly held false beliefs and/or sensory experiences involving any of the five senses that do not have corresponding environmental stimuli.
History
a. Historical
i. The term psychosis was first used in 1841 to indicate a “disease of the mind” in contrast to neurosis which meant “disease of the nervous system”.
ii. Two notable individuals who shaped our understanding of psychotic disorders
1. Emil Kraepelin
a. Founder of modern psychiatry who developed the classification system for psychiatric diseases
b. Called schizophrenia “dementia praecox” with belief that schizophrenia was neurodegenerative illness
2. Eugene Bleuler
a. Contemporary of Kraeplin’s who recognized that individuals with different “dementias” had different ultimate outcomes. Coined term “schizophrenia” to describe individuals with less severe cognitive symptoms whose illness progressively worsened to a point then plateaued.
II. Epidemiology
a. Lifetime prevalence of schizophrenia is roughly 1.1% per the Epidemiologic Catchment Area (ECA) study
b. Male to female ratio of 1:1
Schizophrenia: Diagnosis
a. Two (or more) of the following, each present for a significant portion of time during a 1-month period. At least one of these must be (1), (2), or (3):
i. Delusions
ii. Hallucinations
iii. Disorganized speech
iv. Grossly disorganized behavior or catatonic behavior
v. Negative symptoms
b. For a significant portion of time level of functioning in one or more life areas is markedly below level prior to disease onset.
c. Continuous signs of disturbance for 6 months or more.
Schizo Etiology
d. Etiology - many etiologic processes appear relevant and what we currently consider “schizophrenia” almost certainly represents a heterogeneous group of illnesses with a common presenting phenotype
i. Developmental and Psychological Factors
ii. Genetic Factors
1. Familial transmission
a. Risk of disease in 1st degree relative ~10%
b. Identical twins – 40-65% risk
c. Both parents with schizophrenia
i. Risk 40-50%
d. One parent or one sibling
i. Risk 5-20%
Suceptible genes in schizo.
- Dozens of susceptibility genes have been discovered implicating numerous functions both within and outside the CNS. The most consistent genetic relationship at a population level is associated with the MHC locus on chromosome 6. Gene codes for alleles of CD4 which are associated with different levels of expression of C4A and C4B. Overactivity of C4A in the brain may lead to excessive pruning of synapses during adolescence and early adulthood. This may contribute to the development of schizophrenia for some individuals.
Schizophrenia: 22q11 deletion syndrome
– “DiGeorge Syndrome” or velo-cardio-facial syndrome
a. Only recurrent, clinically recognizable, genetic cause of schizophrenia with currently available laboratory testing
b. ~90% spontaneous mutation, 10% inherited
c. 1% of patients with schizophrenia have this deletion
d. 20-30% of 22q11 patients develop schizophrenia or schizoaffective disorder
e. Symptoms of schizophrenia are indistinguishable though 22q11 patients are more likely to have intellectual impairment
Schizophrenia: Neurotransmitters: Dopamine (DA)
a. Higher than normal number of D-2 receptors
b. PET scans show elevated activity of DA neurons in limbic system which correlate with positive symptoms
c. PET scans show diminished activity of DA neurons in frontal and prefrontal areas with correlate with negative symptoms
Schizophrenia: Neurotransmitters: Serotonin (5-HT)
a. Serotonergic neurons are widely distributed and often inhibit dopaminergic neurons
b. Decreased levels of 5-HT metabolites are often found in patients with schizophrenia
Schizophrenia: Neurotransmitters: Glutamate
a. Decreased in schizophrenia
i. Glu receptor antagonists (ie, PCP) cause schizophrenia-like psychotic symptoms
b. MRI and post-mortem studies show decreased Glu in prefrontal cortex
c. Glu neurons interact with both DA and 5-HT neurons
d. Linked to cognitive deficits in schizophrenia
Schizophrenia: Neuroanatomy
- Structural
a. Over-activity in limbic areas – positive symptoms
b. Under-activity in frontal lobes – negative symptoms - Functional
a. Enlargement of the lateral ventricles
i. Loss of brain mass due to developmental failure of cell death
Schizophrenia: Symptomotology
i. Positive symptoms – added to the presentation
1. Hallucinations
2. Delusions
3. Catatonia
4. Agitation
ii. Negative symptoms – absent from the presentation
1. Flattened affect
2. Apathy
3. Social withdrawal
4. Anhedonia
5. Poverty of thought
6. Poverty of speech
Schizophrenia: Symptomotology 2
iii. Thought process/Thought Form
1. Loosening of associations – connections among ideas become absent or obscure
2. Neologisms – creation of words
3. Verbigerations – persistent repetition of words/phrases
4. Echolalia – repetition of word or phrase of examiner
5. Mutism – functional inhibition of speech
6. Word salad – unintelligible mixture of random words
7. Poverty of thought and Poverty of speech – speech may be complex or limited but overall content is devoid of much information
8. Thought blocking – sudden interruption in speech (and presumably flow of thought)
a. Possibly secondary to hallucination but patient may be unwilling or unable to acknowledge the cause
Schizophrenia: Thought content: Delusion
- Delusions – “fixed, false beliefs”; cannot be changed by logical reasoning and are inconsistent with beliefs typical for the patient’s cultural group (though they may have cultural content); may be pervasive to patient’s life or may be circumscribed and difficult to locate on typical interview
a. Delusions of persecution – others are trying to harm, spy on, interfere with affairs of patient
b. Delusions of reference – random events have special meaning to patient
c. Delusions of influence – belief patient’s thoughts are controlled by outside sources
d. Thought broadcasting – patient’s thoughts are being sent directly to an outside source
e. Grandiose delusions – patients belief they are elevated in importance; more common in psychotic mania
f. Somatic delusions – belief the body has been manipulated in some way; device inserted, body controlled by others, etc.
Schizophrenia: Thought content: Hallucinations
- Hallucinations – sensory experiences that occur without corresponding environmental stimuli
a. Auditory hallucinations – range from indistinct/muffled sounds to complex and multiple voices
i. Command hallucinations – voice(s) tell patient to perform an action; may be so persistent that they are difficult to resist
b. Visual hallucinations – occur in schizophrenia but are more common in “organic” (non-psychiatric) disorders such as delirium
c. Other hallucinations – tactile, gustatory, olfactory; more common in non-psychiatric illnesses but in schizophrenia often connected to delusional system
Schizophrenia: Thought content: Illusions
- Illusions – misperceptions of real environmental objects or events; occur in disordered and healthy individuals
a. “Déjà vu” – happened when hasn’t
b. “Jamais vu” – hasn’t happened when has
c. Hypersensitivity – to light, sound, etc.
d. Distorted perception of time
e. Misperception of movement
Schizophrenia: Cognitive symptoms
- Impaired executive functioning – planning, decision-making, mental flexibility
- Impaired attention and memory
a. Working memory - Impaired learning
a. Loss of educational and occupational progress
Schizophrenia: Other Negative symptoms
- Affect – flattened, blunted, inappropriate; confounded by Parkinsonian effect of drugs
- Sense of self – lost perception of separateness from others/community
- Avolition – difficulty initiating and maintaining goal-directed activities
Schizophrenia: Clinical Course
i. Highly variable
1. Prodromal phase vs not
2. Remission (residual phase) vs none
3. Deteriorating course vs Full remission/recovery (rare)
Schizophrenia: Clinical Course 2
ii. Variability in course is one strong indicator for multi-disease/common phenotype model
iii. Onset - bimodal
1. Late teens to early 20s
a. Earlier in men than women
b. Multiple stresses including separation from parents, transition from education to work settings, marriage, children, etc.
c. Stage of neurodevelopment
2. Second smaller peak in late 40s particularly for women
3. Like many illnesses may have precipitating event (e.g., social or economic stress, trauma, drug use, etc.)
4. Initial presentation – variable and has prognostic significance
a. Abrupt onset – develops over 1-2 days in response to stressor
i. GOOD prognosis as most resolve quickly
b. Insidious prodromal phase – onset over months with social withdrawal, peculiar behavior, neglect of hygiene, blunted affect, odd beliefs, apathy
i. POOR prognosis
Schizophrenia: Prognostics Variables
- POOR – predominance of negative symptoms, insidious onset, poor cognitive performance on testing, abnormalities on CT, lack of mood symptoms
- GOOD – predominance of positive symptoms, acute onset, late onset, female, good premorbid functioning, presence of mood symptoms, family history of mood disorders
Schizophrenia: QOL
i. Small social groups (support networks)
ii. Impaired educational achievement (despite normal or high intelligence)
iii. Barriers to employment (improves outcomes but difficult to obtain and maintain)
iv. Fewer and shorter marriages
v. Criminal behavior – when services are not provided through mental health system enter justice system usually for minor, nonviolent crimes
vi. Homelessness – 5-8% are homeless
vii. High psychiatric co-morbidity – anxiety, depression, substance-use disorders
Schizoaffective Disorder: Diagnosis: DSM 5 Criteria
i. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia
ii. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime of the illness
iii. Symptoms that meet criteria for a mood episode are present for a majority of the total duration of the active and residual portions of the illness.
iv. The disturbance is not attributable to the effects of a substance or another medical condition.
v. Specify type:
Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes)
Depressive Type: if the disturbance only includes Major Depressive Episodes
Schizoaffective Disorder:
Differential Diagnosis
i. Mood Disorders with psychotic features
1. Major depressive disorder with psychotic features – psychotic symptoms are present ONLY during course of FULL major depressive episode
a. Major depressive episodes – Psychotic features are typically mood congruent. Depressive features (flat affect, anhedonia, psychomotor retardation, etc.) may resemble negative symptoms of schizophrenia.
- Bipolar disorder with psychotic features - psychotic symptoms are present ONLY during course of FULL manic or depressive episode
a. Manic episodes – Many individuals with severe mania experience psychotic symptoms including AVHs, delusions, bizarre behaviors, etc. Careful history will reveal additional mood symptoms. Behavioral observations and MSE will also likely reveal differentiating factors.
