Schizophrenia- Exam 3 Flashcards
Give some examples of forms of psychosis. How many do you have to have?
Hallucinations
Delusions
Disorganized or incoherent speech
Disorganized or catatonic behavior
Abnormal emotions
Cognitive difficulties
“A disturbance in the perception of reality”
1+
_____ sensory perceptions in the absence of any external stimuli. What is the key word there?
Hallucinations
**absence
_____ sensory misperceptions of actual external stimuli. What is the key word there?
Illusions
misperceptions
_______ - fixed false beliefs that persist even with evidence to the contrary. What is the key word?
Delusions
Not shared by a defined religion, family, or subculture
fixed false beliefs
What is the DSM definition of schizophrenia?
Psychiatric disorder with chronic or recurrent psychosis that is impairing functioning/severely disabling
Must have a “characteristic symptom”: positive, negative or cognitive symptoms
PLUS
social/occupational dysfunction
for a least 6 MONTHS
Does schizophrenia have a specific s/s?
NO! No clinical sign or symptom is pathognomonic for this disease
What is the typical presentation for a schizophrenic pt? What are the 3 categories of schizophrenia s/s?
Poorly groomed, failure to bathe, and dressed too warmly for the current weather
positive, negative, cognitive
What are hallucinations, delusions,
disorganization of speech, thoughts, behavior classified as? How do you define it?
positive symptoms
Exaggeration of normal processes
What are amotivation, blunted affect, avolution, alogia, anhedonia, social withdrawal classified as? How do you define it?
negative symptoms
“Diminution or absence of normal processes
What are deficits in memory, attention, reasoning and problem solving, processing speed, social cognition and IQ classified as?
cognitive symptoms
Name 4 kinds of hallucinations. What are the MC form of hallucinations? Which kind are the most responsive for antipsychotic meds? Are they considered positive or negative?
Auditory, visual, somatic, olfactory
**auditory is MC and most responsive to meds
postive s/s
_____ fixed, false belief present even in the face of evidence to the contrary. These are often used to defend _____.
delusion
Patients often have delusional explanations for their hallucinations
What are some common forms of delusions? What is the MC?
**delusions of :persecution- MC
grandeur
cotard delusion/nihilistic delusion
erotomania
reference
control
somatic delusions
_____ the belief that one does not exist or has died. What type of delusion?
Cotard Delusion / Nihilistic Delusion
_____ Delusion that someone is in love with the patient. What type of delusion?
erotomania
_____ belief that insignificant remarks, events or objects in one’s environment have personal meaning or significance. What type of delusion?
Delusions of Reference
____ belief that another person, group of people, or other external force controls one’s general thoughts, feelings, or behavior. What type of delusion?
delusions of ocntrol
_____ belief regarding one’s bodily functioning, sensations, or appearance.Usually involves the body being diseased or infested. What type of delusion?
Somatic delusion
What are 8 types of disorganized speech? Which ones are more severe?
tangentiality, circumstantiality, neologisms, derailment, incoherence, clanging, concrete speech, perseveration of idea
More severe - derailment, neologisms, word salad
types of disorganized speech: _________ speech begins in a goal-directed manner, but deviates gradually and consistently off-topic such that answers to questions are not reached. Is it common or severe?
tangentiality
commonly observed
types of disorganized speech: _________ speech is goal-directed but full of unneeded detail and gets to the answer in a “roundabout” way. Is it common or severe?
circumstantiality
commonly observed
types of disorganized speech: _________ speech begins in a goal-directed manner, but topics shift rapidly between sentences with no logical connection to the topic previously discussed. Is it common or severe?
derailment
severe
types of disorganized speech: _________ creation and use of new, nonsensical words. Is it common or severe?
neologisms
severe
types of disorganized speech: _________ Incomprehensible speech due to loss of logical connections between words, phrases and sentences. ____ form - “word salad”. Is it common or severe?
incoherence
word salad is severe
types of disorganized speech: _________ words are used on how they sound rather than what they mean. May cause excessive rhyming or alliteration.
Clanging
types of disorganized speech: _________ inability to use abstract thinking
concrete speech
types of disorganized speech: _________ consistently returning to one topic despite the conversation going in a different direction
perseveration of ideas
Childlike silliness
Unprovoked outbursts of behavior or emotion
Laughter
Hyperactivity
Agitation or violence
Aimless, compulsive, or bizarre behavior
Inappropriate social behaviors
Bizarre clothing choice or general appearance
Severe neglect of hygiene
Catatonic behaviors
What are these an example of?
positive symptoms: disorganized behavior
Is catatonic behavior considered a positive or negative symptom?
positive symptom
but can have positive and negative categories within the positive symptom
Grimacing
Teeth clicking
Rocking
Touching or tapping
Speech mannerisms (robotic, foreign accent)
Echolalia
Echopraxia
What am I?
What category do I fall into?
catatonic behavior: positive schizophrenic symptom
positive catatonic category due to motiveless abnormally increased movement
Immobility (hypokinesia, akinesia)
Mutism
Stupor
Negativism
Waxy flexibility
Posturing/Catalepsy (holding a position for a long time)
Staring
What am I?
What category do I fall into?
catatonic behavior: positive schizophrenic symptom
negative catatonic category due to
motiveless abnormally decreased movement
What is echolalia? Echopraxia? What type of symptom are they?
involuntary repetition of words or phrases that someone else says
involuntary repetition or imitation of another person’s actions
positive catatonic behavior
Social withdrawal
Anhedonia
Flattened affect
Loss of motivation
Alogia (decreased verbal communication)
Loss of hygiene
What am I?
negative schizophrenic symptoms
negative = decrease in or absence of normal psychosocial processes
Deficit schizophrenia affects ____ of schizophrenia pts. Mostly ____ symptoms
More likely in ____; more likely to have 1st degree schizophrenic relatives. Less prone to ????
15-20%
negative
males
addiction, suicidality, depression, and emotional delusions
Processing speed
Attention
Working memory
Speech
Verbal learning and memory
Verbal comprehension
Visual learning and memory
Reasoning/executive functioning
Social cognition
What am I?
cognitive impairment
What other psych disorders are common in schizophrenic patients? What substance is most widely used? What is common in their neuro exam? What are common comorbities?
depression, anxiety and suicide**
nicotine
agraphesthesia and asterognesia
HTN, DM, hyperlipidemia
What is the average age of schizophrenia onset for males and females?
Men: between 10-25 years old
Women: between 25 -35 years old¹
What are some risk factors for schizophrenia?
1st degree relative with schizophrenia
male gender
OB complications or material malnutrition
infections
inflammation/autoimmune disorders
cannabis use
immigrant status
Schizophrenia has a strong genetic componenet. ____ chance if you identical twin has it. ____ risk if nonidenical twin has it. ____ is first degree relative. ____ chance if both parents have schizophrenia. ____ chance if NO family history
50% identical twin
10% for nonidentical twin
10% for first degree relative
40% if both parents
Over 50% of patients have NO family history
____ and _____ are associated infections/inflammation with increased risk of schizophrenia
influenza ( winter/early spring birthdate risk)
toxoplasma gondii
_____
herpes simplex 2
measles antibodies
Inflammation/Autoimmune diseases increase risk for schizophrenia due to increased _____. What disease has a LOWER rate?
cytokines
lower incidence with RA
_____ risk factor for psychosis. Is it dose dependent? ______ may be due to stress and social discrimination. It increases your chances by _____
cannabis
dose-dependent relationship
immigrant status: increases risk by 4X
What is the dopamine hypothesis?
Schizophrenia due to abnormal levels of dopamine
Positive Symptoms → increased dopamine
Negative Symptoms → decreased dopamine
All antipsychotics block dopaminergic D2 receptors
What is the glutamate hypothesis?
due to low function of NMDA glutamate receptor
NMDA antagonists → Psychosis, negative symptoms, cognitive deficits
What is the GABA hypothesis?
Decreased functioning of GABAergic neurons in schizophrenia
Possible decreased synthesis of GABA
What is the actylcholine hypothesis? Treating with nicotinergic substances improves some ____ and _____
led to theory that nicotine corrects fundamental problem in schizophrenia
Unclear if nicotinergic receptors are primary problem or secondary to other neurotransmitter pathophysiology
eye-tracking and EEG abnormalities
Describe some of the structural brain abnormalities in schizophrenia. What about functional?
Decreased brain tissue overall, larger ventricle size, increased rate of brain tissue loss
Cognitive defects often present before positive symptoms
For positive symptoms would want to treat a pt with _____. What about for negative symptoms? What drug in particular?
Positive: generally respond well to antipsychotics
negative: less reponsive to antipsychotics but 2nd gen atypicals work better than 1st generation
Cariprazine (Vraylar)
about ___ of patients with delusions or hallucinations will have a good response. How long does it take to see a response from medication?
70%
4-6 weeks: 6 weeks trial minimum per drug, no high doses until after first 6 weeks
What is the MOA for typical 1st generation antipsychotics? SE? What type of symptoms are they good for?
Dopamine receptor antagonists
More side effects (up to 70%)
Good for positive symptoms
What drugs are considered typical first generation antipsychotics? Which ones are lower vs higher potency?
lower:
chlorpromazine (Thorazine)
thioridazine (Mellaril)
higher:
haloperidol (Haldol)
prochlorperazine (Compazine)
What is the MOA for atypical 2nd generation antipsychotics? SE? What type of symptoms?
Dopamine/5HT antagonists
LESS SE
good for both positive and negative symptoms
Rigidity, fever, autonomic instability, altered mental status
Can lead to fatal ______ and metabolic acidosis
Can happen with any antipsychotic
How long does it take to show up?
Neuroleptic Malignant Syndrome (NMS)
**can lead to fatal hypertensive crisis
1-3 days
What is the treatment for Neuroleptic Malignant Syndrome (NMS)?
cooling measures, supportive tx, dopaminergic meds
What are common SE of antipsychotics?
Neuroleptic Malignant Syndrome (NMS)
Hyperprolactinemia
Anticholinergic
Sedation
Extrapyramidal Symptoms (EPS)
Hypotension
Agranulocytosis
Seizures
Cardiac Arrhythmias
Metabolic Syndrome
Hyperprolactineamia is common with what antipsychotics?
typicals: haloperidol, prochlorperazine chlorpromazine, thioridazine
risperidone
high dose olanzapine or ziprasidone
anticholinergic SE are commonly seen with what Antipsychotics?
Highly likely with low-potency typicals (chlorpromazine, thioridazine) and clozapine
May also be seen with high dose olanzapine, quetiapine
Sedation is commonly seen with what antipsychotics?
Highly likely with low-potency typicals (chlorpromazine, thioridazine) and clozapine
May also be seen with olanzapine, quetiapine
When are extrapyramidal symptoms commonly seen? What are some examples of s/s?
Can happen with any antipsychotic, but more common with high-potency typical (haloperidol, prochlorperazine)
Pseudoparkinsonism - Parkinson-like symptoms
Rigidity, bradykinesia, masked facies, shuffling gait
Akathisia - inner restlessness leading to pacing or fidgeting
Dystonia - spastic, uncontrollable muscle contractions
Tardive Dyskinesia - involuntary movements usually involving the orofacial region that disappear during sleep
When are hypotension commonly seen?
Orthostatic hypotension can occur with any antipsychotic
Highly likely with low-potency typicals (chlorpromazine, thioridazine)
and clozapine
May be seen with risperidone, quetiapine - especially with rapid titration
More common in elderly, pts with hx of HTN or cardiovascular disease
What drug is agranulocytosis associated with? What are the risk factors? what is the monitoring?
Clozapine can cause neutropenia and agranulocytosis commonly seen in the first 3 months of tx
risk: elderly, female, asian
Must have CBC weekly x 6 mo, biweekly x 6 mo, then q 1 mo
When are seizures commonly seen?
Can be seen with any antipsychotic because ALL antipsychotics lower seizure threshold more sedating effect the lower the seizure threshold
Most likely with low-potency typicals (chlorpromazine, thioridazine)
and clozapine
May consider avoiding use of depot antipsychotic
When are cardiac arrhythmias commonly seen?
Seen most often with thioridazine and ziprasidone
dose dependent so avoid giving with other medications that also prolong the QT interval
What antipsychotics are WORSE for weight gain? What drugs minimize weight gain?
Worse with clozapine and olanzapine
aripiprazole, brexpiprazole, cariprazine, lurasidone, ziprasidone
___ and _____ are the worst for glycemic abnormalities?
clozapine and olanzapine
What antipsychotics are worse for dyslipidemia?
low-potency typicals (chlorpromazine, thioridazine), clozapine, olanzapine, quetiapine
overall metabolic problems are worse with ??
intermediate with ???
least with ???
WORST: clozapine and olanzapine
intermediate: low potency typicals (chlorpromazine, thioridazine)
and quetiapine
least: aripiprazole, brexpiprazole, cariprazine, ziprasidone, high-potency typicals (haloperidol and prochlorperazine)
What is the likelihood of causing SE of weight gain and sedation from greatest to least?
What is the treatment for acute psychosis? What do you NOT want to use?
lower antipsychotic doses
Recommended not to use clozapine or olanzapine
use dosing in the lower half of the recommended range
consider adjunct anxiolytic or sedative meds
What is the maintenance treatment for schizoprenia?
antipsychotic medication **indefinitely at the lowest effective dose
psychotherapy
social support services
close clinical follow- up
What are some good and poor prognosis factors for schizophrenia?
_____ is schizophrenia but for less than 1 month.
_____ is schizophrenia but for 1-6 months
Brief Psychotic Disorder
Schizophreniform Disorder
_____ is psychosis with another probable cause
_____ is schizophrenia with a mood disorder as well
_____ is delusions but no other crazy symptoms
secondary psychotic disorder
schizoaffective disorder
delusional disorder
What is the criteria for brief psychotic disorder? What is the treatment? What are some diagnostic clues?
Treatment - Not well studied
May try antipsychotic medication
presence of marked stressor before symptom onset, lack of negative symptoms, confusion during early course of illness, duration <1 month
What are the criteria for schizophreniform disorder? What is the treatment?
Antipsychotic medication - second generation preferred
Generally respond much more quickly than schizophrenics
psychotherapy
What is secondary psychotic disorder? What is the treatment?
psychotic symptoms that are caused by another condition: medical, psychological, substance use
improvement in psychotic symptoms with improvement of underlying cause, presence of symptoms only when underlying disorder is active or uncontrolled
correction of underlying cause
What is the criteria for schizoaffective disorder? What is the important timeframe to note?
Pt meets criteria for both schizophrenia and a major mood disorder, both sets of symptoms are prominent
At least one 2-wk period where hallucinations and/or delusions are present in the absence of a prominent mood episode
What subtype of schizoaffective disorder has the better overall outcome? Is it better to have schizoaffective or schizophrenia? What is the tx?
bipolar has a BETTER outcome than depressive
Schizoaffective has a better prognosis than schizophrenia without mood symptoms
antipsychotic medication - first tx of choice
Antidepressants, mood stabilizers - adjunct
What is the criteria for delusional disorder? What is the treatment?
Isolated delusions in an otherwise high-functioning person for at least 1 month
Typically non-bizarre - followed, poisoned, infected, deceived
generally there no other psychotic symptoms
Antipsychotics, especially atypical antipsychotics
