schizophrenia Flashcards

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1
Q

what is schizophrenia

A

-chronic, debilitating illness involving disturbances of thought, perception, speech, emotions, and behavior
-“Split Mind” – A split between intellect and affect.
-profound distortion in one’s sense of external and internal reality.

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2
Q

why do we need to know it

A

-Prevalence of 1%. 3 million Americans will develop schizophrenia during their lifetime. 100,000 patients take up 20% of psychiatric beds in the US.
-Onset typically in adolescence or young adulthood (Males: Age 18-25 years; Females: 22-32 years)
-Results in increased prevalence of substance abuse
-Results in decreased overall health
-Results in decreased lifespan:15 years
-Results in increased rate of suicide (10%)
-Accounts for approximately $85 Billion in healthcare costs each year

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3
Q

schizophrenia facts

A

-More impact/diagnosis in urban vs rural
-Winter effect (5-8%)-more schizophrenics born during winter and spring than any other time during the year-strong evidence that mothers exposure to viral infections during the second trimester increased risk of schizophrenia. Fall/early winter high incidence of infectious diseases
-Affects both sexes equally

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4
Q

schizophrenia is not caused by

A

-Poor parenting
-Poor familial relations
-Not SPLIT PERSONALITY (Dissociative ID)
-Schizophrenia is a familial disorder-heritability estimated between .60 and .90

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5
Q

history of schizophrenia

A

-Emil Kraepelin(Austrian psychiatrist): Illness develops early in life with chronic deteriorating course- looked like dementia. named it dementia praecox
-Eugene Bleuler(Swiss psychiatrist): renamed Kraepelin’s dementia praecox (paranoia, grandiose delusions, auditory hallucinations, abnormal emotional response, bizarre thoughts) as schizophrenia-1911. Combination of two greek words meaning “split mind”
-Kurt Schneider(German psychiatrist): emphasized role of psychotic symptoms: delusions, hallucinations. Called them”first rank symptoms”.

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6
Q

genetics

A
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6
Q

schizophrenia criteria

A

-1. 2 or more of the following for at least 1 month (or longer period of time), and at least one of them must be a 1, 2, or 3:
-delusions
-hallucinations
-disorganized speech
-grossly disorganized or catatonic behavior
-negative symptoms, such asdiminished emotional expression

  1. Impairment in 1 of major areas of functioning for a significant period of time since the onset of the disturbance: Work, interpersonal relations, or self-care.

-2. sx must last for a continuous period of at least 6 months. This six-month period must include at least one month of symptoms (or less if treated) that meet criterion A (active phase symptoms) and may include periods of residual symptoms. During residual periods, only negative symptoms may be present.

-3. Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out:

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7
Q

twin studies

A

-Traits of Schizophrenic Twin versus -Unaffected Twin:
-Lower birth weight
-More physiological distress
-More submissive, tearful, sensitive child
-Impaired motor coordination noted

-only one twin affected

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8
Q

positive and negative symptoms

A

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
-negative symptoms are not well treated

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9
Q

symptom clusters

A

-Positive: Excesses or distortions of normal behavior
-Negative: Deficits in normal behavior
-Cognitive: Deficits in intellectual processes
-Mood: Lability in emotional state

-Positive: Delusions, Hallucinations, Disorganized speech/thought and Behavior
-Negative: Anhedonia, Asociality, Affect, Avolition, Alogia
-Cognitive: Attention, Memory, Executive Functions, Loss of abstract thought process
-Mood: Depression, Hopelessness, Agitation, Hostility, Suicidality

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10
Q

delusions

A

-Delusions: False beliefs that are not susceptible to argument and are inconsistent with the subject’s sociocultural background. Pt will hold firmly to belief regardless of evidence to the contrary
-Bizarre: strange and completely implausible
-Non bizarre: Possible but very unlikely

-Common Types:
-Grandiose: Belief that one possesses special powers, wealth, skill, influence, or destiny.
-Paranoid/Persecutory: Belief that one is being harmed, watched, ridiculed, manipulated, discriminated against, plotted against.
-Somatic: Belief in some imaginary bodily abnormality, illness, or special attribute.

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11
Q

delusions examples

A

-Pt reports that he invented mathematics and that he is the “Chairman of Math and Science” at numerous universities. Patient presents clinician with what appears to be complex mathematical equation scribbled on napkin, but it is unclear whether this is an actual equation. He demands clinician solve it before he will answer his questions.”
-“Pt reports having nanotechnology placed in his ears by NASA so he can do ‘secret errands’ for them.”
-“Pt claims clinician is one of patient’s cousins. Clinician borrowed $227.00 at last family picnic and neglected to repay loan. Because of this offense, clinician (whom patient believes is cousin) is ‘due for a righteous beat down.’”

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12
Q

hallucinations

A

-A perceptual disturbance that occurs in the absence of external stimuli. Auditory are the most common, followed by visual.

-Common Types:
-Command: A voice is heard instructing one’s behavior. The patient may act on them in order to relieve the stress.
-Derogatory: A voice is heard making insulting, criticizing, or threatening comments.

-olfactory, visual, auditory (MC), tactile

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13
Q

hallucination examples

A

Pt complains of male voice telling him to ‘kill that bitch’ and ‘mess them up.’ He doesn’t know who the voices are referring to. Attempts to block out voices by listening to radio or watching TV, as he does not wish to follow these instructions.

Pt reports increasingly frequent dialogue between numerous voices unfamiliar to him. They call him ‘as**’ and say ‘You’re gonna get it!’”

Pt hit head against wall repeatedly while in solitary. Told to do so by ‘Max,’ a childhood friend who died when they were around 10 years old, but still ‘hangs out a lot.’ Max is the same age as patient (43 years) but is small in stature, ‘can’t grow a beard,’, and always wears jeans and a blue and red sweatshirt.”

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14
Q

Disorganized speech/thought

A

-Disorganized Speech/Thought: Disturbance in organizing ideas and speaking in a comprehensible fashion.

-Clanging: Rhyming of words; thoughts are connected only due to the sound of the words expressed. “He went in entry in trying tieing sighing dying ding-dong dangles dashing dancing ding-a-ling!” “I heard the bell. Well, hell, then I fell.“

-Flight of Ideas: Sequence of loose associations when speaker jumps to unrelated topics “I own five cigars. I’ve been to Havana. She rose out of the water, in a bikini.”

-Neologisms: Made up words that have meaning only to the patient. “I got so angry I picked up a dish and threw it at the geshinker.“

-Word Salad: Nonsensical use of words. “Why do people comb their hair?” elicits a response like “Because it makes a twirl in life, my box is broken help me blue elephant. Isn’t lettuce brave? I like electrons, hello please!”

-Loose Associations: Connections between thoughts are very weak. “He went to the ballpark and bought Frank’s beer belly home in a bag of grass seed.”

-Incoherence: Like loose associations, except the connections between thoughts are unappreciable. “Blue afraid you no carpet cat got fear bricks of orderly mess.”

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15
Q

disorganized thought/speech examples

A

-Question: “What does ‘Look before you leap mean?’”

Think before you jump, like if you’re in gym or maybe you’re just wearing shorts outside because it’s hot. You need an extension cord and boxes.”

“Leap before you creep man, leap before you creep.”

“You rub the angel’s head. He comes from the rooftop into the green and then the two snakes turn into a transcendence of night.”

Subjective: “Patient spends most of his day at home. Nonetheless, he states he ‘pimps out hookers,’ engages in drug deals, runs a stolen car ring, and has even committed murder. He controls the people who work for him through his television set…”

Objective: “Patient has very strong violent preoccupations, grandiose delusions, delusions of influence, and illogical thought content…”

16
Q

disorganized/bizarre behavior

A

-Behavior that is socially inappropriate or out of context.
-Example of Context:
-Taking clothes totally off before taking shower is normal.
-Taking clothes totally off in the middle of this lecture is abnormal

-“Pt covering himself in his own feces.”
-“Pt seated on floor in corner of room, rocking back and forth, talking and laughing to himself.”
-“Pt wearing towel around head like turban. Has fashioned a ‘smock’ out of a sheet and wears no clothes underneath. He has on socks but no shoes.
-“Pt presents in sexually preoccupied manner.”

17
Q

negative symptoms

A

-Anhedonia: Lack of pleasure in activities once enjoyed
-Asociality: Withdrawal from social interaction. Poor social skills, lack of friends or emotional attachments
-Affect (Flat): Face is completely devoid of emotion, yet patient still may experience them
-Avolition: Lack of interest, initiative, or ability to engage in even routine activities
-Alogia: Absence in amount or content of speech

18
Q

schizophrenia criteria

A

-Two or more of the following symptoms, present at least for a six month period AND at least one symptom must be one of the first three (delusions, hallucinations, disorganized speech). Also, the patient must experience at least 1 month of active symptoms.

-Delusions
-Hallucinations
-Disorganized speech
-Grossly disorganized or catatonic behavior
-Negative symptoms

-Symptoms cause difficulties in school, work, interpersonal relations, or self-care.
-Symptoms persist for at least 6 months.
-Symptoms are not due to Major Depressive, Manic states.
-Symptoms are not due to the physiological effects of a substance (e.g., medication, drug abuse) or a general medical condition.
-Symptoms are not due to a Pervasive Developmental Disorder (ie Autism)

19
Q

3 stages

A

1) Prodrome: Gradual onset of behavioral disturbances, social withdrawal, academic decline. May become irritable, suspicious, disorganized, obsessed with odd hobbies or the occult.

2) Acute: Clinically significant signs and symptoms, causing great distress. May be episodic with transient remissions or chronic.

3) Residual: Negative symptoms predominate. Appears withdrawn, preoccupied, flat or depressed. Impoverished speech and poor cognition.

20
Q

psychiatric differential dx

A

-Brief Psychotic Disorder: Psychosis lasts no more than one month. Usually a definable stimulus.
-Schizophrenifom Disorder: Psychosis lasts between one and six months.
-Mania: Increased energy, decreased sleep, euphoria, grandiosity, pressured speech -> if you treat mania schizophrenia goes away
-Depression with Psychotic Features: Mood Congruent delusions/hallucinations or catatonia -> if you tx depression psychosis goes away

21
Q

schizophrenia causes

A

-Genetics: Schizophrenia considered 50% genetic and 50% environmental
Dopamine Hypothesis:
-Positive Symptoms: An excess of Dopamine in the Limbic System of the brain, which regulates emotion, expression, and impulse control.
-Negative Symptoms: A deficit of Dopamine in the Frontal Cortex, which regulates attention, executive function, and motivation.

22
Q

schizophrenia risk factors

A

-Genetics: 15% risk with schizophrenic 1st degree relative; 50% risk with schizophrenic identical twin
-Emotional Stress – Divorce, loss of job, scholastic difficulties, social difficulties, death of loved one
-Physical Stress – Medical illness, substance abuse, head injury
-Support System: Poor support system
-OB/Perinatal Complications: Hypoxia, trauma to fetal brain, ischemic injuries
-Season of Birth: Winter and early spring months

23
Q

imaging findings

A

-Cortical Atrophy leading to enlargement of ventricles
-Cerebral gray matter decreases
-Woods(1998): cell loss in schizophrenics appears suddenly during late adolescence/early adulthood
-less grey matter
-enlarged ventricles

24
Q

structural changes in brain

A

-Reduced cortical gray matter
-Enlarged ventricles-leads to brain tissue deficiency as they take up space normally occupied by brain cells. This suggests neuronal loss.
-Degrees of ventricular enlargement correlated with decrease in IQ
-cortical atrophy (long-term brain damage)
-frontal lobe hypoperfusions

25
Q

schizophrenia and stress

A
26
Q

hx of tx

A

-Little could be done to treat psychotic patients until mid 1950’s-trials of horse tranquilizers, brain surgeries
-Thorazine (chlorpromazine) introduced in the 1953 in the US-used because it calmed surgical patients (and horses)
-Traditional tranquilizers did not show any benefit with schizophrenics during this period.

27
Q

tx- psychopharmacology: First Generation Antipsychotics

A

-Dopamine Antagonist Examples: Haldol! (haloperidol!), Loxitane (loxapine), Mellaril (thioridazine)

-MOA: Strong affinity for Dopamine receptors

-Results:
-Positive Symptoms: Decreased
-Negative Symptoms: Not decreased; possibly worsened

-Side Effects: Dystonia, EPS’s, Tardive Dyskinesia (contortions of the body), Prolactinemia
-Neuroleptic Malignant Syndrome: Potentially fatal triad of fever, muscle rigidity (especially neck), AMS

28
Q

tx- psychopharmacology: second generation antipsychotics

A

-Dopamine/Serotonin Antagonist
Example: Olanzipine (Zyprexa), Quetiapine (Seroquel), Risperidone (Risperdal)

-MOA: Weak affinity for Dopamine receptors/High affinity for Serotonin Receptors

-Results:
-Positive Symptoms: Decreased
-Negative Symptoms: Possibly decreased

-Side Effects: Decreased Dystonia, EPS’s, Tardive Dyskinesia, Prolactinemia
-much less side effects

29
Q

tx: psychopharmacology: third generation antipsychotics

A

-Dopamine Partial Agonist (Agonist/Antagonist)
-Example: Abilify (Aripripazone), Geodon (Ziprasidone)

-Mechanism of Action: Decreases Dopamine where it is too high and increases Dopamine where it is too low.

-Results:
-Positive Symptoms: Decreased
-Negative Symptoms: Possibly decreased

-Side Effects: Decreased dystonia, EPS’s, Tardive Dyskinesia, Prolactinemia
-best side effect profiles

30
Q

meds side effects

A

-Parkinsonism-rigidity, tremor, bradykinesia, masklike facies.
-Manage by lowering antipsychotic dose, changing medication, adding anticholinergic (cogentin, artane)

-Akathisia-restlessness, pacing, fidgeting, subjective jitteriness.
-Manage by lowering antipsychotic dose, changing medications, consider propanolol, benzodiazepines, cogentin

-Acute dystonia-muscle spasm, torticollis, tongue protrusion.
-Treat with IM benadryl or cogentin

-Tardive dyskinesia-involuntary movements after long term antipsychotic therapy.
-Often begins with tongue or digits and progresses to face, limbs.
-Manage by switching medication, lowering dose
-usually a symptom for life

31
Q

tx- psychosocial

A

-Goal: Minimize risk of relapse and optimize functioning among schizophrenic persons

-Tools:
-Psychotherapy and Education – Deal with symptoms, secondary feelings of depression, anger, worthlessness
-Family Therapy – Understand illness, recognize symptoms, reinforce importance of treatment adherence, remind family member he is not alone
-Social skills training – Decrease sense of isolation, and improve self-esteem
-Vocational training – Gain and hold regular employment
-Case management – Follow progress of patient, identify and approach potential problems early on

32
Q

relapse factros

A

-Antipsychotics not effective, nonadherence, stressful life events, polysubstance abuse
-Consequences of relapse include disruption of patients lives, dangerous behaviors, worse prognosis of illness, increased costs all around

33
Q

schizophrenia prognosis

A

-MC course without treatment: Recurrent psychotic episodes with intermittent returns to gradually worsening baseline
-Each recurrence leads to increasing impairment
-Symptoms tend to attenuate around age 50 yrs
-Over a 10 year period 15% mostly or completely recover, 30% improve enough to live independently, 30% improve but require extensive help on a daily basis, 15% do not improve at all, and 10% die, usually from suicide.

34
Q

schizophrenia good vs bad prognosis

A

-Good: Acute onset, later in life onset, rapid progression, positive symptoms, female gender, clear precipitating stressor, early intervention, positive response to medication, stable social and occupational history, lack of family history

Bad: Insidious onset, slow progression, negative symptoms, male gender, early age at onset no clear precipitating stressor, late intervention, poor response to medication, unstable social or occupational history, family history

35
Q

bottom line

A

-Schizophrenia is still a chronic and potentially debilitating disease but the long term outcome is much more optimistic than only a decade ago

-Long term outcome is maximized by:
-1) Early diagnosis
-2) Early intervention
-3) Combined medication, therapy, education, skills training and availability of resources.

36
Q

community approach

A

-Multidisciplinary teams
-Staff ratios in inpatient/outpatient facilities
-Outreach
-Family education and support
-Case managers
-Vocational rehabilitation
-Psychotherapy in addition to medication management

37
Q

schizophobia

A

-Schizophrenia: Disorder of thought and perception lasting more than six months
-Schizophreniform: Disorder of thought and perception lasting less than six months
-Schizoaffective: Schizophrenia + Mood Disorder (Depression/Mania/Bipolar)
-Schizoid: Personality Disorder marked by detachment from social relationships and a restricted range of emotional expression. Lack of social desire.
-Schizotypal: Personality Disorder marked by acute discomfort with close relationships, cognitive and perceptual distortions, and behavioral eccentricities. Isolated due to paranoia.