Schizophrenia Flashcards
what is the “downward drift” of schizophrenia?
prior to onset, patients are psychosocially fully functional (10% lead normal lives)
-as years progress, they lose social stature, income, relationships, and support networks until they become homeless
when does schizophrenia usually start?
rare in children (<1/10,000)
-usually starts in young adulthood (1/100)
what is the definition of schizophrenia?
“split mind” irrational divergence between behavior and thought content
- chronic, debilitating illness associated with deterioration in mental function and behavior
- -clearly involves gene (60-70 related) by environmental interaction
- -not caused by any known social or environmental factor
- -exacerbated by social stress
what is the hallmark symptom of schizophrenia?
psychosis; impairment in reality testing may present as:
- alteration in sensory perceptions (hallucinations)
- abnormalities in thought content (delusions)
- abnormalities in thought process/organization
what is an illusion?
misperception of real external stimuli (misheard a compliment as an insult)
what is a hallucination?
sensory perceptions not generated by external stimuli (hearing someone when no one is there)
what are ideas of reference?
false conviction that one is subject of attention by other people (crowds, TV, radio, internet) or feeling as though people are referring to you in conversations
what are delusions?
false beliefs not correctable by logic or reason, not based on simple ignorance, and not shared by culture
-delusions of persecution are most common
what is the loss of ego boundaries?
not knowing where one’s mind and body end, and those of others begin
what is alogia?
lack of informative content in speech
-lacking/poverty of speech (mute or speaks few words)
what is echolalia/echologia/echophrasia?
all mean clanging; repeating statements of others or associating words by their sounds, but not their meaning
what is thought blocking?
abrupt halt in the train of thinking, often because of hallucinations
what are neologisms?
inventing new words
what is circumstantiality?
in responding to questions, one presents unnecessary and voluminous details ultimately arriving at an answer to the question posed
what is tangentiality?
in responding to questions, begins in logical fashion but then gets further and further from the point, failing to answer question initially posed
what is loose association?
loss of logical meaning between words or thoughts
-when asked a question, illogically jumps from one subject to another
what are characteristic symptoms of schizophrenia?
at least one episode of psychosis with persistent disturbances of thought, behavior, appearance, speech, and affect (emotion) as well as impairment in occupational and social functioning
does clouding of consciousness occur in delirium, substance abuse, or schizophrenia?
the first two only
- schizophrenics have intact attention and memory capacity (when not psychotic)
- -alert and oriented, don’t fluctuate in/out of consciousness/stupor
what are DSM-5 diagnostic criteria of schizophrenia?
- characteristic symptoms
- 2+ of the following present for significant portion of time during 1 mo period (or less if successfully treated)
- -delusions, hallucinations, grossly disorganized or catatonic behavior, negative symptoms (flat affect, alogia, avolition), disorganized speech (frequent derailment or incoherence) - social/occupational dysfunction
- duration
- continuous signs of distirbance persist for at least 6 mo, including at least 1 mo of symptoms that may include periods of prodromal or residual symptoms - schizoaffective and mood disorder exclusion
- substance/general medical condition exclusion
what are positive and negative symptoms in schizophrenia? treatment?
+ additional to expected behavior
- delusions, hallucinations, agitation, talkativeness, thought disorder
- respond well to most traditional and atypical antipsychotic agents
- missing from expected behavior
- amotivation, social withdrawal, flattened affect/emotion, cognitive disturbances, poor grooming, poor/impoverished speech
- sometimes a better response with atypical antipsychotics
what is undifferentiated schizophrenia?
most common
-characteristics of more than one subtype
what is paranoid schizophrenia?
delusions of persecution
- older age of onset
- better functioning than other types
what is residual schizophrenia?
at least one psychotic episode with subsequent negative symptoms
-mild positive symptoms may occur
what is disorganized schizophrenia?
onset < 25 yo
-incoherent speech, bizarre behavior (mirror gazing, facial grimacing, sterotypic movements), poor grooming, inappropriate emotional responses
what is catatonic schizophrenia?
rare since introduction of antipsychotic agents
-stupor or extreme agitation, incoherent speech, blank facial expression, bizarre posturing, waxy flexibility
why were the schizophrenia subtypes taken out of DSM5?
limited diagnostic stability, low reliability, poor validity
-have not been shown to exhibit distinctive patterns of treatment response or longitudinal course
what are the phases of schizophrenia?
- prodromal - prior to first psychotic break
- avoidance of social activities
- quiet and passive, or irritable
- sudden interest in religion or philosophy
- may have physical complaints
- anxiety and depression common - psychotic/active - loss of touch with reality
- associated with positive symptoms - residual - period between psychotic episodes, in touch with reality but doesn’t behave normally
- negative symptoms, peculiar thinking, excentric behavior, withdrawal from social interactions
what is the etiology of schizophrenia?
- role of genetics (concordance rate in twins 50%, dizygotic 10%)
- de novo mutations in advanced paternal aged germ cells
- equally in men and women, but ages are 15-25 in men, 25-35 in women
- -women respond better to antipsychotic medication, but have greater risk of tardive dyskinesia
- -cumulative days of D2 receptor blockade can lead to permanent movement disorder: chorea, athetotic movements (orofacially)
environmental factors of schizophrenia?
- viral infection and exposure to drugs during development have been implicated
- increased incidence when born in cold-weather months (potentially due to seasonal viral infections)
- third trimester maternal use of diuretics
- -severe maternal HTN
- questionably, anti-NMDA receptor Ab in adults
what are neurological abnormalities?
- abnormalities of frontal lobes (decreased use of glucose in prefrontal cortex = hypofrontality)
- lateral and third ventricle enlargement
- abnormal cerebral symmetry (loss of asymmetry)
- changes in brain density
- decreased volume of hippocampus, amygdala, and parahippocampal gyrus - abnormalities in eye movements (poor saccadic smooth visual pursuit)
what is the dopamine hypothesis in schizophrenia?
excessive DA activity in mesolimbic tract
- stimulant drugs, amphetamines, and cocaine can cause psychotic symptoms by amplifying this tract/pathway
- negative symptoms: may involve different abnormality of DA mech; hypoactivity of mesocortical DA tract
- elevated levels of homovanillic acid (DA metabolite) in bodily fluids
describe DA hypothesis for negative symptoms? aims of treatment?
mesocortical (bad executive functioning; negative and cognitive symptoms) and tuberoinfundibular (increased PRL) pathway are inactive
-aim to increase DA neurotransmission
describe DA hypothesis for positive symptoms? aims of treatment?
mesolimbic (psychosis) and nigrostriatal (controls movement) are too active
- aim is to slow down DA neurotransmission, but can cause extrapyramidal symptoms in NS system
- -Parkinsonism, dystonia, akathisia, neuroleptic malignant syndrome
how active is serotonin in schizophrenia?
hyperactive
- hallucinogens like LSD that increaser serotonin cause hallucinations and delusions
- newer atypical antipsychotics have anti-5HT2A receptora ctivity
how active is NE in schizophrenia?
hyperactive
-paranoid subtype may have increased metabolites
what is the glutamate hypothesis in schizophrenia?
as GLU is the major excitatory nt in CNS, think NMDA receptor hypoactivity
- mutated NMDAR proteins are ineffective or underactive
- sit on GABA interneurons between octical GLu pyramidal neuron and its secondary neuron, thus inhibition at second GLU allowing excessive firing and increase in firing of VTA, sending extra DA into limbic system to cause psychosis
- likely causes DA hypothesis
explain normally functioning VS psychotic mesolimbic system
glu-GABA-glu-DA
- normal: glu1 tone high –> GABA tone high –> glu2 tone low –> normal DA
- psychosis (positive symptoms): glu1 tone high –> GABA interneuron low –> glu2 tone hyperactive –> DA hyperactive in limbic system
- -due to hypofunctioning NMDA receptors in prefrontal cortex
explain normally functioning VS psychotic mesocortical system
glu-GABA-glu-GABA-DA
- normal: glu1 tone high –> GABA tone high –> glu2tone low –> GABA2 tone low –> DA high
- psychosis (negative symptoms): glu1 tone high –> GABA interneuron very high –> glu2 tone low –> GABA2 tone very high –> DA tone low
differential diagnoses for schizophrenic patients?
- psychotic disorder caused by general medical condition
- B12/folate deficiency, temporal lobe epilepsy, cortico-steroid induced - manic phase of bipolar disorder
- substance-induced psychotic disorder
- cocaine, crystal meth, ritalin/adderall (stimulants), ketamine, PCP, LSD, bath salts - other psychotic disorders
- brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, shared psychotic disorder
what is brief psychotic disorder?
1-29 days of schizophrenia symptoms
what is schizophreniform disorder?
1 mo to 6 mo of symptoms
what is schizoaffective disorder?
schizophrenia + mania and/or depression
what is delusional disorder?
delusions, but no other schizophrenia symptoms
what is shared psychotic disorder?
one person is delusional, and a second person develops the same delusion
what is management for schizophrenia?
all effective antipsychotics block D2 receptors in the mesolimbic DA path
- life long treatment that doesn’t lower DA availability, but blocks neurons from excessively firing at high [DA]
- traditionally high and low potency (D2 receptor affinity) typical first generation antipsychotics
what is given if there is low compliance due to FGAs and SGAs?
long acting injectable depot (shots that last 2-4 mo)
- Haloperidol decanoate, fluphenazine decanoate are FGAs
- risperidone, paliperidone, aripiprazole are SGAs
how can psychotherapy manage schizophrenia?
- provide long-term support for patient and family
- foster compliance with drug regimen
- cognitive behavioral therapy (CBT)
- -improve executive dysfunction (memory, concentration, planning, prioritizing)
- family therapy
- peer and mentor support or social skills group
why is compliance rate of antipsychotics low?
unpleasant side effects (fatigue, grogginess, sedation) and poor patient insight
difference in action between typical and atypical ant?
typical: high potency/affinity drugs are better at binding and sticking to D2 receptors, and may cause more side effects in nigrostriatal and tuberoinfundibular pathway
atypical: also block 5HT2a receptors, allowing DA to more freely flow in nigrostriatal path
