Schizophrenia* Flashcards
Disturbance in the perception of reality
psychosis
What is psychosis characterized by?
1+ of the following: hallucinations, delusions, disorganized or incoherent speech, disorganized or catatonic behavior, abnormal emotions, cognitive difficulties
Are psychosis and schizophrenia the same?
No, you can be psychotic and not have schizophrenia. Psychosis is a hallmark of schizophrenia
Sensory perceptions in the absence of any external stimuli
hallucinations (can be visual, auditory, olfactory, tactile, gustatory)
Sensory misperceptions of actual external stimuli
Illusions (Ex: we see sunlight but believe it is an alien coming down)
Fixed false beliefs that persist even with evidence to the contrary that are not shared by a defined religion, family, or subculture
Delusions
What is the key difference between hallucinations and illusions?
hallucinations have absence of external stimulus, whereas illusions are misperceptions
If a patient claims every time clothing touches her skin, it feels like it is “burning” what symptom would that be?
illusion
If a patient insists that the government is able to spy on him through his television, even when it is turned off, unless he leaves it unplugged and turns the screen to face the wall. What symptom is this?
delusion
a patient reports hearing people laughing at her and insulting her; others around her are unable to hear these voices/comments. What symptom is this?
hallucination
patient reports that he cannot eat because all food smells like raw sewage. He denies smelling this unless food is present in front of him. What symptom is this?
illusion
psychiatric disorder with chronic or recurrent psychosis that impairs functioning and can be severely diabling
schizophrenia
how is schizophrenia diagnosed?
characteristic symptoms + social and/or occupational dysfunction for at least 6 months in the absence of another diagnosis that would better account for the disease
Cannot be due to a substance
If autistic or developmental delay, must have hallucinations or delusions for at least a month
WHO ranks schizophrenia in top ____ of illnesses contributing to global disease burden
10
to be diagnosed with schizophrenia, how many of the characteristic symptoms have to be present? For how long?
two or more, significant portion of time during a one-month period for 6 months
There is no clinical sign or symptom that is _____ for Schizophrenia
pathognomonic (every sign and symptom can be seen in other psychiatric and neurologic disorders)
What are important patient factors to consider with a schizophrenia diagnosis?
intellectual ability, educational level, culture/subculture
what is the typical patient presentation of schizophrenia?
poorly groomed, failure to bathe, and dressed too warmly for the current weather
(important to take patient factors into account because may not have economic means/education)
What are positive symptoms of schizophrenia?
exaggeration of normal processes thought to be due to increased dopamine activity: hallucinations, delusions, disorganization (speech, thoughts, behaviors)
what are negative symptoms in schizophrenia?
diminution or absence of normal processes thought to be due to decreased dopamine activity
ex catatonia
what is the most common form of hallucinations?
auditory ie voices, music, body noises, machinery
this is often the most responsive symptom of schizophrenia to antipsychotic meds
auditory hallucinations
what are forms of hallucinations in schizophrenia?
auditory, visual, somatic, olfactory/gustatory
somatic hallucinations can include feelings of being _____
touched, pain, or sexual intercourse
what is the least studied of all hallucinations?
olfactory/gustatory
fixed, false belief present even in the face of evidence to the contrary?
delusions
what types of delusions can be present?
bizarre or non-bizarre, mood-congruent or mood-neutral, and many more
Patients often have ______ for their hallucinations
delusional explanations
what is the most common type of delusion and what does it mean?
delusions of persecution: someone/everyone is out to get me (or harrassing, following, poisoning, drugging, etc)
delusion of exaggerated perception of one’s own abilities or importance, may believe famous person or character
delusion of gradeur
delusion that one does not exist or has died
cotard delusion/nihilistic delusion
delusion that someone is in love with the patient
erotomania
delusion that insignificant remarks, events or objects in one’s environment have personal meaning or significance for ex receiving personal messages from TV
delusions of reference
delusion that another person, group of people, or other external force controls one’s general thoughts, feelings, or behavior
delusions of control
belief regarding one’s bodily functioning, sensations, or appearance usually involving the body being diseased or infested
somatic delusions
What is disorganized speech?
disruption in the organization of person’s thoughts during speech
what are the most commonly observed aspects of disorganized speech?
tangentiality, circumstantiality
what are the more severe types of disorganized speech?
derailment, neologisms, word salad
speech begins in a goal-directed manner, but deviates gradually and consistently off-topic such that answers to questions are not reached
tangentiality
circumstantiality
Speech is goal-directed but full of unneeded detail and gets to the answer in a “roundabout” way
derailment
Speech begins in a goal-directed manner, but topics shift rapidly between sentences with no logical connection to the topic previously discussed
creation of new, nonsensical words
neologisms
incomprehensible speech due to loss of logical connections between words, phrases and sentences
incoherence, severe form- word salad
words are used on how they sound rather than what they mean, may cause excessive rhyming or alliteration
clanging
inability to use abstract thinking
concrete speech
consistently returning to one topic despite the conversation going in a different direction
preservation of ideas (stuck on one topic)
what are the types of disorganized speech (8)?
tangentiality, circumstantiality, derailment, neologisms, incoherence, clanging, concrete speech, preservation of ideas
what is disorganized behavior?
behavior that doesn’t correspond with situation
childlike, unprovoked outbursts of behavior or emotion; aimless, compulsive or bizarre behavior, inappropriate social behaviors (ex remarks about genitalia), severe neglect of hygiene, catatonic behaviors
inability to move normally
not always present in schizophrenia and can be due to other disorders or a sign of drug toxicity
catatonic behavior
Catatonia is a ____ symptom but can be ____ or ____
positive, negative, positive
what is negative catatonia?
motiveless abnormally decreased movement
Ex: immobility, mutism, stupor, negativism, waxy flexibility, posturing/catalepsy, staring
what is positive catatonia?
motiveless abnormally increased movement
ex: grimacing, teeth clicking, rocking, touching or tapping, speech mannerisms, echolalia, echopraxia
What are negative symptoms of schizophrenia?
social withdrawal, anhedonia (loss of interest), flattened affect, loss of motication (not taking care of self), alogia (decreased verbal communication), loss of hygiene
Negative symptoms means a _____
decrease or absence of normal psychosocial processes
What cognitive impairment is present in schizophrenia?
deficits in processing speech, attention, working memory, speech, visual learning and memory, reasoning/executive functioning, social cognition
What psychological disorders are commonly present with schizophrenia?
depressive disorder, anxiety disorders, suicide
10% of schizophrenic patients successfully commit suicide
20-50% of schizophrenic patients attempt suicide
what social findings are often present with schizophrenia?
increased substance use and polysubstance use (50% or more of schizophrenic patient)
commonly nicotine (90%), cannabis, alcohol, or cocaine
what neurological findings can be present with schizophrenia?
subtle sensory and motor impairment ie agraphesthesia (can’t understand number in hand), asterognesia (can’t determine identity of object)
what metabolic findings are often present with schizophrenia?
HTN, diabetes, hyperlipidemia due to sedentary lifestyles, smoking, poor lifestyle choices
they have increased insulin resistance (not sure why) and increased medication side effects
what is the epidemiology of schizophrenia?
1% globally
1.5 per 10000 people per year
billions of dollars in yearly cost ($11.5 billion)
Average age of onset: men- 10-25 years old; women- 25-35 years old
What are risk factors of schizophrenia (7)?
1st degree relative with schizophrenia
Male gender
OB complications or maternal malnutrition
infections (birth during winter or summer months)
inflammation/autoimmune
cannabis use
immigrant status
Over ____ of schizophrenia patients have no family history
1/2
if both of your parents have schizophrenia, what is your risk?
40%
What is the difference in diagnosis between women and men?
more common in men, women tend to be diagnosed later in life and typically have less severe symptoms with better response to therapy
what are obstetrical complications that increase risk of schizophrenia?
hemorrhage or blood incompatibility, preterm labor, fetal hypoxia, maternal infection
How do maternal factors impact pregnancy and schizophrenia?
maternal stress increases risk
what particular infections can increase risk of schizophrenia?
influenza during pregnancy or early childhood
toxoplasma gondii during pregnancy (70% risk)
herpes simplex 2 (controversial)
measles antibodies
what is the correlation of inflammation/autoimmune disorders with schizophrenia?
increased cytokines may increase schizophrenia: higher incidence of autoimmune diseases ie acquired hemolytic anemia, interstitial cystitis
what drug is a risk factor for psychosis but depends on dose?
cannabis
how is immigrant status related to schizophrenia?
higher risk possibly due to stress of immigration and social discrimination
What are the theories of etiology of schizophrenia?
dopamine hypothesis
glutamate/NMDA hypothesis
GABA hypothesis
Acetylcholine hypothesis
Structural and functional brain abnormalities
Increased dopamine in the dopamine hypothesis causes
positive symptoms
negative symptoms are due to _____ in the dopamine hypothesis
decreased dopamine
all antipsychotics block _______
dopaminergic D2 receptors
dopamine receptor agonist drugs can cause ____ and dopamine receptor antagonist drugs can ____ psychosis
psychosis, reduce
what is the serotonin hypothesis?
idea that excess serotonin in the brain causes psychosis
because partial serotonin agonists cause psychotic symptoms and 2nd gen antipsychotics block serotonin receptor and improve negative symptoms
**no longer accepted as likely/main theory
What is the glutamate hypothesis?
glutamate is a major CNS excitatory neurotransmitter
Low function of NMDA glutamate receptor is believed to contribute to schizophrenia
NMDA antagonists can lead to psychosis, negative symptoms
what is the gaba hypothesis?
GABA is major CNS inhibitor neurotransmitter
decreased functioning may be related to schizophrenia
what is the acetylcholine hypothesis?
came from higher likelihood of smoking in schizophrenic patients
Theory that nicotine corrects because treating with nicotine improves eye-tracking and EEG
What are structural brain abnormalities with schizophrenia?
decreased overall brain tissue, larger ventricle size, increased rate of brain tissue loss
how are functional brain abnormalities related to schizophrenia?
cognitive defects present before positive symptoms appear
positive symptoms generally respond well to _____
antipsychotics
negative symptoms respond better to which medications?
less responsive to antipsychotics, atypicals work better than typical
Cariprazine (Vraylar) has supporting evidence
What should you screen for prior to beginning antipsychotic drugs due to SE profile?
BMI, waist circumference, HR, BP, EKG
Screen for movement disorder using AIMS score
Labs: CBC (some can cause agranulocytosis), fasting CMP (electrolytes, liver function, renal function, protein), lipids, TFTs (some can change thyroid function)
How are most antipsychotics administered?
oral tablet/capsule
Also available as IM injection, depot IM injection, ER tab, oral solution
About ___ with delusions or hallucinations have a good response to antipsychotics
70% (30% still have moderate to severe positive symptoms)
what is the therapeutic lag for antipsychotics?
4-6 weeks (may see response within 1 week)
minimum of 6 weeks trial per drug and recommended not to try high-dose therapy until 6 week trial done
What are the benefits/cons of typical (1st gen) antipsychotics?
Good for positive symptoms, more side effects
MOA: dopamine receptor antagonists
equal efficacy to atypicals
what are the lower potency/higher potency typical antipsychotics?
lower: thorazine, mellaril
higher: haldol, compazine
what are the benefits, MOA of atypical antipsychotics?
MOA: dopamine/5HT antagonists
less side effects
good for both positive and negative symptoms
equal efficacy to typicals
commonly used atypicals?
clozaril, zyprexa, seroquel, geodon, risperdal, abilify, rexulti, vraylar, latuda, caplyta–> new with less data
what is neuroleptic malignant syndrome?
rigidity, fever, autonomic instability, altered mental status that can lead to fatal hypertensive crisis and can happen with any antipsychotic (often 1-3 days)
how is neuroleptic malignant syndrome treated?
cooling measures, supportive treatment, dopaminergic meds
side effects of antipsychotics?
neuroleptic malignant syndrome, hyperprolactinemia, anticholinergic, sedation, extrapyramidal symptoms, hypotension, agranulocytosis, seizures, cardiac arrhythmias, metabolic syndrome
what medications is hyperprolactinemia common with?
typicals and risperidone, may also be seen with high dose olazapine or ziprasidone
what is hyperprolactinemia?
Side effect that causes gynecomastia, galactorrhea, abnormal menses, sexual dysfunction, acne, hirsutism, infertility
what are anticholinergic symptoms? What drugs are they more common with?
constipation, urinary retention, dry mouth, blurred vision, cognitive impairment (can’t see, spit, shit)
highly likely with low-potency typicals and clozapine, may also see with high dose olanzapine, quetiapine
When is sedation more commonly seen?
low-potency typicals and clozapine, may also see with olanzapine, quetiapine
What are extrapyramidal symptoms and what medications can cause it?
pseudoparkinsonism (rigidity, bradykinesia, masked facies, shuffling gait)
akathisia (inner restlessness leading to pacing or fidgeting)
dystonia (spastic, uncontrollable muscle contractions)
tardive dyskinesia (involuntary movements usually involving the orofacial region that disappear during sleep)
can happen with any antipsychotic but more common with high-potency typical antipsychotics
What medications/populations is hypotension due to antipsychotics more common in?
any antipsychotics but more likely with low-potency typicals and clozapine, rapid titration of risperidone, quetiapine
more common in elderly, HTN, or cardiovasuclar disease
Which medication can cause agranulocytosis? How would you monitor this?
clozapine: usually within first 3 months increased risk in elderly, female, asian ethnicity
must have CBC weekly x 6 mo, biweekly x 6 mo, then q 1 month going forward
What medications can cause seizures?
all antipsychotics and those that are more sedating have more potential of lowering threshold, more common in low-potency typicals and clozapine
What are cardiac arrhythmias that can occur with antipsychotics?
all can cause prolonged ventricular repolarization (long QT), can cause arrhythmia torsades de points and sudden cardiac death
avoid giving with medications that prolong QT interval
seen most often with thioridazine and ziprasidone but dose dependent
What antipsychotics most commonly/least commonly cause weight gain?
clozapine/olanzapine, intermediate with most antipsychotics
minimal with ariprazole, brexpiprazole, cariprazine, lurasidone, ziprasidone
What glycemic abnormalities can occur with antipsychotics? What medications is this worse with?
insulin resistance, DKA, increased glucose in patients with pre-existing DM
worse with clozapine and olanzapine
What medications cause worse dyslipidemia, especially elevated triglycerides?
low-potency typicals, clozapine, olanzapine, quetiapine
overall, metabolic problems are worse with ______; intermediate with ______ and least with _____
clozapine, olanzapine
low-potency typicals and quetiapine
aripiprazole, brexpiprazole, cariprazine, ziprasidone, high-potency typicals
What should you keep in mind when treating the initial episode of schizophrenia?
usually better response to lower antipsychotic doses
Greater vulnerability to SE so recommended not to use clozapine or olanzapine
if agitated, may adjunct anxiolytic or sedative meds
what should you keep in mind with maintenance therapy of schizophrenia?
continue antipsychotic indefinitely at lowest effective dose to reduce relapse
psychotherapy essential
social support services
close clinical follow-up
what is schizophrenia prognosis?
10% eventually recover, 20% do not recover fully but have a good outcome, 30-35% have a stable but intermediate outcome
30-40% have a deteriorating course
significant proportion continue to have psychotic s/s
what patients have a better prognosis of schizophrenia?
later onset, good social support, positive symptoms, acute onset, female sex, few relapses, good premorbid functioning, mood symptoms
what patients have a poorer prognosis of schizophrenia?
early onset, poor social support, negative symptoms, gradual onset, male sex, multiple relapses, poor premorbid functioning, + family history
