Schizophrenia

Question 1

Approach to Psychiatric Diagnosis

Answer 1

Secondary to General Medical Condition or Substance Use

Psychotic Disorder vs. Non‐Psychotic Disorder (“Neurosis”)

Question 2

Psychosis

Definition

Answer 2

• Loss of touch with reality
• An inability to meet the daily demands of life
• Absence of insight

Question 3

Differential Diagnosis of Psychosis

Answer 3

• Schizophrenia
• Schizophreniform disorder
• Brief Psychotic disorder
• Schizoaffective disorder
• Mood disorder with psychotic features
• Delusional disorders
• Psychosis Others & Unspecified

Question 4

Schizophrenia or Mood Disorders

Answer 4

Question 5

Schizophrenia and Related Disorders

Answer 5

Schizophrenia Spectrum

Question 6

DSM 5:

Schizophrenia

Answer 6

A. Two or more for 1 month, one of them must be a delusion, hallucination or thought disorder

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Disorganized or catatonic behavior
5. Negative symptoms: diminished emotional expression or avolition

B. Social and occupational dysfunction

C. Continuous signs of disturbance persist for 6 months

D. Schizoaffective and Mood disorders excluded

E. Substance / General medical condition excluded

Question 7

Schizophrenia

Subtypes

Answer 7

• Paranoid
  
  • Pts mainly present with delusions of persecutions
• Disorganized
  
  • Disorganized behavior and speech and include disturbances in emotional expression
• Catatonic
  
  • Catatonic symptoms: motor syndrome psychosis
  • Waxy flexibility: pt can be molded into any shape and stay there
• Undifferentiated
  
  • When you can’t differentiate what type the pt has
• Residual
  
  • Pt presents with negative symptoms

Question 8

Schizophrenia Spectrum

Time Duration

Answer 8

• Duration > 1 day, but < 1 Month ⇒ Brief Psychotic Disorder
• Duration > 1 month, but < 6 months ⇒ Schizophreniform Disorder
• Duration > 6 months ⇒ Schizophrenia

Question 9

DSM 5:

Schizoaffective Disorder

Answer 9

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Question 10

Catatonia

Answer 10

The clinical picture is dominated by three (or more) of the following symptoms:

1. Stupor (i.e., no psychomotor activity; not actively relating to environment)
2. Catalepsy (i.e., passive induction of a posture held against gravity)
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner)
4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia])
5. Negativism (i.e., opposition or no response to instructions or external stimuli)
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity)
7. Mannerism (i.e., odd, circumstantial caricature of normal actions)
8. Stereotypy (i.e., repetitive, abnormally frequent, non‐goal‐directed movements)
9. Agitation, not influenced by external stimuli
10. Grimacing
11. Echolalia (i.e., mimicking another’s speech)
12. Echopraxia (i.e., mimicking another’s movements)

Question 11

Bush Francis Scale

Catatonia Assessment

Answer 11

Question 12

DSM 5:

Delusional Disorder

Answer 12

• The presence of one (or more) delusions with a duration of 1 month or longer.
• Criterion A for schizophrenia has never been met.
• Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
• The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive‐compulsive disorder.

Question 13

DSM 5:

Delusional Disorder Subtypes

Answer 13

• Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the individual.
• Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
• Jealous type: This subtype applies when the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful.
• Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long‐term goals.
• Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.

Question 14

First Rank Symptoms of Schizophrenia

Answer 14

1. Running commentary hallucinations
2. Voices discussing the patient in 3^rd person
3. Thought echo
4. Thought insertion
5. Thought withdrawal
6. Thought broadcast
7. Passivity experiences (affect, impulse & action)
8. Somatic passivity
9. Delusional perception

Question 15

Schizophrenia

Clinical Features

Answer 15

• Positive Symptoms ⇒ responds well to tx
  
  • Delusions
  • Hallucinations
• Negative Symptoms ⇒ does not respond well to tx
  
  • Alogia
  • Amotivation
• Cognitive
  
  • Memory
  • Planning
  • Problem solving / Executive functioning
• Aggression
  
  • Violence
  • Suicide / Homicide
• Depression
  
  • Anxiety
  • Irritability

Question 16

Schizophrenia

Mental Status Examination

Answer 16

• General Appearance: Can range from Disheveled, Malodorous to obsessively groomed to mute /immobile. Suspicious and Hypervigilant.
• Mood and Affect: Reduced responsiveness, Flat or Blunt Affect. Anxious if suspicious.
• Thought: Formal Thought Disorder. Delusions.
• Perception: Hallucinations
• Orientation
• Cognitive Functioning
• Insight and Judgement

Question 17

Schizophrenia

Physical Exam

Answer 17

• Soft Neurological Signs
• Movement Disorder
• Obesity (Metabolic Syndrome)

Question 18

Schizophrenia

Epidemiology

Answer 18

• Lifetime prevalence around 1% (ECA Studies: 0.6 ‐1.9% prevalence)
• In the US, 0.05% of the population is treated for Schizophrenia
• Only about half all patients with schizophrenia obtain treatment
• Sex ratio equal (? May be slightly more common in men).
• Onset earlier in men

Question 19

Schizophrenia

Biological Factors

Answer 19

• Neurotransmitters
• Neuropathology
• Brain imaging
• Electrophysiology
• Genetic factors
• Neurodevelopmental

Question 20

Schizophrenia

Neurotransmitters

Answer 20

• Dopamine hypothesis
  
  • Dopaminergic over activity is implicated in Schizophrenia
  • Most antipsychotics are D₂ antagonists
    
    • Major classes of Antipsychotics (Neuroleptics)
      
      • 1. Typical
      • 2. Atypical (Serotonin‐ Dopamine Antagonists)
• Glutamate
  
  • Glutamate activity at NMDA receptors is hypofunctional
    
    • Due to abnl formation of glutamatergic NMDA synapses during neurodevelopment
  • NMDA receptor antagonists (PCP or ketamine) ⇒ psychotic condition very similar to schizophrenia
    
    • Mimic not only the positive symptoms of schizophrenia, but also the cognitive, negative and affective symptoms of schizophrenia
• Other neurotransmitters: 5‐HT, NE, GABA

Question 21

Schizophrenia

Neuropathology

Answer 21

No circumscribed anatomical or functional abnormalities specific to Schizophrenia have been identified

Frequent findings:

• Enlargement of ventricular system, specifically third and lateral
• Overall reductions in grey matter
• Limbic System: Reduction in volume, particularly hippocampus, amygdala and parahippocampal gyrus
• Anatomical abnormalities in the prefrontal cortex as well as functional deficits
• Changes in the basal ganglia are variable

Question 22

Schizophrenia

Functional Brain Imaging

Answer 22

• PET allows examination of cerebral blow (CBF) and receptor function
• ↓ CBF in frontal regions, thalamus and cerebellum in Schizophrenia pts performing executive tasks, memory and attentional tasks
• fMRI studies show hypofrontality in schizophrenia
  
  • Related to reduced DA activity in the frontal lobes

Question 23

Schizophrenia

Electrophysiology

Answer 23

Relationship with seizure disorders

Eye movement dysfunction (saccadic movement)

Question 24

Schizophrenia

Genetics

Answer 24

Genetic factors contribute substantially but not exclusively, to the underlying cause of Schizophrenia

• Family studies
• Twin studies
• Adoption studies
  
  • Nature vs nurture studies
  • Found that contribution of genes was greater than environment
• Genetic mechanisms
  
  • Heterogeneous genetic basis
• Bottom Line:
  
  • Many risk genes exist – each with a small effect and common in the general population
  • Patients probably inherit several genes which interact with each other and the environment to cause Schizophrenia once a critical threshold is crossed

Question 25

Schizophrenia Neurodevelopmental Factors

Answer 25

* Schizophrenia is associated with **neurodevelopmental issues**. * **Morphological abnormalities** occur at a higher frequency (aqueduct stenosis, arachnoid cyst, agenesis of corpus callosum) * **Obstetric complications** * Developmental issues: **Intellectual disability, Disruptive behavior disorders** * **Increased minor physical anomalies**

Question 26

Schizophrenia Psychosocial Theories

Answer 26

* **Family theories:** * **Double bind:** mixed messages given to child from parents * **Schisms/skewed:** parents fighting for love of child, ultimately conflicting the child * **Expressed emotions:** * The expressed emotion (EE) is considered to be an **adverse family environment** * Quality of interaction patterns * Nature of family relationships among the family caregivers and patients of schizophrenia and other psychiatric disorders * Hostility, Criticality, Over protectiveness * **Social Theories: ? urbanization** * Does living in an urban environment play a role? * Cities w/ higher population density have a higher rate of Schizophrenia * People with Schizophrenia tend to migrate to cities * **Antipsychiatry** * Movement in the 40’s * Belief that there is no such thing as mental illness * Can foster hostility against labeling psychiatric d/o

Question 27

Schizophrenia Psychological Factors

Answer 27

**Psychoanalytic theories:** Ego defect leads to loss of touch with reality **Learning Theories:** Children learn irrational ways of thinking

Question 28

Schizophrenia Stress vulnerability Model

Answer 28

There is an **underlying psychobiological vulnerability** Onset of illness is determined by **dynamic interplay of biological and psychosocial factors**

Question 29

Schizophrenia Prognosis

Answer 29

* Highly variable * **Fluctuating course in the first 5 years** * **Positive sx tend to diminish in intensity** * **Negative sx worsen** * 10‐20% have a good outcome * \> 50% have a poor outcome * Prognosis in the developing world may be better

Question 30

Schizophrenia Pharmacological treatment

Answer 30

* **Conventional antipsychotics** (Typical Antipsychotics) * High potency * Low potency * CATIE study: could use typicals as 1st line * **Atypical antipsychotics** * Effective in treating positive as well as negative symptoms * No/minimal EPS * Improvement in cognitive and social functioning * Associated with metabolic syndromes (weight gain, dyslipidemia, hyperglycemia) * Hyperprolactinemia * **Second Generation Antipsychotics (SGA)** * TEOSS study: SGAs did not demonstrate superiority * **Serotonin Dopamine Antagonists (SDA)**

Question 31

Schizophrenia Psychosocial treatment

Answer 31

* **Assertive community treatment** * **Most important aspect of Schizophrenia treatment** * Designated case managers who are actively involved in helping the pt in the community * Make sure pts go to apts, fill out rx, etc * Help pts with chores (get benefits, go grocery shopping, go to the bank, find housing, etc)

Question 32

Schizophrenia Procedures of Admission

Answer 32

* **Informal Admission** * **Voluntary Admission (most common) (“201”)** * Voluntary admission but d/c is conditional * Must give 72 hr notice so physician can determine if fit for discharge or need involuntary admission * **Temporary Admission** * Legal admission usu. made by a judge * Pt is admitted for 30 days in order to prepare for court * **Involuntary Admission (“302”)** * Pt admitted against their will by family, friend, or 2 physicians * Must be brought in front of a judge within 120 hrs of admission for review * Risk to themselves or others * Possibility that in the next 30 days they will harm themselves * Max 30 day hold