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BM: Unit 4 > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

Define schizophrenia

A
  1. “Split mind-” irrational divergence between behavior and thought content
  2. Chronic, debilitating illness associated with deterioration in mental function and behavior
    A. Clearly involves a gene by environment interaction
    B. Not caused by any known social or environmental factor
    C. Exacerbated by social stress
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2
Q

When does schizophrenia usually present?

A

Rare in children (

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3
Q

What is the ‘downward drift’ of schizophrenia?

A
  1. Prior to schizophrenia, patients are psychosocially fully functional (10% may lead normal lives…)
  2. As years progress, the average patient loses social stature, income, relationships, support network…
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4
Q

What is the hallmark symptom of schizophrenia?

A

Psychosis

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5
Q

What is psychosis?

A
  1. Impairment in reality testing that may present as:
  2. Alteration in sensory perceptions(hallucinations)
  3. Abnormalities in thought content (delusions)
  4. Abnormalities in thought process/organization
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6
Q

What public resources are utilized in the care of schizophrenia?

A 
1. One of most debilitating psychiatric illnesses and utilizes many resources
A. Welfare
B. Social Security Income
C. Social Security Disability
D. Inpatient and group home stays
E. Incarceration facilities
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7
Q

What are the symptoms of psychosis?

A
  1. Illusion
  2. Hallucinations
  3. Ideas of reference
  4. Delusions
  5. Loss of ego boundaries
  6. Alogia
  7. Echolalia
  8. Thought blocking
  9. Neologisms
  10. Circumstantiality
  11. Tangentiality
  12. Loose associations
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8
Q

Define illusions

A

Misperception of real external stimuli

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9
Q

Define hallucinations

A

Sensory perceptions not generated by external stimuli

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10
Q

Define ideas of reference

A

false conviction that one is subject of attention by other people (Crowds, TV, Radio, Internet). Feeling as though people are referring to you in their conversations…

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11
Q

define delusions

A

False beliefs not correctable by logic or reason, not based on simple ignorance, and not shared by culture; delusions of persecution most common

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12
Q

Define loss of ego boundaries

A

Not knowing where one’s mind and body end and those of others begin

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13
Q

Define alogia

A

Lack of informative content in speech, lacking/poverty of speech
ex. “Patient is mute or speaks few words.”

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14
Q

Define echolalia (clanging)

A

Repeating Statements of Others/Associating words by their sounds, not by their meaning
ex. “I’m very sure I’ve got the cure and I’m not pure.”

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15
Q

Define thought blocking

A

Abrupt halt in the train of thinking, often because of hallucinations
Ex. I have to take my……….

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16
Q

Define neologisms

A

Inventing new words

Ex. Patient states he is ‘fatigloo’ which means he is tired

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17
Q

Define circumstantiality

A

In responding to questions, one presents unnecessary and voluminous details ultimately arriving at an answer to the question posed

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18
Q

Define tangentiality

A

Beginning a response in a logical fashion but then getting further and further away from the point and fail to answer the question initially posed (can understand topic transition)

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19
Q

Define loose associations

A

Loss of logical meaning between words or thoughts; when asked a question, illogically jumps from one subject to another

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20
Q

How is schizophrenia differentiated from delirium or substance abuse?

A

In contrast to delirium or substance abuse, patients with schizophrenia do not have clouding of consciousness
Attention and memory capacity typically intact, when not psychotic
Alert and oriented, do not fluctuate in/out of consciousness/stupor

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21
Q

What are the characteristics of schizophrenia?

A
  1. 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
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22
Q

What are the DSM-V criteria for schizophrenia?

A

A. Characteristic symptoms: 2 or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
Delusions
Hallucinations
Grossly disorganized or catatonic behavior
Negative symptoms (flat affect, alogia, or avolition)
Disorganized speech (frequent derailment or incoherence)
*the DSMIV only req’d 1 symptom
B. Social/occupational dysfunction: One or more major areas of functioning (ie. work, interpersonal relations, or self care) are markedly below level achieved prior to onset
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active phase symptoms) and may include periods of prodromal (symptomatic of the onset) or residual symptoms.
D. Schizoaffective and Mood Disorder exclusion: Symptoms cannot be due to another illness
E. Substance/general medical condition exclusion: Symptoms cannot be due to substance use or a medical disorder or a drug used to treat a medical disorder

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23
Q

What are the key positive symptoms of schizophrenia?

A 
1. Positive symptoms: are additional to expected behavior (i.e. symptoms that are added to a patient’s normal functioning) 
A. Delusions 
B. Hallucinations 
C. Agitation 
D. Talkativeness 
E. Thought Disorder
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24
Q

What do positive symptoms respond to?

A
  1. Respond well to most traditional and atypical antipsychotic agents
  2. Atypical or second generation antipsychotics became widely available in the mid 1990s. They block D2 dopamine receptors and 5HT2a serotonin receptors where their predecessors only accomplished the former
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25
Q

What are the negative symptoms of schizophrenia?

A 
1. Negative symptoms: are missing from expected behavior (i.e. decreased or loss of usual function)
A. Lack of motivation
B. Social withdrawal
C. Flattened affect/emotion
D. Cognitive disturbances
E. Poor grooming
F. Poor/impoverished speech 
2. Sometimes a better response with atypical antipsychotics.
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26
Q

What is the undifferentiated subtype of schizophrenia?

A
  1. Most common

2. Characteristics of more than one subtype

27
Q

What is the paranoid subtype of schizophrenia?

A
  1. Delusions of persecution

2. Older age of onset, better functioning than other types

28
Q

What is the residual subtype of schizophrenia?

A
  1. At least one psychotic episode with subsequent negative symptoms, mild positive symptoms if any
29
Q

What is the disorganized subtype of schizophrenia?

A
  1. Onset often before age 25
  2. Incoherent speech, bizarre behavior (mirror gazing, facial grimacing, stereotypic movts), poor grooming, inappropriate emotional responses
30
Q

What is the catatonic subtype of schizophrenia?

A

Rare since introduction of antipsychotic agents

Stupor or extreme agitation, incoherent speech, blank facial expression, bizarre posturing, waxy flexibility

31
Q

What are the 3 phases of schizophrenia?

A 
1. Prodromal: 
A. prior to first psychotic break
B. Avoidance of social activities
C. Quiet and  passive or irritable
D. Sudden interest in religion or philosophy
E. May have physical complaints
F. Anxiety and depression common
2. Psychotic/Active:
A. loss of touch with reality
B. Associated with positive symptoms
3. Residual:
A. period between psychotic episodes, in touch with reality, but doesn’t behave normally
B. Negative symptoms, peculiar thinking, eccentric behavior and withdrawal from social interactions
32
Q

What are etiological theories of schizophrenia?

A
  1. Genetics
  2. Advanced paternal age
  3. Gender
  4. Environmental factors
  5. Neurological abnormalities
  6. Neurotransmitter abnormalities
33
Q

What environmental factors may contribute to schizophrenia?

A
  1. Viral infection and exposure to drugs during development have been implicated in the etiology of schizophrenia
  2. Increased incidence when born in cold-weather months
  3. Due to viral infections that occur seasonally?
  4. Third-trimester maternal use of diuretics
  5. Severe maternal HTN requiring use of diuretics
34
Q

What neurological abnormalities are present in schizophrenia?

A
  1. Abnormalities of the frontal lobes: neurodegenerative theory
    A. Decreased use of glucose in prefrontal cortex (hypofrontality)
  2. Lateral and third ventricle enlargement
  3. Abnormal cerebral symmetry (loss of asymmetry): neurodevelopmental problem
  4. Changes in brain density
    A. Decreased volume of hippocampus, amygdala and parahippocampal gyrus
  5. Decreased alpha waves, increased theta and delta waves and epileptiform activity on EEG
  6. Abnormalities in eye movements (ex. poor saccadic smooth visual pursuit)
35
Q

What neurotransmitter abnormalities are present in schizophrenia?

A
  1. Dopamine Hypothesis: excessive dopaminergic (DA) activity in mesolimbic tract
    A. Stimulant drugs, amphetamines and cocaine, can cause psychotic symptoms by amplifying this tract/pathway
    B. Negative symptoms; may involve different abnormality of dopaminergic mechanism: hypoactivity of mesocortical dopamine tract/pathway
    C. Elevated levels of homovanillic acid, a metabolite of DA in bodily fluids of patients with schizophrenia suggests more DA activity and use in the central nervous system (CNS)
36
Q

What neurotransmitter: dopamine abnormalities are present in schizophrenia?

A
  1. Dopamine Hypothesis: excessive dopaminergic (DA) activity in mesolimbic tract
    A. Stimulant drugs, amphetamines and cocaine, can cause psychotic symptoms by amplifying this tract/pathway
    B. Negative symptoms; may involve different abnormality of dopaminergic mechanism: hypoactivity of mesocortical dopamine tract/pathway
    C. Elevated levels of homovanillic acid, a metabolite of DA in bodily fluids of patients with schizophrenia suggests more DA activity and use in the central nervous system (CNS)
37
Q

What neurotransmitter: serotonin abnormalities are present in schizophrenia?

A 
1. Serotonin (5HT) hyperactivity
A. Hallucinogens such as LSD,
which increase serotonin, 
cause hallucinations and 
delusions
B. Newer atypical antipsychotics 
(ex. clozapine) have anti-5HT2A  receptor activity
38
Q

What is schizoaffective disorder?

A

Meets criteria for recurrent depression or recurrent mania much of the time BUT must have periods of >2 weeks without affective symptoms and only schizophrenia symptoms

39
Q

What is delusional disorder?

A

Delusions only, no other schizophrenia symptoms

40
Q

What is brief psychotic disorder?

A

Schizophrenia symptoms up to 1 month, after this the diagnosis changes to ‘schizophreniform disorder

41
Q

What is schizophreniform disorder?

A

Schizophrenia symptoms 2 -6 months. After this the diagnosis changes to ‘schizophrenia

42
Q

What are the characteristics of medical management for schizophrenia?

A
  1. All effective antipsychotics block D2 receptors in the hyperactive mesolimbic DA path
  2. Often a life long treatment
    A. This does not lower DA availability, but blocks neurons from excessively firing even in the face of high DA concentrations
43
Q

What are the synapse depleters?

A
  1. Reserpine
    A. Is used for hypertension, it blocks VMAT so that vesicles with monoamines cannot be released into synapses. (opposite of stimulants perhaps)
    B. Less Norepi –> less depression (and less blood pressure)
    C. Less Dopamine  more depression and perhaps less psychosis
  2. Tetrabenazine
    A. Is used to for Huntington’s Chorea
    B. By lowering DA availability (VMATi)in the synapse, choreic movements lessen
44
Q

What are the D2 receptor antagonists?

A
  1. First generation (typical) antipsychotics = FGAs

2. 2nd generation (atypical) antipsychotics = SGAs

45
Q

What are the D2 receptor antagonists?

A
  1. First generation (typical) antipsychotics = FGAs

2. 2nd generation (atypical) antipsychotics = SGAs

46
Q

What are the nonselective FGA antipsychotics moa?

A
  1. Non selective, occurs in all DA 4 pathways
    A. Tuberoinfundibular where antagonism causes prolactinemia
    B. Nigrostriatal where it causes extrapyramidal syndomes (later)
    C. Mesocortical where it causes executive dysfunction, negative sx
    D. Mesolimbic where it causes DA firing to lower and psychosis to lessen
47
Q

What are the nonselective FGA antipsychotics high potency drug moa?

A
  1. Have high affinity for D2 receptor antagonism and require only a few mg of drug to occupy 60% of D2 receptors to alleviate psychosis
  2. Very selective and have few side effects outside of those from lowering D2 activity
  3. Blocking D2 in the mesolimbic pathway alleviates psychosis by returning this pathway from high DA activity back to normal
  4. Blocking D2 activity in the nigrostriatal pathway causes abnormally low DA activity and extrapyramidal side effects (EPS to occur)
48
Q

What are the FGA high potency SE?

A
  1. Extrapyramidal Syndromes (EPS) occur when DA activity is forced too low
    A. Akathisia = restlessness
    B. Dystonia = muscle spasm
    C. Parkinsonism= identical to Parkinson’s Disease but is reversible (tremor, rigidity, instability, bradykinesia, etc)
    D. Neuroleptic Malignant Syndrome (NMS)
    -Hyperthermia
    -Muscle rigidity
    -Vital sign instability
    -Rhabdomyolysis
    -BTW treatment is dantrolene or a D2 agonist like pramipexole
49
Q

What are the anticholingerics and their SEs?

A
  1. Benztropine, trihexyphenadyl, diphenhydramine
    Used to treat EPS syndromes
    A. Side effects include: dry mouth, blurred vision, tachycardia(racing heart), constipation, confusion, delirium, hallucinations
50
Q

What is tardive dyskinesia?

A
  1. Chronic D2 receptor antagonism may cause permanent movement disorder called TD
  2. Choreic Movements are fast, quirky in nature
  3. Athetotic Movements are slow, writhing in nature
    A. Pushing DA too low creates dyskinesia
    B. Pushing DA too high with levodopa can too
51
Q

What are the moa of FGA-low potency drugs?

A
  1. Have low affinity for D2 antagonism and require more mg of drug to provide antipsychotic effects
  2. They antagonize D2, but are ‘messy’ or ‘multifactorial’ as they also manipulate other receptors associated with side effects
52
Q

What are the se of FGA-low potency drugs?

A
  1. D2 receptor antagonism -> EPS (less than high potency FGA)
  2. Histamine 1 (H1) receptor antagonism
    A. Fatigue and increased appetite/weight
  3. Anticholinergic muscarinic antagonism
    A. Dry mouth, blurred vision, constipation…
  4. Noradrenergic Alpha 1 receptor antagonism
    A. Orthostasis (faint/dizzy)
53
Q

What are the high potency FGA drugs?

A

Haloperidol
Fluphenazine
Thiothixine

54
Q

What are the low potency FGA drugs?

A

Chlorpromazine

Thioridazine

55
Q

What is the moa of SGA?

A
  1. D2 receptor antagonism->improves psychosis, mania, aggression
  2. Serotonin 2a (5HT2a) antagonism-> lessens EPS risks
  3. In fact, this allows greater blocking of DA in the mesolimbic system, while allowing better transmission in all other DA pathways (improving selectivity compared to FGA)
56
Q

What are the SGA dones?

A 
Risperidone
Paliperidone
Ziprasidone
Iloperidone
Lurasidone
57
Q

What are the SGA pines?

A 
Olanzapine
Quetiapine (XR)
Asenapine
Clozapine
Antagonizes D4 and D1 receptors too
58
Q

What are the SGA RIPS

A

Aripiprazole

Actually is a partial agonist at D2 and D3 receptors

59
Q

What is the most risky se of clozapine?

A
  1. Risk of agranulocytosis
  2. Requires WBC and ANC monitoring
  3. Most metabolic risk of any agent
    Little to zero EPS/TD
  4. Also causes extreme drooling
60
Q

What is the goal of psychotherapy for schizophrenia?

A
  1. Provide long-term support for patient and family

2. Foster compliance with drug regimen

61
Q

What are the types of psychotherapy?

A
  1. Cognitive Behavioral Therapy (CBT)
    A. Improve executive dysfunction
    B. Memory, concentration, planning, prioritizing
  2. Family Therapy
  3. Peer and Mentor support or social skills Group
62
Q

What is the prognosis for schizophrenia?

A
  1. Lifelong impairment, with chronic, downhill course in 90%
  2. Often stabilizes in midlife, however, with more negative symptoms predominating
  3. suicide is common in patients with schizophrenia
    >50% attempt suicide, 10% die in the attempt
    Post-psychotic depression
    “Command” hallucinations
63
Q

What are the good prognostic factors for schizophrenia?

A
  1. Female gender
  2. Older age at onset
  3. Married
  4. Have social relationships
  5. Good employment history
  6. Presence of mood symptoms
  7. Presence of positive symptoms
  8. Few relapses

BM: Unit 4 (5 decks)

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