Schizophrenia Flashcards
A 37-year-old Caucasian male with a history of chronic paranoid schizophrenia is hospitalized for a relapse of symptoms. He is given parenteral haloperidol because he is very agitated and threatening. The patient continues to be belligerent and has to be put in physical restraints. The next day the patient is less agitated and belligerent, but he reports feeling nauseated and tired and toward evening is found to be disoriented to time and place. His laboratory work-up shows an increase in BUN and creatinine. He is diagnosed with acute renal failure and transferred to the medical floor. What could be the cause of his acute presentation?
A. Intramuscular injection
B. Myoglobinuria due to muscle breakdown secondary to struggling when restrained
C. Dystonia secondary to multiple doses of pareneteral antipsychotic
D. All of the above
D. All of the above
Intramuscular injections can lead to muscle injury and an increase in CPK values. When an agitated patient is put in restraints and struggles against the restraints, the patient may develop physical injuries, which can lead to muscle breakdown. Parenteral injections can lead to acute dystonic reactions, which can also lead to muscle breakdown. Muscle breakdown can lead to myoglobinuria, which in turn can lead to acute renal failure.
A 32-year-old patient has been under treatment for chronic paranoid schizophrenia. He presents to the ER with a relapse of symptoms and is admitted to the hospital because he is very agitated. He had missed an appointment with his psychiatrist a few days before, although he had his WBC count done the day before that. He is started back on clozapine at the same dosage he was receiving before admission: 450 mg. The next morning he is found unconscious near his bed with a bump on the head. Which of the following could have led to this clinical situation?
A. Starting the patient on clozapine
B. Starting the patient on the same dosage of clozapine as previously
C. Not starting the patient on benztropine
D. None of the above
B. Starting the patient on the same dosage of clozapine as previously
A patient who has been off clozapine for more than 36 hours needs to be put back on the starting dosage and the dose slowly increased. Starting at a higher dosage can lead to orthostatic hypotension and other side effects associated with clozapine.
A 58-year-old African American male with a long history of NIDDM develops blindness. Approximately 6 months later, he is brought to the ER by his girlfriend. According to the girlfriend, the patient has been reporting seeing burglars breaking into their house. The patient is well oriented to time and place, and he reports that although he realizes what he is seeing is untrue, the experience is very unsettling for him. What is this phenomenon called? A. Doppelganger B. Reflex hallucinations C. Charles Bonnet syndrome D. Functional hallucinations
C. Charles Bonnet syndrome
Charles Bonnet syndrome is seen in people with recently developed blindness. The person knows that the visual hallucination is not real. A hallucination of one’s own body, which leads to the belief that one has a double, is called doppelganger.
Which of the following is one of the four As identified by Eugene Bleuler as the primary symptoms of schizophrenia? A. Abnormal association B. Autistic behavior C. Ambivalence D. All the above
D. All the above
According to Bleuler, the four primary symptoms of schizophrenia are abnormal associations, autistic behavior, abnormal affect, and ambivalence.
What is the total direct and indirect cost of schizophrenia to the U.S. economy annually? A. $100 billion B. $50 billion C. $65 billion D. $40 billion
C. $65 billion
The direct and indirect costs of schizophrenia are estimated to cost the U.S. economy around $65 billion annually. Direct cost to the United States is approximately $20 billion.
What is the concordance rate for schizophrenia in monozygotic twins? A. 90-100% B. 10-20% C. 30-40% D. 40-50%
D. 40-50%
Monozygotic twins have a concordance rate of 40-50% for schizophrenia. The lifetime prevalence of schizophrenia for relatives of schizophrenic patients is 4-5% for parents, around 10% for siblings, 13-15% for children with one parent who has schizophrenia, and around 35% for children of parents who are both schizophrenic.
Which of the following cognitive impairments is found in persons with schizophrenia? A. Deficits in information processing B. Deficits in executive function C. Deficits in language ability D. None of the above E. All of the above
E. All of the above
Patients with schizophrenia show impaired attention and concentration, information processing, executive functions, and memory and language functions.
Which season of birth is associated with a higher incidence of schizophrenia? A. Spring B. Summer C. Autumn D. Winter
D. Winter
Which of the following brain regions has consistently been shown to have abnormal volume measurements? A. Occipital and parietal regions B. Parietal region C. Temporal region D. Frontal and temporal regions
D. Frontal and temporal regions
It has consistently been shown persons with schizophrenia have decreased volume of the frontal and temporal regions. Schizophrenia has also been implicated in reduced volume of the superior temporal gyrus, hippocampus, and thalamus.
Which of the following antipsychotics has been used in receptor-binding PET studies of schizophrenia? A. Droperidol B. Amisulpride C. Clozapine D. Raclopride
D. Raclopride
Which of the following psychoanalysts introduced the concept of the schizophrenogenic mother? A. Bateson B. Fromm-Reichmann C. Vaughn and Leff D. Brown
B. Fromm-Reichmann
Frieda Fromm-Reichmann propounded the concept of the schizophrenogenic mother, described as being cold, overprotective, moralistic, rejecting, and dominant.
A 28-year-old Southeast Asian man presents to the ER accompanied by his parents. According to family members, the patient has been extremely anxious, not sleeping at night and not going to work regularly. During the interview, the patient reports that he is afraid his penis is becoming small and receding into his body. What is the clinical situation described by this man? A. Dhat B. Piblokto C. Latah D. Koro
D. Koro
Koro is a culture-bound syndrome seen in Southeast Asia that involves the fear that the penis is shrinking and receding into the abdomen. Dhat is found among Indian men and involves fears about discharge of semen in urine. Piblokto is seen among Eskimo women and involves the person tearing off her clothing, screaming, and crying and running about wildly in the snow. Latah, which is found in women on the Malay Peninsula, is characterized by echolalia, echopraxia, and other extremely compliant behavior.
Which French psychiatrist introduced the concept of “folie circulaire” (circular insanity)? A. Jean-Pierre Falret B. Jules Baillarger C. Benjamin Rush D. Gabriel Langfeldt
A. Jean-Pierre Falret
Jules Baillarger described “folie à double forme.” Gabriel Langfeldt described schizophreniform psychosis. Benjamin Rush, a signer of the American Declaration of Independence, is considered the father of psychiatry in the United States.
A patient with chronic schizophrenia walks the floors of the state hospital where he is an inmate swearing aloud at other inmates. The resident in charge of this patient tells him that he has to earn the right to watch TV from now on. According to the treatment plan submitted to the patient, for every half hour that he is able to prevent himself from using obscenities, he can earn a ticket for a half hour of TV time. What is this treatment plan an example of? A. Extinction B. Token economy C. Counterconditioning D. None of the above
B. Token economy
Token economy involves using contingency management for a group of patients living together in a ward or halfway house. Token economy uses positive reinforcement to encourage desirable behaviors.
What is the peak onset of schizophrenia in men? A. 22-27 years B. 24-31 years C. 17-25 years D. 26-45 years
C. 17-25 years
The peak onset of schizophrenia in males is between the ages of 17 and 25 years. Peak onset in females is later, 24 to 35 years.
Which of the following did Bleuler consider a primary symptom of schizophrenia? A. Abnormal associations B. Autistic behavior C. Abnormal affect D. Ambivalence E. All of the above
E. All of the above
Eugene Bleuler divided the symptoms of schizophrenia into primary symptoms and secondary symptoms. His four primary symptoms, also known as the four As of schizophrenia, are abnormal associations, abnormal affect, autistic behavior, and ambivalence. Of these four, Bleuler considered the disconnection between thought process and perception and among thought, emotion, and behavior to be the most important.
Which of the following is considered a bad consequence of deinstitutionalization of schizophrenic patients?
A. Some of the patients were transferred to alternative forms of unregulated custodial care like nursing homes and poorly managed shelter systems.
B. Some patients were let free into nearby communities, which were unable or unwilling to take care of the released patients.
C. Responsibility for care was transferred to patients’ families, for whom it has become a burden.
D. Some of the released patients ended up in the prison system.
E. All of the above
E. All of the above
Deinstitutionalization involved transferring the patients from a hospital setting to a community care setting. This movement gained momentum during the 1960s, but it had severe repercussions for the patients and for society. Some of the patients were transferred from hospitals to nursing homes and poorly managed shelter systems. Others were just released into the community. In some situations the responsibility for care was transferred to the patients’ families, many of which felt burdened and unable to cope with it. Many patients finally wound up in the prison system.
For which of the following gene locations is there the strongest research evidence of linkage with schizophrenia in genetic studies of the disorder? A. Chromosome 4 B. Chromosome 8 C. Chromosome 15 D. Chromosome 6
D. Chromosome 6
Which of the following is considered a possible marker distinguishing schizophrenic probands and their biological relatives from controls? A. Smooth-pursuit eye movements B. Continuous performance tasks C. Sensory gating D. All of the above
D. All of the above
Biological markers of schizophrenia are neurophysiological features that reveal underlying pathophysiology and also serve as diagnostic tests. They help in predicting which persons may develop the disease and also help in predicting prognoses. Among the biological tests for schizophrenia are the following: CAT scan, regional cerebral blood flow, structural MRI, functional MRI, magnetic resonance spectroscopy, evoked potentials, smooth-pursuit eye movement test, tests of continuous performance tasks, and tests of sensory gating.
Which of the following abnormalities is shown by magnetic resonance imaging (MRI) studies of the brains of schizophrenic patients?
A. Decreased cortical gray matter in the temporal cortex
B. Decreased volume of limbic structures
C. Increased volume of basal ganglia nuclei
D. All of the above
D. All of the above
Studies show decreased cortical gray matter in the temporal cortex and limbic structures in persons with schizophrenia. Some studies show that individuals with schizophrenia also have increased numbers of basal ganglia nuclei.
Which of the following areas in the brain shows decreased blood flow during the Wisconsin Card Sorting Test in schizophrenic patients? A. Dorsolateral temporal cortex B. Parietal cortex C. Prefrontal cortex D. None of the above
C. Prefrontal cortex
Persons with schizophrenia who are doing the Wisconsin Card Sorting Test have been shown to have decreased blood flow in the frontal cortex.
A 23-year-old college student is brought to the ER in the early morning by friends who found him behaving strangely. He was very irritable, abusive, and assaultive toward them. He also reported getting special messages from the TV instructing him to perform special missions. What should the psychiatry resident who sees him in the ER do first?
A. Contact the patient’s family to obtain a history regarding mental illness in the family.
B. Give the patient an injection of long-acting risperidone.
C. Do a urine drug screen and other laboratory tests.
D. Place the patient on one-to-one observation.
D. Place the patient on one-to-one observation.
The symptoms presented by the patient can be a feature of either acute schizophrenia or substance-induced acute psychosis, so testing the urine for any drugs and getting laboratory tests to rule out other causes of acute psychosis is an absolute necessity. An acutely psychotic patient is very unpredictable and the patient’s actions may lead to harm to the patient or others. The first thing to do in this situation is to maintain one-to-one observation of the patient to prevent any harm.
Which of the following neurotransmitters has been implicated in the pathophysiology of schizophrenia? A. Glutamate B. Serotonin C. Dopamine D. All of the above
D. All of the above
According to the dopaminergic theory of schizophrenia, the symptoms of schizophrenia are mainly due to an excess of dopamine. This is also shown by the fact that antipsychotics are mostly dopamine antagonists. Phencyclidine, which exerts its effects through its action on the glutamate receptors, can lead to schizophrenia-like symptoms. The atypical antipsychotics exert their therapeutic effect through serotonin-dopamine antagonism.
The study of which of the following substances of abuse has substantiated the argument that serotonin plays a role in the development of schizophrenia? A. PCP B. LSD C. Marijuana D. None of the above
B. LSD
Lysergic acid diethylamide (LSD) is a hallucinogen that blocks serotonin receptors in the brain. The atypical antipsychotics have been shown to have antagonist properties at both dopamine and serotonin receptors.
Which of the following anesthetic agents has been shown to have a mechanism of action similar to PCP and can lead to the development of schizophrenia-like symptoms? A. Midazolam B. Fentanyl C. Ketamine D. None of the above
C. Ketamine
PCP (phenycyclidine) acts as an antagonist at the NMDA receptor. It is also known by the street names angel dust, dust, wet, killer weed, and purple rain. It was developed in the 1950s as a general anesthetic. PCP use can lead to severe agitation and hallucinations. The anesthetic ketamine acts as an antagonist at the NMDA receptors and can lead to postanesthetic agitation and hallucinatory behavior.
Clonidine has been found by some studies to reduce psychotic symptoms in schizophrenic patients. Which of the neurotransmitters do these studies implicate as playing a role in the development of schizophrenia? A. Serotonin B. Aspartate C. Norepinephrine D. Dopamine
C. Norepinephrine
Clonidine, a presynaptic alpha-2 agonist, leads to a decrease in the release of norepinephrine. Clonidine’s effect of reducing schizophrenic symptoms in some individuals implicates norepinephrine as playing a role in the development of schizophrenia.
A 52-year-old woman who is a resident of a state psychiatric hospital is admitted to a private hospital for treatment of her medical problems. When speaking with the resident physician, she claims she is the president of the company that owns the private hospital. However, she willingly takes all the medicines given to her and willingly stays in the room she shares with another patient. What term denotes this phenomenon? A. Double depression B. Double bookkeeping C. Both of the above D. None of the above
B. Double bookkeeping
Some individuals with schizophrenia are totally convinced of the reality of their delusions, but this does not influence their actions and beliefs. This paradox is called double orientation or double bookkeeping.
A parent of a schizophrenic patient criticizes the patient, saying that he is not showing any affection toward his parents. The same parent shies away when the patient wants to show affection in public. How did Gregory Bateson describe this kind of family interaction? A. Expressed emotions B. Double-bind communications C. Discursive speech D. None of the above
B. Double-bind communications
The double-bind communication pattern was described by Bateson and Jackson. In this type of communication pattern, the family members or caretakers of the patient give mutually incompatible messages like the example shown in the question.
Emil Kraepelin described persons with dementia praecox as having a prolonged deteriorating course. What percentage of Kraepelin's sample of patients recovered completely? A. None B. 10% C. 22% D. 4%
D. 4%
Kraepelin described dementia praecox as having a chronic deteriorating course, but he also reported that, in his sample of patients, 4% recovered completely and 13% had significant remission.
Which of the following described the first-rank symptoms of schizophrenia? A. Manfred Bleuler B. Kurt Schneider C. Ernst Kretschmer D. None of the above
B. Kurt Schneider
The symptoms Schneider called first-rank symptoms are characteristic of schizophrenia and rarely found in other illnesses. These include hearing thoughts as if spoken aloud, third-person auditory hallucinations, hallucinations in the form of commentary, somatic hallucinations, thought withdrawal or thought insertion, thought broadcasting, delusional perception, and feelings or actions experienced as made or influenced by external agencies.
Which of the following is the most common symptom of acute schizophrenia? A. Auditory hallucinations B. Delusions of reference C. Suspiciousness D. Lack of insight
D. Lack of insight
Ninety-seven percent of persons with an acute onset of schizophrenia have lack of insight, 74% have auditory hallucinations, less than 70% have delusions of reference, and around 65% report feeling suspicious.
Which of the following statements is true regarding periodic catatonia?
A. It was described by R. Gjessing.
B. The patients have periodic recurrent incidences of both stuporous and excited catatonic states.
C. Each episode is associated with a shift in the patient’s metabolic nitrogen balance.
D. All of the above
D. All of the above
Periodic catatonia, first described by Gjessing, is characterized by periodic recurrent incidences of both stuporous and excited catatonic states. Each episode is associated with a shift in the patient’s metabolic nitrogen balance.
Which of the following forms of schizophrenia has the best prognosis? A. Paranoid schizophrenia B. Catatonic schizophrenia C. Disorganized schizophrenia D. Schizophrenia, undifferentiated type
A. Paranoid schizophrenia
Persons who develop paranoid schizophrenia have a later onset (usually in their late 20s or in their 30s). By then they have already established an identity. They have completed their education and started working. Their ego resources have been described as better than those of catatonic and disorganized schizophrenics.
A 34-year-old woman is referred to a psychiatrist by her primary care physician. According to her husband, the patient has been behaving differently in the last few months. She is paying less attention to her appearance. She has become less industrious in keeping the house clean and taking care of her children and seems isolated from the family. She doesn't get up until late afternoon. Husband reports that these changes appeared gradually over the last two years and that the patient is showing further deterioration. The patient reports fleeting delusional beliefs and hallucinations. Which of the following is the best diagnosis? A. Paranoid schizophrenia B. Undifferentiated schizophrenia C. Stuporous catatonia D. Simple schizophrenia
D. Simple schizophrenia
According to DSM-IV research criteria, persons with simple schizophrenia (simple deteriorative disorder) are characterized by a progressive deterioration over a period of at least 1 year. They show a marked decline in occupational or academic functioning. They show a gradual appearance of and worsening of negative symptoms. They also show a decline in their relationships. Hallucinations and delusions are rare and, even when present, are fleeting.
A 42-year-old with schizophrenia keeps repeating certain words in the same fashion. What is this phenomenon called? A. Echolalia B. Perseveration C. Echopraxia D. Verbigeration
D. Verbigeration
Verbigeration is characterized by use of words in a stereotypical fashion. Echolalia is the repetition of the examiner’s words. Perseveration is the repetition of words even after the significance of the same is past. Verbigeration is found exclusively in chronic and regressed patients with schizophrenia.
Which of the following stressed the inability of schizophrenics to use their ability of abstraction? A. Norman Cameron B. Kurt Goldstein C. Lidz D. None of the above
B. Kurt Goldstein
Kurt Goldstein described the thinking of persons with schizophrenia as being very concrete and talked about the decrease in their ability to use abstraction. According to Norman Cameron, overinclusive thinking is a significant feature of persons with schizophrenia. Overinclusion refers to the tendency of these persons to include many irrelevant items in their beliefs and behavior. Lidz did psychoanalytic studies in families of schizophrenic patients and reported two types of abnormal family pattern: marital schism and marital skew.
Which of the following is not a feature of Type I schizophrenia, according to Crow's classification? A. Acute onset B. Predominantly positive symptoms C. Insidious onset D. Good social functioning
C. Insidious onset
Crow et al. described two types of schizophrenia. Type I is characterized by acute onset, mostly positive symptoms, and good social functioning during periods of remission, and it responds well to treatment with antipsychotics. Type II has an insidious onset, poor prognosis, and mostly negative symptoms.
Which of the following is a good prognostic indicator for schizophrenia? A. Prominent affective symptoms B. Insidious onset C. Ventriculomegaly D. Negative symptoms
A. Prominent affective symptoms
Prominent affective symptoms are a good prognostic indicator. Poor prognostic indicators are insidious onset, male gender, venticulomegaly, social isolation, poor occupational history, earlier onset, negative symptoms, single marital status (widowed, separated, never married, or divorced), and prolonged episode. Good prognostic indicators are acute onset, no prior psychiatric history, paranoid subtype, good social and occupational history, married or in a stable relationship.
According to Vaughn and Leff, what is the optimal duration of contact between patients and their family members? A. Less than 48 hours per week B. Less than 72 hours per week C. More than 48 hours per week D. Less than 35 hours per week
D. Less than 35 hours per week
Vaughn and Leff described the effect of expressed emotion in relatives and patient’s response to medications. Spending less than 35 hours per week with relatives was optimal for patients taking antipsychotic medications. According to Vaughn and Leff spending less than 35 hours leads to a relapse rate of 15%. The more time spent with relatives with high expressed emotion, the higher the relapse rate.
