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3. Psychosis > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

what is schizophrenia

A

a mental disorder characterized by the presence of positive symptoms (delusions, hallucinations), disorganization, and negative symptoms

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2
Q

is there is difference in gender prevalence between men and women in schizophrenia

A

generally same between men and women—> differ in course and onset of illness

DSM V says that may be slightly less common in women

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3
Q

when is the incidence of first episode of psychosis highest for men

A

between ages of 18-24

incidence subsequently declines rapidly

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4
Q

when is the incidence of first episode of psychosis highest amongst women

A

bimodal distribution

one peak in late 20s and then secondary peak between ages 50-54

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5
Q

how does the presentation vary in women compared to men for schizophrenia

A

women tend to have more positive symptoms and lesss negative symptoms (especially with late onset schizophrenia)

also tends to be more affect driven in women

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6
Q

criterion A for schizophrenia

A

TWO (or more) of the following, each present for a significant period of time during a ONE MONTH PERIOD (or less if successfully treated):

  1. delusions
  2. hallucinations
  3. disorganized speech
  4. grossly disorganized or catatonic behaviour
  5. negative symptoms
    * at least one must be 1, 2, or 3
    * these are the active phase symptoms
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7
Q

criterion B schizophrenia

A

for a significant portion of the time since the onset of the disturbance, LEVEL OF FUNCTIONING in one or more areas (i.e work, interpersonal relations, or self care) is MARKEDLY BELOW the level achieved prior to the onset

if onset is in childhood or adolescence, there is failure to achieve expected levels of interpersonal, academic or occupational functioning

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8
Q

criterion C schizophrenia

A

CONTINUOUS signs of the disturbance persist for at least SIX MONTHS

this 6 month period must include at least ONE MONTH OF SYMPTOMS that meet criterion A (active phase symptoms) and may include periods of PRODROMAL or RESIDUAL symptoms

during prodromal or residual periods, signs of disturbance may be only negative symptoms or be one or two symptoms from criterion A present in attenuated form

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9
Q

criterion D schizophrenia

A

schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1. no major depressive or manic episodes have occurred concurrently with the active phase symptoms
or
2. if mood episodes have occurred during active phase symptoms, they have been present for a MINORITY of the total duration of the active and residual phases of the illness

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10
Q

criterion E schizophrenia

A

not attributable to physiologic effects of a substance or another medical condition

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11
Q

criterion F schizophrenia

A

if there is a history of AUTIS spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required sx of schizophrenia, are also present for at least one month

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12
Q

is there any single symptom that is pathognomonic for schizophrenia

A

no

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13
Q

what is often the first sign of schizophrenia

A

individuals who were previously socially active may become withdrawn from previous routines

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14
Q

what other features not mentioned in the criteria may support dx schizophrenia

A
  1. display of inappropriate affect–> i.e laughing in absence of appropriate stimulus
  2. dysphoric mood that can look like depression, anxiety or anger
  3. disturbed sleep pattern
  4. lack of interest in eating or food refusal
  5. depersonalization, derealization and somatic concerns –> may reach delusional intensity
  6. cognitive deficits
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15
Q

what types of cognitive deficits can be seen in schizophrenia

A

problems with:

declarative memory

working memory

language function

executive functions

slower processing speed

theory of mind

ALSO

abnormalities in:

sensory processing

inhibitory capacity

reductions in attention

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16
Q

what is anosognosia

A

lacking insight or awareness of their disorder

may be present throughout entire course of illness

*typically symptom of illness itself rather than coping strategy

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17
Q

what is the most common predictor of nonadherence to treatment

A

anosognosia/lack of insight

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18
Q

what types of things does the presence of anosognosia/lack of insight predict

A

nonadherence to treatment

higher relapse rates

increased number of involuntary admissions

poorer psychosocial functioning

aggression

poorer course of illness

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19
Q

what differences in brain structure can be seen between those with schizophrenia and those without

A

differences in:

cellular architecture

white matter connectivity

gray matter volume

–> in a number of regions including PREFRONTAL and TEMPORAL cortices

reduced overall brain volume

increased brain volume reductions with age

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20
Q

list neurological soft signs that may be seen in those with schizophrenia

A

impairments in:

  • motor coordination
  • sensory integration
  • motor sequencing of complex movements

left right confusion

disinhibition of associated movements

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21
Q

what is the lifetime prevalence of schizophrenia

A
  1. 3-0.7%

* there is reported variation across race/ethnicity, across countries and by geographic origin

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22
Q

when do psychotic features of schizophrenia usually arise

A

between late teens and mid 30s

*onset before adolescence is RARE

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23
Q

describe the typical onset of symptoms for most people

A

usually slow and gradual development of variety of clinically significant signs and symptoms

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24
Q

what % of individuals who develop schizophrenia with gradual course of onset complain of depressive symptoms

A

about 50%

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25
Q

how does age at onset affect predicted outcome? why is this likely to be the case?

A

generally thought that younger age of onset predicts worse outcomes

thought to be because age at onset likely related to gender, with males having worse premorbid adjustment, lower educational achievement, more prominent negative symptoms and cognitive impairment and in general a worse outcome

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26
Q

do cognitive impairments dissipate when positive symptoms do during treatment for schizophrenia

A

may persist and contribute to the disability of the disease

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27
Q

do we know why some things are predictors of outcome and course in schizophrenia

A

no–are largely unexplained

course and outcome may not be reliably predicted

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28
Q

in what % of people is the course of schizophrenia FAVORABLE

A

about 20%

*a small number are reported to recover completely

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29
Q

what is the usual course of schizophrenia

A

most will require formal or informal daily living supports

many remain chronically ill with exacerbations and remissions of active symptoms

others can have a course of progressive deterioration

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30
Q

how do psychotic symptoms change over the lifecourse in schizophrenia

A

tend to diminish

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31
Q

why do they think psychotic symptoms tend to decline with age in schizophrenia

A

perhaps in assoc. with normal age related declines in dopamine activity

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32
Q

are negative or positive symptoms more closely related to prognosis in schizophrenia

A

NEGATIVE symptoms

tend to be the most persistent

also cognitive deficits may not improve over the course of the illness

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33
Q

how does schizophrenia manifest in childhood

A

essential features are the same but harder to diagnose

delusions and hallucinations may be LESS ELABORATE than in adults

tend to resemble poor outcome adult cases–> GRADUAL onset + prominent NEGATIVE symptoms

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34
Q

what types of hallucinations are more common in schizophrenia in children

A

visual

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35
Q

for a patient who later receives a dx of schizophrenia, what psychiatric manifestations might they have shown in childhood

A

nonspecific emotional-behavioural disturbances and psychopathology

intellectual and language alterations

subtle motor delays

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36
Q

what gender is more likely to present with late onset schizophrenia

A

females

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37
Q

what is considered late onset schizophrenia

A

after age 40

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38
Q

how might a late onset schizophrenia present

A

predominance of psychotic symptoms

preservation of affect and social functioning

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39
Q

environmental risk factors for schizophrenia

A
  1. season of birth
  2. being raised in urban environment
  3. some minority ethnic groups
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40
Q

which seasons of birth are associated with higher rates of schizophrenia

A

late winter/early spring in some areas

summer is assoc. with deficit form of the disease

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41
Q

genetic and physiologic risk factors for schizophrenia

A
  1. strong contribution for genetic factors in determining risk for schizophrenia–> spectrum of risk alleles–> each allele contributes only small fraction to total population variance
  2. greater paternal age
  3. pregnancy and birth complications with hypoxia
  4. prenatal adversities–> stress, infection, malnutrition, maternal diabetes, other medical conditions
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42
Q

do most people diagnosed with schizophrenia have a relative with the disease?

A

no–most have no family history of psychosis

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43
Q

what prenatal adversities may increase risk of schizophrenia

A

stress

infection

maternal diabetes

malnutrition

medical conditions

*vast majority of babies with these risk factors do not develop schizophrenia

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44
Q

list differences between presentations of schizophrenia in men and women

A
  1. incidence lower in women
  2. age at onset later among women
  3. woman have second mid life peak
  4. symptoms more affect laden among women
  5. more psychotic symptoms among women –> psychotic symptoms more likely to worsen later in life
  6. less frequent negative symptoms and less disorganization among women
  7. social functioning tends to be better preserved in women
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45
Q

what % of people with schizophrenia die by suicide

A

5-6%

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46
Q

what % of people with schizophrenia attempt suicide

A

20%

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47
Q

how does suicide risk change over the lifespan for people with schizophrenia

A

remains HIGH throughout the life span for males and females

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48
Q

in what population might suicidal risk be especially high amongst patients with schizophrenia

A

younger males with comorbid substance use

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49
Q

list risk factors for suicide risk in people with schizophrenia

A
  1. younger male
  2. comorbid substance use
  3. depressive symptoms
  4. feelings of hopelessness
  5. being unemployed
  6. in the period after a psychotic episode or hospital discharge
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50
Q

ddx for schizophrenia

A
  1. MDD or bipolar disorder with psychotic or catatonic features
  2. schizoaffective disorder
  3. schizopphreniform disorder
  4. brief psychotic disorder
  5. delusional disorder
  6. schizotypal personality disorder
  7. OCD
  8. Body dysmorphic disorder
  9. PTSD
  10. autism or communication disorders
  11. other mental disorders with a psychotic episode
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51
Q

how do you distinguish between MDD or bipolar with psychotic features and schizophrenia

A

by the temporal relationship between the mood disturbance and the psychosis and on the severity of the depressive or manic features

if delusions or hallucinations occur during a depressive or manic episode exclusively then the dx is depressive or bipolar disorder with psychotic features

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52
Q

how do you distinguish between schizophrenia and schizoaffective disorder

A

dx of schizoaffective disorder requires that a major depressive or manic episode occur CONCURRENTLY with the active phase symptoms and that the mood symptoms be present for a MAJORITY of the total duration of the active periods

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53
Q

how do you distinguish between schizophrenia and schizotypal PD

A

schizotypal PD is characterized by SUBTHRESHOLD symptoms that are associated with persistent personality features

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54
Q

how might PTSD resemble schizophrenia

A

PTSD may include flashbacks that have a hallucinatory quality and hypervigilance may reach paranoid proportions

(but PTSD has to have traumatic event and other characteristic symptom features).

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55
Q

what % of people with schizophrenia also have tobacco use disorder

A

over 50%

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56
Q

what other mental health conditions are more common in those with schizophrenia than in the general population

A

anxiety disorders

OCD

panic disorder

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57
Q

how does schizophrenia affect life expectancy? how does it do this?

A

it is reduced in those with schizophrenia

due to associated medical conditions

weight gain, diabetes, metabolic syndrome, CV and pulmonary disease = more common in schizophrenia than in gen. pop.

58
Q

risk factors for suicide

A

male gender

high socioeconomic background

high intelligence

high expectations

being single

lack of social supports

having awareness of symptoms

recent discharge from hospital

59
Q

estimate of what % of people with schizophrenia die by suicide

A

5-13% (according to psych DB)

60
Q

are cognitive deficits generally more or less severe in schizophrenia than in bipolar disorder

A

more severe in schizophrenia

61
Q

list good prognostic factors for schizophrenia

A

late or acute onset (rather than insidious)

obvious precipitating factor (i.e substance use)

good pre morbid functioning

family history of mood disorders

married

good support systems

positive symptoms (i.e most delusions/hallucinations)

62
Q

what can you do to significant decrease the risk for violence and crime in schizophrenia

A

treat with medications

63
Q

list poor prognostic factors for schizophrenia

A

young at age of onset

insidious onset

lack of obvious precipitating factors

isolation

family history

negative symptoms

neurological signs and symptoms

perinatal trauma hx

lack of remission

recurrent relapses

history of violence/assault

64
Q

what % of people with schizophrenia meet the criteria for recovery

A

about 13%

65
Q

who has better outcomes in schizophrenia–those in developed or developing countries

A

developing

66
Q

what % of people with schizophrenia experience insomnia

A

close to 50%

*insomnia is predictive of onset of psychotic experiences

67
Q

heritability accounts for what % of the liability of schizophrenia

A

about 80%

HIGHLY heritable

68
Q

what is the baseline general population risk for schizophrenia

A

1%

69
Q

how much does the risk of schizophrenia increase if you have a second degree relative with schizophrenia

A

increases to 2% risk

70
Q

how much does the risk of schizophrenia increase if you have a non-twin sibling with schizophrenia

A

increases to 9%

71
Q

what is your risk for schizophrenia if one parent has schizophrenia

A

13%

72
Q

what is the risk of schizophrenia if both parents have schizophrenia

A

30-50% chance of developing the disorder

73
Q

what is the concordance rate for schizophrenia in identical twins

A

40-50%

74
Q

how much does advanced paternal age (over 35) increase the risk of schizophrenia

A

increases risk to 1.5-3%

75
Q

what is paraphrenia

A

previously used to describe psychotic symptoms in the elderly –> now use “late life psychosis”

76
Q

what are partition delusions

A

belief that people or objects can transgress impermeable barriers and access their omes with malign intent (more common in late life schizophrenia)

77
Q

how does the effective dosage of antipsychotic differ between typical schizophrenia and schizophrenia with onset in late life

A

for schizophrenia that arises in late life, it tends to respond well to antipsychotic treatment, requiring about 50% of the dose of antipsychotic required for younger patients

78
Q

name a rating scale for schizophrenia

A

PANSS

positive and negative syndrome scale

*patient rated from 1-7 on 30 different symptoms based on interview and collateral

there is also the BPRS (brief psychiatric rating scale)

79
Q

how might you assess depression in schizophrenia

A

using the Calgary depression scale for schizophrenia (CDSS)

80
Q

what is the dopamine hypothesis of schizophrenia

A

one theory in the pathophysiology of schizophrenia

holds that an INCREASE in dopamine activity causes the POSITIVE symptoms of schizophrenia
–> similar to how meth and cocaine increases dopamine activity, which can also cause psychosis

81
Q

which dopaminergic pathway is most associated with the positive symptoms of schizophrenia in the dopamine hypothesis

A

mesolimbic

82
Q

how to antipsychotics work according to the dopamine hypothesis of schizophrenia

A

target the mesolimbic pathway to BLOCK dopamine and decrease incidence of positive symptoms

–> bind to dopaminergic neuroreceptors

83
Q

list neuroimaging findings in schizophrenia

A

ventricular enlargement (in 3rd and lateral ventricles)

reduced hippocampus, parahippocampal gyrus and amygdala volume

reduced grey matter volume

neuronal loss in the medial thalamus

functional neuroimaging showing HYPOactivity of dorsolateral prefrontal cortex (DLPFC)

84
Q

is there a molecular subtype of schizophrenia that can be identified?

A

yes–> DiGeorge Syndrome

85
Q

what is DiGeorge Syndrome

A

a molecular subtype of schizophrenia that can be identified

is a deletion syndrome

86
Q

what is the deletion associated with DiGeorge Syndrome

A

22q11.2 deletion

87
Q

what is the risk of schizophrenia associated with DiGeorge syndrome/22q11.2 deletion syndrome

A

1 in 4 chance to develop schizophrenia (20-30x increased risk of schizophrenia compared to population risk)

*remains under recognized and under diagnosed

88
Q

what is the most common microdeletion syndrome in humans

A

DiGeorge Syndrome (22q11.2)

89
Q

what other abnormalities are associated with DiGeorge syndrome

A

congenital heart problems

facial dysmorphia

developmental delay

learning problems

cleft palate

(can also have renal problems, hearing loss, infections and autoimmune disorders)

90
Q

what is the prevalence of DiGeorge Syndrome

A

1 in 4000 people

91
Q

other than schizophrenia, people with DiGeorge syndrome are also at higher risk of what disorder

A

early onset parkinsons

92
Q

what % of cases of DiGeorge syndrome are new diagnoses with no family history

A

90%

93
Q

what test is recommended as first line test for DiGeorge SYndrome

A

clinical microarray

*actually this is a first line test recommended for any individual with intellectual disability, developmental delay or multiple congenital abnormalities

94
Q

how might someone with DiGeorge syndrome present clinically

A

hypernasal speech

long, narrow face

narrow palpebral fissures

flat cheeks

prominent nose

small ears

small mouth

retruded chin

heart defects

95
Q

does schizophrenia “look” different in those with DiGeorge syndrome

A

no–> indistinguishable from idiopathic forms

similar age at onset and similar prodromal symptoms

thus, same treatment recommended

96
Q

what is the estimated prevalence of schizophrenia patients having DiGeorge

A

1 in 100-200 patients

97
Q

patients with DiGeorge are at greater risk of what adverse events when treated with clozapine (more than others with schizophrenia)

A

higher risk of seizures–> may need lower doses of prophylactic seizure meds

neutropenia

myocarditis

98
Q

list two infectious diseases thought to increase risk of schizophrenia

A

toxoplasma gondii
(thus exposure to cats in childhood is risk factor for schizophrenia)

influenza

99
Q

describe the theory behind the etiology of influenza infections and schizophrenia

A

The etiology behind influenza infections and psychosis is thought to be linked to processes such as maternal immune activation, disruption of cytokine networks, and microglial activation of pathogenic processes that lead to schizophrenia. More recent theories also focus on neuronal autoimmunity and the NMDA receptor

100
Q

have there even been documented cases of people with congenital blindness developing schizophrenia

A

No

*perhaps those who cannot see at birth rely on context extracted from other sense which results in model of the world less susceptible to false interference

101
Q

what was the first term for schizophrenia? who developed it?

A

dementia praecox–> Emil Kraeplin

102
Q

why was schizophrenia first called dementia praecox

A

because it was assumed that it was a form of juvenile dementia caused by a degenerative process

103
Q

why has there been such a drive behind early intervention in psychosis programs?

A

meant to reduce duration of untreated psychosis and thus degree of neurogeneration–> stemming from idea that schizophrenia causes progressive deterioration

104
Q

does the data support that early intervention in schizophrenia leads to better outcomes?

A

initially, we thought yes–> but more recently, a paper suggested that “lead time bias” in research methods may confound the assoc. between untreated psychosis and illness course

105
Q

is there evidence that untreated psychosis damages brain structures?

A

recent meta analysis showed minimal evidence that untreated psychosis damages brain structures

106
Q

what does the more recent research suggest with regard to schizophrenia being degenerative/progressive?

A

increasing research suggests schizophrenia not progressive–> neuropsychological functioning can remain stable over time

107
Q

list theories other than the dopamine hypothesis that speak to development of schizophrenia

A
  1. ?synaptic pruning/global neuronal dysfunction may play a role
  2. ?sensory prediction deficits might explain why psychotic symptoms develop
    - -> and why those with schizotypal personalities are more likely to tickle themselves compared to general population
  3. HPA axis disruption
  4. endocrine disruption
108
Q

what bloodwork might reasonably be ordered in the assessment of a patient with schizophrenia

A

CBC
lytes
creatinine/GFR

urine drug screen

inflammatory markers–> CRP, ESR, RF, ANA, C3/C4, dsDNA

thyroid–> TSH, T3, T4, anti-thyroid peroxidase (anti-TPO)

toxins–> lead level

infectious markers–> HIV, Hep A/B/C, syphillis

metabolic screen–> HBA1c, LDL, HDL, total cholesterol, triglycerides

109
Q

what toxin should be screened for in schizophrenia

A

lead

110
Q

list some indications for neuroimaging when assessing a patient with suspected schizophrenia

A
  1. if signs or symptoms of intracranial pathology i.e headache, nausea, vomiting, seizure like activity, and/or late onset of psychotic symptoms
  2. rapid progression of cognitive and memory deficits in conjunction with psychotic symptoms
  3. clinical features suggestive of autoimmune encephalitis –> do MRI
111
Q

is routine head imaging recommended in first episode psychosis?

A

no

112
Q

other than blood work and psychiatric interview, what other assessment might be considered in those with schizophrenia

A

neuropsychological testing–> esp. in first episode psychosis or poor treatment response

113
Q

what is the benefit of first episode psychosis programs?

A

comprehensive care for first episode psychosis can improve FUNCTIONAL and CLINICAL outcomes

*effects more pronounced for those with shorter duration of untreated psychosis

114
Q

how often should you reassess someone with schizophrenia who is stable

A

every 3 months

115
Q

what is the gold standard treatment for schizophrenia

A

antipsychotics

116
Q

what % of individuals will only have one, single episode of psychosis

A

1-20%

117
Q

how long should someone remain on antipsychotic treatment after first episode psychosis

A

18 months

118
Q

how long should someone remain on antipsychotic treatment after having a acute episode (not first episode) of psychosis requiring treatment?

A

2-5 years following resolution of symptoms

  • BUT–> relapse rates are very high
  • consensus that those with chronic schizophrenia should remain on therapy long term
119
Q

what % of people will relapse with psychosis within 5 years

A

up to 80% with med discontinuation

120
Q

studies have suggested that what % of first episode psychosis patients are able to achieve good outcomes with either low or no doses of antipsychotic

A

up to 40%

BUT–> other retrospective studies have shown that more breaks in antipsychotic treatments may result in greater risk of relapse and longer time to remission

121
Q

is med discontinuation or continuation more evidence based currently in schizophrenia

A

med continuation

122
Q

is there evidence supporting using more than one antipsychotic in schizophrenia

A

no

123
Q

what is the average prevalence of antipsychotic polypharmacy

A

20%

more than 80% of these people were successfully discontinued off their second antipsychotic

124
Q

those with schizophrenia die how much earlier than those without?

A

up to 20 years earlier

125
Q

what is the major cause of excess mortality in those with schizophrenia

A

cardiovascular disease

126
Q

what % of people with schizophrenia meet criteria for treatment-resistant schizophrenia

A

25-30%

127
Q

what are the official criteria for treatment resistant schizophrenia

A

persistence of 2 or more POSITIVE symptoms with at least MODERATE severity

or

a SINGLE positive symptom with SEVERE severity

that still remain after TWO OR MORE adequate trials of different, non-clozapine antipsychotics

128
Q

for first episode psychosis, is there a difference in efficacy between typical or atypical antipsychotics

A

no

clozapine is only exception

129
Q

what is a adequate trial of an antipsychotic

A

reasonable adherence to med for at least 6 weeks at midpoint of therapeutic dose range

(or 6 weeks of treatment AFTER reaching steady state for LAIs)

130
Q

what is considered an adequate trial of clozapine

A

8-12 weeks at 400mg or above per day

131
Q

what are response rates to clozapine in the treatment resistance schizophrenia population

A

30-60%

132
Q

what are the criteria for categorizing someone with clozapine resistant schizophrenia

A

adequate trial of clozapine fails

133
Q

what should you do if clozapine fails

A

consider why treatment response not occurring

consider medication adherence

consider revisiting the diagnosis–> might want a broader differential diagnosis

i.e consider doing neuro exam, autoimmune causes, other medical conditions

134
Q

list psychosocial treatments/approaches for schizophrenia

A
  1. family interventions
  2. supported employment
  3. various psychotherapies
135
Q

what are the benefits to assertive community treatment teams for those with chronic psychosis

A

can help:

reduce hospitalization rates

improve occupational functioning

improve quality of life

BUT–> they do not improve overall clinical state and do not change overall costs of care

136
Q

what do family interventions in schizophrenia entail?

A

communication skills

problem solving

psychoeducation

*should be offered to all families

137
Q

what is the bare minimum that should be offered to famililies of those with schizophrenia with regard to family interventions

A

minimum 10 sessions over three month period

138
Q

what is the benefit from family interventions in schizophrenia

A

RCTs have shown they can both reduce severity of patients symptoms and reduce chance of hospitalization

139
Q

how does living in a family with highly expressed emotion affect patients risk for relapse in schizophrenia

A

those who live in households with high expressed emotion are at significant greater risk of relapse than those living in lower expressed emotion households

140
Q

list psychotherapies shown to be effective in schizophrenia

A
  1. CBT for psychosis
  2. family intervention
  3. cognitive remediation
  4. social skills training i.e similar to what is offered to those with ADHD
141
Q

what is the minimum recommended number of CBT for psychosis sessions

A

16

3. Psychosis (10 decks)

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