Schizophrenia and Other Psychotic Disorders Flashcards
What are the 4 criteria for diagnosing Schizophrenia?
Criteria A: Active Phase signs and sx
Criteria B: Social occupational dysfunction: how bad is it?
Criteria C: Time duration
Criteria D: Another diagnostic explanation
What is Criteria A?
What is required to meet Criteria A?
Criteria A = Signs and Symptoms
- Hallucinations
- Delusions
- Disorganized thinking
- Disorganized behavior
- Negative symptoms
Need two symptoms, o_n_e which must be a “positive” symptom (hallucination, delusion or disorganized thinking, disorganized behavior)
What is psychosis
what types of experiences/symptoms does the patient experience?
Grossly impaired reality testing
Persons incorrectly evaluatel teh accuracy of their perceptions and thoughts and make incorreect inferences about external reality, even in the face of contrary evidence
Psychosis commonly means the patient is experiencing DELUSIONS and HALLUCINATIONS, refered to as POSITIVE symptoms of schizo.
Disorganized thinking = psychotic thinking, or psychosis, is also a positive symptoms
What are hallucinations?
what are the types of hallucinations that exist? which is the most common?
When can hallucinations not be pathological?
Hallucinations are perceptions without stimuli (perceived senses with no stimuli - you see something but there is nothing there, you feel something that isn’t there, you hear sounds that are non-existant)
Auditory = hearing voices, most common
Visual = seeing things, second most common
Tactile, feeling things that are not there, such as bugs on or under one’s skin; not as common, can be seein in substance withdrawal syndromes
Gustatory and olfactory are rare; perhaps with neuro involvement or connected with an aura
**The person needs to be fully awake! Hypogogic and hypomonic (night/morning) are not necessarily pathological since the person might not be fully awake
What are delusions?
What types of delusions occur?
How can we approach a delusional patient?
Delusions = unfounded, unrealistic BELIEFS that is held withouth supporting evidence and are not amenable to change when conflicting evidence is presented; person is convinced that whaty they belive is true - can often lead to conflict with others
DELUSIONS ARE THOUGHTS perceived to be 100% true
Non-bizarre delusions - thoughts with a certain amount of plausibility when you first hear about it but then it becomes less plausible with time; but they are 100% sure that it is happening and do not consider other possibilities (ie - my SO is being unfaithful, I am being watched/monitored, harassed by my neighbors)
Bizarre delusions- clearly impossible, not understandable and/or do not derive from ordinary life experiences. Usually easy oto identify though can be difficult to judge situations involving diff cultures (ie- my SO is being unfaithful with Elvis, currently; Alien controlled neighbors are monitoring/harassing me)
Approach: collateral hx, ask about “conflicts” they may currently be having
What is disorganized thinking?
What are the different types?
Derailment vs tangenital speech
Disorganized thinking = sx that substantially impair effective communication, infered primarily upon the individual’s speech
Derailment = person talking about a topic…derails/stops…resumes on a different topic; there is loose associations, person slips off track from one topic to another topic, while the associations btw topics is weak/unclear
Tangential Speech = answers are unrealted or only vaguely related to the question, incoherent or word salad = severely disorganized speech, nearly incomprehendable
What is disorganized behavior?
What theme surrounds this sx?
Disorganized behavior = grossly disorganized, seen in wide range of possible behaviors. Childlike silliness to upredictable agitation, problems with any form of goal directed behavior - can lead to difficult performing activities of daily living (meal prep, maintaining personal hygiene)
Many times the theme around disorganized behavior is social impairment, caused by decreased daily activities
What are negative symptoms?
What criteria must be met?
Only need to have 1 negative symptoms to qualify as having neg. symptoms
- Affective flattering: lack of emotion, interpersonal emotional cues (facial expresison, eye contact, body language) are lacking
- Alogia - poverty of speech; brief, laconic, empty replies
- Avolition - lack of motivation; inability to initiate and persist in goal direct activities
- Anhedonia - lack of pleasure; unable to enjoy activities
What is criteria B signify?
What is meant by the downward drift hypothesis? relate this with the # of schizophrenics in lower socio-economic groups and within the homeless population
Social Occupational Dysfunction, how bad is it?
For a signifiacnt portion of the time since the onset of the disturbance, ONE OR MORE major areas of functioning - work, interpersonal relationships or self-care - are markedly below the level achieved prior to the onset (OR if the onset is in childhood / adolescence, failure to achieve expected level of interpersonal, academic or occupational achievement)
Downward Drift Hypothesis: hypothesizes that the social-occupational dysfunction of schizophrenia results in those who start out with resources available but gradulaly lose them and “drift downward” into the low socio-economic group.
- A disproportionate number of people with schizoprenia are in the low socio-economic group*
- 33% of homeless population have schizophrenia*
What is Critera C?
If criteria C is NOT met, what could this otherwise signify?
Criteria C = Time Duration
continuous signs of the disturbance that persists for at least SIX months - criteria A does NOT need to be met for the entire time; at least ONE MONTH where criteria A (active phase symptoms) is met
If duration of sx is < 1 month = brief psychotic disorder / psychosis NOS (non otherwise specified)
If duration lasts 1 mo < sx < 6 months- schizophreniform
Onset of illness - prodromal phase = gradual onset and building of symptoms of schizophrenia; often it is not realized until the symptoms have gotten serioud (first break of pychosis) that the behaviours were abnormal and part of a prodromal phase
What does Criteria D require?
According to Criteria D, what are other possibilities (6):
Criteria D ensures that another diagnositc explanation is not the cause of the symptoms.
What are other possibilities:
- Another psychotic disorder - schizoaffective disorder, delusional disorder, schizophreniform disorder, brief psychotic disorder, psychosis N.O.S
- Mood disorder with psychosis - bipolar disorder w/ psychotic features, MD with spychotic features
- Psychosis due to a substance - substance intoxication/withdrawal, psychosis secondary to medication rxn
- General medical condition -any medical illenss that effects the CNS - neurological, endocrine, metabolic
- Developmental disorders - autism, Rhett’s disorder, Asperger’s
- Personality disorders - Cluster A paranoid, schizoid, schizotypal
What is schizoaffective disorder?
It is a psychotic disorder that could be another diagnostic explanation.
A major mood episode (MD, bipolar) is concurrent with Criteria A.
Major mood symptoms are present for the majority of the total duriation of the illness. At least TWO WEEK period of hallucinations/delusions WITHOUT mood symptoms present.
What is delusional disorder?
Bizzare or non-bizzare delusion; most common - persecutory, jealousy
Sx for at least ONE MONTH and do not meet criteria A for schizophrenia
No real mood symptoms or present for a brief period of time
What are examples of mood disorders with psychosis and what overlaping symptoms do they have with schizophrenia?
Bipolar disorder with psychosis -
symptoms that overlap: grandiosity (delusions?), flight of ideas (disorganized speech)
Major depression with psychosis-
symptoms that overlap with neg. sx- anhedonia, avolution (lack of energy), affective flattening (disturbned mood?)
What are examples of psychosis due to a substance (4):
Intoxication with alcohol
Any illicit drug
Withdrawal - alcohol, sedatives, hypnotics, anxiolytics
Medications- anesthetics, anti-convulsants, anti-histamines, anti-hypertensives, cardiovascular meds, anti-microbial meds, anti-parkinsonian meds, chemotherapeutic agents, STERIODS, GI meds, muscle relaxants, NSAIDS, OTC, anti-depressants, disulfiram
- *Typically resolves quickly*
- *Half of the schizo pt have or have had an illict drug disorder which makes it more difficult*
What are examples of general medical condtions that could have overlaping symptoms with schizophrenia?
Neurological- neoplasms, dementia, CVAs, epilepsy, CNS infection, Huntington’s disease
Endocrine - hyper/hypo-thyroid, hypoparathyroid, hypoglycemia
Metabolic- delirum due to hypoxia, hypercarbia, hepatic diseases, renal diseases, fluid or electrolyte imbalances
What are developmental disorders that could have overlaping symptoms with schizophrenia?
Autism, Rhett’s, Aspergers,
Overlaping symptoms: poor communication skills (disorganized thinking/speech), por reciprocal social skills (flat affect, anhedonia?)
Developmental disorders are usually dx in younger age, whereas schizophrenia is more rarely diagnozed young
What are 3 major personality disorders and their sx that could be confused with schizophrenia?
Paranoid - pattern of distrust, suspiciousness of others (delusions?)
Schizoid - social detachment, restricted affect (neg sx?)
Schizotypal - odd beliefs/unusual perceptual experiences (psychosis?), odd speech (disorg. thinking?), odd/eccentric behavior (disorg. behavior?)
sx are usually milder, have somewhat okay communication skills and personal care; many can still hold jobs; usually not delusional/hallucinations/positive symptoms
Schizophrenia Epidemiology:
Incidence in the US:
Lifetime prevalence:
M vs F? Difference in severity?
Peak age onset?
Where do the 2.2 million individuals w/schizophrenia live?
Schizophrenia Epidemiology:
Incidence in the US: 0.3 -0.6 per 1000 individuals
Lifetime prevalence: 1%
M vs F? M= F
Typically, severity of illness is worse in males; also the earlier the onset, generally, the more severe.
Peak onset of 1st active phase:
Male - usually earlier; 15/18-25 years; >50% have 1st hospitalization by 25
Females - usually later; 25-35/45; ~33% have 1st hospitalization by age 25
Childhood onset rare, ~1%
Where do the 2.2 million individuals w/schizophrenia live? Majority do not live indenendently (w/family memebrs, in a group/supervised home, in a nursing home,…)
What are the 3 phases of schizophrenia?
1. Prodromal phase - vague symptoms, social isolation/withdrawal, peculiar behavior, impaired personal hygiene, inappropriate affect, abnormal speech, odd beliefs; often the prodromal phase is not identified until after the first active phase (psychotic break)
2. Active phase (relapse) - patient meets Criteria A for schizophrenia
3. Residual phase (remission) - after active phase(s) have taken place, no longer clearly meets the “A” criteria; much overlap with prodromal phase
What cognitive impairment is seen in schizophrenic patients? (5)
When is impairment seen through the course?
What test is frequently used?
What additional impairment does this cause?
- SMART*
- S: Speed*
- M: Memory (working, visual, verbal)*
- A: Attention*
- R: Reasoning*
- T: Tact (social congnition)*
Pt are moderately –> severely impaired compared to the general population
Appears early in course, persists and is stable
The Wisconsin Card Sort test is used to analyze these signs
–> Anosognosia = lack of awareness / lack of insigh of illness
some pt have no/partial awareness of their illness; For those that may have awareness, often is still todecline as illness progresses, especially as their illness goes into and out of the active phase
What types of substance abuses are seen commonly in schizophrenic patients (3).
What percentage of patients with schizophrenia have or have had, a problem with alcohol or illicit drugs?
50% of pt have had/have a problem with Etoh or illict drugs
30-50% alcohol abuse/dependence
10-15% marijuana abuse/dependence
5-10% cocaine abuse/dependence
What is the outcome of schizophrenia?
% of favorable course?
% that live independently?
% that don’t work
% that don’t marry
What is the outcome of schizophrenia:
% of favorable course? 20%, small # recover completely
GREAT MAJORITY IS UNFAVORABLE:
% that live independently? 33%
% that don’t work: 75%
% that don’t marry: 60-70%
Suicide among schizophrenic patients:
Completed suicide?
Attempted?
What are risk factors for suicide amongst schizophrenic pt?
Predictors of worse outcomes (7) vs predictor of better (6):
What is the BEST PROGNOSIS factor?
Suicide among schizophrenic patients:
Completed suicide? 6-8% (compare to gen pop 1%)
Attempted? ~20% (50X higher than gen pop)
What are risk factors for suicide amongst schizophrenic pt?
Suicide risk remains present over the entire lifespan for both males and females.
Especially high for YOUNG, MALES with comorbid SUBSTANCE ABUSE
Other risks: depressive sxs, feelings of hopelessness, unemployment
HIGHER RISK: period AFTER psychotic episode / hospital discharge
Predictor of worse outcomes: insidious onset, fam hx, earlier age of onset, male, many negative sxs, minimal to no initial response to meds, substance abuse
Predictor of better outcomes: acute/sudden onset (no premorbid phase), no fam hx, later onset (30’s, 40’s), female, lack of negative sxs, initial response very good to medications (**strongest correlation with outcome**)
