Schizophrenia & Related Disorders Flashcards
1
Q
A disturbance in the perception of reality
A
Psychosis
2
Q
psychosis is characterized by 1+ of the following:
A
- Hallucinations
- Delusions
- Disorganized or incoherent speech
- Disorganized or catatonic behavior
- Abnormal emotions
- Cognitive difficulties
3
Q
sensory perceptions in the absence of any external stimuli
A
Hallucinations
4
Q
types of Hallucinations
A
Visual, auditory, olfactory, tactile, gustatory
5
Q
sensory misperceptions of actual external stimuli
A
Illusions
6
Q
fixed false beliefs that persist even with evidence to the contrary
A
Delusions
Not shared by a defined religion, family, or subculture
7
Q
what is schizophrenia
A
- Psychiatric disorder with chronic or recurrent psychosis
- Impaired functioning
- Severely disabling - can be catastrophic to quality of life
8
Q
Schizo is diagnosed by ?
A
“characteristic sx” + social and/or occupational dysfunction x 6 mo
- sx: delusions, hallucinations, disorganized speech or behavior, and/or negative sx
9
Q
presentation of schizo
A
Poorly groomed, failure to bathe, and dressed too warmly for the current weather
10
Q
positive sx for schizo?
cause?
A
- “Exaggeration of normal processes”
- increased dopamine
- Hallucinations
- Delusions
- Disorganization - Speech, Thoughts, Behavior
11
Q
negative sx of schizo?
cause?
A
- “Diminution or absence of normal processes”
- decreased dopamine
12
Q
sx of schizo
A
- positive sx: Hallucinations, Delusions, Disorganization, catatonic behavior
- negative sx: social withdrawal, Anhedonia, Flattened affect, Loss of motivation, Alogia, Loss of hygiene
- cognitive sx: Processing speed, Attention, Working memory, Speech, Verbal/visual learning and memory, Verbal comprehension,, Reasoning/executive functioning, Social cognition
13
Q
MC form of hallucination
A
Auditory
- Voices, music, body noises, machinery
- May seem to come from inside head or an external source
14
Q
auditory hallucinations are often most responsive sx to what tx?
A
antipsychotic meds
15
Q
2 main subtypes of delusions
A
- Bizarre or Non-bizarre
- Mood-congruent or Mood-neutral
16
Q
Mc type of delusion
A
-
Delusions of Persecution
- Someone/Everyone is “out to get me” or “judging me”
- May involve being harassed, followed, poisoned, drugged,
conspired against, spied on, etc.
17
Q
Exaggerated perception of one’s own abilities and importance; May actually believe they are a famous person or character
which type of delusion
A
Delusions of Grandeur
18
Q
The belief that one does not exist or has died
which type of delusion
A
Cotard Delusion / Nihilistic Delusion
19
Q
Delusion that someone is in love with the patient
which type of delusion
A
Erotomania
20
Q
Belief that insignificant remarks, events or objects in one’s environment have personal meaning or significance
which type of delusion
A
Delusions of Reference
21
Q
Reflects a disruption in the organization of person’s thoughts
A
Disorganized Speech
22
Q
Belief that another person, group of people, or other external force controls one’s general thoughts, feelings, or behavior
which type of delusion
A
Delusions of Control
23
Q
Belief regarding one’s bodily functioning, sensations, or appearance; being diseased or infested
A
Somatic Delusions
24
Q
MC Disorganized Speech
A
tangentiality, circumstantiality
25
More severe forms of disorganized speech in schizo
derailment, neologisms, word salad
26
Speech begins in a goal-directed manner, but **deviates gradually** and consistently off-topic such that answers to questions are not reached
Tangentiality
27
Speech is goal-directed but full of unneeded detail and gets to the answer in a “**roundabout**” way
Circumstantiality
28
Speech begins in a goal-directed manner, but topics shift rapidly between sentences with **no logical connection** to the topic previously discussed
Derailment
29
Creation and use of new, **nonsensical words**
Neologisms
30
**Incomprehensible** speech due to loss of logical connections between words, phrases and sentences
Incoherence
31
severe form of Incoherence
word salad
32
Words are used on how they sound rather than what they mean
→ May cause excessive **rhyming** or alliteration
Clanging
33
Inability to use **abstract thinking**
Concrete Speech
34
Consistently returning to **one topic** despite the conversation going in a different direction
Perseveration of Ideas
35
Positive sx - Disorganized Behavior
1. Childlike silliness
2. Unprovoked outbursts of behavior or emotion: Laughter, Hyperactivity, Agitation or violence
3. Aimless, compulsive, or bizarre behavior
4. Inappropriate social behaviors
5. Bizarre clothing choice or general appearance
6. Severe neglect of hygiene
7. Catatonic behaviors
36
Inability to move normally
Catatonic
| Not always present in schizophrenia
37
2 types of catatonic behavior
1. **Negative**: Motiveless abnormally dec movement
- Immobility (hypokinesia, akinesia)
- Mutism
- Stupor
- Negativism
- Waxy flexibility
- Posturing/Catalepsy
- Staring
2. **Positive**: Motiveless abnormally inc movement
- Grimacing
- Teeth clicking
- Rocking
- Touching or tapping
- Speech mannerisms (robotic, foreign accent)
- Echolalia
- Echopraxia
38
which type of schizo:
* Mostly negative sx
* MC males; MC 1st degree schizophrenic relatives
* Less prone to addiction, suicidality, depression, and emotional delusions
Deficit Schizophrenia
39
other common findings for schizo
1. **Psych** - ↑ depressive d/o, anxiety d/o, _suicide_
2. **Social** - ↑ substance use and polysubstance use - _MC Nicotine_
3. **Neuro** - subtle sensory and motor impairment (Agraphesthesia, asterognesia)
4. **Metabolic** - HTN, DM, hyperlipidemia
- Sedentary lifestyles, smoking, poor lifestyle choices
- ↑ insulin resistance
- ↑ SE
40
age onset for schizo
1. younger (10-25 y/o): M>F
2. older (25-35): F>M
41
risk factors for schizo
1. 1st degree relative
2. Male (earlier onset & worse sx)
3. OB complications or maternal malnutrition
- Unwanted pregnancy and prenatal death of father
4. Infections (birth during winter or early spring months)
5. Inflammation / Autoimmune
6. Cannabis use
7. Immigrant status
42
what is the genetic component/family hx for schizo
1. Strong genetic component
- _Monozygotic (identical) twins_ - **50%** risk of
developing schizo if their twin has the disease
- _Dizygotic (nonidentical) twins_ - **10%** risk if their twin has the disease
- _1st degree relatives_ - **10%** risk if a first degree relative has the disease
--- _Increases to 40% or higher if both parents_
2. _>½ of pts have no FHx_
43
Obstetrical complications that can inc risk of schizo
1. Hemorrhage or blood incompatibility
2. Preterm labor
3. Fetal hypoxia
4. Maternal infection
44
general theory of how Obstetric/Maternal is a risk factor for schizo
maternal stress negatively impacts pregnancy
45
infection is a risk factor for schizo especially when?
_maternal_ or early childhood
46
2 types of infections that are risk factors for schizo
1. **Influenza**
- May be associated with winter/early spring birthdate risk
2. **Toxoplasma gondii**
- Can increase risk by up to 70% (if high maternal Ig levels)
3. Herpes simplex type 2 (controversial)
4. Measles antibodies
47
how is inflammation/autoimmune a risk factor for schizo
increased **cytokines**
1. Higher incidence of many autoimmune diseases
- Acquired hemolytic anemia, interstitial cystitis, thyrotoxicosis,
celiac disease, bullous pemphigoid
- _Lower incidence of RA_ - unclear why
48
how is cannabis and immigrant status a risk factor for schizo
1. Cannabis - risk factor for psychosis
2. Immigrant Status - stress, social discrimination
49
etiology theories for schizo
1. **Neurochemical** Abnormalities
- Dopamine Hypothesis
- (Serotonin Hypothesis)
- Glutamate/NMDA Hypothesis
- GABA Hypothesis
- Acetylcholine Hypothesis
2. **Structural Brain** Abnormalities
3. **Functional Brain** Abnormalities
50
describe how dopamine hypothesis explains schizo
1. _Positive sx_ → **inc dopamine**
- Dopamine receptor agonists can cause psychosis
- Dopamine receptor antagonist can reduce psychosis
2. _Negative sx_ → **dec dopamine**
3. **_All_ antipsychotics block dopaminergic D2 receptors**
51
what dopamine receptor agonist drugs can cause psychosis
Cocaine, amphetamines, cannabis
52
explain the serotonin hypothesis for schizo
1. Excess serotonin in the brain causes psychosis
- _Partial serotonin agonists_ → psychotic symptoms - LSD, Mescaline
- _2nd-Gen antipsychotics_ → block some serotonin receptors and improve negative symptoms
**No longer accepted as likely/main theory**
53
explain the glutamate hypothesis for schizo
**Low function of _NMDA glutamate receptor_**
1. NMDA antagonists → Psychosis, negative sx, cognitive deficits
54
what is the major CNS excitatory neurotransmitter
Glutamate
55
what is the major CNS inhibitory neurotransmitter
GABA
56
describe the GABA hypothesis for schizo
1. **dec functioning of GABAergic neurons**
2. Possible dec synthesis of GABA
57
describe the ACH hypothesis for schizo
1. **Higher likelihood of smoking in schizophrenic pts** = nicotine *corrects* fundamental problems
- nicotinergic substances _improves_ some eye-tracking and EEG abnormalities
58
what brain abnormalities can be seen in schizo
1. _Structural_ - **dec brain tissue overall**, larger ventricle size, increased rate of brain tissue loss
2. _Functional_ - **Cognitive defects** often present _before_ positive sx
59
positive schizo symptoms responds well to what type of meds?
**antipsychotics**
_Negative sx_ - **less responsive**
60
what med in particular seems to have supporting evidence for improving negative symptoms
Cariprazine (Vraylar)
61
pre-tx screening for schizo
1. BMI, waist circumference, HR, BP, EKG
2. Screen for signs of movement disorder (AIMs score)
3. Labs - CBC, fasting CMP, lipids, and TFTs
62
tx response for schizo
1. **Treatment Response** - about _70%_ with delusions or hallucinations will have a _good response_
2. **Therapeutic Lag** - _4-6 weeks_
- May start to see a response within 1 week
- Minimum of _6 weeks trial_ per drug (as long as no adverse SE)
- Recommended not to try high-dose therapy until 6-week trial done
63
what class of antipsychotic
Dopamine receptor antagonists
More side effects (up to 70%)
Good for positive symptoms
Typical (1st gen.)
64
what class of antipsychotic
Dopamine/5HT antagonists
Less side effects
Good for positive and negative symptoms
65
which 1st gen antipsychotics have lower potency
chlorpromazine (Thorazine)
thioridazine (Mellaril)
66
which 1st gen antipsychotics have higher potency
haloperidol (Haldol)
prochlorperazine (Compazine)
67
what are the 2nd gen antipsychotics (10)
1. clozapine (Clozaril)
2. olanzapine (Zyprexa)
3. quetiapine (Seroquel)
4. ziprasidone (Geodon)
5. risperidone (Risperdal)
6. aripiprazole (Abilify)
7. brexpiprazole (Rexulti)
8. cariprazine (Vraylar)
9. lurasidone (Latuda)
10. lumateperone (Caplyta)*
68
SE of antipsychotics (10)
1. Neuroleptic Malignant Syndrome (NMS)
2. Hyperprolactinemia
3. Anticholinergic
4. Sedation
5. Extrapyramidal Symptoms (EPS)
6. Hypotension
7. Agranulocytosis
8. Seizures
9. Cardiac Arrhythmias
10. Metabolic Syndrome
69
pt on antipsychotics is experiencing:
Rigidity, fever, autonomic instability, altered mental status
what could they be experiencing?
Neuroleptic Malignant Syndrome (NMS)
- slow onset (often 1-3 days)
- Can lead to *fatal hypertensive crisis*, metabolic acidosis
- Can happen with **any** antipsychotic
70
tx for Neuroleptic Malignant Syndrome (NMS)
cooling measures, supportive tx, dopaminergic meds
71
what antipsychotics can MC cause hyperprolactinemia
1. Common with **_typicals_** and **_risperidone_**
2. May be seen with high dose _olanzapine_ or _ziprasidone_
72
gynecomastia, galactorrhea, abnormal menses, sexual dysfunction, acne, hirsutism, infertility
are SE of what from antipsychotics
Hyperprolactinemia
73
Constipation, urinary retention, dry mouth, blurred vision, cognitive impairment
are what SE from antipsychotics
Anticholinergic
74
Anticholinergic SE are MC in what antipsychotics
1. **_low-potency typicals_** and **_clozapine_**
2. May be seen with high dose _olanzapine, quetiapine_
75
sedation SE is MC in what antipsychotics
1. **_low-potency typicals_** and **_clozapine_**
2. May be seen with high dose _olanzapine, quetiapine_
76
what are Extrapyramidal Symptoms (EPS)
1. _Pseudoparkinsonism_ - Parkinson-like symptoms
- Rigidity, bradykinesia, masked facies, shuffling gait
2. _Akathisia_ - inner restlessness leading to pacing or fidgeting
3. _Dystonia_ - spastic, uncontrollable muscle contractions
4. _Tardive Dyskinesia_ - involuntary movements usually involving the orofacial region that **disappear during sleep**
77
EPS can be seen MC in what antipsychotics
high-potency typical antipsychotics
78
hypotension SE is MC seen in what antipsychotics
1. Highly likely with **_low-potency typicals_** and **_clozapine_**
2. May be seen with _risperidone, quetiapine_ - ***especially with rapid titration***
Orthostatic hypotension can occur with any antipsychotic
79
hypotension SE is MC seen in what kind of schizo pts?
elderly, pts with hx of HTN or cardiovascular disease
80
what antipsychotic MC causes Agranulocytosis
1. **_Clozapine_** can cause neutropenia and agranulocytosis
- 1% incidence - usually within *first 3 months of tx*
- _risk_ - elderly, female, Asian ethnicity
2. ***Must*** have CBC weekly x 6 mo, biweekly x 6 mo, then q 1 mo
81
what antipsychotics is more likely to induce seizures
1. Most likely with **_low-potency typicals_** and **_clozapine_**
2. _All antipsychotics lower seizure threshold_ - caution if hx of seizures
- More sedating = more lowering of threshold
3. May consider avoiding use of depot antipsychotics
82
Cardiac Arrhythmias are MC seen in what antipsychotics
1. Seen most often with **_thioridazine_** and **_ziprasidone_**
2. _All can cause_ prolonged ventricular repolarization (long QT)
- Can cause the arrhythmia torsades de pointes → sudden cardiac death
- 2x higher incidence of sudden cardiac death vs. general population
- Avoid giving with other meds that prolong the QT interval
3. Dose dependent
83
weight gain is worse in what antipsychotics
clozapine and olanzapine
84
weight gain is minimal with what antipsychotics
1. aripiprazole
2. brexpiprazole
3. cariprazine
4. lurasidone
5. ziprasidone
85
what glycemic abnormalities can be seen in antipsychotics
Insulin resistance, DKA, increased glucose in pts with pre-existing DM
86
Glycemic Abnormalities are worse in what antipsychotics
clozapine and olanzapine
87
Dyslipidemia is worse in what antipsychotics
low-potency typicals, clozapine, olanzapine, quetiapine
88
overall metabolic problems is worse, intermediate, and mild in what antipsychotics
1. Worse: clozapine and olanzapine
2. Intermediate: low-potency typicals and quetiapine
3. Least: aripiprazole, brexpiprazole, cariprazine, ziprasidone, high-potency typicals
89
when does tx for acute psychosis have better response than multiple psychotic episodes
Initial episode
90
when does tx psychosis have a Greater vulnerability to SE such as weight gain, EPS? what is not recommended?
Initial episode
Recommended not to use clozapine or olanzapine
91
if there are agitation symptoms with psychosis, what can be given?
adjunct anxiolytic or sedative meds
92
maintenance tx for schizo
1. **continue meds indefinitely** at the lowest effective dose
- lower chance of relapse
2. **_Psychotherapy_** is essential for reintegration into society
3. Social support services
4. **Close clinical f/u**
- Compliance with medication
- Treatment of comorbid disorders
- Monitoring of antipsychotic SE
93
prognosis of schizo
1. 10% of patients eventually recover
2. 20% of patients do not recover fully but have a good outcome
3. 30-35% have a stable but intermediate outcome
4. 30-40% have a deteriorating course
Significant proportion continue to have psychotic s/s
94
what other medical disorders can cause secondary psychotic disorder
1. Neuro - CNS infections, cancer, vascular events, cognitive disease, porphyria, seizures
2. Endocrine - thyroid, parathyroid, or adrenal disease
3. Metabolic - hypoxia, hypercarbia, hypoglycemia, fluid or electrolyte imbalance, and abnormal copper clearance
4. Hepatic or Renal Impairment
5. Autoimmune - SLE (lupus)
95
1+ psychotic sx
Determined to be secondary to
another condition
what psychotic disorder is this
Secondary Psychotic Disorder
96
what substances could cause secondary psychotic disorder
1. Alcohol or Cannabis
2. Sedatives/Hypnotics - barbiturates, benzodiazepines
3. Cocaine or other Stimulants - amphetamines, methamphetamines, methylphenidate
4. Other Illicit Substances - LSD, MDMA (ecstasy), phencyclidine (PCP)
5. Prescriptions
- fluoroquinolones
- high-dose antihistamines or dextromethorphan
- corticosteroids
- isotretinoin (acne med)
- levodopa
- antiepileptics
97
what other psych disorders can cause secondary psychotic disorder
MDD
BP
98
meets criteria for both schizophrenia and a major mood disorder
<2-wk period where hallucinations and/or delusions are present in the absence of a prominent mood episode
what disorder is this describing
Schizoaffective Disorder
99
which major mood disorder has a better prognosis for schizoaffective disorder
Bipolar
- more likely to have schizo + Fhx of bipolar
- better than MDD
100
what psychotic disorder has a better prognosis than schizophrenia without mood symptoms
Schizoaffective Disorder with either bipolar and MDD
101
presentation of Brief Psychotic Disorder
1+ psychotic sx
presence of marked stressor before sx onset
NO negative sx,
confusion during early course of illness
duration <1 month
102
2+ psychotic sx
Negative sx
Sx last > 1 month but < 6 months
More rapid onset than classic schizophrenia
_most go on to be diagnosed with schizophrenia_
what psychotic disorder is this
Schizophreniform Disorder
103
tx for Schizoaffective Disorder
**antipsychotic medication**
Antidepressants, mood stabilizers - adjunct
104
Isolated delusions in an otherwise high-functioning person for at least 1 month
Typically non-bizarre
generally no other psychotic symptoms
what psychotic disorder is this
Delusional Disorder
⅔ of patients recover or improve significantly
105
tx for delusional disorder
antipsychotics _ESP ATYPICALS_
