Rosenthal - Schizophrenia

Question 1

How long do symptoms need to persist post-OD to be considered chronic?

Answer 1

• About one month post-sobriety

Question 2

Why do the atypicals have less risk of EPS than the typicals?

Answer 2

• Less affinity for the D2 receptor

Question 3

College kid presents with psychosis. What should you do? What might be going on?

Answer 3

• Do a blood screen: PCP, LSD -> if only due to drugs, these ppl may bounce back quite quickly
• Family hx is key to a more grim prognosis
• If disorganized speech, loose associations, neologisms (making up words), flight of ideas, and delusions -> give Haloperidol
  
  1. If he doesn’t want to take it, you can’t make him unless he is a danger to himself or others
• You can commit this person

Question 4

How should you counsel pts taking Benztropine and Haloperidol together to control EPS?

Answer 4

• Benztropine: anti-cholinergic
  
  1. Has a shorter half-life than Haloperidol, so if pt stops taking his drugs, Haloperidol will be affecting body longer, leading to EPS
• Can do depot shot if pt is having trouble with adherence

Question 5

Why is Clozapine a last-choice drug?

Answer 5

• Can cause agranulocytosis
• Use after 2 other drugs have been failed -> works in 30% of pts resistant to other antipsychotics
• Also has strong anti-suicide effect

Question 6

What syndrome can change from an atypical to typical antipsychotic cause?

Answer 6

• NMS

- STOP THE DRUG, and give Dantrolene or Bromocriptine

Question 7

What are some of the negative symptoms of schizophrenia?

Answer 7

• Poor grooming and hygiene

- Reclusiveness

Question 8

What is a psychosis? Classic characteristics?

Answer 8

• Mental disorder in which thoughts, affective response, ability to recognize reality, and ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality
• Classical characteristics of psychosis are impaired reality testing (loss of ability to accurate perceive reality), hallucinations, delusions, and illusions

Question 9

What are the 7 schizophrenia spectrum disorders?

Answer 9

• Schizophrenia
• Schizotypal (personality) disorder
• Catatonia
• Brief psychotic disorder, including post-partum psychosis
• Schizophreniform disorder
• Substance/medication-induced psychotic disorder
• Psychotic disorder due to another medical condition

Question 10

What are the key features of schizophrenia spectrum disorders?

Answer 10

• POSITIVE symptoms:
  
  1. Delusions
  2. Hallucinations
  3. Disorganized thinking and speech
  4. Grossly disorganized or abnormal motor behavior, incl. catatonia
• NEGATIVE symptoms:
  
  1. Diminished emotional expression
  2. AVOLITION, i.e., DEC in motivated and self-initiated purposeful activity
  3. ALOGIA: diminished speech output
  4. ANHEDONIA: diminished ability to experience pleasure
  5. ASOCIALITY: lack of interest in social interactions

Question 11

What is the definition of positive symptoms in schizophrenia?

Answer 11

• Psychotic behaviors not seen in healthy people, such as delusions, hallucinations, disordered thinking and speech
• Often “lose touch” with reality
• Can come and go
• Sometimes severe, and at other times hardly noticeable, depending on whether the individual is receiving treatment

Question 12

What is the definition of negative symptoms in schizophrenia?

Answer 12

• Disruptions to normal emotions and behaviors
• Harder to recognize as part of the disorder and can be mistaken for depression or other conditions
• Include:
  
  1. “FLAT AFFECT:” a person’s face does not move or he or she talks in a dull or monotonous voice
  2. Lack of pleasure in everyday life
  3. Lack of ability to begin and sustain planned activities
  4. Speaking little, even when forced to interact
• These ppl need help with everyday tasks, and often neglect basic personal hygiene -> may seem lazy or unwilling to help themselves, but problems are symptoms caused by schizophrenia

Question 13

What are the key differences between schizophrenia, schizophreniform disorder, and delusional disorder?

Answer 13

• Schizophrenia: pt must have been sick for 6 months or more
  
  1. NOTE: olfactory, gustatory, visual hallucinations uncommon in schizophrenia -> in these cases, you need to think about something medical (auditory hallucinations more common)
• Schizophreniform disorder: pts who show delusions, hallucinations, and behavioral disturbances but recover faster than in 6 months (must last at least one month)
• Delusional disorder: pt’s behavior is basically normal, other than having delusions
  
  1. These involve disturbance in thought rather than perception: FIRMLY HELD BELIEFS that are UNTRUE and contrary to a person’s educational and cultural background

Question 14

What is formication?

Answer 14

• Tactile hallucinations possible in schizophrenia: sensation of insects crawling under the skin

Question 15

What are the typical stages of schizophrenia?

Answer 15

• PRODROMAL: insidious onset over months or years with subtle behavior changes, incl. social withdrawal, work impairment, blunting of emotion, avolition, and odd ideas and behavior
• ACTIVE: psychotic symptoms devo, incl. hallucinations, delusions, or disorganized speech and behavior -> eventually lead to medical intervention
• RESIDUAL: active-phase symptoms absent or no longer prominent -> often role impairment, negative symptoms, or attenuated positive symptoms
  
  1. Acute-phase symptoms may reemerge during the residual phase -> ACUTE EXACERBATION

Question 16

What is schizoaffective disorder? Tx?

Answer 16

• Major mood disorder concurrent with schizophrenia-like psychosis
• Hallmark is presence of depressive or manic episode with concurrent symptoms characteristic of schizo, like delusions, hallucinations, or disorganized speech
  
  1. Hallucinations and delusions must be present for 2 WEEKS OR MORE in absence of prominent mood symptoms, but mood symptoms must be present for majority of the total duration of illness
• Treat psychotic issues with antipsychotics and depressive issues with anti-depressants
  
  1. Depression tends to resolve more quickly than the psychosis

Question 17

What is delusional disorder?

Answer 17

• Circumscribed and often bizarre delusion, in an otherwise normal-appearing patient -> DELUSIONS WILL HAVE LASTED AT LEAST 1 MONTH
• Pt’s delusions may seem potentially logical, but can also be very bizarre
• When not talking about the delusions, the patient appears otherwise normal

Question 18

What is brief psychotic disorder?

Answer 18

• Transient psychosis, precipitated by stress or excitement; also includes postpartum psychosis
• At least one day, but no more than one month

Question 19

What are the features of schizotypal personality disorder?

Answer 19

• Classified twice in DSM-5 nomenclature, as both a personality disorder and a schizophrenia spectrum disorder
• Characterized by:
  
  1. Pervasive pattern of social and interpersonal deficits,
  2. Reduced capacity for relationships,
  3. Eccentricities, odd thinking and speech,
  4. Suspiciousness, ideas of reference, and
  5. Unusual perceptual experiences

Question 20

What 5 psychotic disorders are common in medical settings?

Answer 20

• Substance/medication induced psychotic disorder
• Psychotic disorder due to general medical condition
• Catatonia
• Delirium
• Dementia

Question 21

What are the features of substance/medication-induced psychotic disorder?

Answer 21

• Persistent, prominent delusions and/or hallucinations that developed during or soon after substance intoxication or withdrawal, or after exposure to a medication that is capable of producing these symptoms
• This is NOT the same as a delirium!
• Don’t make this diagnosis if the condition would be better explained by a pre-existing psychotic disorder

Question 22

What are the features of psychotic disorder due to another medical condition?

Answer 22

• Evidence from history, physical, and labs that the psychosis is due to the physiological effects of a medical condition
• Did not precede the onset of the medical condition
• Does not exclusively occur during a delirium
• Examples: malignant lung neoplasm, multiple sclerosis, brain injury, hypothyroidism

Question 23

What should be on your Ddx for schizophrenia?

Answer 23

• PSYCH ILLNESS: bipolar, major depression, schizoaffective, brief psychotic disorder, delusional disorder, panic disorder, OCD, personality disorders
• OTHER MED ILLNESS: temporal lobe epilepsy, tumor, stroke, brain trauma, endocrine/metabolic disorders, vitamin deficiency, infectious disease, autoimmune disorder
• DRUGS: stimulatns, hallucinogens, anticholinergics, alcohol or barbiturate withdrawal

Question 24

What is catatonia? Tx of choice?

Answer 24

• Severe psychomotor disturbance that may be associated with many different disorders, incl. schizophrenia, depressive stupor, variety of serious medical conditions
• Pts may experience extreme loss of motor skill or even constant hyperactive motor activity
  
  1. Will sometimes HOLD RIGID POSES for hours and will ignore any external stimuli -> can suffer from exhaustion if not treated
  2. May also show STEREOTYPED, REPETITIVE mvmts
• Behavioral abnormality manifested by stupor
• Mutism, rigidity, automatic obedience
• Treatment of choice BNZ
  
  1. Antipsychotics can actually make worse or malignant
• This can be a feature of many different conditions, including tumors and other cancers

Question 25

What is delirium? Key features?

Answer 25

• Characterized by altered mental status, lasting hours to days
• Due to medical reasons; reversible
• Potentially life threatening
• Acute disorder usually associated with medical illness, drugs, metabolic disorders, etc.
• Fluctuating course
• Altered level of consciousness, excitable, delusions, hallucinations

Question 26

What are the key features of dementia?

Answer 26

• Cognitive deficit in multiple domains, usually but not always including memory
• Progressive deterioration over months to years
• Cognitive impairment interferes with activities of daily life
• No disorder of alertness