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Behavioral dynamics > Schizophrenia & Related Disorders > Flashcards

Schizophrenia & Related Disorders Flashcards

1
Q

A disturbance in the perception of reality

A

Psychosis

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2
Q

psychosis is characterized by 1+ of the following:

A
  1. Hallucinations
  2. Delusions
  3. Disorganized or incoherent speech
  4. Disorganized or catatonic behavior
  5. Abnormal emotions
  6. Cognitive difficulties
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3
Q

sensory perceptions in the absence of any external stimuli

A

Hallucinations

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4
Q

types of Hallucinations

A

Visual, auditory, olfactory, tactile, gustatory

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5
Q

sensory misperceptions of actual external stimuli

A

Illusions

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6
Q

fixed false beliefs that persist even with evidence to the contrary

A

Delusions
Not shared by a defined religion, family, or subculture

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7
Q

what is schizophrenia

A
  1. Psychiatric disorder with chronic or recurrent psychosis
    - Impaired functioning
    - Severely disabling - can be catastrophic to quality of life
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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
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9
Q

presentation of schizo

A

Poorly groomed, failure to bathe, and dressed too warmly for the current weather

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10
Q

positive sx for schizo?
cause?

A
  1. “Exaggeration of normal processes”
    - increased dopamine
    - Hallucinations
    - Delusions
    - Disorganization - Speech, Thoughts, Behavior
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11
Q

negative sx of schizo?
cause?

A
  1. “Diminution or absence of normal processes”
    - decreased dopamine
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12
Q

sx of schizo

A
  1. positive sx: Hallucinations, Delusions, Disorganization, catatonic behavior
  2. negative sx: social withdrawal, Anhedonia, Flattened affect, Loss of motivation, Alogia, Loss of hygiene
  3. cognitive sx: Processing speed, Attention, Working memory, Speech, Verbal/visual learning and memory, Verbal comprehension,, Reasoning/executive functioning, Social cognition
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13
Q

MC form of hallucination

A

Auditory
- Voices, music, body noises, machinery
- May seem to come from inside head or an external source

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14
Q

auditory hallucinations are often most responsive sx to what tx?

A

antipsychotic meds

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15
Q

2 main subtypes of delusions

A
  1. Bizarre or Non-bizarre
  2. Mood-congruent or Mood-neutral
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16
Q

Mc type of delusion

A
  1. 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.
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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

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18
Q

The belief that one does not exist or has died

which type of delusion

A

Cotard Delusion / Nihilistic Delusion

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19
Q

Delusion that someone is in love with the patient

which type of delusion

A

Erotomania

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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

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21
Q

Reflects a disruption in the organization of person’s thoughts

A

Disorganized Speech

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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

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23
Q

Belief regarding one’s bodily functioning, sensations, or appearance; being diseased or infested

A

Somatic Delusions

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24
Q

MC Disorganized Speech

A

tangentiality, circumstantiality

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25
Q

More severe forms of disorganized speech in schizo

A

derailment, neologisms, word salad

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26
Q

Speech begins in a goal-directed manner, but deviates gradually and consistently off-topic such that answers to questions are not reached

A

Tangentiality

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27
Q

Speech is goal-directed but full of unneeded detail and gets to the answer in a “roundabout” way

A

Circumstantiality

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28
Q

Speech begins in a goal-directed manner, but topics shift rapidly between sentences with no logical connection to the topic previously discussed

A

Derailment

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29
Q

Creation and use of new, nonsensical words

A

Neologisms

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30
Q

Incomprehensible speech due to loss of logical connections between words, phrases and sentences

A

Incoherence

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31
Q

severe form of Incoherence

A

word salad

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32
Q

Words are used on how they sound rather than what they mean
→ May cause excessive rhyming or alliteration

A

Clanging

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33
Q

Inability to use abstract thinking

A

Concrete Speech

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34
Q

Consistently returning to one topic despite the conversation going in a different direction

A

Perseveration of Ideas

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35
Q

Positive sx - Disorganized Behavior

A
  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
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36
Q

Inability to move normally

A

Catatonic

Not always present in schizophrenia

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37
Q

2 types of catatonic behavior

A
  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
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38
Q

which type of schizo:

  • Mostly negative sx
  • MC males; MC 1st degree schizophrenic relatives
  • Less prone to addiction, suicidality, depression, and emotional delusions
A

Deficit Schizophrenia

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39
Q

other common findings for schizo

A
  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
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40
Q

age onset for schizo

A
  1. younger (10-25 y/o): M>F
  2. older (25-35): F>M
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41
Q

risk factors for schizo

A
  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
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42
Q

what is the genetic component/family hx for schizo

A
  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
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43
Q

Obstetrical complications that can inc risk of schizo

A
  1. Hemorrhage or blood incompatibility
  2. Preterm labor
  3. Fetal hypoxia
  4. Maternal infection
44
Q

general theory of how Obstetric/Maternal is a risk factor for schizo

A

maternal stress negatively impacts pregnancy

45
Q

infection is a risk factor for schizo especially when?

A

maternal or early childhood

46
Q

2 types of infections that are risk factors for schizo

A
  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
Q

how is inflammation/autoimmune a risk factor for schizo

A

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
Q

how is cannabis and immigrant status a risk factor for schizo

A
  1. Cannabis - risk factor for psychosis
  2. Immigrant Status - stress, social discrimination
49
Q

etiology theories for schizo

A
  1. Neurochemical Abnormalities
    - Dopamine Hypothesis
    - (Serotonin Hypothesis)
    - Glutamate/NMDA Hypothesis
    - GABA Hypothesis
    - Acetylcholine Hypothesis
  2. Structural Brain Abnormalities
  3. Functional Brain Abnormalities
50
Q

describe how dopamine hypothesis explains schizo

A
  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
Q

what dopamine receptor agonist drugs can cause psychosis

A

Cocaine, amphetamines, cannabis

52
Q

explain the serotonin hypothesis for schizo

A
  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
Q

explain the glutamate hypothesis for schizo

A

Low function of NMDA glutamate receptor

  1. NMDA antagonists → Psychosis, negative sx, cognitive deficits
54
Q

what is the major CNS excitatory neurotransmitter

A

Glutamate

55
Q

what is the major CNS inhibitory neurotransmitter

A

GABA

56
Q

describe the GABA hypothesis for schizo

A
  1. dec functioning of GABAergic neurons
  2. Possible dec synthesis of GABA
57
Q

describe the ACH hypothesis for schizo

A
  1. Higher likelihood of smoking in schizophrenic pts = nicotine corrects fundamental problems
    - nicotinergic substances improves some eye-tracking and EEG abnormalities
58
Q

what brain abnormalities can be seen in schizo

A
  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
Q

positive schizo symptoms responds well to what type of meds?

A

antipsychotics

Negative sx - less responsive

60
Q

what med in particular seems to have supporting evidence for improving negative symptoms

A

Cariprazine (Vraylar)

61
Q

pre-tx screening for schizo

A
  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
Q

tx response for schizo

A
  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
Q

what class of antipsychotic
Dopamine receptor antagonists
More side effects (up to 70%)
Good for positive symptoms

A

Typical (1st gen.)

64
Q

what class of antipsychotic

A

Dopamine/5HT antagonists
Less side effects
Good for positive and negative symptoms

65
Q

which 1st gen antipsychotics have lower potency

A

chlorpromazine (Thorazine)
thioridazine (Mellaril)

66
Q

which 1st gen antipsychotics have higher potency

A

haloperidol (Haldol)
prochlorperazine (Compazine)

67
Q

what are the 2nd gen antipsychotics (10)

A
  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
Q

SE of antipsychotics (10)

A
  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
Q

pt on antipsychotics is experiencing:
Rigidity, fever, autonomic instability, altered mental status
what could they be experiencing?

A

Neuroleptic Malignant Syndrome (NMS)
- slow onset (often 1-3 days)
- Can lead to fatal hypertensive crisis, metabolic acidosis
- Can happen with any antipsychotic

70
Q

tx for Neuroleptic Malignant Syndrome (NMS)

A

cooling measures, supportive tx, dopaminergic meds

71
Q

what antipsychotics can MC cause hyperprolactinemia

A
  1. Common with typicals and risperidone
  2. May be seen with high dose olanzapine or ziprasidone
72
Q

gynecomastia, galactorrhea, abnormal menses, sexual dysfunction, acne, hirsutism, infertility
are SE of what from antipsychotics

A

Hyperprolactinemia

73
Q

Constipation, urinary retention, dry mouth, blurred vision, cognitive impairment
are what SE from antipsychotics

A

Anticholinergic

74
Q

Anticholinergic SE are MC in what antipsychotics

A
  1. low-potency typicals and clozapine
  2. May be seen with high dose olanzapine, quetiapine
75
Q

sedation SE is MC in what antipsychotics

A
  1. low-potency typicals and clozapine
  2. May be seen with high dose olanzapine, quetiapine
76
Q

what are Extrapyramidal Symptoms (EPS)

A
  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
Q

EPS can be seen MC in what antipsychotics

A

high-potency typical antipsychotics

78
Q

hypotension SE is MC seen in what antipsychotics

A
  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
Q

hypotension SE is MC seen in what kind of schizo pts?

A

elderly, pts with hx of HTN or cardiovascular disease

80
Q

what antipsychotic MC causes Agranulocytosis

A
  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
Q

what antipsychotics is more likely to induce seizures

A
  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
Q

Cardiac Arrhythmias are MC seen in what antipsychotics

A
  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
Q

weight gain is worse in what antipsychotics

A

clozapine and olanzapine

84
Q

weight gain is minimal with what antipsychotics

A
  1. aripiprazole
  2. brexpiprazole
  3. cariprazine
  4. lurasidone
  5. ziprasidone
85
Q

what glycemic abnormalities can be seen in antipsychotics

A

Insulin resistance, DKA, increased glucose in pts with pre-existing DM

86
Q

Glycemic Abnormalities are worse in what antipsychotics

A

clozapine and olanzapine

87
Q

Dyslipidemia is worse in what antipsychotics

A

low-potency typicals, clozapine, olanzapine, quetiapine

88
Q

overall metabolic problems is worse, intermediate, and mild in what antipsychotics

A
  1. Worse: clozapine and olanzapine
  2. Intermediate: low-potency typicals and quetiapine
  3. Least: aripiprazole, brexpiprazole, cariprazine, ziprasidone, high-potency typicals
89
Q

when does tx for acute psychosis have better response than multiple psychotic episodes

A

Initial episode

90
Q

when does tx psychosis have a Greater vulnerability to SE such as weight gain, EPS? what is not recommended?

A

Initial episode
Recommended not to use clozapine or olanzapine

91
Q

if there are agitation symptoms with psychosis, what can be given?

A

adjunct anxiolytic or sedative meds

92
Q

maintenance tx for schizo

A
  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
Q

prognosis of schizo

A
  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
Q

what other medical disorders can cause secondary psychotic disorder

A
  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
Q

1+ psychotic sx
Determined to be secondary to
another condition
what psychotic disorder is this

A

Secondary Psychotic Disorder

96
Q

what substances could cause secondary psychotic disorder

A
  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
Q

what other psych disorders can cause secondary psychotic disorder

A

MDD
BP

98
Q

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

A

Schizoaffective Disorder

99
Q

which major mood disorder has a better prognosis for schizoaffective disorder

A

Bipolar
- more likely to have schizo + Fhx of bipolar
- better than MDD

100
Q

what psychotic disorder has a better prognosis than schizophrenia without mood symptoms

A

Schizoaffective Disorder with either bipolar and MDD

101
Q

presentation of Brief Psychotic Disorder

A

1+ psychotic sx
presence of marked stressor before sx onset
NO negative sx,
confusion during early course of illness
duration <1 month

102
Q

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

A

Schizophreniform Disorder

103
Q

tx for Schizoaffective Disorder

A

antipsychotic medication
Antidepressants, mood stabilizers - adjunct

104
Q

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

A

Delusional Disorder
⅔ of patients recover or improve significantly

105
Q

tx for delusional disorder

A

antipsychotics ESP ATYPICALS

Behavioral dynamics (19 decks)

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