Schizophrenia Spectrum and Other Psychotic d/os Flashcards
Peak ages of schizophrenia onset
10-25 years in men
25-35 years in women
Women display a bimodal age distribution with a second peak occurring in middle age
When is schizophrenia characterized as late onset?
When onset occurs after age 45 years
Reproductive factors in schizophrenia
Increase in marriage and fertility rates among persons with schizophrenia due to:
Use of psychopharmacological drugs
Open-door policies of hospitals
Deinstitutionalization in state hospitals
Emphasis on rehabilitation and community-based care
Seasonal factors and infection in schizophrenia
Influenza exposure in the second trimester of pregnancy
In the Northern hemisphere, being born in January to April
Genetic factors in schizophrenia
Individuals who are genetically vulnerable to schizophrenia do not inevitably develop schizophrenia; other factors must be involved
Some data indicate that age of the father >60 years is a RF
Biochemical factors in schizophrenia- hypotheses
schizophrenia results from too much dopaminergic activity
Serotonin excess
Degeneration of NE
Loss of GABAergic neurons
Alteration in neuropeptide mechanisms
Antagonism of glutamate
Decreased muscarinic and nicotinic receptors in the caudate-putamen, hippocampus, and selected regions of the prefrontal cortex
Neuropathology in schizophrenia
CTs have shown lateral and third ventricular enlargement and some reduction in cortical volume
Reduced symmetry in temporal, frontal, and occipital lobes
Decrease in the size of the limbic system
Hippocampus is functionally abnormal
Volume shrinkage or neuronal loss in the thalamus
Disease in basal ganglia and cerebellum
Additional biochemical factors in schizophrenia
Neural circuit disturbances Lower levels of phosphomonoester and inorganic phosphate Higher levels of phosphodiester Abnormal electrophysiology Abnormal evoked potentials Eye movement dysfunction
DSM-5 criteria for schizophrenia
A. Two or more of the following, each present for a significant portion of time during a 1-mo period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative sx
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset
C. Continuous signs of the disturbance persist for at least 6 months. This 6-mo period must include at least 1 mo of sx (or less if successfully treated) that meet criterion A and may include periods of prodromal or residual sx.
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out
F. If there is hx of autism spectrum disorder or a communication d/o of childhood onset, the additional dx of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required sx of schizophrenia, are also present for at least 1 mo (or less if successfully treated)
Main categories of negative sx in schizophrenia
Affective flattening or blunting Alogia Avolition- apathy Anhedonia-asociality Attention
Neg sx in schizophrenia- affective flattening or blunting
Unchanging facial expressions Decreased spontaneous movement Paucity of expressive gesture Poor eye contact Affective nonresponsivity Inappropriate affect Lack of vocal inflections
Neg sx in schizophrenia- alogia
Poverty of speech
Poverty of content of speech
Blocking
Increased latency of response
Neg sx in schizophrenia- avolition- apathy
Grooming and hygiene
Impersistence at work or school
Physical anergia
Neg sx in schizophrenia- anhedonia-asociality
Recreational interests and activities
Sexual interest and activities
Intimacy and closeness
Relationships with friends
Neg sx in schizophrenia- attention
Social inattentiveness
Inattentiveness during testing
Positive sx in schizophrenia
Psychotic sx, such as hallucinations, which are usually auditory, delusions, and disorganized speech and behavior
Cognitive sx in schizophrenia
Neurocognitive deficits
Pts also find it difficult to understand nuances and subtleties of interpersonal cues and relationships
Mood sx in schizophrenia
Pts often seem cheerful or sad in a way that is difficult to understand
They often are depressed
Mental status examination details noticed in schizophrenia
The pt may be unduly suspicious of the examiner or be socially awkward
The pt may express a variety of odd beliefs or delusions
The pt often has a flat affect
The pt may admit to hallucinations or respond to auditory or visual stimuli that are no apparent to the examiner
The pt may show thought blocking, in which long pauses occur before he or she answers a question
The pt’s speech may be difficult to follow because of the looseness of his or her associations
The pt has difficulty with abstract thinking
The speech may be circumstantial or tangential
Pt’s thoughts may be disorganized, sterotyped, or perseverative
The pt may make odd movements
The pt may have little insight into his or her problems
Orientation is usually intact
Workup for schizophrenia
Schizophrenia is not associated with any characteristic laboratory results
Labs are done to r/o other or concomitant illnesses
CBC
Liver, thyroid, and renal function tests
Electrolyte, glucose, vit B12, serum methylmalonic acid, folate, and calcium levels
Pregnancy test
Urine testing for drugs of abuse
Urine for culture and sensitivity
Brain imaging to r/o subdural hematomas, vasculitis, cerebral abscesses, and tumors
Other lab tests to consider for schizophrenia, if the history provides any reason for suspicion
Urine and serum copper and ceruloplasmin
Twenty-four hour urine collections for porphyrins, copper, or heavy metals
Dexamethasone suppression test for hypercortisolism
Corticotropin stimulation test for hypocortisolism
RPR
HIV antibodies
Lyme antibodies
ANA for SLE
Chest radiography to r/o pulmonary illness or occult malignancy
EEG
Tx of schizophrenia: typical pharmacotherapy
First episode: Starting a long-acting injectable antipsychotic is more effective than starting an oral antipsychotic, according to one study
How to choose an antipsychotic: No clear choice.
Second generation antipsychotics have a better SE profile than 1st gen antipsychotics
Clozapine is most effective but is not first line due to AEs
If compliance needs to be maximized, use IM preparations
Tx of schizophrenia: other pharmacotherapy
Anticholinergic agents (e.g., benztropine, trihexyphenidyl, and diphenhydramine) and amantadine are often used in conjunction with the conventional antipsychotic agents to prevent dystonic movements or to treat EPS
Psychosocial goals of tx for schizophrenia
To have few or stable sx
To avoid hospitalization
To manage his or her own funds and medications
To be either working or in school at least half-time
Psychosocial tx for schizophrenia
Cognitive remediation
Vocational rehabilitation
Assertive community tx with case managers
Family intervention
Tx for schizophrenia: diet and activity
Many of these meds can cause weight gain
Nutritional counseling is very important
Bizarre vs nonbizarre delusions
Bizarre delusions are clearly implausible
Nonbizarre delusions are about situations that could occur in real life, such as being followed, being loved, having an infection, and being deceived by one’s spouse
What is an overvalued idea?
An unreasonable belief that is not firmly held
Definition of delusions
False beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary
These beliefs are not ordinarily accepted by other members of the person’s culture or subculture
Etiology of delusional disorder
Familial relationship with schizophrnia and schizotypal personality disorder
Lesions of the basal ganglia and temporal lobe
Abnormal voluntary saccadic and smooth pursuit eye movements
Hyperdopaminergic states
Increased prevalence of a polymorphism at the D2 receptor gene at amino acid 311
Cognitive theory that pts with delusions selectively attend to certain information
They make conclusions based on insufficient info, attribute negative events to external personal causes, and have difficulty in envisaging others’ intentions and motivations
DSM-5 criteria for delusional disorder
The presence of one or more delusions with a duration of 1 mo or longer
Criterion A for schizophrenia has never been met
-Hallucinations, if present, are not prominent and are related to the delusional theme
Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd
If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional period
Delusional d/o: erotomanic type
When the central theme of the delusion is that another person is in love with the individual
Delusional d/o: grandiose type
When the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery
Delusional d/o: jealous type
When the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful
Delusional d/o: persecutory type
When the central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harrassed, or obstructed in the pursuit of long-term goals
Delusional d/o: somatic type
When the central them of the delusion involves bodily functions or sensations
Delusional d/o: mixed type
This subtype applies when no one delusional theme predominates
Delusional d/o: unspecified type
This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types
Tx principles of delusional d/o
Establish a therapeutic alliance and negotiate mutually acceptable symptomatic tx goals. Start where the “the pt is at”, and offer empathy, concern, and interest in the pt’s experiences
With the appropriate permission from the pt, include the pt’s family members in decision-making and educate them
Consider the impact of culture on illness experience
Avoid direct confrontation of the delusion sx to enhance the possibility of tx compliance and response
Use medication judiciously to target core sx and associated problems
Use outpt tx unless there is high likelihood of self-harm or violence or an inability to care for self
Tailor tx strategies to the individual needs of the pt and focus on maintaining social function and improving QOL
Recognize and treat comorbid psychiatric d/os
Tx of delusional d/o
Pharmacotherapy: standard trial of an antipsychotic or, for somatic delusions, an SSRI
Psychotherapy: social skills training and minimizing risk factors that my increase sx, including sensory impairment, isolation, stress, and precipitants of violence
Cognitive psychotherapeutic approaches, especialy with persecutory type
DSM-5 criteria for schizophreniform d/o
A. Two or more of the following, each present for a significant portion of time during a 1-mo period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganizaed or catatonic behavior
5. Negative sx
B. An episode of the disorder lasts at least 1 mo but less than 6 mos. When the dx must be made without waiting for recovery, it should be qualified as “provisional”
C. Schizoaffective disorder and depressive or bipolar d/o with psychotic features have been ruled out
Etiology of schizoaffective d/o
May involve abnormalities of serotonin, NE, and dopamine
Reduced hippocampal volumes, thalamic abnormalities, and white-matter abnormalities
Possibility of in utero exposure to viruses, malnutrition, or even birth complications
MSE of schizoaffective d/o: apperance, eye contact, facial expression
Appearance- ranges from well-groomed to disheveled
Eye contact- appropriate, increased, or decreased
Facial expression- neutral, angry, euphoric, or sad
MSE of schizoaffective d/o: motor, cooperativeness, mood
Motor: possible psychomotor agitation or retardation
Cooperativeness- pt may cooperate or may be uncooperative
Mood- euthymic, depressed, or manic
MSE of schizoaffective d/o: affect, speech, suicidal ideation, homicidal ideation
Affect: ranges from appropriate to flat
Speech: ranges from poverty to flight of ideas or pressured
SI: may or may not be present
HI: may or may not be present
What else should be assessed during the MSE of schizoaffective d/o?
Orientation Consciousness Concentration and attention Reading and writing Memory Delusions Hallucinations Insight Judgment You must ask about suicidal ideation and homicidal ideation at each visit
Workup for schizoaffective d/o
Sequential multiple analysis CBC RPR TSH level or thyroid function tests Urine drug screen Urine pregnancy test UA Lipid panel HIV test Structured Clinical Interview for DSM-5
DSM-5 criteria for schizoaffective d/o
A. An uninterrupted period of illness during which there is a major mood episode (either depressive or manic) concurrent with Criterion A of schizophrenia
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness
C. Sx that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness
Tx of schizoaffective d/o
Depressive subtype: combinations of antidepressants plus an antipsychotic
Manic subtype: combinations of mood stabilizers plus an antipsychotic
Psychotherapy
