Schizophrenia Flashcards
Hypnogogic and hypnopompic hallucinations
Hallucinations that happen when you’re first waking up or falling asleep. It’s a normal thing.
Schizophrenia effects not only cognition, perception, emotions, and behaviors, it also effects
socialization and eye movement
Genetics of schizophrenia
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
Neurodevelopmental theory of schizophrenia
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.
Brain abnormalities in schizophrenia
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
Neurotransmitter differences in schizophrenia
Too much DA in the mesolimbic pathway
Not enough DA in the mesocortical pathway
Too much glutamate
Not enough serotonin and GABA
Risk factors
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
schizophrenia gender differences
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
Earlier age of onset
Tend to be male Worse premorbid functioning More brain abnormalities More negative symptoms More cognitive symptoms Worse prognosis
Positive symptoms are caused by
Too much DA in the mesolimbic pathway
Negative symptoms are caused by
Not enough DA in the mesocortical pathway
The most debilitating symptoms are
negative
What happens with the different kinds of symptoms over time
Positive symptoms decrease, negatives remain
Things that give you a good prognosis
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
Physical exam findings of schizophrenia
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
A more detailed look at structural abnormalities of the schizophrenic brain
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
Functional changes in the schizophrenic brain
Hypofrontal
Decreased cerebral blood flow and metabolism
Diffuse hypometabolic action in cortical-subcortical circuitry
2nd gen mode of action
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.
What do 2nd gens do in the mesolimbic pathway
It blocks DA, which decreases positive symptoms
What do 2nd gens do in the mesocortical pathway
The increase DA, which helps with negative symptoms
What do 2nd gens do in the nigrostriatal pathway
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)
What do 2nd gens do in the tuberoinfundibular
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.
The 5 components of EPS
Akathisia
Akinesia- opposite of akathisia, you can’t move
Dystonia
Pseudo-parkinsons
TD
Overview of how 1st gens work
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.
1st gen potency
high potency meds have more EPS but less sedation and anticholinergic
Low potency meds are the opposite; more sedation/anticholinergic but less EPS
Caffeine and nicotine
Diminish the effects of antipsychotics, you may need to raise the dose
Cause of EPS
When you decrease DA, ACh increases
TD
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
Rating scales for EPS
SAS
AIMS
DISCUS
NMS
More common in 1st gens
Increased risk with rapid dose escalation, using high potency antipsychotics, parenteral administration
Assess for:
- elevated CPK, WBCs, and LFTs
- Altered sensorium, hyperthermia, hyperreflexia (which are the symptoms that occur first)
- Autonomic instability- hypotension, rigidity, hyperthermia, tachy, tachypnea, sweating, coma, death
Treatment for NMS
dantrolene, bromocriptine
acetaminophen and cooling blanket for hyperthermia
intravenous hydration
benzos for rigidity
1st gens also cause side effects unrelated to DA:
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
Nonpharm treatment of schizophrenia
Therapy is usually supportive rather than insight oriented
schizophrenia common comorbidities
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
schizophrenia general health considerations
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
If they ask anything about risk related to BMI
All of the disease are 2.1 to 3 times more likely with an overweight BMI
schizophrenia in children
Hallucinations and delusions are less elaborate and less bizarre
VH is more common than AH
schizophrenia in older adults (overview)
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
schizophrenia in older adults, risk factors
Postmenopausal
Presence of human leukocyte antigen
Positive family history
schizophrenia in older adults, symptoms
Mostly positive symptoms
Persecutory delusions and hallucinations
Less disorganized
They remain interested in social and occupational interests
Perform annual eye exam if they are taking
1st gens or seroquel
Rating scales for schizophrenia
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)
Schizophreniform
the prodome, active phase, and residual phases all happens within 6 months
More common in men
1/3 recover, the others get schizophrenia
Schizoaffective disorder
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
Delusional disorder
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
Jealous delusions are usually held by
men
Brief Psychotic disorder
Lasts at least 1 day, but less than a month
Usually starts in teens or early adult
Predominantly positive symptoms
Shared psychotic disorder (folie a deux)
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
Eye differences in schizophrenia
Abnormal smooth pursuit eye movements
Abnormal saccadic eye movement
rapid eye blinking
Neuro differences in schizophrenia
Astereognosis
Dysdiadochokinesia
Twitches, tics
Left-right confusion
Mirroring
Weakness
Decreased reflexes
Impaired fine-motor movement
Poor eye-hand coordination (clumsy or awkward)
Differences of head structure
Highly arched palate
Narrow or wide set eyes
Subtle ear malformations
