Schizophrenia Flashcards
what is schizophrenia
a mental disorder characterized by the presence of positive symptoms (delusions, hallucinations), disorganization, and negative symptoms
is there is difference in gender prevalence between men and women in schizophrenia
generally same between men and women—> differ in course and onset of illness
DSM V says that may be slightly less common in women
when is the incidence of first episode of psychosis highest for men
between ages of 18-24
incidence subsequently declines rapidly
when is the incidence of first episode of psychosis highest amongst women
bimodal distribution
one peak in late 20s and then secondary peak between ages 50-54
how does the presentation vary in women compared to men for schizophrenia
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
criterion A for schizophrenia
TWO (or more) of the following, each present for a significant period of time during a ONE MONTH PERIOD (or less if successfully treated):
- delusions
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behaviour
- negative symptoms
* at least one must be 1, 2, or 3
* these are the active phase symptoms
criterion B schizophrenia
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
criterion C schizophrenia
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
criterion D schizophrenia
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
criterion E schizophrenia
not attributable to physiologic effects of a substance or another medical condition
criterion F schizophrenia
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
is there any single symptom that is pathognomonic for schizophrenia
no
what is often the first sign of schizophrenia
individuals who were previously socially active may become withdrawn from previous routines
what other features not mentioned in the criteria may support dx schizophrenia
- display of inappropriate affect–> i.e laughing in absence of appropriate stimulus
- dysphoric mood that can look like depression, anxiety or anger
- disturbed sleep pattern
- lack of interest in eating or food refusal
- depersonalization, derealization and somatic concerns –> may reach delusional intensity
- cognitive deficits
what types of cognitive deficits can be seen in schizophrenia
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
what is anosognosia
lacking insight or awareness of their disorder
may be present throughout entire course of illness
*typically symptom of illness itself rather than coping strategy
what is the most common predictor of nonadherence to treatment
anosognosia/lack of insight
what types of things does the presence of anosognosia/lack of insight predict
nonadherence to treatment
higher relapse rates
increased number of involuntary admissions
poorer psychosocial functioning
aggression
poorer course of illness
what differences in brain structure can be seen between those with schizophrenia and those without
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
list neurological soft signs that may be seen in those with schizophrenia
impairments in:
- motor coordination
- sensory integration
- motor sequencing of complex movements
left right confusion
disinhibition of associated movements
what is the lifetime prevalence of schizophrenia
- 3-0.7%
* there is reported variation across race/ethnicity, across countries and by geographic origin
when do psychotic features of schizophrenia usually arise
between late teens and mid 30s
*onset before adolescence is RARE
describe the typical onset of symptoms for most people
usually slow and gradual development of variety of clinically significant signs and symptoms
what % of individuals who develop schizophrenia with gradual course of onset complain of depressive symptoms
about 50%
how does age at onset affect predicted outcome? why is this likely to be the case?
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
do cognitive impairments dissipate when positive symptoms do during treatment for schizophrenia
may persist and contribute to the disability of the disease
do we know why some things are predictors of outcome and course in schizophrenia
no–are largely unexplained
course and outcome may not be reliably predicted
in what % of people is the course of schizophrenia FAVORABLE
about 20%
*a small number are reported to recover completely
what is the usual course of schizophrenia
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
how do psychotic symptoms change over the lifecourse in schizophrenia
tend to diminish
why do they think psychotic symptoms tend to decline with age in schizophrenia
perhaps in assoc. with normal age related declines in dopamine activity
are negative or positive symptoms more closely related to prognosis in schizophrenia
NEGATIVE symptoms
tend to be the most persistent
also cognitive deficits may not improve over the course of the illness
how does schizophrenia manifest in childhood
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
what types of hallucinations are more common in schizophrenia in children
visual
for a patient who later receives a dx of schizophrenia, what psychiatric manifestations might they have shown in childhood
nonspecific emotional-behavioural disturbances and psychopathology
intellectual and language alterations
subtle motor delays
what gender is more likely to present with late onset schizophrenia
females
what is considered late onset schizophrenia
after age 40
how might a late onset schizophrenia present
predominance of psychotic symptoms
preservation of affect and social functioning
environmental risk factors for schizophrenia
- season of birth
- being raised in urban environment
- some minority ethnic groups
which seasons of birth are associated with higher rates of schizophrenia
late winter/early spring in some areas
summer is assoc. with deficit form of the disease
genetic and physiologic risk factors for schizophrenia
- strong contribution for genetic factors in determining risk for schizophrenia–> spectrum of risk alleles–> each allele contributes only small fraction to total population variance
- greater paternal age
- pregnancy and birth complications with hypoxia
- prenatal adversities–> stress, infection, malnutrition, maternal diabetes, other medical conditions
do most people diagnosed with schizophrenia have a relative with the disease?
no–most have no family history of psychosis
what prenatal adversities may increase risk of schizophrenia
stress
infection
maternal diabetes
malnutrition
medical conditions
*vast majority of babies with these risk factors do not develop schizophrenia
list differences between presentations of schizophrenia in men and women
- incidence lower in women
- age at onset later among women
- woman have second mid life peak
- symptoms more affect laden among women
- more psychotic symptoms among women –> psychotic symptoms more likely to worsen later in life
- less frequent negative symptoms and less disorganization among women
- social functioning tends to be better preserved in women
what % of people with schizophrenia die by suicide
5-6%
what % of people with schizophrenia attempt suicide
20%
how does suicide risk change over the lifespan for people with schizophrenia
remains HIGH throughout the life span for males and females
in what population might suicidal risk be especially high amongst patients with schizophrenia
younger males with comorbid substance use
list risk factors for suicide risk in people with schizophrenia
- younger male
- comorbid substance use
- depressive symptoms
- feelings of hopelessness
- being unemployed
- in the period after a psychotic episode or hospital discharge
ddx for schizophrenia
- MDD or bipolar disorder with psychotic or catatonic features
- schizoaffective disorder
- schizopphreniform disorder
- brief psychotic disorder
- delusional disorder
- schizotypal personality disorder
- OCD
- Body dysmorphic disorder
- PTSD
- autism or communication disorders
- other mental disorders with a psychotic episode
how do you distinguish between MDD or bipolar with psychotic features and schizophrenia
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
how do you distinguish between schizophrenia and schizoaffective disorder
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
how do you distinguish between schizophrenia and schizotypal PD
schizotypal PD is characterized by SUBTHRESHOLD symptoms that are associated with persistent personality features
how might PTSD resemble schizophrenia
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).
what % of people with schizophrenia also have tobacco use disorder
over 50%
what other mental health conditions are more common in those with schizophrenia than in the general population
anxiety disorders
OCD
panic disorder
how does schizophrenia affect life expectancy? how does it do this?
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.
risk factors for suicide
male gender
high socioeconomic background
high intelligence
high expectations
being single
lack of social supports
having awareness of symptoms
recent discharge from hospital
estimate of what % of people with schizophrenia die by suicide
5-13% (according to psych DB)
are cognitive deficits generally more or less severe in schizophrenia than in bipolar disorder
more severe in schizophrenia
list good prognostic factors for schizophrenia
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)
what can you do to significant decrease the risk for violence and crime in schizophrenia
treat with medications
list poor prognostic factors for schizophrenia
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
what % of people with schizophrenia meet the criteria for recovery
about 13%
who has better outcomes in schizophrenia–those in developed or developing countries
developing
what % of people with schizophrenia experience insomnia
close to 50%
*insomnia is predictive of onset of psychotic experiences
heritability accounts for what % of the liability of schizophrenia
about 80%
HIGHLY heritable
what is the baseline general population risk for schizophrenia
1%
how much does the risk of schizophrenia increase if you have a second degree relative with schizophrenia
increases to 2% risk
how much does the risk of schizophrenia increase if you have a non-twin sibling with schizophrenia
increases to 9%
what is your risk for schizophrenia if one parent has schizophrenia
13%
what is the risk of schizophrenia if both parents have schizophrenia
30-50% chance of developing the disorder
what is the concordance rate for schizophrenia in identical twins
40-50%
how much does advanced paternal age (over 35) increase the risk of schizophrenia
increases risk to 1.5-3%
what is paraphrenia
previously used to describe psychotic symptoms in the elderly –> now use “late life psychosis”
what are partition delusions
belief that people or objects can transgress impermeable barriers and access their omes with malign intent (more common in late life schizophrenia)
how does the effective dosage of antipsychotic differ between typical schizophrenia and schizophrenia with onset in late life
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
name a rating scale for schizophrenia
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)
how might you assess depression in schizophrenia
using the Calgary depression scale for schizophrenia (CDSS)
what is the dopamine hypothesis of schizophrenia
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
which dopaminergic pathway is most associated with the positive symptoms of schizophrenia in the dopamine hypothesis
mesolimbic
how to antipsychotics work according to the dopamine hypothesis of schizophrenia
target the mesolimbic pathway to BLOCK dopamine and decrease incidence of positive symptoms
–> bind to dopaminergic neuroreceptors
list neuroimaging findings in schizophrenia
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)
is there a molecular subtype of schizophrenia that can be identified?
yes–> DiGeorge Syndrome
what is DiGeorge Syndrome
a molecular subtype of schizophrenia that can be identified
is a deletion syndrome
what is the deletion associated with DiGeorge Syndrome
22q11.2 deletion
what is the risk of schizophrenia associated with DiGeorge syndrome/22q11.2 deletion syndrome
1 in 4 chance to develop schizophrenia (20-30x increased risk of schizophrenia compared to population risk)
*remains under recognized and under diagnosed
what is the most common microdeletion syndrome in humans
DiGeorge Syndrome (22q11.2)
what other abnormalities are associated with DiGeorge syndrome
congenital heart problems
facial dysmorphia
developmental delay
learning problems
cleft palate
(can also have renal problems, hearing loss, infections and autoimmune disorders)
what is the prevalence of DiGeorge Syndrome
1 in 4000 people
other than schizophrenia, people with DiGeorge syndrome are also at higher risk of what disorder
early onset parkinsons
what % of cases of DiGeorge syndrome are new diagnoses with no family history
90%
what test is recommended as first line test for DiGeorge SYndrome
clinical microarray
*actually this is a first line test recommended for any individual with intellectual disability, developmental delay or multiple congenital abnormalities
how might someone with DiGeorge syndrome present clinically
hypernasal speech
long, narrow face
narrow palpebral fissures
flat cheeks
prominent nose
small ears
small mouth
retruded chin
heart defects
does schizophrenia “look” different in those with DiGeorge syndrome
no–> indistinguishable from idiopathic forms
similar age at onset and similar prodromal symptoms
thus, same treatment recommended
what is the estimated prevalence of schizophrenia patients having DiGeorge
1 in 100-200 patients
patients with DiGeorge are at greater risk of what adverse events when treated with clozapine (more than others with schizophrenia)
higher risk of seizures–> may need lower doses of prophylactic seizure meds
neutropenia
myocarditis
list two infectious diseases thought to increase risk of schizophrenia
toxoplasma gondii
(thus exposure to cats in childhood is risk factor for schizophrenia)
influenza
describe the theory behind the etiology of influenza infections and schizophrenia
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
have there even been documented cases of people with congenital blindness developing schizophrenia
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
what was the first term for schizophrenia? who developed it?
dementia praecox–> Emil Kraeplin
why was schizophrenia first called dementia praecox
because it was assumed that it was a form of juvenile dementia caused by a degenerative process
why has there been such a drive behind early intervention in psychosis programs?
meant to reduce duration of untreated psychosis and thus degree of neurogeneration–> stemming from idea that schizophrenia causes progressive deterioration
does the data support that early intervention in schizophrenia leads to better outcomes?
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
is there evidence that untreated psychosis damages brain structures?
recent meta analysis showed minimal evidence that untreated psychosis damages brain structures
what does the more recent research suggest with regard to schizophrenia being degenerative/progressive?
increasing research suggests schizophrenia not progressive–> neuropsychological functioning can remain stable over time
list theories other than the dopamine hypothesis that speak to development of schizophrenia
- ?synaptic pruning/global neuronal dysfunction may play a role
- ?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 - HPA axis disruption
- endocrine disruption
what bloodwork might reasonably be ordered in the assessment of a patient with schizophrenia
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
what toxin should be screened for in schizophrenia
lead
list some indications for neuroimaging when assessing a patient with suspected schizophrenia
- if signs or symptoms of intracranial pathology i.e headache, nausea, vomiting, seizure like activity, and/or late onset of psychotic symptoms
- rapid progression of cognitive and memory deficits in conjunction with psychotic symptoms
- clinical features suggestive of autoimmune encephalitis –> do MRI
is routine head imaging recommended in first episode psychosis?
no
other than blood work and psychiatric interview, what other assessment might be considered in those with schizophrenia
neuropsychological testing–> esp. in first episode psychosis or poor treatment response
what is the benefit of first episode psychosis programs?
comprehensive care for first episode psychosis can improve FUNCTIONAL and CLINICAL outcomes
*effects more pronounced for those with shorter duration of untreated psychosis
how often should you reassess someone with schizophrenia who is stable
every 3 months
what is the gold standard treatment for schizophrenia
antipsychotics
what % of individuals will only have one, single episode of psychosis
1-20%
how long should someone remain on antipsychotic treatment after first episode psychosis
18 months
how long should someone remain on antipsychotic treatment after having a acute episode (not first episode) of psychosis requiring treatment?
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
what % of people will relapse with psychosis within 5 years
up to 80% with med discontinuation
studies have suggested that what % of first episode psychosis patients are able to achieve good outcomes with either low or no doses of antipsychotic
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
is med discontinuation or continuation more evidence based currently in schizophrenia
med continuation
is there evidence supporting using more than one antipsychotic in schizophrenia
no
what is the average prevalence of antipsychotic polypharmacy
20%
more than 80% of these people were successfully discontinued off their second antipsychotic
those with schizophrenia die how much earlier than those without?
up to 20 years earlier
what is the major cause of excess mortality in those with schizophrenia
cardiovascular disease
what % of people with schizophrenia meet criteria for treatment-resistant schizophrenia
25-30%
what are the official criteria for treatment resistant schizophrenia
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
for first episode psychosis, is there a difference in efficacy between typical or atypical antipsychotics
no
clozapine is only exception
what is a adequate trial of an antipsychotic
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)
what is considered an adequate trial of clozapine
8-12 weeks at 400mg or above per day
what are response rates to clozapine in the treatment resistance schizophrenia population
30-60%
what are the criteria for categorizing someone with clozapine resistant schizophrenia
adequate trial of clozapine fails
what should you do if clozapine fails
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
list psychosocial treatments/approaches for schizophrenia
- family interventions
- supported employment
- various psychotherapies
what are the benefits to assertive community treatment teams for those with chronic psychosis
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
what do family interventions in schizophrenia entail?
communication skills
problem solving
psychoeducation
*should be offered to all families
what is the bare minimum that should be offered to famililies of those with schizophrenia with regard to family interventions
minimum 10 sessions over three month period
what is the benefit from family interventions in schizophrenia
RCTs have shown they can both reduce severity of patients symptoms and reduce chance of hospitalization
how does living in a family with highly expressed emotion affect patients risk for relapse in schizophrenia
those who live in households with high expressed emotion are at significant greater risk of relapse than those living in lower expressed emotion households
list psychotherapies shown to be effective in schizophrenia
- CBT for psychosis
- family intervention
- cognitive remediation
- social skills training i.e similar to what is offered to those with ADHD
what is the minimum recommended number of CBT for psychosis sessions
16
