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Board Certification 2 (Purple book) > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

Hypnogogic and hypnopompic hallucinations

A

Hallucinations that happen when you’re first waking up or falling asleep. It’s a normal thing.

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2
Q

Schizophrenia effects not only cognition, perception, emotions, and behaviors, it also effects

A

socialization and eye movement

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3
Q

Genetics of schizophrenia

A

50% risk for an identical twin, 15% of non identical
40% risk if both parents have schizophrenia

A polygenic SNIP defect is suspected

Chromosomes 6p24-22 have been implicated

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4
Q

Neurodevelopmental theory of schizophrenia

A

Genetic defects can cause abnormal cell development, connection, organization, and migration.
These include inadequate synapse formation, excessive pruning of synapses, and excitotoxic death of neurons.

There can be intrauterine insults like toxins, O2 deprivation, malnutrition, substance abuse, etc.

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5
Q

Brain abnormalities in schizophrenia

A

Enlarged ventricles

Reduced symmetry in the temporal, frontal, and occipital lobes

Smaller frontal and temporal lobes
Cortical atrophy
Decreased cerebral blood flow
Hippocampal and amygdala redurection

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6
Q

Neurotransmitter differences in schizophrenia

A

Too much DA in the mesolimbic pathway

Not enough DA in the mesocortical pathway

Too much glutamate

Not enough serotonin and GABA

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7
Q

Risk factors

A 
Urban born
First born
Poor 
Born in winter or early Spring 
More common in men
Prenatal exposure to flu or virus 
malnutrition
Obstetrical complications 
CNS infection in early childhood
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8
Q

schizophrenia gender differences

A

men’s onset is 18 to 25
They have more negative symptoms, worse prognosis, more hospitalizations, and less response to meds

women’s onset is 25 to 35
They have less premorbid dysfunction, more dysphoria than men, more likely to have paranoid delusions and hallucinations

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9
Q

Earlier age of onset

A 
Tend to be male
Worse premorbid functioning
More brain abnormalities 
More negative symptoms 
More cognitive symptoms 
Worse prognosis
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10
Q

Positive symptoms are caused by

A

Too much DA in the mesolimbic pathway

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11
Q

Negative symptoms are caused by

A

Not enough DA in the mesocortical pathway

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12
Q

The most debilitating symptoms are

A

negative

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13
Q

What happens with the different kinds of symptoms over time

A

Positive symptoms decrease, negatives remain

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14
Q

Things that give you a good prognosis

A

Family history of mood disorder, but no family history of schizophrenia

High level of premorbid functioning 
Acute onset
Later age of onset
Clear precipitating event 
Married/Good support system
Positive symptoms
Getting treatment quickly 
Absence of brain abnormalities
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15
Q

Physical exam findings of schizophrenia

A

Abnormal smooth pursuit eye movements
Abnormal saccadic eye movement
Poor eye-hand coordination (clumsy or awkward)

Astereognosis 
Twitches, tics, rapid eye blinking
Dysdiadochokinesia
Impaired fine-motor movement
Left-right confusion
Mirroring

Weakness
Decreased reflexes

Highly arched palate
Narrow or wide set eyes
Subtle ear malformations

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16
Q

A more detailed look at structural abnormalities of the schizophrenic brain

A

Enlargement of lateral ventricles
Widened cortical sulci

Diffuse decrease in volume of gray and white matter

Decreased volume of temporal lobe
Decreased volume in hippocampus, amygdala, and thalamus

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17
Q

Functional changes in the schizophrenic brain

A

Hypofrontal
Decreased cerebral blood flow and metabolism
Diffuse hypometabolic action in cortical-subcortical circuitry

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18
Q

2nd gen mode of action

A

Normally, serotonin binds to 5HT2a on DA neurons, which means it further shuts off the release of DA.

The second gens antagonize (block) the 5HT2a receptors on DA neurons, which increases DA in the nigrostriatal, tuberoinfundibular, and mesocortical pathways.

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19
Q

What do 2nd gens do in the mesolimbic pathway

A

It blocks DA, which decreases positive symptoms

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20
Q

What do 2nd gens do in the mesocortical pathway

A

The increase DA, which helps with negative symptoms

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21
Q

What do 2nd gens do in the nigrostriatal pathway

A

DA has a reciprocal relationship with ACh. When serotonin is blocked by the 2nd gen, DA increases, which means ACh decreases. Because there is less ACh, you have less EPS (EPS is caused by too much ACh, which is why we give ANTIcholinergics)

22
Q

What do 2nd gens do in the tuberoinfundibular

A

DA inhibits prolactin. The blockade of DA by 2nd gens causes prolactin to increase, causing galactorrhea and gynecomastia.

Hyperprolactinemia associated with the antipsychotics may cause sexual problems, galactorrhea, amenorrhea, gynecomastia, and bone demineralization in postmenopausal women not on estrogen.

23
Q

The 5 components of EPS

A

Akathisia

Akinesia- opposite of akathisia, you can’t move

Dystonia

Pseudo-parkinsons

TD

24
Q

Overview of how 1st gens work

A

They improve positive symptoms by blocking DA in the mesolimbic pathway, but they might actually make negative symptoms worse by blocking DA in the mesocortical.

25
Q

1st gen potency

A

high potency meds have more EPS but less sedation and anticholinergic

Low potency meds are the opposite; more sedation/anticholinergic but less EPS

26
Q

Caffeine and nicotine

A

Diminish the effects of antipsychotics, you may need to raise the dose

27
Q

Cause of EPS

A

When you decrease DA, ACh increases

28
Q

TD

A

occurs in people who are treated for at least a year

Screen for this every 6 months

Higher risk in women, older adults, people with mood or cognitive disorders

29
Q

Rating scales for EPS

A

SAS
AIMS
DISCUS

30
Q

NMS

A

More common in 1st gens

Increased risk with rapid dose escalation, using high potency antipsychotics, parenteral administration

Assess for:

  1. elevated CPK, WBCs, and LFTs
  2. Altered sensorium, hyperthermia, hyperreflexia (which are the symptoms that occur first)
  3. Autonomic instability- hypotension, rigidity, hyperthermia, tachy, tachypnea, sweating, coma, death
31
Q

Treatment for NMS

A

dantrolene, bromocriptine

acetaminophen and cooling blanket for hyperthermia

intravenous hydration

benzos for rigidity

32
Q

1st gens also cause side effects unrelated to DA:

A

Alpha adrenergic blockade causes

  • cardiovascular side effects
  • Orthostatic hypotension

Muscarinic cholinergic blockade causes

  • Dry mouth
  • Blurred vision
  • Constipation
  • Urinary retention

Endocrine side effects

  • Weight gain
  • Increased prolactin levels

Neurological side effects
-Lowering seizure threshold

Other side effects

  • Photosensitivity
  • agranulocytosis
33
Q

Nonpharm treatment of schizophrenia

A

Therapy is usually supportive rather than insight oriented

34
Q

schizophrenia common comorbidities

A

20 to 40% have substance abuse

80 to 90% have nicotine dependence (and they tend to smoke cigarettes with the highest nicotine content)

Panic disorder, OCD, and other anxiety disorders

35
Q

schizophrenia general health considerations

A

They live 10 to 25 years less than the average population

10% commit suicide

20 to 40% attempt suicide

Risks for suicide include recent hospitalization, post-psychotic period, 45 or younger

36
Q

If they ask anything about risk related to BMI

A

All of the disease are 2.1 to 3 times more likely with an overweight BMI

37
Q

schizophrenia in children

A

Hallucinations and delusions are less elaborate and less bizarre

VH is more common than AH

38
Q

schizophrenia in older adults (overview)

A

Late onset is rare, but if it does happen it’s more likely in women

They are often married

They have a better prognosis

Black box warning for 2nd gens used with dementia-psychosis

39
Q

schizophrenia in older adults, risk factors

A

Postmenopausal

Presence of human leukocyte antigen

Positive family history

40
Q

schizophrenia in older adults, symptoms

A

Mostly positive symptoms

Persecutory delusions and hallucinations

Less disorganized

They remain interested in social and occupational interests

41
Q

Perform annual eye exam if they are taking

A

1st gens or seroquel

42
Q

Rating scales for schizophrenia

A

PANSS (positive and negative sydnrome scale)

BPRS (brief psychotic rating scale)

SAPS (scale for assessment of positive symptoms)

SANS (scale for assessment of negative symptoms)

43
Q

Schizophreniform

A

the prodome, active phase, and residual phases all happens within 6 months

More common in men

1/3 recover, the others get schizophrenia

44
Q

Schizoaffective disorder

A

Men and women are =

There’s a period of at least 2 week where they have delusions or hallucinations, but without the mood symptoms

The negative symptoms are usually less severe than in schizophrenia

45
Q

Delusional disorder

A

They have one or more delusions, but everything else is normal. It doesn’t always effect their functioning, but it’s possible to have legal problems as a result of the delusion, or become depressed as a result.

Mean onset is 40.

Men are more likely to be paranoid

Women are more likely to be erotomania

It’s more common in people with disorders of the limbic system and basal ganglia

46
Q

Jealous delusions are usually held by

A

men

47
Q

Brief Psychotic disorder

A

Lasts at least 1 day, but less than a month

Usually starts in teens or early adult

Predominantly positive symptoms

48
Q

Shared psychotic disorder (folie a deux)

A

Sharing a delusion with someone who you have a close relationship with.

Usually the person that shared the delusion has schizophrenia, is the dominant person in the relationship, gradually imposes the delusion on the other person, and aside from the delusion, their behavior may be very normal

Good prognosis if you can separate them from the person who shared the delusion

49
Q

Eye differences in schizophrenia

A

Abnormal smooth pursuit eye movements

Abnormal saccadic eye movement

rapid eye blinking

50
Q

Neuro differences in schizophrenia

A

Astereognosis


Dysdiadochokinesia

Twitches, tics


Left-right confusion

Mirroring
Weakness

Decreased reflexes

Impaired fine-motor movement
Poor eye-hand coordination (clumsy or awkward)

51
Q

Differences of head structure

A

Highly arched palate

Narrow or wide set eyes

Subtle ear malformations

Board Certification 2 (Purple book) (22 decks)

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