Schizophrenia Spectrum Snd Other Psychotic Disorders Flashcards
What are the 5 psychotic symptom disorders?
- Delusions
- Hallucinations
- Disorganized speech
Above 3 are “core” domains
- Disorganized or catatonic behavior
- Negative symptoms
Explain the psychotic DELUSION symptom domain
Delusion(core)- A fixed belief that is not amenable to change, even with conflicting evidence
- delusion of grandeur(grandiose)
- delusion of persecution (paranoid)
- Delusion of control(external force controlling behavior)
- Delusion of reference (belief that outside action refers directly to the person or has special personal meaning’
- Thought broadcasting delusion (thoughts being transmitted to others)
Explain the psychotic HALLUCINATION symptom domain
A sensory perception without an external stimulus (auditory are the most common)
Describe the psychotic symptom domain : disorganized speech (core)
Speech (thinking) lacks the normal, logical connections between thoughts. Patients who exhibit this symptom are described as having m
A formal thought disirder
Loose associations in thinking
Describe symptoms of the psychotic domain: disorganized or catatonic behavior
Disorganized: non-goal oriented behavior (e.g., wandering aimlessly)
Catatonic: multiple motor/behavioral abnormalities thatreflect diminished reactivity to the environment:
- posturing
- waxy flexibility
- stereotypes
- Non-responsiveness
- mutism
Describe symptoms os the psychotic domain: negative symptoms
Diminished emotional expression
Avolition(decrease in motivated self-initiated purposeful activities
Alogia(diminished speech output)
Anhedonia(inability to feel pleasure)
Asociality (lack of self interactions)
What are the diagnostic criteria of schizophrenia?
At least 2 psychotic domain symptoms :
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized behavior
- Negative symptoms
Atleast 1 core symptom domain (1, 2 or 3)
Give the schizophrenia diagnosis timeline
Signs of the disturbance for 6+ months (including any prodromal and/or residual phases)
6+ months of prodromal phase, active phase (must be 1+ month). And residual phase
Prodromal and residual phases often manifest as only negative symptoms and/or do,Ian symptoms in subthreshold forms
What are the subtypes of schizophrenia?
DSMno longer subtypes schizophrenia except to specify “with catatonia”
Presentation of schizophrenia varies depending on which psychotic domain symptoms are most important
Give the differential of schizophrenia
Substance-induced psychosis, (e.g., consider psychomotomimetic drugs such as stimulants and dissociative anesthetics)
What are the associated features of schizophrenia?
- nicotine dependence(self medication)
- increased suicide risk
Aggression
- patient may be aggressive to protect himself/herself
- If command hallucinations(or uses drugs), patient is at greater risk 9f being violent
- Despite publicity, schizophrenics are not at higher risk of homocide
Give the epidemiology of schizophrenia
1% of general population with no gender bias(though males have greater illness severity)
There is a higher prevelance of schizophrenics with low socioeconomic status (SES): “downward drift” phenomenon
High number of schizophrenics amongst the homeless, largely as a result of de institutionalization
Describe schizophrenic onset
- typical onset: late teens, slightly later onset in women
- A negative symptom prodrome often precedes the onset of positive symptoms by a few weeks to months
- Late-onset(40+ years): More in women and characterized by positive symptoms and less severe course
- childhood onset (+13 years): severe form of disorder associated with more pronounced deficits in neurodevelopment
Give the course and outcome of schizophrenia
Slow gradual decline in function, or one characterized by fluctuating symptoms
The disorder is chronic
Majority of patients have a moderate to severe disability with need for periodic hospitalization
Give the etiology of schizophrenia
Dopamine(DA) pathway and consequent neuromodulation disruption
- Too much DA= positive symptoms
- Disconnect between “normal” cognition (I.e., internal dialogue ) and perception of that dialogue
- Too little DA in frontalbareas = negative symptoms and cognitive impairment
What are dopamine pathways?
Mesolimbic pathway(positive symptoms)
Mesocortical pathway(negative symptoms)
Nigrostriatal pathway(extrapyramidal syndrome)
Tuberoinfundibular pathway (increased prolactin release)
Explain the dopamine pathway: mesolimbic pathway
Positive symptoms
- projections from ventral tegmental area (VTA) to nucleus acumbens(NA)
- reward, reinforcement, motivation, motor function
Explain the dopamine pathway: mesocortical pathway
Negative symptoms
- projections from VTA to DLPFC
- Executive functions
- projections from VTA to VMPFC
- emotions and affect
Explain the dopamine pathway: nigrostrital pathway
Extrapyramidal syndrome
- Projectiond from substantia nigra to striatum (caudate and putamen)
- stimulation of purposeful movement
Explain the dopamine pathway: tuberoinfundibular pathway(increased prolactin pathway )
Increased prolactin release
- projections from the hypothalamus to the infundibulum region
- normally inhibits prolactin release
Give the schizophrenia etiology with dopamine not being the whole story
Dopamine not the entire story
-33% of patients do not respond to “typical” antipsychotics
- more than just dopamine this excess
- Non-dopaminergic sub-type of schizophrenia
- reduced glutamate in frontal lobes and glutamine increase= cognitive impairment
- viral infection in uterus increases risk
How can neuroanatomical chang3s lead to schizophrenia?
Enlarged cerebral ventricles(ventriculomehaly)
Cortical atrophy
Smaller size and cellular disorganization of temporal lobe
Cellular disorganization suggests that schizophrenia is a neurodevelopmental disorder
What are the neuropsychological effects of schizophrenia?
-Impairments are seen in a variety of cognitive functions such as attention, memory, verbal fluency and “executive “ functions (I.e., initiating, planning, shifting, following though)
List as many words as you can think of that start with the letter “D”. Schizophrenics would have a difficult time searching their “lexicon” to generate words
How can schizophrenia be treated?
First generation (typical) antipsychotics
- thorazine(chlorpromazine)
- Haldol(haloperidol)
Dopamine (DA) receptor blockers(antagonists)
Alleviates positive symptoms (hallucinations, delusions)
Side effects: extrapyramidal syndrome (ES) due to blockage of nigrostriatal (motor system) dopamine
What is extrapyramidal syndrome?
- Dystonia- sustained muscle contractions of the head and neck, often develops first week
- Parkinsonism- tremor and shuffling , often develops in first few months
- Akathisia -excessive movements dye to “inner restlessness”, often develops in the first few months
4 tar dive Dyskinesia- repetitive, involuntary, purposelessness movements of the face and extremities - comes due to long term side eff3cts of meds
What is neuroleptic malignant syndrome?
- Tachycardia, hypertension, rapid respiration, fever, extreme rigidity, delirium, and death
- Within 2 weeks of starting medication or increasing dosage
- Results from a previous drop in dopamine that impacts hypothalamic function (autonomous nervous. System )
How can schizophrenia be treated( 2nd generation)?
2nd generation(atypical treatments) antipsychotics Clozaril (clozapine) Risperdal(risperidone)
-dopamine (DA) receptor blockers (antagonists ) and serotonin antagonist
Alleviates positive(hallucinations) and negative (anhedonia) symptoms
Side effects: Agranulocytosis is seen in 1-2% of patients taking clozapine
How can schizophrenia be treated without antipsychotics?
Psychotherapy- for secondary effects, not primary effects
- behavioral therapy to increase activities of daily living
- supportive psychotherapy (if indicated)
- family education with the goal of diminishing household/environmental stress
Electroconvulsive therapy
Not usually as effective as medications but may be more useful for catatonic subtype
What are the diagnostic criteria of schizophreniform ?
- identical symptoms to schizophrenia, distinguished by duration
- 1+ month but less than 6. Months of active phase symptoms
Sometimes provisional fir schizophrenia until 6-month symptom duration is reached
- delusions
- hallucinations
- Disorganized speech
- Disorganized or catatonic behavior
- diminished range of emotional expression
What are the diagnostic criteria of Brief psychotic disorder symptoms?
- Atleast 1 core psychotic domain symptom (I.e., delusions, hallucinations, disorganized speech)
- episode lasts less than 1 month
- Person returns to full premorbjd functioning
- specify trigger of episode:
- with marked stressor
- without marked stressor
Give diagnostic criteria if delusi9n dusirder
The presence of a delusion
Symptoms must last 1+ month
No other psychotic domains
No functional impairment aside from the direct impact of the delusion
Specify: Non-bizarre delusion: a belief that involves something that could occur in real life, is physically possible
Bizzare delusion: A belief that is clearly implausible and not derived from ordinary life experiences
How may delusional disorder occur?
A delusion may develop in the context of a close relationship with a psychotic individual
- Partner comes to believe the same delusion as the psychotic individual
- The person is also diagnosed with Delusional disorder(formerly “shared psychotic disorder”)
What are the delusional disorder subtypes ?
Persecutory type: belief of malevolent treatment
Grandiose type: belief of having some great (but unrecognized ) talent or insight or having made some important discovery
Erotomatic type: belief that someone else is in love with the individual
Jealous type : belief of infedility of partner
Somatic type: belief involving bodily functions/sensations, such as parasitosis, maldorous, organ dysfunction
Unspecified type- theme of none above
What are the differentials of delusional disorder?
- bidy Dysmorphic disorder (BDD) with absent insught(delusional belief): in BDD, delusion is appearance-related
- illness anxiety disorder (IAD): IAD patients worry about health but they are not delusional
Unspecified(theme is none of the above)
Briefly describe schizoaffective
Active phase of schizophrenia occurs concurrently with a Major mood episode (MDE or manic episode)
Active phase lasts 2+ weeks without mood
Mood symptoms are present for “the majority of the total durstion” of symptomatic periods of illness
How can schizoaffective disorder be diagnosed?
- concurrent psychosis and mood
- psychosis alone
- mood symptoms duration proportional with psychotic symptoms duration
Subtypes:
- Bipolar type (if mania is experienced)
- depressive type(if depression is experienced without mania)
Give the etiologies of delusional disorder and schizoaffective disorder
Delusion disorder (DD) -Genetic-DD is more common in people who have family members with DD or schizophrenia
- dopamine and serotonin imbalance
- environmental/psychologica- triggered by stress, isolation, alcohol and drug abuse might contribute
Schizoaffective disorder
-unknown but thought to overlap with schizophrenia
How can schizoaffective and delusional disorders be affected?
- antipsychotic medications
- individuals psychotherapy to identify underlying distorted thoughts
- CBT to recognize and change thought patterns and behaviors
- psychosocial therapy to assist with employment, living arrangements
- family therapy to help families deal more effectively with a loved one
