schizophrenia and other psychotic disorders Flashcards
Psychosis
Psychosis DOES NOT EQUAL SCHIZOPHRENIA
an imprecise term denoting a syndrome characterized by a distorted or non existent sense of reality
Manifested by disturbances in the formation and content of thoughts behaviors and affects
Crazy insane violent
heterogenous group of disorders
Can be a Symptoms (secondary to something else aka steroids)
Core feature of a disorder (psychotic disorder)
Where can psychosis occur
Med Neuro conditions
General medical conditions, Dementia (neurocognitive disorder), Delirium (medications, infectious causes), Substance-induce
Mood disorders: Bipolar disorder- manic or depressive episode (NOT hypomanic), MDD
Psychotic disorders- Brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, delusional disorder
Personality disorder- schizotypal, schizoid, paranoid, borderline
Schizophrenia DSM5 diagnosis
2 or more of the following each present for a significant portion of time during a 1 MONTH PERIOD (or less if successfully treated) with at least one being 1 2 or 3
- delusions (do not have to be bizarre)
- hallucinations (does not have to be 2 + conversing)
- Disorganized speech (frequent derailment or incoherence)
- grossly disorganized or catatonic behavior
- negative symptoms (affective flattening, alogia, or avolition)
Positive symptoms: things that happen in addition to normal behavior (hallucinations)
Negative symptoms: things that are withdrawn from normal behavior (avolition/faceless expressions)
Social dysfunction: one or more major areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to the onset
Duration: continuous signs of the disturbance for at least 6 months, including prodromal, active phase and residual periods
Schizoaffective and mood disorder exclusion, substance/ gen med condition exclusion
changes in DSM5
the symptom threshold is raised need 2 sx, Delusions dont need to be bizzare, hallucinations dont need to be 2 + conversing
Schizophrenia epi
1% of population, M=F for rate, M 15 -25, F 25-35 peak onset
Wide spectrum of spectrum of presentations reflects a spectrum of heterogenous diseases
current DSM criteria draws from past classifications, Deteriorating course, positive symptoms (Added symptoms), Negative symptoms (removed symptoms)
Schizophrenia natural hisotry
every psychotic episode will lower the baseline affect
Prodomal symptoms start in puberty adolescence and get worse until mid to old age
Prodrome of schizophrenia
subclinical constellation of symptoms, often resembling depression, but more subtle
Often diagnosed in retrospect when you ask where tthere any behavioral changes
Most families will be able to describe a change in behavior, how outgoing or social someone used to be even before they had a florid psychotic break
Can also be a time of attenuated symptoms, odd beliefs, that by themselves are not concerning, but taken with the gestalt, show a picture of illness
Schizophrenia symptom domains, (positive, negative and cognitive)
Positive: delusions, hallucinations, disorganization
Negative: Anhedonia (inability to feel pleasure), Avolition (no movement to goals), Affective flattening
Cognitive: executive function, working memory
symptoms of schizophrenia
Formal thought disorder (disorder in the formation of thoughts: loose associations, tangentially, circumstantially, thought blocking, ideas of reference
Behaviors: bizzare, inappropriate, disorganized, catatonia, amotivational, Violence (SI HI)
Affect- emotional state: blunted, restricted, incongruent with mood
Delusions- disoder of the content of thought: Fixed, false beleif, not socially sanctioned, Jealousy, guilt, grandiosity, religious, somatic, persecution, often based in kernnel of truth, bizarre or non bizarre
Halluinations of schizophrenia
Cortical phenomena, perception of a stimulus in the absence of one, Alone do not mean psychosis (hypnagogic vs hypnopompic (right before sleeping vs right after waking up and these psychosis are normal)
Any sensory modality: auditory in many primary psychotic illnesses, visual in other causes of psychosis (delirium), gustatory, tactile (drugs), olfactory (TLE)
Theres a bottle of water that you think is a snake: ILLUSION
Theres nothing and you think there is something: Hallucination
Schizophrenia Etiology
brain abnormality that interacts with environment and social stressors: biochemical, anatomical, genetic envrionmental, psychosocial
Schizophrenia and neurotransmitters
Dopamine excess: psychosis, amphetamines: medications are D2 antagonists, drugs that increase dopamine cause psychosis (amphetamines)
Serotonin: 5HT2A antagonism is thought to have interaction with DA, second generation antipsychotic have more 5HT2A action
Glutamate: deficiency can result in psychosis (NMDA receptor hypofunction), several pathways are possible via limbic system, PCP and ketamine are NMDA antagonists and can induce psychosis
Dopamine pathways LEARN THESE!!
Mesolimbic pathway–> Positive symptoms
Mesocortical pathway to DLPFC–> Secondary negative sx or worsening of cognitive sx
Mesocortical pathway to VMPFC–> Secondary negative sx or worsening of affective sx
Nigrostriatal pathway –> EPS (parkinsonism) extrapyramidal symptoms
Tuberoinfundibular pathway from the hypothalamus to the pituitary–> Prolactin release (breast milk)
Etiology of schizophrenia
polygenic and epigenetic
Identical twin will have a 50% chance of getting it
sibling 10%,
Environmental- birth in the winter, pregnancy influenza, complications, stressor in pregnancy advanced paternal age, cannabis
Psychococial- biologic, all sx have some meaningf or the patient, patients with high expressed emotions relapse more often, social class downward drift, you cant hold a job if youre hallucinating all the time
treatment pharmacology of schizophrenia
Chlorpromazine , DA receptro antagonists, typical= older, D2»_space;>5HT and NE treat the positive symptoms
The atypicals ore newer drugs– broad receptor spectrum d2 and 5ht treat positive and negative symptoms
Vocabulary of psychopharmacology of schizophrenia
neuroleptics-antipsychotic interchangable
first gen Ap= typical AP= conventional AP (D2, high potency, and low potency)
Second gen AP= Atypical AP
most are available as long acting injection
2 categories of antipsychotics
Typicals: Primarily d2 blockade, higher EPS risk
ATYPICALs: not just D2 blockade but also 5HT2 blockade as well at higher affinity (5HT2/D2 ratio >1)
Clozapine unique in that has little D2 blockade at all and much more D4 blockade (can kill you via agranulocytosis)
Atypicals have higher metabolic syndrome
Side effects of antipsychotics
Immediate- Parkinsonism (excessive dopamine blockade NS pathway), acute dystonia, acute akathisia
Delayed- MEtabolic syndrome, tardive dyskinesia
Emergent- Neuroleptic malignant syndrome
Neuroleptic malignant syndrome
FEVER- life threatening
Fever: hyperthermia
Encephalopathy: delirium, changes in consciousness, alertness
Vitals: autonomic instability
Elevated CPK (from rhabdomyolysis, toxic to kidneys)
Rigidity (but not uniformly, stop the offending drug)
Medication comparison
Receptors that get blocked cause the side effects:
A1: orthostatic hypotension
H1: sedation, weight gain
M1: dry mouth, constipation, urinary retention
D2: EPS, hyperprolactinemia
Medication strategy
Start with AP based side effect profile, previous response
Continue older meds only if effective and with minimal side effects
Consider long acting injectable (LAI)
Clozapine is most effective, but has significant side effects
ECT is an option for refractory psychosis in conjuction with antipsychotics
Hospitalization for acute stabilization
Treat co- morbid conditions: depression, anxiety
Psychosocial therapy
behavior/social skills training, family therapy (expressed emotion, psycho-ed)
Case management
Group therapy Individual therapy (supportive, cognitive behavioral, insight-oriented (least evidence)
Prognostic factors
Generally chronic, downhill course, suicide risk (post psychotic depression is very common, shorter life expectancy)
Positive prognositic factors: older age of onset, married, social supports, female, employed, mood sx are present, fewer negative sx, few relapses
schizophrenia review
2 psychotic symptoms for 1 month (shorter if treated), Same signs for at least 6 months
Impairment in social or occupational functioning
Not due to mood, schizoaffective disorder, not due to meds, nuerologic or substances
Brief psychotic disorder
only positive symptom from schizophrenia (delusions, hallucinations, disorganized speech, disorganized or catatonic behavior)
no negative symptoms
duration of one day to one month
Not due to medicalm neurologic or substance induced disorder
schizophreniform disorder
meets criterion A from schizofrenia (2 psychotic symptoms)
Positive and negative sx
Duration longer than one month but less than 6 months with complete remission of symptoms
not due to medical, neurologic or substance induced disorder
schizoaffective disorder
an uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with criterion A of schizophrenia
2 weeks of psychotic symptoms in absence of mood symptoms
Moods symptoms represent significant portion of time both in active and residual phases
not due to medical neurological or substance induced disorder
DSM 5- emphasis on major mood episode
Delusional disorder
Delusions for one at least 1 month (being followed, poisoned, infected, loved, decieved)
Has never met psychotic criteria for schizophrenia
Functioning is not markedly impaired
Subtypes- erotomanic, grandiose, jealous, persecutory, somatic, mixed
Substance med induced psychotic disorder
Prominent hallucinations or delusions, evidence supports direct consequence of substance use
LSD, mushrooms, amphetamines, alcohol hallucinosis, PCP cocain steroids
Balnce risk of antipsychotics with side effects, worsening medical conditions
Does occur in context of delirium, balance risk of antipsychotics with side effects worsening medical condition
Temporal lobe epilepsy, neoplasm, stroke, trauma, AIDs herpes encephalitis, lupus, wernike korsakoff syndrome
