Schizophrenia And Sp3ctrum 2 Flashcards
Describe the brain as a narrative making machine
- Corpus collosum severed – no signals between left and right hemispheres
- Right hemisphere detects visual images on the left of the body
- Left hemisphere detects visual images on the right of the body
- Left hemisphere controls speech
- Left hemisphere sees chicken claw and points to a picture of a chicken. Right hemisphere sees a snow scene and points to a picture of a snow shovel. Both hemispheres see the chosen pictures.
- “…the chicken claw goes with the chicken,”
- “You need a shovel to clean out the chicken shed”
Describe the etiology of schizophrenia
- Dopamine (DA) pathway & consequent neuromodulation disruption
- Too much DA = positive symptoms
• Disconnect between “normal” cognition (i.e., internal dialogue)
and perception of that dialogue
• Too little DA in frontal areas = negative symptoms & cognitive
impairment (25% of patients)
What’s the impact of dopamine in schizophrenia etiology?
- DA = motivational salience to internal/external stimuli (i.e., what “grabs attention” and directs behavior)
- Schizophrenia = increased DA release in absence of stimuli
• Attribution of salience to random stimuli by temporal association
(brain = narrative machine)
• Social adversity leads to paranoid biases and a persecutory
nature to the narrative
• Delusion is crystallization of the narrative
What is the Mesolimbic dopamine pathway?
Mesolimbic Pathway (positive
symptoms)
• Projectionsfromventraltegmental area (VTA) to Nucleus Accumbens (NA)
• Reward,reinforcement,motivation, motor function)
What are mesocortical pathways?
Mesocortical Pathway (negative
symptoms)
• Projections from VTA to DLPFC
• Executive functions
• Projections from VTA to VMPFC
• Emotions & affectWhat is the nigrostriatal dopamine pathway?
(Extrapyramidal Syndrome with some antipsychotics) • Projectionsfromsubstantianigrato striatum (caudate and putamen) • Stimulationofpurposefulmovement)
What is the tuberoinfundibulnar dopamine pathway?
Tuberoinfundibular Pathway (Increased prolactin Release with some antipsychotics) • Projections from the hypothalamus to the infundibular region • Normally inhibits prolactin release
Describe dopamine not being the entire story of schizophrenia
- Dopamine not the entire story:
- 33% of patients do not respond to “typical” antipsychotics
- More than just dopaminergic excess
- Non-dopaminergic sub-type of schizophrenia?
- Reduced glutamate in frontal lobes and glutamine increase = cognitive impairment
- Viral infection in utero increases risk
- Diathesis-Stress model? Perhaps with coping….
How is Schizophrenia treated?
Antipsychotic drugs are the mainstay treatment
• First generation neuroleptics (e.g., chlorpromazine)
• Second generation neuroleptics (e.g., clozapine)
All are D2 receptor antagonists but some block D2 receptors:
• More potently
• Less selectively
What are the effects and examples of First Generation antipsychotics?
- Examples:
- Chlorpromazine (1st antipsychotic), haloperidol
- Mechanism of Action: D2 antagonist
• Effect: Relieves positive symptoms
• Side Effects: Extrapyramidal
syndrome, Neuroleptic
Malignant Syndrome
What tracts are involved in extrapyramidal syndrome?
What is involved in extrapyramidal syndrome?
1) Dystonia
• Sustained muscle contractions of
the head and neck
• Often develops in the first week
2) Parkinsonism
• Tremor and shuffling
• Often develops in first few months
3) Akathisia
• Excessive movements due to “inner restlessness”
• Often develops in the first few months
4) Tardive Dyskinesia • Repetitive, involuntary, purposeless movements of the face and extremities • Develops as a long-term side effect after years of medication
What Is neuroleptic malignant syndrome?
Characterized by tachycardia, hypertension, rapid respiration, fever, extreme rigidity, delirium, &
death
• Usually occurs within first 2 weeks of
starting medication or increasing
dosage
• Likely results from a precipitous drop
in dopamine that impacts hypothalamic function
Describe the second generation (atypical) antidepressants
Examples:
• Clozapine
• Risperidone
• Olanzapine
- Mechanism of Action: D2, 3, 4 and 5-HT2A receptor antagonist
- Effect: Relieves positive and negative symptoms
- Side Effects:
- Agranulocytosis (only clozapine)
- Lowered risk of extrapyramidal syndrome
What are additional side effects of antipsychotic effects?
Additional side effects of all antipsychotics:
• weight gain
• sedation
• sexual dysfunction
Due to side effects, medication compliance can be a problem
How is schizophrenia treated?
Psychosocial Environmental Support • Housing and social support • Vocational rehabilitation • Individual psychotherapy • Family education
ECT Augmentation
• Used for medication-refractory
schizophrenia (e.g., catatonic type)
Describe Schizophreniform disorder diagnosis
Identical symptoms and diagnostic criteria to schizophrenia but distinguished by duration
• Total duration of symptoms 1+ month but less than 6 months
• Sometimes provisional for schizophrenia until 6-month symptom duration is reached
– Delusions
– Hallucinations
– Disorganized speech
– Disorganized or catatonic behavior
– Negative symptoms (i.e., diminished range of emotional expression)
Describe brief psychotic disorder diagnosis
- At least 1 CORE psychotic domain symptom (i.e., delusions, hallucinations, disorganized speech)
- Episode lasts less than 1 month
- Person returns to full premorbid functioning
- Specify trigger of episode:
- with marked stressor
- without marked stressor
Describe schizoaffective disorder diagnosis
- Active Phase of schizophrenia occurs concurrently with a major mood episode (MDE or manic episode)
- Active Phase lasts 2+ weeks without mood symptoms
- Mood symptoms are present for “the majority of the total duration” of symptomatic periods of the illness
Describe the shorthand approach to schizoaffective disorder diagnosis. What are the subtypes?
Shorthand Approach to Diagnosis □ Concurrent psychosis & mood? □ Psychosis alone? □ Mood symptoms duration proportional with psychotic symptoms duration?
Subtypes:
• Bipolar Type (if mania is experienced)
• Depressive Type (if depression is experienced without mania)
Describe delusional disorder diagnosis
- The presence of a delusion
- Symptom must last 1+ month
- No other psychotic domain symptoms
- No functional impairment aside from the direct impact of the delusion
Specify if Delusional Disorder is with bizarre content
– Non-bizarre delusion: A belief that involves something that could occur in real life; is physically possible.
– Bizarre delusion: A belief that is clearly implausible and not derived from ordinary life experiences.
What is shared psychotic disorder?
- A delusion may develop in the context of a close relationship with a psychotic individual
- Partner comes to believe the same delusion as the psychotic individual
- The person is also diagnosed with Delusional Disorder (formerly “Shared Psychotic Disorder”)
What are the delusional disorder subtypes?
- Persecutory Type: Belief of malevolent treatment
- Grandiose Type: Belief of having some great (but unrecognized) talent or insight or having made some important discovery
- Erotomanic Type: Belief that someone else is in love with the individual
- Jealous Type: Belief of infidelity by partner
- Somatic Type: Belief involving bodily functions/sensations, such as parasitosis, malodorous, organ dysfunction
- Differentials:
- Body dysmorphic disorder (BDD) with absent insight
- (delusional belief): In BDD, delusion is appearance-related
• Illness anxiety disorder (IAD): IAD patients worry about health
but they are not delusional Unspecified Type (theme is none of the above)
Describe the etiology of Delusional Disorder
Delusional Disorder (DD) • Genetic-DD is more. common in people. who have family members with DD or schizophrenia
- Dopamine and seroton inimbalance
- Environmental/psychological-Triggered by stress.Isolation,alcohol and drug abuse might contribute
What is the etiology of Schizoaffective disorder ?
Schizoaffective Disorder (SD) • Form of schizophrenia?
What are the treatments of delusional disorder?
Delusional disorder (DD):
• Antipsychotic medications
• Cognitive-behavioral therapy (CBT) to recognize and change thought
patterns and behaviors – while taking medication
• Family therapy to help families deal more effectively with a loved one
Close relationship delusion disorder treatment:
• Trial separation from partner
• Increasing sources of reality testing (e.g., CBT) to recognize and
change thought patterns and behaviors
Why is the brain a narrative making machine?
- The brain is a narrative-making, association machine
- It does this to predict the future and increase the odds of survival
- Connecting this with physiology allows us to understand symptomatology in patients
- Schizophrenia is a disease of neurotransmitter function that relies on physiological intervention
- May be multiple types of disease underlying psychosis
