Schizophrenia and Related Disorders

Question 1

____ is a symptom of a mental illness/condition, not a specific medical condition in itself

Answer 1

Psychosis

Question 2

Symptoms of psychosis include ____

Answer 2

hallucinations, delusions, thought disorganization, and
agitation/aggression, or other odd behaviors

Question 3

Primary vs. Secondary psychosis

Answer 3

• Primary psychotic disorders: include schizophrenia, schizoaffective disorder, schizophreniform, and delusional disorders
• Secondary psychosis : due to medical conditions, medications, and substance use

Question 4

Associated risk factors of psychosis

Answer 4

■ Living in an urban area
■ Immigration
■ Family history of schizophrenia
■ Obstetrical complications
■ Late winter/early spring birth (considered to be due to exposure to influenza virus during neural
development)
■ Advanced paternal age at conception (associated with increased risk of de novo mutations)

Question 5

Schizophrenia genetics

Answer 5

■ Exact mechanism unknown and believed to be largely in connection with environmental factors
as well
■ Higher risk in first degree relatives
■ Rate in monozygotic twins is 40-50%, and rate in dizygotic twins is 10-15%

Question 6

Obstetrical complications of schizophrenia (increase risk by two fold)

Answer 6

Preterm labor, blood group incompatibilities, fetal hypoxia, maternal infection

Question 7

T/F there is a Higher prevalence of schizophrenia seen with some autoimmune conditions

Answer 7

T

Question 8

Structural and functional brain abnormalities in people with schizophrenia

Answer 8

○ Structural brain abnormalities
■ Reduction in gray matter volume in multiple brain regions
■ Enlarged ventricles
○ Functional brain abnormalities
■ PET and MRI scans show abnormal brain activation with schizophrenia
■ Abnormalities typically in storage or retrieval of information

Question 9

Neurotransmitters involved in schizophrenia

Answer 9

○ Dopamine (most widely accepted): Hypothesized that excess dopamine in the mesolimbic tract causes positive psychotic symptoms
○ Glutamate (excitatory NT): Believed to be due to hypofunction of the NMDA glutamate receptor
○ Gamma amino butyric acid (GABA) (inhibitory NT): Decrease in GABA reuptake transporter mRNA levels
○ Acetylcholine: Increased incidence of tobacco use in people with schizophrenia has led to the hypothesis that nicotine (stimulates a subset of ACh receptors) may provide some therapeutic correction in schizophrenia

Question 10

Symptoms of schizophrenia

Answer 10

■ Hallucinations
■ Delusions
■ Disorganized speech
■ Grossly disorganized or catatonic behavior
■ Negative symptoms (affective flattening, alogia)

Question 11

Schizophrenia positive symptoms

Answer 11

● Visual hallucinations
● Auditory hallucinations (most common hallucination)
● Somatic hallucinations
● Delusions
● Paranoia
● Disorganized thinking and speech

Question 12

Schizophrenia negative symptoms

Answer 12

● Flat affect
● Monotonous / little to no speech (alogia)
● Anhedonia / apathy, poor grooming & hygiene
● Extreme isolation
● Lack of emotional and facial expression
● Catatonia

Question 13

catatonia symptoms

Answer 13

● Stupor (oblivious inability to move or respond to stimuli)
● catalepsy (hold a position you move them into passively)
● Mutism (little to no verbal communication)
● Waxy flexibility (body remains in whatever position, resistance to being moved)
● Negativism (lack of verbal response, no response to external stimuli)
● Posturing (rigid body posture, holding a posture or position that goes against gravity, active)
● Mannerisms (extreme or odd movements and mannerisms)

Question 14

First line treatment of schizophrenia

Answer 14

antipsychotic medications (dopamine receptor antagonists

Question 15

Treatment resistant schizphrenia

Answer 15

General guidelines are if a patient has failed 2 different antipsychotic medications, they are considered to have treatment resistant schizophrenia and should be evaluated for clozapine (also a SGA)

Question 16

Treat catatonia with _____

Answer 16

benzodiazepines

Question 17

After recovery from first acute psychotic episode, it is recommended to continue antipsychotic medication for
_____ before considering taper

Answer 17

2-3 years
■ Many will require indefinite treatment, and discontinuation is associated with higher rate of relapse

Question 18

If there is good response for positive schizophrenia symptoms with an antipsychotic, but negative symptoms persist, could consider adding _____

Answer 18

an antidepressant or mood stabilizer

Question 19

Non-medication recommended therapies for schizophrenia

Answer 19

■ Psychotherapy / CBT → often best for patients with a degree of insight regarding their psychosis (Lower rates of hospitalization and relapse)
■ Family based interventions
■ Social skills training → improvement in interpersonal and everyday life skills

Question 20

Schizophrenia prognosis

Answer 20

○ The life expectancy of people with schizophrenia is reduced by more than a decade compared to the
general population, Largely due to heart disease
○ The rate of suicide among people with schizophrenia is over 4 times higher than the general population

Question 21

Psychotic Disorder presentation

Answer 21

Brief psychotic disorder is characterized by 1 or more symptoms of psychosis lasting from one day and resolve
within 1 month with full return of previous functioning
■ Hallucinations
■ Delusions
■ Disorganized speech
■ Disorganized behavior

Question 22

Psychotic Disorder Diagnosis

Answer 22

○ Must meet DSM V criteria (previous slide)
○ Need to rule out substance and medical related causes of psychosis, as well as MDD or Bipolar
○ Diagnosis usually made provisionally or retrospectively
○ Lack of negative symptoms

Question 23

Psychosis subtypes

Answer 23

■ With marked stressor → previously called brief reactive psychosis (more common subtype). Occur shortly after a significant
stressor such as death of a loved one, moving to a new country, natural disaster
■ Without marked stressor → unknown cause (less common)
■ With postpartum onset → within 4 weeks of delivery

Question 24

Psychotic Disorder treatment

Answer 24

○ Same as general initial management of psychosis regardless of cause
○ Second generation antipsychotic medication
○ Short acting benzodiazepine for severe anxiety and agitation

Question 25

Schizophreniform

Answer 25

● Epidemiology, clinical presentation, and diagnostic evaluation are the exact same as schizophrenia but the total
duration of illness is more than 1 month and less than 6 months before full symptom recovery.
● Cause is thought to be a combination of genetics, aspects of one’s environment, and life experiences.

Question 26

Schizoaffective disorder

Answer 26

Condition in which both schizophrenia and a mood disorder are present

Question 27

2 types of schizoaffective disorder

Answer 27

○ Schizoaffective disorder, bipolar type
○ Schizoaffective disorder, depressed type

Question 28

With schizoaffective disorder, psychosis occurs in _____

Answer 28

the absence of a mood episode (would not see in psychotic
mood disorders)

Question 29

Must meet DSM V criteria for both schizophrenia & either bipolar disorder or MDD with

Answer 29

Schizoaffective disorder

Question 30

Schizoaffective disorder treatment

Answer 30

The ONLY medication FDA approved for specifically schizoaffective d/o is paliperidone (an atypicalantipsychotic)
○ Consider additional medications such as mood stabilizers for bipolar features, or antidepressants if only MDD
features present
○ Combination of medication and psychotherapy is most effective

Question 31

Delusional Disorder is more common in

Answer 31

women

Question 32

Risk factors for delusional disorder

Answer 32

Individuals with sensory impairment (especially hearing or vision), immigrants, or those
with a family history of marked suspiciousness or jealousy

Question 33

Subtypes of delusional disorder

Answer 33

■ Persecutory type → delusions of being watched, conspired against, or potentially harmed
■ Jealous type → Believes significant other is unfaithful, finds “evidence” to support delusion, and
relentlessly tries to substantiate offense
● More common in males
■ Erotomanic type → Believes another person is secretly in love with them. Usually not part of their
social circle and unlikely to be attainable.
■ Grandiose type → Believe they have special prominence or unusual fame
■ Somatic type → Believe something awful is wrong with their body. Believe they are ill with
undiagnosed disease, delusional parasitosis, or that parts of their body are misshapen or ugly. Tend to
doctor shop, often disappointed by failure to diagnose a medical problem.
■ Mixed type → No one delusional theme predominates

Question 34

Delusional Disorder treatment

Answer 34

○ Antipsychotics are first line
○ Psychotherapy
○ Usually will not seek treatment unless forced to by friends, family, employer, etc., as many do not believe
anything is wrong with them mentally, and instead are upset at others for not believing them
○ It is important not to accept or “play into” the delusion as it can confuse the patient’s reality and lead to distrust
○ Even with medication treatment, delusions typically do not disappear completely but rather become less
important to the patient

Question 35

Secondary Psychotic Disorder

Answer 35

In substance/medication induced psychotic disorders, the symptoms are a manifestation of intoxication, acute
withdrawal, or med side effect and do not persist after the individual is sober/completed withdrawal, or the
medication is discontinued.

Question 36

Only 2 medications have been found to decrease suicidal behavior

Answer 36

→ Lithium and clozapine