Schizophrenia Flashcards
what is psychosis?
Psychosis is a pathological mental state characterized by the abnormal
interpretation,
organization of cognitive stimuli, those generated internally and encountered externally.
It includes an inability to distinguish between real and not real stimuli.
psychosis is a ______, and _____ can lead to psychosis
symptoms, multiple illnesses
Early schizophrenia characteristically was described as having:
loss of distinct cognitive processes and early onset of deteriorating disorder (including hallucination and delusion)
when Schneider described schizophrenia he:
began focusing on the positive aspects of the disease, i.e. auditory hallucinations, voices telling you how to move or controlling your actions, breathing, etc (also maybe the devil doing throught broadcasting, etc)
what is psychosis?
A break from reality involving
Delusions
Perceptual disturbances
Disordered thinking
epidemiology of schizophrenia:
Lifetime prevalence: 0.5-1% Average age of onset: 18 for men, up to 25 for women. ~50% of psychiatric beds ~15% of all treated mental illness Costs to society: ~$30 billion/yr 2.5% of total health care costs 9th leading cause of disability worldwide Suicide: 50% attempt, 10% complete
difference between men and women with schizophrenia:
men often are diagnosed at a young age, and they become homeless, drug users, etc. The females often get married, have kids, come to doctors appointments, tke medications, etc
having support and taking medication makes a huge difference!
TEST: if 21 yr old shows up in ed naked with aluminum foil hat talking about aliens reading his thoughts and hasn’t slept for 5 days:
can’t be diagnosed with schizophrenia because you have to have continous signs of disturbance that persist for at least 6 months
the characteristic symptoms of schizophrenia (must have 2 or more) include:
Delusions
Hallucinations
Disorganized Speech
Grossly disorganized or catatonic behavior
Negative symptoms (flat affect, apathy, alogia, or avolition)
before you can diagnose someone with schizophrenia, you must first:
rule out schizoaffective and mod disorders, as well as substance abuse and general medical conditions
delusions refers to:
if the person coughs and thinks they have lung cancer, the doctor does tests, and shows that they don’t, they’ll still believe they do and that the md is lying to them
types of delusions:
Erotomanic: delusions resolve around love
Grandiose: inflated self-worth
Jealous: delusions of unfaithfulness
Somatic: physical delusions
Percusatory: delusions of being persecuted
Mixed: more than 1 delusion
people with schizophrenia are often unable to hold down a job bc:
Erotomanic: delusions resolve around love
Grandiose: inflated self-worth
Jealous: delusions of unfaithfulness
Somatic: physical delusions
Percusatory: delusions of being persecuted
Mixed: more than 1 delusion
positive vs negative symptoms:
positive is something more than what we need (hearing stuff, seeing stuff, thinking more than we should), negative is lacking what we need to have (lacking affect, emotion, etc)
negative symptoms of schizophrenia:
Anhedonia-asociality
Recreation, sex, intimacy, friendship
Attention
Social inattentiveness
Affective Flattening
Facial expression, eye contact, vocal inflection, inappropriate affect
Alogia
Poverty of speech/content of speech, blocking
Avolition-Apathy
Poor self care, loss of persistence in school/work
how do you measure schizophrenia?
Brief Psychiatric Rating Scale (BPRS) 18-24 symptoms
Scale for Assessment of Positive Symptoms (SAPS)
4 domains: auditory hallucinations, delusions, bizarre behaviors, formal thought disorder
0 (absent) to 5 (severe)
Scale for Assessment of Negative Symptoms (SANS)
5 domains: flat affect, alogia, avolition-apathy, anhedonia, inattention
Clinician rated from 0 (absent) to 5 (severe)
Positive And Negative Symptoms of Schizophrenia (PANSS)
45 minute clinician interview
30 different symptoms rated from 1-7
before you diagnose someone with psychosis:
you have to rule out other medical causes (i.e. huntingtons, parkinsons, vit B, etc)
how do we thinschizophrenia work?
The DA hypothesis of schizophrenia, as originally postulated, proposed that schizophrenia is due to an excess of DA activity in limbic brain areas,
the nucleus accumbens, stria terminalis,
lateral septum,
olfactory tubercle (e.g., mesolimbic dopamine hyperactivity).
This hypothesis was based on evidence that chronic administration of the stimulant d-amphetamine produced a psychosis that resembles paranoid schizophrenia.
what is the problem with dopaminergic pathway?
when the limbic system is effected, you have all the fibers criss crossing throughout the entire brain, and you cannot just cut out or burn one part without effecting the brain on all levels
starting medication early is VERY important bc:
it is shown that schizophrenia patients have a loss of brain tissue mass, and if they take medication early they can prevent loss of brain matter
diagnosing schizophrenia;
there is not 1 test, it must be tested in multiple ways, the entire brain, to diagnose someone with schizophrenia
TEST: physically, one of the main things we can see in regards to the brain deteriorating is:
ventriculomegaly;
the enlargement of the 3rd and 4th ventricles and decrease of the cortical regions, and we definitely have a 5-10% loss in brain mass the same way they postulated 150 years ago
etiology of schizophrenia:
The stress–diathesis model posits that a biological predisposition toward developing schizophrenia is inherited genetically, and that this vulnerability interacts with environmental challenges.
TEST brief psychotic disorder:
we will have delusions, hallucinations, and disorganized speech and behavior, and symptoms will only have been present for at least 1 day and less than 1 month with full return to baseline; characterised by delusions or hallucinations for a short period of time usually after exposure to some external stressor
TEST: if boy shows up naked with aluminum foil hat on and says his roomate is trying to poison him, and aliens are coming for him, and says he has been like this for 2 weeks, he will be diagnosed with:
brief psychotic disorder
TEST: if boy shows up naked with aluminum foil hat on and says his roomate is trying to poison him, and aliens are coming for him, and says he has been like this for 6 weeks, he will be diagnosed with:
schizophreniform: Present for at least 1 month but less than 6 months
TEST: three stages of schizophrenia to know
brief psychotic disorder (up to 1 month), schizophreniform (1 month to 6 months), schizophrenia (6 months and longer)
schizoaffective disorder:
having a major mood disorder (bipolar or major depression) and then must have 2 weeks of hallucinations and delusions present in the absence of mood symptoms
people with schizoaffective disorder:
get psychotic when they’re manic; they have a baseline of psychotic features, they go all out manic and quit their job, move to cali, buy two cars, divorce wife, all for world domination
for schizoaffective disorder, the diagnosis is made when:
The diagnosis is made when the patient has features of both schizophrenia and a mood disorder—either bipolar disorder or depression—but does not strictly meet diagnostic criteria for either alone. Must be within 2 week period
In addition to drug induced hallucinations/delusions, you can also have:
psychosis due to a general medical condition/another medical condition
man that had an ear infection and it spread to his brain and caused schizophrenia (believed GOD made him Jesus and he flipped)
Prominent hallucinations or delusions
Symptoms do to not occur only during episode of delirium( impaired attention and awareness (more visual symptoms)
Evidence to support a medical cause for the psychosis (history, physical, lab work)
psychosis due to general medical condition is a situation in which:
someone becomes schizophrenic without the help of TBI, medications, drugs, etc
possible medical conditions that could cause hallucinations:
neuro disorders (seizures, HD, hydrocephalus, lupus, PD, pick's AD) infectious disease: brain abscess, syphilis, steroid abuse, etc
delusional disorder:
Delusions that are relatively plausible
Erotomanic “She loves me”
Jealous “She loves me not”
Grandiose “Everyone loves me” (I’m so great)
Persecutory “Everyone hates me”
Somatic “The parasites love me”
No hallucinations, no negative symptoms
Exclude: Schizophrenia, substances, general medical condition
diff between schizophrenia and delusional disorder:
Delusional disorder will just have ONE problem or issue that they will not accept, believe, wrap their head around, etc
woman believes her childhood friend had a daughter that went to med school and that this was all so that she could become a psychiatrist and commit her (and the girl lives in california and has no contact with the woman whatsoever)
delusional disorder (other than this one delusion, the woman can function, work, etc)
difference between types of psychosis:
delirium and substance induced will be accompanied by fever, autonomic instability, etc, and schizophrenia will just have flattened affect, disorganized thoughts and dizarre delusions or hallucinations
difference between typical or atypical medications:
Conventional or “typical” antipsychotics
(e.g., chlorpromazine, haloperidol)
Dopamine (D2) receptor blockade
“Atypical” antipsychotics (e.g., olanzepine, risperidone, quetiapine)
Dopamine (D2 ) and Serotonin (5HT2A) blockade
problem with first generation antipsychotic medications:
extrapyramidal symptoms (eps) Akathisia—a subjective feeling of restlessness
Acute dystonic reactions—abrupt onset muscular spasms of the neck, eyes, trunk, extremities*
Parkinsonism—stiffness, tremor, impaired gait
*Chronic dopamine blockade can lead to tardive dyskinesia (TD)
TEST: Tardive dyskinesia:
A movement disorder that may occur following treatment with antipsychotic medications
risperidone _______ that :
interferes with the dopamine
21 yr old brought ED by parents bc he has not slept, bathed or eaten for 3 days. The parents report that for 6 months their son has been acting strangly “not himself,” he has been locking himself in his room, talking to himself, writing on walls. 6 weeks prior to visit, their son became convinced that a fellow student was stealing his thoughts and making him unable to learn his school material. In the past 2 weeks they noticed that their son has become depressed and has stopped taking care of himself (no bathing, eating, getting dressed, etc). On exam, he appears dirty, disheveled, low energy, and suicidal:
schizoaffective disorder (only actively been not bathing, eating, been depressed, etc for 2 weeks at most if not 3 days).
20 yr old woman brought to ed, after family can’t get her to eat or drink for 2 days. Patient is awake bu completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months, she has become increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see:
catatonic schizophrenia, characterized by marked psychomotor disturbances including prolonged immobility, posturing, extreme negativism (the patient actively resists any attempts made to change his or her position). or waxy flexibility (patient maintains the position in which she is placed), mutism, echolalia (repitition of words said by another person), echopraxia (repetition of movements made by another person) Periods of immobility and nutism can alternate with periods of extreme agitation
35 yr old has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering solftly to herself, looking at her reflection in a small mirror. She needs helpwith dressing showering, and she often giggles and laughs for no apparent reason:
schizophrenia: disorganized speech and behavior, flat or inappropriate affect, great functional impairment, and inability to perform basic activities such as showering or preparing meals. Grimacing along with silly and odd behaviorand mannerisms is common
schizophrenia mnemonic
THREAD
Thinking disturbed, neologisms
Hallucinations, typically auditory
Reduced contact with reality
Emotional control affected – incongruous affect
Arousal may lead to worsening of symptoms
Negative symptoms
LESS
Loss of volition, under-activity, social withdrawal (anergy, anhedonia)
Emotionally flat (apathy)
Speech reduced, monosyllabic (alogia)
Slowness in movement and thought, psychomotor retardation
Types mnemonic
MS. D= SAD that the BPD Screened for Schizophrenia
Med Induced mnemonic:
NINE Other
Substance induced mnemonic:
Picked KALE
15 yr old is hospitalized for suicide attempt. Made attempt after fight with bff after a party, and had several month history of irritability, worsening performance in school, poor sleep, anhedonia, anergia, and isolation from her family and friends. Diagnosed with depression and released. Comes back happy, says suicide was only for attention, and seems all good. Parents then say she thought there were camera’s in the doctors office recording her and that she is being stalked by several of the boys at her school:
schizoaffective: diagnosed with mdd with suicide attempt, treated and now has evidence of paranoia
A’s of Negative effects of psychosis
Affective flattening – unchanging facial expression, reduced movement, poor eye contact.
Alogia – poverty of speech, thought block, delayed response.
Anergia – loss of energy.
Anhedonia – loss of interest in things/sex/relationships.
Apathy – poor hygiene, lack of interest.
50 yr old with history of chronic treatment-resistant schizophrenia was admitted last night after reemergence of command auditory hallucinations telling him to “do bad things.” He had been recently hospitalized and stabilized on clozapine. He denies missing any doses. What addition is the most common form of substance abuse in patients with schizophrenia and likely contributed to the patient’s recent psychotic episode?
nicotine is the most frequent used substance by schizophrenics. Patients with schizophrenia are three times more likely to be addicted to nicotine compared to the general population. Smoking induces cytochrome P450 enzyme activity which results in significantly lower clozapine concentrations, and resulted in reemergence of psychotic symptoms.
45 yr old man with history of schizophrenia and alcohol use disorder was brought by ambulance after he was found sleeping on the floor of a homeless shelter. He appears drowsy, but arousable, and mumbles, “the voices are killing me.” He admits to taking a bottle of lorazepam because “I just couldn’t take it anymore.” Which of the following antipsychotics has been associated with decreased suicide attempts?
clozapine has been shown to reduce suicide attempts in patients suffering from schizophrenia and schizoaffective disorder
26 yr old woman brought to ed by husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previousl, the couples two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she wil not eat bc she believes he has been poisoning her food, and she has not slept for the past 2 days. The pateint believe that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit spontaneously. which of the following would be her most likely diagnosis?
delirium schizophreniform disorder mdd with psychotic features brief psychotic disorder PTSD
brief psychotic disorder is characterized by the sudden appearance of delusions, hallucinations, and disorganized speech or behavior, usually following a severe stressor. The episode lasts at least 1 day and less than 1 month, and is followed by full spontaneous remission. For the woman in the question, the psychotic episode was clearly precipitated by the death of the children. Schizophreniform disorder is differentiated from brief psychotic disorder by temporal factors (in schizophreniform disorder, symptoms are required to last more than 1 month) and lack of association of a stressor. PTSD has a more chronic course and is characterized by affective, dissociateive, and behavioral symptoms
22 yo man brought to ed after becoming exceedingly anxious in college dormroom, stating that the college administration was sending a hit squad to kill him. He also notest that he can see visions of men dressed in black who are carrying guns and stalking him. His thought process is relatively intact, without thought blocking or losse associations. His urine test is positive for; barbiturates heroin benzodiazepine amphetamines MDMA (ecstasy)
amphetamine intoxication can result in a psychosis very closely resembling acute paranoid schizophrenia, with symptoms incuding paranoid delusions and visual hallucinations. Some investigators believe that prominent visual hallucinations and a relative absence of thought disorder are more charactersitc of amphetamine psychosis, but other investigators believe the symptoms are indistinguishable. Other drugs that produce psychosis similar to schizophrenia include PCP and LSD
72 yo woman is brought to ed by daughter after she was found rummaging in the garbage cans outside. Daugher states that the patient never had behavior like this. On interview, the patient states she sees martians hiding around her home and on occasion she hears them, too. She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patients behavior except one.
Which symptom is common in patients with a psychiatric cause for their behavior instead of medical?
patients age
no previous history
visual hallucinations
auditory hallucinations
constructional apraxia
auditory hallucinations are quite common in psychiatrically caused psychoses, but the rest of the items point to a medical psychosis. Other signs that point to a medical cause could be altered mental status signs such as speech, movement or gait disorders, problems with alertness, memory, concentration, or orientation, and concurrent substance abuse history or medical problem
62 yr old with chronic schizophrenia is brought to ed after wandering his halfway house confused and disoriented. His serum sodium was 123 meq/L and urine sodium was 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control. His roomate reports that the patient often complains of feeling thirsty. Which of the following is the cause of the symptoms? renal failure inappropriate ADH secretion addison disease psychogenic polydipsia nephrotic syndrome this is made worse by?
schizophrenic drink excessive water and it is made worse by lithium and carbamazepine bc it causes water retention
a 49 yo bank teller without a psychiatric history says that for the past 2 months, she has been increasingly convinced that a well-known pop music star is in love with her and they have an ongoing affair. She is well groomed, with no eveidence of thought disorder, and has been functioning well at work, and in social functions: delusional disorder acute reactive psychosis prodomal schizophrenia paranoid personality disorder schizophreniform disorder
delusional disorder:
her high social and occupational functioning rules out any of the psychotic/schizophrenia spectrum diagnoses and possibilities and she is not paranoid. Her illness is clearly well circumscribed and is of delusional intensity only
36 yo woman is brought to the psychiatrist by her husband bc for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors’ leaving the garbage cans out on the street to try to trip her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be “better if they would leave me alone.” She denies hearing the neighbors or anyone else talking to her, but she is sure that they are out to “cause her death and mayhem.”
Delusional disorder schizophreniform disorder schizoaffective disorder schizophrenia major depression with psychotic features
delusional disorder is the presence of one or more nonbizarre delusions without deterioration of psychosocial functioning and in the absence of bizarre or odd behavior. Auditory and visual hallucinations, if present are not prominent and are related to the delusional theme.
a 22 yo business owner believes that he is infested with parasites. He otherwise is in good health, has had a recent physical, and is able to maintain good social contacts and relationships at work:
delusional disorder
a 45 yr old mother of 2 is convinced that she is HIV positive and has the AIDS virus. She is currently in good health, has had no changes in her health over the past 10 years, and has been tested for HIV 4 times, and has always tested negative
delusional disorder
47 yo woman is brought to ED after she jumped off an overpass in a suicide attempt. In the ED she states that she wanted to kill herself bc the dvil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her.
Delusional disorder schizophreniform disorder schizoaffective disorder schizophrenia, paranoid type major depression with psychotic features
schizoaffective disorder is diagnosed whenever the required criteria for schizophrenia are met (delusions, hallucinations, disorganized speech or behavior, and/or negative symptoms; durationg of the disturbance, including prodromal and residual period of at least 6 months, with at least 1 month of active symptoms) and the patient experiences at some point in the course of the illness a major depressive episode or a manic episode.
Delusional disorder is not accompanied by a decline in function (socially, etc)
19 yr old woman is brought to ed by her roomate after the patient told her that “the voices are telling me to kill the teacher.” The roommate states the patient has always been isolative and “odd” but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. Which of the following tests are likely to be abnormal in this patient?
CT (lateral and third ventricle enlargement will be seen)
19 yr old woman is brought to ed by her roomate after the patient told her that “the voices are telling me to kill the teacher.” The roommate states the patient has always been isolative and “odd” but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. The patient becomes agitated in the ED and tries striking one of the nurses before being restrained. Which of the following treatment options would be recommended?
haloperidol and lorazepam IM clozapine PO Fluphenazine decanoate IM Mellarill IM Lorazepam PO
haloperidol and lorazepam:
The use of a benzodiazepine and a high-potency antipsychotic has several advantages. While the antipsychotic treats the psychosis whithout a lot of anticholinergic side effects, the benzodiazepine reduces the amount of antipsychotic needed and protects the patient against dystonic reactions. Clozapine or fluphenazine decanoate would never be given in an acute setting
19 yr old woman is brought to ed by her roomate after the patient told her that “the voices are telling me to kill the teacher.” The roommate states the patient has always been isolative and “odd” but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. The patient becomes agitated in the ED and tries striking one of the nurses before being restrained. The patient was admitted and started on a daily dose of fluphenazine. After discharge from the hospital, she was kept on a low dose of the medication for 6 weeks and showed only a minimal response to the drug, even after it was raised to a moderate dosage level. Which is the next therapeutic step?
give a high dose of fluphenazine give a low dose of clozaril give a low dose of haloperidol give fluphenazine decanoate IM give a low dose of olanzapine
give a low dose of olanzapine
if patient doesn’t respond to a conventional dopamine receptor antagonist (first generation- typical) then it is unlikely that the patient will respond well to another. It is better to switch to a low dose of serotonin dopamine antagonists (second-generation antipsychotic). It is too early in treatement to give up and go to clozapine
a 19 yr old is brought to the physician by his parents after he called them from college, terrified that the mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans bc “they are into everything-I can’t be too careful!.” He is convinced that the mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. his roommate states that for the past 2 months the patient has been increasingly withdrawn and suspic.
schizophreniform disorder and chronic schizophrenia differ only in the duration of the symptoms and the fact that the impaired social or occupational functioning assoiated with chronic schizophrenia is not required to diagnose schizophreniform. As with schizophrenia, schizophreniform disorder is characterized by the presence of delusions, hallucinations, disorganized thoughts and speech and negative symptoms.
a 40 yr old woman is arrested by police after she is found crawling throught the window of a movie stars home. She states that the movie star invited her into his home because the two are secretly married and "it just wouldn't be good for his career if everyone know." The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. delusional disorder schizoaffective disorder bipolar I disorder cyclothymia schizophreniform disorder
delusional disorder
This patient is suffering from an erotomanic delusion-the delusion of having a special relationship with another person, often someone famous
a 28 yr old is brought to the psychiatrist by her mother. The patient has been progressively isolating herself from everyone, is talking to people who aren't there, is having auditory hallucinations, and the delusional belief that her mother is going to kick her out of the house so it can be turned into a theme park. Which of the following is the lifetime prevalaence for this disorder? 1% 3% 5% 10% 15%
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