Schizophrenia and Psychosis Flashcards
Very brief summary of schizophrenia
In DSM-5, schizophrenia is defined by a group of characteristic symptoms, such as hallucinations, delusions, or negative symptoms (i.e., affective flattening, alogia, avolition); deterioration in social, occupational, or interpersonal relationships; and continuous signs of the disturbance for at least 6 months.
Technical DSM-V diagnostic criteria for Schizophrenia
Three dimensions of symptoms in schizophrenia
psychoticism, negative symptoms, and disorganization
DSM-5 lists two negative symptoms as characteristic of schizophrenia:
- Diminished emotional expression/affect
- Avolition (a loss of the ability to initiate goal-directed behavior and to carry it through to completion)
Alogia
Diminution in the amount of spontaneous speech or a tendency to produce speech that is empty or impoverished in content when the amount is adequate
Abnormal motor behaviors in schizophrenia
Chief distinction from schizoaffective disorder and a psychotic mood disorder
In schizophrenia, a full depressive or manic syndrome either is absent, develops after the psychotic symptoms, or is brief relative to the duration of psychotic symptoms.
Brain findings in schizophrenia
- Sulcal enlargement
- Cerebellar atrophy
- Ventricular enlargement (associated with poorer functioning and more negative symptoms)
- Decreased frontal lobe mass relative to controls
Probable mechanism of action of antipsychotics
Ability to block postsynaptic dopamine D2 receptors in the limbic forebrain.
Serotonin and glutamate receptor blockade are also observed in second generation antipsychotics.
Treatment of acute psychosis
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First-line: Haloperidol (high potency conventional antipsychotic) or risperidone, olanzapine (second generation antipsychotics)
- Second-generation antipsychotics are generally better tolerated
- Second line: Clozapine (associated with reduced suicidal behavior, but risk of developing neutropenia. Useful in patients with high risk of suicidality.)
Maintenance therapy for schizophrenia
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At least 1–2 years of treatment with antipsychotic medication are recommended after the initial psychotic episode
- Due to high risk of relapse in this period
- At least 5 years of treatment for multiple episodes is recommended because a high risk of relapse remains
- Indefinite—perhaps lifelong—treatment is likely to be needed by most patients
- Oral and injectable medications available
- Long- acting injectable antipsychotics are particularly useful in patients who lack insight or have been shown to be noncompliant with medication.
Adjunctive treatments for schizophrenia
- Many patients benefit from anxiolytics (e.g., benzodiazepines) when anxiety is prominent
- Antidepressants are sometimes used to treat depression in schizophrenic patients and appear effective
- Electroconvulsive therapy is sometimes used, particularly to treat concurrent depression or catatonic symptoms.
Hospitalization of schizophrenic patients
Most treatment occurs in the community and not in the hospital.
Hospitalization should be reserved for patients who pose a danger to themselves or others; are unable to properly care for themselves (e.g., refuse food or fluids); or require special medical observation, tests, or treatments
Hallmark of a schizoaffective disorder
Overlapping, concurrent symptoms of schizophrenia and a mood disorder
Hallucinations or delusions must be present for at least 2 weeks in the absence of a mood episode
Delusion disorder
Characterized by the presence of well-systematized delusions of length >1 month accompanied by affect appropriate to the delusion occurring in the presence of a relatively well-preserved personality. Absence of symptoms of schizophrenia, mood disorders, and substance use.
The person may be unimpaired, other than for the immediate impact of the delusion. If hallucinations are present, they are not prominent and are related to the theme of the delusion.
Clinical management of delusional disorder
- Clinical experience suggests that response to antipsychotics is often poor; they may help relieve agitation and anxiety, but the core delusion remains intact.
- Haloperidol or 2nd generation antipsychotic
- SSRIs (e.g., fluoxetine, paroxetine) also have been reported to be helpful in reducing delusional beliefs in some patients.
Schizophreniform disorder
Diagnosis used for patients who present with symptoms typical of schizophrenia but have been ill for less than 6 months. The diagnosis changes to schizophrenia if the condition persists past 6 months
In DSM-5, the definition requires that the following features be present: 1) the patient has psychotic symptoms characteristic of schizophrenia, such as hallucinations, delusions, or disorganized speech; 2)the symptoms are not due to a substance of abuse, a medication, or a medical condition; 3) schizoaffective disorder and mood disorder with psychotic features have been ruled out; and 4) the duration is at least 1 month but less than 6 months.
Brief Psychotic Disorder
Patients with a brief psychotic disorder have psychotic symptoms that last at least 1 day but no more than 1 month, with gradual recovery, and other causes of psychosis have been ruled out.
May be post-partum. Postpartum psychosis, as it is often called, tends to arise in otherwise normal individuals, develop during pregnancy or within 4 weeks after delivery, and resolves within 2–3 months.
Prototypical courses of schizophrenia
Schizophrenia phases
Diagnosis of schizophrenia summary
“Generations” of antipsychotics
Mechanisms of first vs second generation antipsychotics
Efficacy, off-label uses, and side effects of antipsychotics
Region of the brain most associated with insight
Dorsolateral prefrontal cortex
