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M2 Psychiatry > Psychosis > Flashcards

Psychosis Flashcards

1
Q

What is the prevalence of schizophrenia?

A
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2
Q

What factors increase the chances of developing schizophrenia?

A
  • Increased risk in lower SES groups, childhood trauma
  • Increased risk with environmental insults:
    • First trimester exposure to famine, epidemic, summer, perinatal trauma or anoxia
  • Heritability of Schizophrenia
    • 1% concordance in unrelated individuals
    • 5% in parents of proband with SCZ
    • 10% in siblings, children
    • 50% in identical twins
    • Many spontaneous cases
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3
Q

Describe the onset of schizophrenia.

A

Late adolescence and early adult hood: when there is brain maturation, lots of neuronal change

  • Onset typically teens to 20s
  • Rare after age 45
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4
Q

Describe the gender difference in the onset of schizophrenia.

A
  • Later onset, better premorbid function in women
  • Better medication response in women (at least to FGAs)—first generation antipsychotics
    • Estrogen has neuroprotective effects and inhibits D2 receptors
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5
Q

Describe the natural course of schizophrenia.

A

o Prodromal phase: social, cognitive deficits may precede active phase by many years

o First Episode: highly treatment responsive

o Active phase: full syndrome, typically 3-4 decades (teens or 20’s to 50’s)

o Residual phase: ~1/3 remission, ~1/3 attenuation of symptoms in older years

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6
Q

What are the (social) complications of schizophrenia?

A

Complications of Schizophrenia

  • Homelessness: ~50% of homeless have severe mental illness
  • Unemployment, underemployment
  • Undereducation
  • Impaired relationships
  • Family discord
  • Suicide: 20-40% attempt, 10% complete
    • 20-50 x general population suicide rate
    • Typically in first decade of illness, between psychotic episodes
    • May be related to frustration and decreased functionality – between psychotic episodes
  • Violence: Increased risk associated with command hallucinations or persecutory delusions
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7
Q

How likely is it that a patient with schizophrenia will become violent?

A
  • Violence: Increased risk associated with command hallucinations or persecutory delusions
    • Violence no more likely than gen pop when stable
    • Clozapine reduces risk of suicide & violence
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8
Q

What is the life expectancy of a patient with schizophrenia?

A

10-30 yrs shortened

  • Shortest in untreated
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9
Q

What factors contribute to a shortened life expectancy in schizophrenia?

A
  • Co-occuring substance disoders – substance use destabilizes schizophrenia
  • Chronic medical conditions (COPD, DM-2)
  • Poor self-care (nutrition, exercise)
  • Suicide
  • Medication effects
    • Neuroleptic Malignant Syndrome
    • QTc prolongation
    • Metabolic (i.e. weight gain –> increase risk of hyperlipidemia and hyperglycemia)
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10
Q

What is the prevalence of substance use disorders in patients with schizophrenia?

A

Co-occuring substance disorders—substance destabilize schizophrenia

  • Schizophrenia associated with 50% lifetime, 25% current diagnosis with SUD
  • 3-5 X odds of SUD
  • Even moderate substance use destabilizes schizophrenia
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11
Q

What is the prevalence of tobacco use in patients with schizophrenia?

A
  • 70-90% people with schizophrenia smoke
  • Nicotine administration - reduce cognitive deficits
    • Nicotine is a cholinergic agonist
  • Lung disease significantly elevated

Side note: Frequent caffeine overuse as well

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12
Q

What is neuroleptic malignant sydrome?

A

Neuroleptic malignant syndrome (NMS) is a rare, but life-threatening, idiosyncratic reaction to neuroleptic medications (i.e. chlorpromazine) that is characterized by:

  • fever
  • muscular rigidity
  • altered mental status
  • autonomic dysfunction.

NMS often occurs shortly after the initiation of neuroleptic treatment, or after dose increases.

Source: Medscape

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13
Q

What genetica

A
  • Many areas of genome associated with schizophrenia (g72, MRDS, DISC1, RG54, COMT, GRM3, GAD67)– another that correlates with signaling of neuronal migration
  • Learning, memory and neuronal plasticity genes
  • Regulation of Prefrontal Cortex circuits and interplay of dopamine, glutamate, and GABA
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14
Q

What is the link between cannabis use and the development of schizophreniform disorder?

A

Cannabis susceptibility related to COMT genotype

  • a specific COMT genotype (Val/Val) confers a much stronger correlation between adolescent cannabis use and subsequent development of schizophreniform disorderin adulthood.
  • COMT–Catechol-o-methyl transferase - primary metabolism of DA in PFC
    • Met allele – decreased activity – better memory
    • Val allele – increased activity
      • Val-val associated with poorest function on PFC tasks
      • Val allele associated with schizophrenia
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15
Q

What is the stress diathesis in the context of schizophrenia?

A

Neurobiologic vulnerability

  • Genetics explain ~50% of variance
  • Other early brain insults

Various stressors may trigger onset

  • Hormonal changes
  • Social stressors
  • Drug use
  • Traumatic brain injury
  • Sleep deprivation
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16
Q

The appearance of which brain structures change in schizophrenia?

A
  • Cerebral atropy about 5%
  • Ventricular enlargement–Biological Psychiatry 2001
    • Begins in prodromal phase
    • Present by the time a person meets criteria for schizophrenia
    • Longer duration of treatment with typical antipsychotic drugs during the interscan interval correlated with smaller ventricular volumes in patients at baseline and follow-up scans; however, there was no association with cumulative antipsychotic dose.
    • patients with smaller ventricles at baseline may be more compliant with treatment.
    • progressive enlargement of ventricles in poor-outcome patients is unlikely to be related to treatment.
      • Persistent positive and negative sx may result in progressive ventricular enlargement
  • Reduced volume of structures (caudate, hippocampus)
    • Restoration of hippocampus with exercise, and improvement of cognitive impairment
  • Poor organization of cortical layers
    • Histological evidence of disordered neuronal migration, connection, and atrophy
  • Decrease in dendritic spines in schizophrenia
17
Q

What are the functional brain abnormalities in schizophrenia?

A

Functional brain abnormalities

  • Diffuse cerebral dysfunction, particularly prefrontal + medial temporal
  • Abnormalities in the following may be involved in cognitive deficits seen in schizophrenia
    • Dorsolateral prefrontal cortex (DLPC)
    • Thalamus
    • Hippocampal formation
  • fMRI deficits in PFC and hippocampus during specific tasks
18
Q

What is the dopamine hypothesis of schizophrenia?

A

The predominant hypothesis regarding the pathophysiology of schizophrenia is that it is associated with impaired dopamine neurotransmission.

Four main dopaminergic pathways have been described

  1. The mesolimbic pathway originates from the midbrain ventral tegmental area and innervates the ventral striatum (nucleus accumbens), olfactory tubercle, and parts of the limbic system.
    • Overactivity of the mesolimbic pathway has been implicated in development of positive symptoms of schizophrenia
  2. The mesocortical pathway also originates from the midbrain ventral tegmental area and innervates areas of the frontal cortex. It has been implicated in aspects of learning and memory.
    • The negative and some cognitive symptoms of schizophrenia have been associated with a reduction of dopamine activity in the mesocortical pathways
  3. The nigrostriatal pathway is involved in control of movement.
  4. The tuberoinfundibular pathway projects from the hypothalamus to the anterior pituitary gland and controls prolactin secretion.

The overall goal of treatment is to reduce the activity of hyperactive pathways mediating psychosis and to increase the activity of hypoactive pathways that seem to mediate negative and cognitive symptoms, while simultaneously preserving the activity of those pathways that regulate motor movement and prolactin secretion.

19
Q

Describe the neurodegeneration characteristic of schizophrenia? What substances cause sx that mimic the presentation of schizophrenia?

A
  • NMDA glutamate receptors mediate neuronal cell death, pruning
    • dysregulation may lead to apoptosis
  • NMDA antagonists replicate symptoms of schizophrenia
    • PCP, ketamine
20
Q

Describe the criteria for attenuated psychosis syndrome.

A

Attenuated Psychosis Syndrome- not yet in DSM-5, under review

  • A. 1+ in attenuated form, intact reality testing
      1. Delusions
      1. Hallucinations
      1. Disorganized speech
  • B. >/= once/week for past month
  • C.Begun or worsened past year
  • D.Sufficiently distressing and disabling
  • E.Not better explained by another disorder
  • F.Criteria for psychotic disorder never met
21
Q

What is the diagnositc criteria for schizoaffective disorder?

A

A. Major depressive, manic or mixed episodes concurrent with criterion A for SCZ

  • Criterion A for SCZ: Characteristic Symptoms: 2 or more, each for significant portion of 1 month
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behavior
  • Negative sxs

B. Delusions or hallucinations for 2+ weeks in the absence of mood symptoms

C. Mood symptoms present for majority of total duration

D. Substance/general medical exclusion

  • Subtypes:
    • Bipolar type
    • Depressive type
  • Specifiers: same as SCZ

The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.

  • First episode,
    • currently in acute episode: first manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
    • currently in partial remission: partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
    • currently in full remission: full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
  • Multiple episodes,
    • currently in acute episode: multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
    • currently in partial remission
    • currently in full remission
  • Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.

Specify:

  • With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119–120, for definition).
  • current severity:
22
Q

What is the diagnositc criteria for Brief Psychotic Disorder?

A

A. One or more of:

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behavior

B. Duration 1 day - 1 mo, with full return to premorbid function

C. Not better accounted for by other disorders.

Specifiers:

  • With marked stressor
  • Without marked stressor
  • With postpartum onset
  • With catatonia
23
Q

What is the diagnositc criteria for Delusional Disorder?

A

A. One or more delusions, 1+ month

B. Criterion A for SCZ never met- If hallucinations, not prominent and related

C. Functioning, behavior not markedly impaired

D. Mood episodes brief relative to delusional periods

E. Substance/general medical exclusion

DSM-5 Criteria for Schizophrenia (2013) –American Psychiatric Association

A. Characteristic Symptoms: 2 or more, each for significant portion of 1 month

    1. Delusions
    1. Hallucinations
    1. Disorganized speech
  • i4. Grossly disorganized or catatonic behavior
    1. Negative sxs
24
Q

What is the timeline of progression of disorders that lead to schizophrenia?

A
  1. Attenuated Psychosis Syndrome- not yet in DSM-5: sx >/= once/week for past month
  2. Schizoaffective disorder: delusions or hallucinations for 2+ weeks in the absence of mood symptoms
  3. Brief Psychotic Disorder: Duration 1 day - 1 mo, with full return to premorbid function
  4. Delusional Disorder: one or more delusions, 1+ month
  5. Schizophreniform Disorder “Pre-schizophrenia”: duration 1-6 months
  6. Schizotypal (Personality) Disorder: Sub-syndromal – enriched in 1o relatives:
  7. Schizophrenia: sx, 2 or more, each for significant portion of 1 month
25
Q

What is the diagnositc criteria for Schizophreniform Disorder ?

A

M2 Psychiatry (7 decks)

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