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Psychiatry > Schizophrenia Spectrum and Other Psychotic Disorders > Flashcards

Schizophrenia Spectrum and Other Psychotic Disorders Flashcards

1
Q

In what mood and cognitive disorders can you find psychosis?

A

Mood:
MDD
BPAD1
BPAD2

Cognitive disorders:
Dementia / cognitive impairment
Delirium / encephalopathy

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2
Q

What are the features of “psychotic” behavior?

A

Delusions
Hallucinations
Disorganized speech
Disorganized and catatonic behavior

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3
Q

What is the most common type of delusion?

A

Persecutory / Paranoid

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4
Q

What are the three types of control delusions?

A
  1. Insertion - Someone is inserting thoughts in my head
  2. Withdrawal - someone is taking thoughts out of my head
  3. Broadcasting - someone is letting everyone hear my thoughts
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5
Q

What is a guilt delusion?

A

Belief that someone is responsible for something, like a storm, war, or death

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6
Q

Define: somatic, nihilistic, and erotomanic delusions.

A

Somatic - Preoccupation with health / body function (i.e. believe that formication is real)

Nihilistic - Belief that a major catastrophe will occur

Erotomanic - Believe that in individual is in love with them (i.e. a celebrity)

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7
Q

What is the most common type of hallucination, and how can it be differentiated from delirium?

A

Auditory hallucination -> especially command hallucinations with voices distinct from one’s own thoughts
-> different from delirium when these delusions occur in clear sensorium

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8
Q

What type of hallucination is common in psychosis due to another medical condition?

A

Visual hallucinations, especially human-like figures, but can be lights / shapes

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9
Q

Give an example of a tactile hallucination?

A

Sensation of bugs crawling under skin - formication

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10
Q

What is meant by disorganized speech?

A

Any change in thought process from tangential thinking, to loose associations, to total incoherence

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11
Q

What is meant by disorganized behavior?

A

Age inappropriate silliness, agitation, bizarre appearance, catatonia, inappropriate social behavior & outbursts of emotion

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12
Q

What is meant by catatonic behavior?

A 
Decrease in reactivity
Includes (possibly):
1. Negativism - resistance to instruction or doing the exact opposite
2. Rigid / bizarre posture (catalepsy)
3. Mutism
4. Lack of motor response - stupor
5. Stereotypes like grimacing, staring
6. Echolalia/Echopraxia
7. Purposeless or excessive motor activity - catatonic excitement
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13
Q

What symptoms are thought to be most debilitating in schizophrenia? Describe them

A

Negative symptoms - more difficult to treat

Includes negative clarity and tone of speech, emotional expression, and motivation
Problems with social interactions, slowed movements

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14
Q

Why is it difficult to treat the negative symptoms of schizophrenia?

A

Hard to tell what falls into the range of normal behavior, what is due to antipsychotic side effects, if the patient is depressed or demoralized, and if it’s due to environmental understimulation (can only walk the halls of a psychiatric hospital)

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15
Q

What aspects of cognitive functioning are hurt in schizophrenia?

A

All aspects

Memory, attention, executive function, processing speed, social / cognitive deficits (can’t perceive emotion)

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16
Q

What are the A criteria for Schizophrenia?

A

For greater than 1 month (or less if treatment), presence of 2+

Hallucinations
Delusions
Disorganized speech
Disorganized or catatonic behavior
Negative Symptoms

At least 1 of the 2 has to come from first three (the first three are positive symptoms).

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17
Q

What is the remaining criteria for Schizophrenia?

A

Must have a decreased functioning in some aspect of life, and symptoms persist for at least 6 months which are at least prodromal, residual, attenuated, or negative symptoms of Criterion A.

That is, even when Criterion A symptoms are treated, you still have not returned to baseline for 6 months.

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18
Q

What features make it difficult to treat schizophrenic patients?

A

They have decreased insight -> leads to poor adherence

Furthermore, they often have comorbid anxiety, depression, and substance abuse

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19
Q

What is downward drift?

A

The phenomenon that after a schizophrenia diagnosis, patients tend to drift to a lower SES and may even become homeless

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20
Q

Why is life expectancy decreased in Schizophrenia?

A

Increase in cardiovascular problems
Weight gain and diabetes are common side effects of atypical antipsychotics
Substance abuse
Insufficient counseling / screening by doctors
Suicide / Violence

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21
Q

When is Schizophrenia usually diagnosed, and how do symptoms tend to change overtime?

A

Usually diagnosed in late teens to early adulthood, with prodromal symptoms not appearing before adolescence.

Usually, positive symptoms tend to decrease overtime, while negative symptoms are persistent

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22
Q

Give three possible symptomatic courses in schizophrenia (outcomes are variable)?

A
  1. Episodic - without interepisode deficits - the best. No cognitive symptoms / deficits within episodes
  2. Episodic - with interepisode deficits - no return to baseline between episodes.
  3. Chronic, deteriorating - just gets progressively worse between episodes, never return to the same point you were before.
23
Q

What are some factors which indicate good prognosis in schizophrenia?

A

Female (tend to be diagnosed later, also have higher incidence of mood disorder)
Later onset
Precipitating event or stressor with acute onset
Paranoid features
Family history of mood disorder, and associated mood change in illness
Good interepisode function
No gross brain abnormality

24
Q

What are some factors which indicate poor prognosis in schizophrenia?

A

Physical illness comorbid
Substance abuse comorbid
Family history of schizophrenia (less related to mood disorders)
High emotional conflicts at home
Low treatment compliance
Experience side effects w/ antipsychotics

25
Q

What is the strongest genetic association with schizophrenia, and what neurological process is this thought to underlie?

A

Strongly associated with the major histocompatibility complex

-> process of errant and excessive synaptic pruning during adolescence and early adulthood may underlie brain volume decrease and prodromal impairments in emotional, cognitive, and motor function

26
Q

How can family interactions play a role in development of schizophrenia?

A

High expressed emotion is associated with increased severity, and family interactions can modulate the course of illness by changing schizophrenic patients’ stress levels.

27
Q

What evidence is consistently associated with increased risk of developing schizophrenia?

A

Prenatal stressors, i.e. maternal poverty, poor nutrition, and depression. Influenza, war, Rh incompatbility, and maternal inflammation via C-reactive protein all play a role in modulating the baby’s brain development

28
Q

What are the gross brain and neuronal changes which occur with schizophrenia?

A

Brain - decreased cerebral size, enlarged ventricles

Neurons - Increased neuronal density due to decreased synapse density, with smaller neuronal size (too much synaptic pruning)

29
Q

What lab abnormalities may be seen in schizophrenia?

A
  1. Schizophrenic patients over-drink water -> decreased urine specific gravity and electrolyte abnormalities
  2. Increased CPK if neuroleptic malignant syndrome (NMS)
30
Q

By what mechanism are positive and negative symptoms in schizophrenia thought to be controlled

A

Mesocortical pathway (ventral tegmental area to prefrontal cortex) is thought to lead to cognitive and negative symptoms, and this is due to a decrease in dopamine.

Increased dopamine to mesolimbic pathway (VTA to NAcc) leads to positive symptoms

31
Q

What is the dopamine theory of schizophrenia, and its primary issue?

A

Dopamine agonists worsen psychosis, and dopamine antagonists reduce psychosis, so Schizophrenia must be due to too much dopamine.

Primary issue -> decreased dopamine in mesocortical pathway is thought to underlie the negative symptoms of schizophrenia

32
Q

What is the unifying NMDA theory of schizophrenia?

A

Hypofunction of the glutamate NMDA receptor underlies schizophrenia.

In the Mesolimbic system, there is an interneuron which is improperly activated when glutamate function is low. As a result, this GABA interneuron cannot inhibit dopamine release to NAcc -> Increased dopamine.

In the Mesocortical system, there is no interneuron. We simply cannot stimulate the dopamine releasing neuron to the prefrontal cortex properly because NMDA receptors are not working. Thus, there is decreased dopamine in the prefrontal cortex.

33
Q

How is the NMDA theory in accordance with our current understanding of antipsychotic drugs?

A

Since the mesolimbic system is responsible for positive symptoms of schizophrenia due to too much dopamine, dopamine antagonist antipsychotics work really well for positive symptoms.

Since the mesocortical system has too little dopamine, blocking dopamine receptors does little to help the negative symptoms of schizophrenia.

34
Q

How are African Americans often mis-diagnosed, and are there culturally normal hallucinations? Should minorities take more meds?

A

Often overdiagnose schizophrenia in African Americans, and underdiagnose BPAD1

Yes, it is possible to have culturally normal hallucinations, like talking to a dead person

Theoretically, they have a slower metabolism for the meds but tend to be overprescribed

35
Q

How does the prognosis of schizophrenia in developing countries differ from the US and why?

A

It is better, because they tend to have more cohesive family units and more non-immediate family support (i.e. aunts, uncles)

36
Q

Why do men have a worse prognosis in schizophrenia than women?

A

Earlier onset
Worse premorbid function with more cognitive impairment
Tend to have more prominent negative symptoms

37
Q

How is schizophreniform disorder diagnosed?

A

Same diagnostic criteria as schizophrenia, although the prodromal, active, and residual phases have gone on less than 6 months at this point.

ALSO

Decline of function is not required at this point.

38
Q

Does schizophreniform always go on to schizophrenia?? Who has a better chance?

A

No, about 1/3 will recover

Better prognosis - shorter prodromal period before symptoms start (very prominent psychotic symptoms within 4 weeks of first symptoms change). Also, less negative symptoms and more confusion / delirium aspects in psychosis (can be recovered from)

39
Q

What is Brief Psychotic Disorder?

A

Same diagnostic criterion A as schizophrenia, MINUS the negative symptoms.

Duration at least 1 day to less than 1 month.

Premorbid level of functioning will return

40
Q

What are two important specifiers of Brief Psychotic Disorder?

A
  1. With marked stressor - occur shortly after very stressful event
  2. With postpartum onset - within 4 weeks postpartum
41
Q

What predisposes you to Brief Psychotic Disorder, and is it dangerous?

A

Personality disorders

  • > occurs in late teens and early twenties
  • > very dangerous due to labile affect and high risk of suicide in this short period (psychosis)
42
Q

What is Schizoaffective Disorder? (Diagnostic criteria)

A
  1. Period of major depressive or manic episode
    AND
  2. Criteria A for Schizophrenia (full)
    AND
  3. 2+ week period of delusions / hallucinations in absence of major mood symptoms has occurred
    AND
  4. Minimum duration of one month
43
Q

What is Delusional Disorder?

A

Presence of delusions for >1 month in absence of otherwise bizarre behavior and functional deficits.

Hallucinations may present if in accordance to delusions

44
Q

When does delusional disorder normally occur, and how can it cause violence?

A

Middle to late adulthood

Causes violence in persecutory and jealous (believe partner is unfaithful) subtypes

45
Q

How is the diagnosis of psychotic disorder due to another medical condition made? What factors would make you lean towards this diagnosis

A

Prominent hallucinations or delusions with evidence from history, physical exam, or labs which show it is the direct physiological consequence of another medical condition

Factors:
Atypical age of onset
Documented in literature
Non-auditory hallucinations (usually visual)
Absence of personal or family history
46
Q

What are two drug types commonly associated with substance / medication induced psychotic disorder?

A
  1. Anticholinergics
  2. Steroids

-> features must present soon after substance intoxication or withdrawal

47
Q

What features make you point more to primary psychotic disorder than substance-induced?

A

Symptoms precede use
Symptoms persist for >1 month after withdrawal
History of unrelated episodes

48
Q

What psychotic features are associated with amphetamine and cocaine intoxication?

A
  1. Persecutory delusions
  2. Distortion of body image
  3. Formication
49
Q

What are depot antipsychotics?

A

Antipsychotics suspended in oil which are released overtime from intramuscular injection, improves adherence in patients who are treatment-resistant

50
Q

Why are atypical antipsychotics first line?

A

More effective treatment of negative symptoms, less side effects

51
Q

Why are family psychosocial interventions important to schizophrenia?

A

Crisis intervention - if patient is not adherent to meds

Problem solving skills - improving family dynamics can modulate the course of the disease

52
Q

What is assertive community treatment (ACT) and who should use it?

A

A team of community mental health workers, social workers, and psychiatrists have 24/7 availability and will go to schizophrenic patient’s homes, for treatment of severe and persistent mental illness

53
Q

What is NAMI?

A

National Alliance on Mental Illness - grassroots mental health organization for improving lives of persons living with serious mental illness

Psychiatry (23 decks)

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