Schizophrenia Flashcards
Approach to Psychiatric Diagnosis
Secondary to General Medical Condition or Substance Use
Psychotic Disorder vs. Non‐Psychotic Disorder (“Neurosis”)
Psychosis
Definition
- Loss of touch with reality
- An inability to meet the daily demands of life
- Absence of insight
Differential Diagnosis of Psychosis
- Schizophrenia
- Schizophreniform disorder
- Brief Psychotic disorder
- Schizoaffective disorder
- Mood disorder with psychotic features
- Delusional disorders
- Psychosis Others & Unspecified
Schizophrenia or Mood Disorders
Schizophrenia and Related Disorders
Schizophrenia Spectrum
DSM 5:
Schizophrenia
A. Two or more for 1 month, one of them must be a delusion, hallucination or thought disorder
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized or catatonic behavior
- 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
Schizophrenia
Subtypes
-
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
Schizophrenia Spectrum
Time Duration
- Duration > 1 day, but < 1 Month ⇒ Brief Psychotic Disorder
- Duration > 1 month, but < 6 months ⇒ Schizophreniform Disorder
- Duration > 6 months ⇒ Schizophrenia
DSM 5:
Schizoaffective Disorder
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.
Catatonia
The clinical picture is dominated by three (or more) of the following symptoms:
- Stupor (i.e., no psychomotor activity; not actively relating to environment)
- Catalepsy (i.e., passive induction of a posture held against gravity)
- Waxy flexibility (i.e., slight, even resistance to positioning by examiner)
- Mutism (i.e., no, or very little, verbal response [exclude if known aphasia])
- Negativism (i.e., opposition or no response to instructions or external stimuli)
- Posturing (i.e., spontaneous and active maintenance of a posture against gravity)
- Mannerism (i.e., odd, circumstantial caricature of normal actions)
- Stereotypy (i.e., repetitive, abnormally frequent, non‐goal‐directed movements)
- Agitation, not influenced by external stimuli
- Grimacing
- Echolalia (i.e., mimicking another’s speech)
- Echopraxia (i.e., mimicking another’s movements)
Bush Francis Scale
Catatonia Assessment
DSM 5:
Delusional Disorder
- 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.
DSM 5:
Delusional Disorder Subtypes
- 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.
First Rank Symptoms of Schizophrenia
- Running commentary hallucinations
- Voices discussing the patient in 3rd person
- Thought echo
- Thought insertion
- Thought withdrawal
- Thought broadcast
- Passivity experiences (affect, impulse & action)
- Somatic passivity
- Delusional perception
Schizophrenia
Clinical Features
-
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
Schizophrenia
Mental Status Examination
- 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
Schizophrenia
Physical Exam
- Soft Neurological Signs
- Movement Disorder
- Obesity (Metabolic Syndrome)
Schizophrenia
Epidemiology
- 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
Schizophrenia
Biological Factors
- Neurotransmitters
- Neuropathology
- Brain imaging
- Electrophysiology
- Genetic factors
- Neurodevelopmental
Schizophrenia
Neurotransmitters
-
Dopamine hypothesis
- Dopaminergic over activity is implicated in Schizophrenia
- Most antipsychotics are D2 antagonists
- Major classes of Antipsychotics (Neuroleptics)
- Typical
- Atypical (Serotonin‐ Dopamine Antagonists)
- Major classes of Antipsychotics (Neuroleptics)
-
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
-
Glutamate activity at NMDA receptors is hypofunctional
- Other neurotransmitters: 5‐HT, NE, GABA
Schizophrenia
Neuropathology
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
Schizophrenia
Functional Brain Imaging
- 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
Schizophrenia
Electrophysiology
Relationship with seizure disorders
Eye movement dysfunction (saccadic movement)
Schizophrenia
Genetics
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
Schizophrenia
Neurodevelopmental Factors
- 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
Schizophrenia
Psychosocial Theories
-
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
- The expressed emotion (EE) is considered to be an adverse family environment
-
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
Schizophrenia
Psychological Factors
Psychoanalytic theories: Ego defect leads to loss of touch with reality
Learning Theories: Children learn irrational ways of thinking
Schizophrenia
Stress vulnerability Model
There is an underlying psychobiological vulnerability
Onset of illness is determined by dynamic interplay of biological and psychosocial factors
Schizophrenia
Prognosis
- 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
Schizophrenia
Pharmacological treatment
-
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)
Schizophrenia
Psychosocial treatment
-
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)
Schizophrenia
Procedures of Admission
- 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
