Schizophrenia & Related Disorders Flashcards
A disturbance in the perception of reality
Psychosis
psychosis is characterized by 1+ of the following:
- Hallucinations
- Delusions
- Disorganized or incoherent speech
- Disorganized or catatonic behavior
- Abnormal emotions
- Cognitive difficulties
sensory perceptions in the absence of any external stimuli
Hallucinations
types of Hallucinations
Visual, auditory, olfactory, tactile, gustatory
sensory misperceptions of actual external stimuli
Illusions
fixed false beliefs that persist even with evidence to the contrary
Delusions
Not shared by a defined religion, family, or subculture
what is schizophrenia
- Psychiatric disorder with chronic or recurrent psychosis
- Impaired functioning
- Severely disabling - can be catastrophic to quality of life
Schizo is diagnosed by ?
“characteristic sx” + social and/or occupational dysfunction x 6 mo
- sx: delusions, hallucinations, disorganized speech or behavior, and/or negative sx
presentation of schizo
Poorly groomed, failure to bathe, and dressed too warmly for the current weather
positive sx for schizo?
cause?
- “Exaggeration of normal processes”
- increased dopamine
- Hallucinations
- Delusions
- Disorganization - Speech, Thoughts, Behavior
negative sx of schizo?
cause?
- “Diminution or absence of normal processes”
- decreased dopamine
sx of schizo
- 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
MC form of hallucination
Auditory
- Voices, music, body noises, machinery
- May seem to come from inside head or an external source
auditory hallucinations are often most responsive sx to what tx?
antipsychotic meds
2 main subtypes of delusions
- Bizarre or Non-bizarre
- Mood-congruent or Mood-neutral
Mc type of delusion
-
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.
Exaggerated perception of one’s own abilities and importance; May actually believe they are a famous person or character
which type of delusion
Delusions of Grandeur
The belief that one does not exist or has died
which type of delusion
Cotard Delusion / Nihilistic Delusion
Delusion that someone is in love with the patient
which type of delusion
Erotomania
Belief that insignificant remarks, events or objects in one’s environment have personal meaning or significance
which type of delusion
Delusions of Reference
Reflects a disruption in the organization of person’s thoughts
Disorganized Speech
Belief that another person, group of people, or other external force controls one’s general thoughts, feelings, or behavior
which type of delusion
Delusions of Control
Belief regarding one’s bodily functioning, sensations, or appearance; being diseased or infested
Somatic Delusions
MC Disorganized Speech
tangentiality, circumstantiality
More severe forms of disorganized speech in schizo
derailment, neologisms, word salad
Speech begins in a goal-directed manner, but deviates gradually and consistently off-topic such that answers to questions are not reached
Tangentiality
Speech is goal-directed but full of unneeded detail and gets to the answer in a “roundabout” way
Circumstantiality
Speech begins in a goal-directed manner, but topics shift rapidly between sentences with no logical connection to the topic previously discussed
Derailment
Creation and use of new, nonsensical words
Neologisms
Incomprehensible speech due to loss of logical connections between words, phrases and sentences
Incoherence
severe form of Incoherence
word salad
Words are used on how they sound rather than what they mean
→ May cause excessive rhyming or alliteration
Clanging
Inability to use abstract thinking
Concrete Speech
Consistently returning to one topic despite the conversation going in a different direction
Perseveration of Ideas
Positive sx - Disorganized Behavior
- 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
Inability to move normally
Catatonic
Not always present in schizophrenia
2 types of catatonic behavior
-
Negative: Motiveless abnormally dec movement
- Immobility (hypokinesia, akinesia)
- Mutism
- Stupor
- Negativism
- Waxy flexibility
- Posturing/Catalepsy
- Staring -
Positive: Motiveless abnormally inc movement
- Grimacing
- Teeth clicking
- Rocking
- Touching or tapping
- Speech mannerisms (robotic, foreign accent)
- Echolalia
- Echopraxia
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
other common findings for schizo
- Psych - ↑ depressive d/o, anxiety d/o, suicide
- Social - ↑ substance use and polysubstance use - MC Nicotine
- Neuro - subtle sensory and motor impairment (Agraphesthesia, asterognesia)
-
Metabolic - HTN, DM, hyperlipidemia
- Sedentary lifestyles, smoking, poor lifestyle choices
- ↑ insulin resistance
- ↑ SE
age onset for schizo
- younger (10-25 y/o): M>F
- older (25-35): F>M
risk factors for schizo
- 1st degree relative
- Male (earlier onset & worse sx)
- OB complications or maternal malnutrition
- Unwanted pregnancy and prenatal death of father - Infections (birth during winter or early spring months)
- Inflammation / Autoimmune
- Cannabis use
- Immigrant status
what is the genetic component/family hx for schizo
- 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 - >½ of pts have no FHx
Obstetrical complications that can inc risk of schizo
- Hemorrhage or blood incompatibility
- Preterm labor
- Fetal hypoxia
- Maternal infection
general theory of how Obstetric/Maternal is a risk factor for schizo
maternal stress negatively impacts pregnancy
infection is a risk factor for schizo especially when?
maternal or early childhood
2 types of infections that are risk factors for schizo
-
Influenza
- May be associated with winter/early spring birthdate risk -
Toxoplasma gondii
- Can increase risk by up to 70% (if high maternal Ig levels) - Herpes simplex type 2 (controversial)
- Measles antibodies
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
how is cannabis and immigrant status a risk factor for schizo
- Cannabis - risk factor for psychosis
- Immigrant Status - stress, social discrimination
etiology theories for schizo
-
Neurochemical Abnormalities
- Dopamine Hypothesis
- (Serotonin Hypothesis)
- Glutamate/NMDA Hypothesis
- GABA Hypothesis
- Acetylcholine Hypothesis - Structural Brain Abnormalities
- Functional Brain Abnormalities
describe how dopamine hypothesis explains schizo
-
Positive sx → inc dopamine
- Dopamine receptor agonists can cause psychosis
- Dopamine receptor antagonist can reduce psychosis - Negative sx → dec dopamine
- All antipsychotics block dopaminergic D2 receptors
what dopamine receptor agonist drugs can cause psychosis
Cocaine, amphetamines, cannabis
explain the serotonin hypothesis for schizo
- 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
explain the glutamate hypothesis for schizo
Low function of NMDA glutamate receptor
- NMDA antagonists → Psychosis, negative sx, cognitive deficits
what is the major CNS excitatory neurotransmitter
Glutamate
what is the major CNS inhibitory neurotransmitter
GABA
describe the GABA hypothesis for schizo
- dec functioning of GABAergic neurons
- Possible dec synthesis of GABA
describe the ACH hypothesis for schizo
-
Higher likelihood of smoking in schizophrenic pts = nicotine corrects fundamental problems
- nicotinergic substances improves some eye-tracking and EEG abnormalities
what brain abnormalities can be seen in schizo
- Structural - dec brain tissue overall, larger ventricle size, increased rate of brain tissue loss
- Functional - Cognitive defects often present before positive sx
positive schizo symptoms responds well to what type of meds?
antipsychotics
Negative sx - less responsive
what med in particular seems to have supporting evidence for improving negative symptoms
Cariprazine (Vraylar)
pre-tx screening for schizo
- BMI, waist circumference, HR, BP, EKG
- Screen for signs of movement disorder (AIMs score)
- Labs - CBC, fasting CMP, lipids, and TFTs
tx response for schizo
- Treatment Response - about 70% with delusions or hallucinations will have a good response
-
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
what class of antipsychotic
Dopamine receptor antagonists
More side effects (up to 70%)
Good for positive symptoms
Typical (1st gen.)
what class of antipsychotic
Dopamine/5HT antagonists
Less side effects
Good for positive and negative symptoms
which 1st gen antipsychotics have lower potency
chlorpromazine (Thorazine)
thioridazine (Mellaril)
which 1st gen antipsychotics have higher potency
haloperidol (Haldol)
prochlorperazine (Compazine)
what are the 2nd gen antipsychotics (10)
- clozapine (Clozaril)
- olanzapine (Zyprexa)
- quetiapine (Seroquel)
- ziprasidone (Geodon)
- risperidone (Risperdal)
- aripiprazole (Abilify)
- brexpiprazole (Rexulti)
- cariprazine (Vraylar)
- lurasidone (Latuda)
- lumateperone (Caplyta)*
SE of antipsychotics (10)
- Neuroleptic Malignant Syndrome (NMS)
- Hyperprolactinemia
- Anticholinergic
- Sedation
- Extrapyramidal Symptoms (EPS)
- Hypotension
- Agranulocytosis
- Seizures
- Cardiac Arrhythmias
- Metabolic Syndrome
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
tx for Neuroleptic Malignant Syndrome (NMS)
cooling measures, supportive tx, dopaminergic meds
what antipsychotics can MC cause hyperprolactinemia
- Common with typicals and risperidone
- May be seen with high dose olanzapine or ziprasidone
gynecomastia, galactorrhea, abnormal menses, sexual dysfunction, acne, hirsutism, infertility
are SE of what from antipsychotics
Hyperprolactinemia
Constipation, urinary retention, dry mouth, blurred vision, cognitive impairment
are what SE from antipsychotics
Anticholinergic
Anticholinergic SE are MC in what antipsychotics
- low-potency typicals and clozapine
- May be seen with high dose olanzapine, quetiapine
sedation SE is MC in what antipsychotics
- low-potency typicals and clozapine
- May be seen with high dose olanzapine, quetiapine
what are Extrapyramidal Symptoms (EPS)
-
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
EPS can be seen MC in what antipsychotics
high-potency typical antipsychotics
hypotension SE is MC seen in what antipsychotics
- Highly likely with low-potency typicals and clozapine
- May be seen with risperidone, quetiapine - especially with rapid titration
Orthostatic hypotension can occur with any antipsychotic
hypotension SE is MC seen in what kind of schizo pts?
elderly, pts with hx of HTN or cardiovascular disease
what antipsychotic MC causes Agranulocytosis
-
Clozapine can cause neutropenia and agranulocytosis
- 1% incidence - usually within first 3 months of tx
- risk - elderly, female, Asian ethnicity - Must have CBC weekly x 6 mo, biweekly x 6 mo, then q 1 mo
what antipsychotics is more likely to induce seizures
- Most likely with low-potency typicals and clozapine
-
All antipsychotics lower seizure threshold - caution if hx of seizures
- More sedating = more lowering of threshold - May consider avoiding use of depot antipsychotics
Cardiac Arrhythmias are MC seen in what antipsychotics
- Seen most often with thioridazine and ziprasidone
-
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 - Dose dependent
weight gain is worse in what antipsychotics
clozapine and olanzapine
weight gain is minimal with what antipsychotics
- aripiprazole
- brexpiprazole
- cariprazine
- lurasidone
- ziprasidone
what glycemic abnormalities can be seen in antipsychotics
Insulin resistance, DKA, increased glucose in pts with pre-existing DM
Glycemic Abnormalities are worse in what antipsychotics
clozapine and olanzapine
Dyslipidemia is worse in what antipsychotics
low-potency typicals, clozapine, olanzapine, quetiapine
overall metabolic problems is worse, intermediate, and mild in what antipsychotics
- Worse: clozapine and olanzapine
- Intermediate: low-potency typicals and quetiapine
- Least: aripiprazole, brexpiprazole, cariprazine, ziprasidone, high-potency typicals
when does tx for acute psychosis have better response than multiple psychotic episodes
Initial episode
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
if there are agitation symptoms with psychosis, what can be given?
adjunct anxiolytic or sedative meds
maintenance tx for schizo
-
continue meds indefinitely at the lowest effective dose
- lower chance of relapse - Psychotherapy is essential for reintegration into society
- Social support services
-
Close clinical f/u
- Compliance with medication
- Treatment of comorbid disorders
- Monitoring of antipsychotic SE
prognosis of schizo
- 10% of patients eventually recover
- 20% of patients do not recover fully but have a good outcome
- 30-35% have a stable but intermediate outcome
- 30-40% have a deteriorating course
Significant proportion continue to have psychotic s/s
what other medical disorders can cause secondary psychotic disorder
- Neuro - CNS infections, cancer, vascular events, cognitive disease, porphyria, seizures
- Endocrine - thyroid, parathyroid, or adrenal disease
- Metabolic - hypoxia, hypercarbia, hypoglycemia, fluid or electrolyte imbalance, and abnormal copper clearance
- Hepatic or Renal Impairment
- Autoimmune - SLE (lupus)
1+ psychotic sx
Determined to be secondary to
another condition
what psychotic disorder is this
Secondary Psychotic Disorder
what substances could cause secondary psychotic disorder
- Alcohol or Cannabis
- Sedatives/Hypnotics - barbiturates, benzodiazepines
- Cocaine or other Stimulants - amphetamines, methamphetamines, methylphenidate
- Other Illicit Substances - LSD, MDMA (ecstasy), phencyclidine (PCP)
- Prescriptions
- fluoroquinolones
- high-dose antihistamines or dextromethorphan
- corticosteroids
- isotretinoin (acne med)
- levodopa
- antiepileptics
what other psych disorders can cause secondary psychotic disorder
MDD
BP
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
which major mood disorder has a better prognosis for schizoaffective disorder
Bipolar
- more likely to have schizo + Fhx of bipolar
- better than MDD
what psychotic disorder has a better prognosis than schizophrenia without mood symptoms
Schizoaffective Disorder with either bipolar and MDD
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
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
tx for Schizoaffective Disorder
antipsychotic medication
Antidepressants, mood stabilizers - adjunct
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
tx for delusional disorder
antipsychotics ESP ATYPICALS
