Psychotic disorders

Question 1

Common types/themes of delusions

Answer 1

Persecution/paranoia (people after me)
Ideas of reference (TV talking to me)
Thought broadcasting (others can read my thoughts) or thought insertion (thoughts are being placed in my head)
Grandeur (I am the king of the mountaintop)
Guilt (I’m responsible for WWII)
Somatic delusions (I have __ disease)

Question 2

What is an illusion?

Answer 2

Misperception of sensory stimulus

Question 3

What is a hallucination?

Answer 3

Sensory perception without sensory stimulus

-Auditory, visual, olfactory, or tactile

Question 4

Differential diagnosis (broad) of psychosis

Answer 4

Psychosis 2/2 medical condition
Substance or medication induced
Delirium/dementia
Bipolar disorder, manic or mixed episode
Major depression with psychotic features
Brief psychotic disorder
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder

Question 5

Medical causes of psychosis

Answer 5

CNS disease (stroke, MS, cancer, Alzheimer's, PD, HD, syphilis, epilepsy, encephalitis, HIV, etc)
Endocrinopathies (Addison's, Cushing's, thyroid, hyper/hypocalcemia, hypopituitarism)
Nutritional/vitamin deficiency (B12, folate, niacin)
Other (Rheum disease, porphyria)

Question 6

DSM-V criteria for psychotic disorder due to other medical condition

Answer 6

Prominent hallucinations or delusions
Sypmtoms do not occur only during an episode of delirium
Evidence from history/physical/lab support medical cause

Question 7

Medications that can cause medication-induced psychotic disorder

Answer 7

Anesthesia, antibiotics, steroids, anti-parkinsonian drugs, anticonvulsants, antihistamines, anticholinergics, antihypertensives, NSAIDs, digitalis, methylphenidate, chemotherapy

Substance-induced: Alcohol, cocaine, LSD, PCP, ecstasy, cannabis, benzos, barbiturates, inhalants

Question 8

Positive symptoms of schizophrenia

Answer 8

Hallucinations, delusions, bizarre behavior, disorganized speech

*Respond well to antipsychotic meds

Question 9

Negative symptoms of schizophrenia

Answer 9

Flat or blunted affect, anhedonia, apathy, alogia, lack of interest in socialization

*Often resistant to treatment

Question 10

Cognitive symptoms of schizophrenia

Answer 10

Impairments in attention, executive function, and working memory

Question 11

Three phases of schizophrenia

Answer 11

Prodromal phase: decline in functioning, social withdrawal, irritability
Psychotic phase: Perceptual disturbances, delusions, and disordered thought
Residual phase: Follows an episode of active psychosis. Mild hallucinations or disturbances and negative symptoms

Question 12

Diagnostic criteria for schizophrenia

Answer 12

Two or more of the following present for at least one month:
-Delusions
-Hallucinations
-Disorganized speech
-Grossly disorganized or catatonic behavior
-Negative symptoms
Significant social, occupational, or self-care functional impairment
Duration of illness>6mos
Symptoms not due to substance or medical condition

Question 13

Typical findings on psychiatric exam in patients with schizophrnia

Answer 13

Disheveled appearance
Flat affect
Disorganized thought process
Intact procedural memory and orientation
Auditory hallucinations
Paranoid delusions
Ideas of reference
Lack of insight

Question 14

Difference in male vs. female presentations of schizophrenia

Answer 14

Men tend to present in early/mid 20s, women in late 20s

Men tend to have more negative symptoms and worse outcomes

Question 15

Epidemiology of schizophrenia

Answer 15

Ages 15-55
Strong genetic component
Often comorbid substance abuse

Question 16

Pathophysiology of schizophrenia

Answer 16

Increase in dopaminergic activity in mesocorticolimbic tracts (–> positive symptoms)
Decrease in dopaminergic activity in prefrontal-cortical tracts (–> negative symptoms)

Question 17

Effects of antipsychotic blockade of dopaminergic activity in tuberoinfundibular pathway

Answer 17

Reduces tonic dopaminergic inhibition of prolactin release, leading to hyperprolactinemia (–> gynecomastia, galactorrhea, sexual dysfunction, menstrual irregularities)

Question 18

Effects of antipsychotic blockade of dopaminergic activity in nigrostriatal pathway

Answer 18

Parkinsonism/extrapyramidal signs (tremor, rigidity, slurred speech, akathisia, dystonia, etc)

Question 19

Other (besides dopamine) neurotransmitter abnormalities in schizophrenia

Answer 19

Elevated serotonin (some second gen antipsychotics [risperidone and clozapine] block serotonin)
Elevated norepinephrine
Decreased GABA
Decreased number of glutamate NMDA receptors

Question 20

Factors associated with better prognosis in schizophrenia

Answer 20

Later onset
Good social support
Positive symptoms
Mood symptoms
Acute onset
Females
Few relapses
Good premorbid functioning

Question 21

Factors associated with worse prognosis in schizophrenia

Answer 21

Early onset
Poor social support
Negative symptoms
Family history
gradual onset
Male
Many relapses
Poor premorbid functioning
Substance use

Question 22

Pharmacologic treatment of schizophrenia

Answer 22

Typical or atypical antipsychotics

Question 23

Which antipsychotics are more likely to produce extrapyramidal signs/symptoms (EPS)?

Answer 23

Typical, high-potency (haloperidol) antipsychotics

Question 24

Treatment for EPS

Answer 24

Anticholinergics (benztropine, diphenhydramine), beta-blockers for akathisia (or benzos)

Question 25

Low-potency typical antipsychotic meds have what receptor activities?

Answer 25

HAM
Histaminergic blockade
alpha-adrenergic blockade
Muscarinic blockade

Question 26

Main side effect of atypical antipsychotics?

Answer 26

Metabolic syndrome (insulin resistance, weight gain, increased BP, hyperlipidemia)

**Less with aripiprazole or ziprasidone

Question 27

What is schizophreniform disorder?

Answer 27

Features of schizophrenia for <6 months but >1mo

Question 28

What is brief psychotic disorder?

Answer 28

Features of schizophrenia for <1mo

Question 29

Prognosis and treatment of schizophreniform disorder?

Answer 29

1/3 of patients recover completely, 2/3 progress to schizoaffective or schizophrenia

Treat with 6 month course of antipsychotics and psychotherapy

Question 30

Diagnostic criteria for schizoaffective disorder

Answer 30

• Major depressive or manic episode during which psychotic symptoms are present
• Delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms (this criterion distinguishes between schizoaffective and mood disorder with psychotic features)
• Mood symptoms present for majority of illness
• Symptoms not due to effects of a substance/medical condition

Question 31

Treatment for schizoaffective disorder?

Answer 31

Supportive psychotherapy
Antipsychotics (atypicals may help more with mood)
Mood stabilizers, anti-depressants, or ECT may help

Question 32

Diagnostic criteria for delusional disorder

Answer 32

One or more delusions for at least 1 month
Doesn’t meet criteria for schizophrenia
Functioning in life not significantly impaired, and behavior not obviously bizarre

Question 33

Types of delusions

Answer 33

Erotomanic (this person is in love with me)
Grandiose (I am awesome)
Somatic (I have liver failure)
Persecutory (they are after me)
Jealous (she's cheating on me)
Mixed 
Unspecified

Question 34

Treatment for delusional disorder

Answer 34

Supportive therapy

Antipsychotic medications