Schizophrenia Spectrum and Other Psychotic Disorders

Question 1

schizophrenia etiology, RF, and sxs

Answer 1

• most common psychotic disorders that are characterized by loss of contact with reality
• onset < 25yo, persists throughout life, M > F
• RF: 1st deg relative (10x), advanced paternal age at conception, urban living area, immigration, obstetrical complications, late winter or early spring birth
• etiology: excess dopamine in mesolimbic tract, dec dpamine in prefrontal cortex, hypofn of the NMDA glutamate receptor, dysfnal GABAergic interneurons, MC hallucinations = auditory (threatening, obscene, accusatory, insulting)
• sxs:
  
  • 2+ of following 5 present for significant portion of 1mo period: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative sxs
  • impairment in one or more areas of fning
  • continuous signs for at least 6mo
  • RO schizoaffective and mood disorder with psychotic features (no concurrent MDD, mania, or mixed episodes)
  • disturbance not due to direct physiologic effects of substance or other medical condition
  • if autistic or other pervasive developmental disorder, schizophrenia only dx if prominent delusions or hallucinations for at least 1 mo

Question 2

schizophrenia dx and tx

Answer 2

• clinical dx of exclusion, major distinguishing feature = psychotic sxs occur in absence of prominent mood sxs, at least 2 of 5 criteria must include delusions, hallucinations, or disorganized speech, must specify presence of catatonia, must rate severity of criteria in A-E
• tx: atypical antipsychotics = 1st line (risperidone, olanzapine, quetiapine, ziprasidone, clozapine)
• comorbidities: DM, HLD, HTN, substance abuse, mood and anxiety sxs

Question 3

paranoid schizophrenia

Answer 3

• dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory variety and perceptual disturbances
• distturbances of affect, volition, and speech, and catatonic sxs are NOT prominent
• common sx: delusions of persecution, reference, exalted birth, special mission, bodily change, or jealousy
  
  • hallucinatory voices that threaten the pt or give commands, or auditory hallucinations without verbal form, such as whistling, humming, or laughing
  • hallucinations of smell or taste, or of sexual or other bodily sensations; visual hallucinations may occur but are rarely predominant
• MOST COMMON TYPE

Question 4

Disorganized schizophrenia

Answer 4

• behavior is distrubed and has no purpose, marked by disorganized speech, thinking, and behavior on the pts part coupled with flat or inappropriate emotional responses to a situation (affect), the pt may act silly or withdraw socially to an extreme extent
• sxs: active behavior but in an aimless and not constructive way, bizarre and inappropriate emotional responses (laughter), difficulty feeling pleasure, delusions, grimacing, lack of motivation, hallucinations, strange or silly behavior, speech that makes no sense

Question 5

catatonic schizophrenia

Answer 5

• prominent motoric immobility
  
  • OR
• excessive purposeless motor activity
• sxs: negativism (motiveless physical resistance to instruction or attempts to move the person), mutism (refusal to speak in certain situations or to certain people)

Question 6

Undifferentiated Schizophrenia

Answer 6

• pts in this category have characteristic positive and neg sxs of schizo but dont meet specific criteria for paranoid, disorganized, or catatonic subtypes
• difficult dx to make with any confidnece because it depends on establishing slowly progressive development of characteristic “negative” sxs of schizo without any hx of hallucinations, delusions, or other manifestations of an earlier psychotic episode and with significant changes in personal behavior, manifest as a marked loss of interest, idleness, and social withdrawal

Question 7

Delusional Disorder

Answer 7

• A persistent delusion that is not part of any other mental disorder, specifically, criteria for schizophrenia have not been met
• EXCEPTION: pt with olfactory or tactile hallucinations consistent with the delusion, but no audiotry hallucinations
• prevalence: M = F, mean onset 35-45yo
• RF: +FHx paranoid personality disorder, sensory impairment
• subtypes: persecutory (48%), jealous (11%), mixed (11%), somatic (5%), NOS (23%)

Question 8

Delusional Disorder sxs, signs, dx, and tx

Answer 8

• sxs: presence of 1+ delusions with duration of at least 1mo, criteria for schizophrenia have never been met
  
  • apart from impact of delusions or its ramifications, fn not impaired, behavior not bizarre or odd (this means they could occur in real life - being followed, poisoned, infected, etc.)
  • if manic or depressive eps have occured, these have been brief relative to duration of delusional periods, not attributable to other physiological effects of substance or other mental disorder
• signs: alert, oriented, memory and attention WNL, insight and judgement impaired
• dx: absence of other positive sxs of psychosis (except hallucinations that are part of delusional theme), absence of fnal impairment
• tx: ANTIPSYCHOTICS = 1st line, CBT for pts who cant tolerate meds, tx comorbidities (depression, anxiety)
• prognosis: in 2/3 of cases disorder is lifelong

Question 9

Schizoaffective disorder

Answer 9

• primary psychotic disorder (psychosis underlying everything) PLUS mood sxs intermittently (there MOST OF THE TIME), same time fram for schizophrenia sxs
• sxs: sx of schizophrenia with superimposed sxs of major depression and/or mania (precede or develop with psychotic manifestations), psychotic episode lasts ≥ 2 wks in absence of any mood sxs
• dx: differentiate from bipolar I disorder - psychosis can/does occur in absence of mood episodes, while in bipolar I, psychosis occurs only with mania or major depression
• tx: manic = lithium or carbamazepine, depression = SSRI, psychosis = antipsychotic
• prognosis: outcome bettter than schizophrenia, but worse than mood disorders

Question 10

Schizophreniform disorder

Answer 10

• sxs: psychotic sxs present at leat 1mo but NO LONGER THAN 6mo, 2+ types of psychotic sxs present for significant portion of 1 mo period if left untreated, negative sxs constitute one of the characteristic types of sxs present, no impairment in social or occupational functioning
• dx: distinguish from brief psychotic disorder and schizphrenia by symptom duration, <6 mo
• tx: tx as for schizophrenia