schizophrenia

Question 1

what is schizophrenia

Answer 1

-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

Question 2

prevalence, onset, consequences of schizo

Answer 2

Prevalence: 1%, 3 million US pts, 20% of psychiatric beds in US
- m = f

onset: adolescence to young adulthood
- Men: 18-25
- Women: 22-32
- If sx presents at older age, think of organic causes!

Consequences:
- Increased prevalence of substance abuse
- Decreased overall health
- Decreased lifespan
- Increased suicide rate
- accounts for $85 billion in healthcare costs/yr

Question 3

risk factors for schizo

Answer 3

• Urban > Rural: Schizophrenia has a higher diagnosis rate in urban areas
• winter effect (5-8%): more pts are born in winter and spring than other seasons -> evidence that exposure to viral infections during the second trimester increases risk
• (higher incidence of infectious ds in fall/early winter)
• M = F
• Heritability: Schizophrenia is a familial disorder with heritability estimates ranging from 0.60 to 0.90

Question 4

Schizophrenia Is Not Caused By:

Answer 4

Poor Parenting:
Poor Familial Relations:
Not Split Personality (Dissociative Identity Disorder)

Question 5

history of schizophrenia

Answer 5

Emil Kraepelin (Austrian Psychiatrist):
- Described schizophrenia as an illness that develops early in life with a chronic deteriorating course resembling dementia.
- named it dementia praecox

Eugene Bleuler (Swiss Psychiatrist):
- Renamed Kraepelin’s dementia praecox to schizophrenia in 1911
- based on symptoms like paranoia, grandiose delusions, auditory hallucinations, abnormal emotional responses, and bizarre thoughts.
- The term schizophrenia comes from the Greek words meaning “split mind”

Kurt Schneider (German Psychiatrist):
- Emphasized “first-rank symptoms”: psychotic sx like delusions and hallucinations

Question 6

schizophrenia DSM5

Answer 6

Two or more of the following symptoms, present for at least 1 month AND at least one symptom must be one of the ones below. The disturbances persist for at least 6 months

MUST HAVE at least one: “first rank” and 2+ total
- Delusions**
- Hallucinations **
- Disorganized Speech **
- Grossly disorganized or catatonic behavior
- Negative sx

impairment:
- must have significant impairment work, interpersonal relations, or self-care, since the onset of the disorder.

Duration:
- The disorder must persist for at least 6 months, which includes at least 1 month of active symptoms
- may include periods of residual sx: only negative sx present

must r/o:
- Schizoaffective disorder and bipolar or depressive disorder with psychotic
- physiological effects of substance or medical conditions
- pervasive developmental disorder/autism

Question 7

Answer 7

idk

Question 8

Traits of Schizophrenic Twin versus -Unaffected Twin:

Answer 8

-Lower birth weight
-More physiological distress
-More submissive, tearful, sensitive child
-Impaired motor coordination noted
-only one twin affected

Question 9

Symptom Clusters

Answer 9

positive: Excesses or distortions of normal behavior
- Delusions, Hallucinations, Disorganized speech/thought and Behavior

Negative: Deficits in normal behavior
- Anhedonia, Asociality, Affect, Avolition (lack of motivation), Alogia

Cognitive: Deficits in intellectual processes
- Attention, Memory, Executive functions, Loss of abstract thought process

Mood: Lability in emotional state (laughing at funeral)
- Depression, Hopelessness, Agitation, Hostility, Suicidality

Question 10

positive sx vs negative sx

Answer 10

positive:
- Hallucinations, most often auditory
- Delusions of grandeur, persecution
- Disordered thought processes
- bizarre behavior

Negative:
- Social Withdrawal
- flat affect* (blunted emotional response)
- anhedonia
- Reduced Motivation, Poor focus on tasks
- Alogia (reduced speech output)
- Catatonia (reduced movement)
-negative symptoms are not well treated

Question 11

negative sx vs depression

Answer 11

Negative:
- Social Withdrawal
- flat affect* (blunted emotional response)
- anhedonia
- Reduced Motivation, Poor focus on tasks
- Alogia (reduced speech output)
- Catatonia (reduced movement)

Negative Schizo are socially withdrawn due to a psychotic feeling of a fear of getting hurt
Depression is characterized by an excessive wave of sadness

Question 12

delusions definition and common types

Answer 12

Def: 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.

Question 13

-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.’”

what are these

Answer 13

delusions examples

Question 14

hallucinations definition and types

Answer 14

A perceptual disturbance that occurs in the absence of external stimuli.
-auditory (MC), visual (2nd MC), tactile, olfactory

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.

Question 15

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.”

Answer 15

hallucination examples

Question 16

Disorganized speech/thought - what type of sx and types

Answer 16

positive sx: Disturbance in organizing ideas and speaking in a comprehensible fashion.

types:
- clanging
- flight of ideas
- neologisms
- word salad
- loose associations
- incoherence

Question 17

” He went in entry in trying tying sighing dying ding-dong dangles dashing dancing ding-a-ling! “

” heard the bell. Well, hell, then I fell.”

what is this

Answer 17

clanging - disorganized thought

Clanging: Rhyming of words; thoughts are connected only due to the sound of the words expressed

Question 18

“I own five cigars. I’ve been to Havana, She rose out of the water, in a bikini “

what is this

Answer 18

Flight of Ideas: Sequence of loose associations when speaker jumps to unrelated topics

Question 19

I got so angry I threw a geshinker at the wall

what is this

Answer 19

Neologisms: Made up words that have meaning only to the patient

Question 20

Blue afraid you no carpet cat got fear bricks of orderly mess

Answer 20

Incoherence:
- Like loose associations, except the connections between thoughts are unappreciable
- Sentences are grammatically correct or close to correct, but meaning is lost.

(Loose Associations: Connections between thoughts are very weak)

Question 21

He went to the ballpark and bought Frank’s beer belly home in a bag of grass seed

Answer 21

Loose Associations: Connections between thoughts are very weak

Question 22

A comb makes a twirl in life, my box is broken help me blue elephant.

Answer 22

Word Salad: Nonsensical use of words
- no logical progression or connection between the phrases.

Question 23

disorganized/bizarre behavior: defintion, what type of sx and examples

Answer 23

definition
-Behavior that is socially inappropriate or out of context.
- positive sx

example:
-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.”

Question 24

negative symptoms: what are they

Answer 24

-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

Question 25

Presentation of schizo: what are the three stages

Answer 25

Prodrome:
- Gradual onset of behavioral disturbances, social withdrawal, academic decline
- May become irritable, suspicious, disorganized, obsessed with odd hobbies or the occult
- Age Onset: Teen years

Acute:
- Clinically significant signs and symptoms, causing great distress
- Delusions and Hallucinations come on
- May be episodic with transient remissions or chronic
- Age Onset: 20-35

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

Question 26

DDx for schizo: what are some common ones

Answer 26

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

Question 27

DDx schizoaffective ds

Answer 27

Primary psychotic disorder with prominent mood episodes that comprise the majority of the time of illness
- History must be positive for at least a 2-week period of psychosis WITHOUT mood disorder
- Rules out mood disorder with psychosis

Question 28

schizophrenia causes

Answer 28

-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.

Question 29

schizophrenia risk factors

Answer 29

-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

Question 30

imaging findings on schizo + structural changes in brain

Answer 30

CT:
- ventricles + brain tissue deficiency/neuronal loss
-decreased gray matter and cortical volume
- appears suddenly during late adolescence/early adulthood
-Degrees of ventricular enlargement correlated with decrease in IQ
-cortical atrophy (long-term brain damage)

PET scan:
-frontal lobe hypoperfusions

Question 31

Answer 31

cortical atrophy - long term brain damage

Question 32

hx of schizo tx

Answer 32

-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.

Question 33

tx- psychopharmacology: Antipsychotics what is the difference betwen gen 1-3

Answer 33

Gen 1: dopamine antagonist
- MOA: strong affinity to dopamine
- decreases positive sx; does not effect negative sx (possibly worsen)

Gen 2: serotonin/dopamine antagonist
- strong affinity for serotonin, weak affinity to dopamine
- decreases positive sx, possibly decreases negative sx

Gen 3: partial dopamine agonist/antagonist
- decreases dopamine when its too high and increases when its too low
- decreases positive sx, possibly decreases negative sx
- try a 3rd gen because the SE profile is the best compared to the other generations

Question 34

antipsychotic pance notes

Answer 34

2nd gen:
- Risperidone: greater incidence of movement ds, MC prescibed
- olanzapine: WT GAIN, HYPERLIPIDEMIA/DM
- quetiapine: lower incidence of movement ds

3rd gen:
- Aripiprazole: less ADR but increased risk of akathisia
- Ziprasidone: higher chance of prolonged QT

1st gen:
- best for + sx but increased risk for EPS and NEUROLEPTIC MALIGNANT SYNDROME

Question 35

Antipsychotics first second third gen names

Answer 35

1:
- Haloperidol
- Loxapine
- Thioridazine
- can cause: neuroleptic malignant syndrome fatal triad: fever, muscle rigidity, AMS

2:
- Olanzapine (Zyprexa): wt gain, hyperglycemia, atypical antipsychotic
- Quetiapine (Seroquel): drowsiness
- Risperidone (Risperdal): increase tremor frequency

3:
- Aripripazone (Abilify)
- Ziprasidone (Geoden)

Question 36

ADRs of antipsychotics

Answer 36

all 3 gens:
- acute dystonia: muscle spasm, torticollis, tongue protrusion
- Extrapyramidal sx: Parkinsonism, akathisia, dystonia
- Tardive Dyskinesia: involuntary movements after long term antipsychotic therapy. Often begins with tongue or digits and progresses to face, limbs
- Prolactinemia
- Parkinsonism-rigidity, tremor, bradykinesia, masklike facies
- Akathisia-restlessness, pacing, fidgeting, subjective jitteriness

gen 1:
- Neuroleptic Malignant Syndrome: Potentially fatal triad of fever, muscle rigidity (especially neck), AMS

try gen 3 first!!! least ADRs

Question 37

ADRs of antipsychotics: how to manage side effects

Answer 37

parkinsonism:
- lower dose
- change med
- tx = anticholinergic: benztropine (cogentin), diphenydramine, trihexyphenidyl (artane)

Akathisea:
- lower dose
- change med
- consider propanol, benzodiazepine, benztropine

acute dystonia:
- tx: anticholinergics - IM diphenydramine or benztropine

tardive dyskinesia:
- lower dose
- change med to atypical (quetiapine)

Question 38

schizo: psychosocial tx - goal and treatment options

Answer 38

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

Question 39

relapse factors for schizo + long term outcome maximized by what

Answer 39

relapse factors:
-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

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

Question 40

schizophrenia good vs bad prognosis

Answer 40

Good:
- Acute onset **
- later age 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 **
- early age onset **
- negative symptoms **
- male gender, no clear precipitating stressor, late intervention, poor response to medication, unstable social or occupational history, family history

Question 41

community approach

Answer 41

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

Question 42

schizophobia: ddx Schizophrenia vs Schizophreniform

Answer 42

-Schizophrenia: Disorder of thought and perception lasting more than six months

-Schizophreniform: Disorder of thought and perception lasting less than six months

Question 43

schizophobia: ddx Schizophrenia vs Schizoaffective

Answer 43

-Schizoaffective: Schizophrenia + Mood Disorder (Depression/Mania/Bipolar)

schizophrenia involves only thought and perception disturbances. (NO MOOD DS)

Question 44

schizophobia: ddx Schizoid vs Schizotypal

Answer 44

Schizoid: Personality Disorder
- detachment from social relationships and a restricted range of emotional expression
- Lack of social desire.

Schizotypal: Personality Disorder
- acute discomfort with close relationships, cognitive and perceptual distortions, and behavioral eccentricities
- Isolated due to paranoia

Question 45

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

Answer 45

decade ago