Psychotic Disorders Flashcards
When is peak onset for schizophrenia?
Late adolescence and early adulthood
Precipitating events to schizophrenia may include psychosocial stressors, traumatic events, and/or drug and alcohol abuse. For example, _______ use increases risk of developing schizophrenia by at least 6x
Cannabis
Prodromal signs and symptoms may exist before symptoms of schizophrenia. What are some examples?
Schizoid or schizotypal personalities
Few close friends as adolescents
Minimal social activities
Genetic association of schizophrenia as evidenced by monozygotic vs. dizygotic twins
Monozygotic twins (100% shared genes) concordence rate with schizophrenia = 40-50%
Dizygotic twins (50% shared genes) concordence rate with schizophrenia = 10-15%
[genes don’t play a huge role!]
Meta-analysis of literature have found that _____ ____ _____ increase risk of schizophrenia by 1.5-2x, a greater effect than any common genetic variant
Early life complications (ELCs)
[aka potentially adverse events that occur during pregnancy and labor, at delivery, and early in neonatal life]
The interaction between genomic risk and ELCs is mainly driven by the _____ genome, and is relatively independent of gene-environment interactions related to parental genomes per se.
Genes highly and differentially expressed in the ________ drive the interaction between polygenic risk scores and early-life complications on schizophrenia risk
Fetal
Placenta
Prenatal exposure to _____ ______ during the first trimester of pregnancy appears to increase the risk of developing schizophrenia, making offsprine 7x more likely to develop it
Influenza virus
The Copenhagen perinatal cohort stated that maternal ______ during any time in pregnancy was associated with a 3x increased risk of schizophrenia in offspring by age 47
URI
The “revised dopamine hypothesis” proposes hyperactive dopamine transmission in the ______ areas and hypoactive dopamine transmission in the _________ in schizophrenia pts
Mesolimbic; prefrontal cortex
In addition to the mesolimbic brain areas in schizophrenic pts, dopamine dysregulation is also observed in brain regions including the _____ and _______, which are important for emotional processing
Amygdala; prefrontal cortex
PET-studies have identified differences in dopamine contents in the prefrontal cortex, cingulate cortex, and _________ between schizophrenia pts and neuropsychiatric healthy control subjects.
Hippocampus
[“In particular, the dopamine system in the hippocampus is OVERACTIVE in schizophrenia pts”]
In terms of hormonal roles in schizophrenia, there is evidence that people with schizophrenia experience both periods of heightened and decreased _____ secretion
Cortisol
One set of symptoms that define psychotic disorders is known as “positive” symptoms, aka those symptoms that indicate a better prognosis.
What are the “positive” symptoms?
Delusions
Hallucinations
Disorganized thinking (speech)
Grossly disorganized or abnormal motor behavior (including catatonia)
One set of symptoms that define psychotic disorders is known as “negative” symptoms, aka those symptoms that indicate a worse prognosis.
What are the “negative” symptoms?
Diminished emotional expression
Avolition
Alogia
Anhedonia
Asociality
Fixed beliefs that are not amenable to change in light of conflicting evidence
Delusions
6 types of delusions
Persecutory
Grandiose
Referential
Erotomanic
Nihilistic
Somatic
Perceptions that occur without an external stimulus; may occur in any sensory modality
Hallucinations
_____ hallucinations are most common in schizophrenia
Auditory
[usually experienced as voices, whether familiar or unfamiliar; are perceived as distinct from individual’s own thoughts]
_______ hallucinations are those that occur while waking up
_______ hallucinations are those that occur while falling asleep
Hypnopompic
Hypnagogic
T/F: hypnagogic and/or hypnopompic hallucinations are highly indicative of psychosis
False
These types of hallucinations are NOT indicative of psychosis, but may indicate some other psychiatric issue; highly related to seizure activity
Types of disorganized thinking
Tangentiality (diverging from previous course)
Derailment or loose associations
Incoherence or “word salad”
Examples of grossly disorganized motor behavior include:
________ behavior = marked decrease in reactivity to the environment
_______ _______ = purposeless and excessive motor activity without obvious cause
Catatonic
Catatonic excitement
Types of disorganized motor behavior
Negativism (resistance to instructions)
Inappropriate or bizarre posture (waxy flexibility)
Mutism and stupor (a complete lack of verbal and motor responses)
Repeated stereotyped movements (staring, grimacing, mutism, and echoing of speech)
What 2 “negative” symptoms are particularly prominent in schizophrenia?
Diminished emotional expression — decreased eye contact, speech intonation (prosody), and movements of the hand, head, and face
Avolition — a decrease in motivated self-initiated purposeful activities
____ is a negative symptom manifested by diminished speech output
Alogia
_____ is a negative symptom characterized by decreased ability to experience pleasure; also found in depression, borderline, etc
Anhedonia
Diagnostic criteria for schizophrenia require _____ or more of the following for most of ______ (time); and at least 1 of the first 3 symptoms from Criterion A:
- ____
- ____
- _____
- _____
- _____
Two; 1 month
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms
Differentiate presentation of schizophrenia in adults vs. child or adolescent in terms of functioning as stated in the DSM criteria
Adult — level of functioning after symptom onset is far below what it was prior to onset
Child or adolescent — failure to achieve expected level of functioning
Diagnostic criteria (C) for schizophrenia require continuous signs of the disturbance persisting for at least _______ (time). This MUST include at least _______ (time) of symptoms from Criterion A [delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms]. This MAY include periods of prodromal or residual symptoms
6 months; 1 month
[Note: during prodromal or residual periods there may only be ‘negative’ symptoms, or at least 2 group A symptoms that present in an attenuated form, such as having odd beliefs or unusual perceptual experiences]
According to the DSM, if there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if … what?
Only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated)
The Schizophrenia: Catatonic Type, the clinical picture is dominated by at least ____ of the following:
- ____
- ___
- ___
- ____
- ____
- Motoric immobility as evidenced by catalepsy or stupor
- Excessive motor activity (apparently purposeless and not influenced by external stimuli)
- Extreme negativism or mutism
- Peculiarities of voluntary movements such as posturing, stereotyped movements, prominent mannerisms, or prominent grimacing
- Echolalia or echopraxia
Single leading cause of death in schizophrenia pts
Suicide
[attempts occur in 20-50% of pts; risk is greatly increased with substance use, comorbid major depression, and previous high functioning]
At what time during the disease process do most schizophrenic pts attempt/commit suicide?
Usually near illness onset
Diagnosis of schizophrenia is made based on clinical symptoms. Medical screening must be utilized to rule out other possible causes — like what?
Seizure disorder
Metabolic disorder
Thyroid dysfunction
Brain tumor
Neurosyphilis
Street drug use
Tests ordered in workup for schizophrenia
Labs Drug screen Imaging (CT/MRI) Neuro consult EEG
Schizophrenia treatment for pts experiencing acute psychosis
Hospitalization if needed for pt safety, and to get them stabilized
IM injections more commonly used while inpatient — Haloperidol, fluphenazine, lorazepam
Schizophrenia treatment during stabilization phase
Consider converting to newer, atypical antipsychotics
Examples include: cloazpine, risperidone, olanzapine, quetiapine, ziprasidone, iloperidone, or aripiprazole
2nd gen antipsychotic with side effects of agranulocytosis and weight gain
Clozapine
2nd gen antipsychotic with very common side effect of weight gain and metabolic disorders (i.e., diabetes)
Olanzapine
2nd gen antipsychotics with side effect of QTc prolongation
Ziprasidone
Iloperidone
T/F: Schizophrenic pts tend to respond well to insight-oriented group and individual psychotherapy modalities
False — insight oriented group and individual psychotherapy modalities have been found to make symptoms worse
[Programs that do work include behavioral medicine clinics, residential living facilities, and care managers. Also: self-help programs and ECT]
Pharmacologic treatment for catatonic type schizophrenia
Benzodiazepines
DSM criteria for delusional disorder
Presence of 1 or more delusions with duration of 1 month or longer
Criterion A for schizophrenia has never been met
Apart from impact of delusion, functioning is not impaired, and behavior is not obviously bizarre or odd
If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods
Not caused by direct effects of a substance or a general medical condition
[types include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified]
DSM criteria for Brief Psychotic Disorder
A. Presence of 1 or more of the following and at least 1 must be 1, 2, or 3:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized/catatonic behavior
B. Duration of an episode of the disturbance is at least 1 day, but less than 1 month, with eventual full return to premorbid level of functioning
C. The disturbance is not better explained by another disorder or substance abuse
DSM criteria for schizophreniform disorder
A. 2 or more of the following, each present for a significant portion of a 1 month time period, and at least 1 must be 1, 2, or 3:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized/catatonic behavior
- Negative symptoms
B. An episode of the disorder lasts at least 1 month but less than 6 months
C. Schizoaffective disorder or other mood disorder has been ruled out
D. Disturbance not due to substance abuse
DSM criteria for schizoaffective disorder
A. Uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness
D. The disturbance is not attributable to substance abuse or other medical condition
DSM criteria for substance/medication-induced psychotic disorder
A. Presence of delusions and/or hallucinations
B. BOTH of the following: symptoms in criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication AND the involved substance/medication is capable of producing symptoms in criterion A
C. The disturbance is not better explained by a psychotic d/o that is not substance/medication-induced
D. The disturbance does not occur exclusively during the course of a delirium
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other functioning
DSM criteria for Psychotic Disorder due to Another Medical Condition
A. Prominent hallucinations or delusions
B. Evidence that the disturbance is the direct pathophysiologic consequence of another medical condition
C. The disturbance is not better explained by another mental d/o
D. The disturbance does not occur exclusively during the course of a delirium
E. The disturbance causes clinically significant distress or impairment in functioning
In the criteria for Catatonia Associated with Another Mental Disorder, the clinical picture is dominated by 3 or more of what symptoms?
Stupor Catalepsy Waxy flexibility Mutism Negativism Posturing Mannerism Stereotypy Agitation Grimacing Echolalia Echopraxia
Echolalia vs. echopraxia
Echolalia = mimicking another’s speech
Echopraxia = mimicking another’s movement
Symptom found in catatonia characterized by repetitive, abnormally frequent, non-goal-directed movements
Stereotypy
Symptom found in catatonia characterized by odd, circumstantial caricature of normal actions
Mannerism
Symptom found in catatonia characterized by opposition or no response to instructions or external stimuli
Negativism
Symptom found in catatonia characterized by spontaneous and active maintenance of a position against gravity
Posturing
Symptom found in catatonia characterized by slight, even resistance to positioning by examiner
Waxy flexibility
Symptom found in catatonia characterized by passive induction of a posture held against gravity
Catalepsy
Symptom found in catatonia characterized by no psychomotor activity; not actively relating to environment
Stupor
Components of “Other specified Schizophrenia Spectrum and Other Psychotic Disorder”
Causes significant distress or impairment but does not meet full criteria for any of the other psychotic disorders
Persistent auditory hallucinations in absence of other features
Delusions with significant overlapping mood episodes
Attenuated psychosis syndrome
Delusional symptoms in partner of individual with delusional disorder
What is the difference in timeline for schizophrenia vs. schizophreniform vs. brief psychotic disorder?
Schizophrenia think >6 months
Schizophreniform think 1-6 months
Brief psychotic disorder <1 month
Which of the following is characterized as schizotypal + psychosis?
A. Schizoid B. Schizotypal C. Schizophrenia D. Schizoaffective E. None of the above
C. Schizophrenia
Which of the following is characterized as very introverted and voluntarily withdraws from social interactions?
A. Schizoid B. Schizotypal C. Schizophrenia D. Schizoaffective E. None of the above
A. Schizoid
Which of the following is characterized as schizoprenia + mood disorder?
A. Schizoid B. Schizotypal C. Schizophrenia D. Schizoaffective E. None of the above
D. Schizoaffective
Which of the following is characterized as schizoid symptoms + magical thinking + odd behavior
A. Schizoid B. Schizotypal C. Schizophrenia D. Schizoaffective E. None of the above
B. Schizotypal
Schizophrenic pts are NOT more likely to commit homicide. However, there are risk factors that make these pts more likely to commit acts of violence. What are these risk factors?
Personality traits found in antisocial and/or borderline PD
History of violent acts
Paranoid beliefs
Content of auditory hallucinations
Substance abuse
Impulsivity
Talking about violence
