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Behavioral Medicine > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

Schizophrenia diagnostic criteria

A
  • two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
    1. delusions
    2. hallucination
    3. disorganized speech
    4. grossly disorganized or catatonic behavior
    5. negative symptoms (i.e. diminished emotional expression or avolition)
  • at least one of these must be 1, 2, or 3 to meet criteria
  • schizophrenia is a psychotic disorder
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2
Q

Treatments for schizophrenia

A
  • no pharmacological treatments available
  • there are treatments for the symptoms
  • depakote and lamotragine (anticonvulsants) help improve sooner
  • goal of treatment is to alleviate sxs and enable the best possible functionality and life quality
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3
Q

psychosis

A
  • a severe mental illness
  • loss of ego functioning
  • refers to disorders that include loss of reality testing (cannot tell what is fantasy and reality), therefore include hallucinations and delusions
  • all psychotic disorders have hallucinations and/or delusions or paranoia
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4
Q

Functional illness vs organic illness

A
  • Functional illness - things people could not trace an organic etiology (ex. schizophrenia, depression, psychosis)
  • Organic illness - like major neurocognitive disorder (dementia)
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5
Q

neruotic vs. pscyhotic

A

-neurotic - means a learned inappropriate response to life circumstance or events: reality testing intact

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6
Q

borderline personality disorder

A

-is in extreme stress an individual moves from a neurotic state to a psychotic state

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7
Q

exogenous vs endogenous

A
  • exogenous - from the outside or learned

- endogenous - from within

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8
Q

etiology of schizophrenia

A
  • family of disorders
  • people with schizophrenia have more people in their families with schizophrenia than they have people with bipolar disorder, but they still have more people in their families with bipolar disorder than so the general population
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9
Q

schizophrenia age of first admission

A 
males = 28
females = 31.8
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10
Q

hallucination in schizophrenia

A
  • perceptual experience that lacks actual environmental cause
  • one third or less visual. Two-thirds auditory (if the primary is visual, think organic)
  • can be one or more people talking
  • usually negative, hostile, or critical
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11
Q

illusion

A
  • see something as something else

- ex) raincoat and hat that are hung up and are mistaken for a person

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12
Q

bizarre delusion

A

something that cannot be true

ex) i am being dominated by space aliens/Devil replaced family members with doubles (capgras syndrome)

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13
Q

non-bizarre delusion

A

can be true

ex) my co-workers are plotting against me

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14
Q

affective disorders

A

major depressive disorder

bipolar disorder

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15
Q

schizoaffective disorder

A

a mixed presentation of schizophrenia and an affective disorder (major depressive or manic)

  • need to distinguish from a substance-induced psychosis
  • organic illness
  • onset after age 45 suspect an organic process
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16
Q

prodromal phase of schizophrenia

A
  • pre first schizophrenia “break”
  • deterioration from normal functional behaviors in daily life, work, social engagement, and personal care
  • in adolescents you see social withdrawal, avoiding family and friends, not bathing, resentment, anger toward parents, worsening grades
  • patients perspective is that internal mental life is becoming more complicated - see as social withdrawal
  • experiencing complexity, a sense of strangeness in ordinary experience, confusion, increased terror, misunderstanding of ordinary experience
  • Occurs until 1st psychotic break
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17
Q

1st psychotic break

A

-clear loss of reality testing with prominent hallucinations and delusions and disorganized behavior, anxiety and confusion

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18
Q

Disturbances you see in schizophrenia

A
  1. language and communication
  2. content of thought
  3. perception
  4. affect
  5. self
  6. motor behavior
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19
Q

schizophrenia language and communication disturbances

A
  • alogia (poverty of speech)
  • loss of linearity in thought processes and speech
  • circumstantial speech (person talks around an idea but never gets to it)
  • tangential speech (deviates from subject)
  • poverty of content (person only talks about a few things)
  • neologisms (invent new words)
  • word salad (looks like Wernicke’s aphasia)
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20
Q

schizophrenia content of thought disturbances

A
  • delusions of thought broadcasting (everyone knows what I’m thinking
  • thought insertion (someone putting thoughts in my head)
  • delusions of control (someone is controlling your actions)
  • capgras syndrome - replacement of important people
  • frugoli syndrome - individual is dead and is an animated cadaver (zombie)
  • being watched or followed (CIA, FBI)
  • delusion of special powers (God speaks to me)
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21
Q

schizophrenia perception disturbances

A
  • hallucinations - usually auditory and negative

- command hallucinations - voices telling individual to do something - especially associated with harm to self or others

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22
Q

schizophrenia affect disturbances

A
  • outward manifestations of emotion (not mood - mood is experience, affect is what you show)
  • May be up and down (labile), flat (not variable), full (full range of display), or restricted; typically see flat or restricted affective display when not in a psychotic episode
  • anhedonia - impaired pleasure experience
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23
Q

schizophrenia motor behavior disturbances

A
  • catatonic - behavior so disturbed you cant tell person is not in a coma
  • can have increase or decrease in motor behavior
  • catatonic posturing - individual has ‘waxy flexibility’ GUMBY LIKE. can move person and they stay there
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24
Q

positive symptoms of schizophrenia

A

excess

  • hallucinations
  • delusions
  • bizarre, agitated, or catatonic behavior
  • disorganized speech
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25
Q

negative symptoms of schizophrenia

A

absences

  • linearity (thoughts should go in sequence)
  • avolition (hard time developing drive, e.g. poor hygiene, lazy)
  • anhedonia
  • attentional deficit
  • autism
  • emotional blunting
  • social withdrawal
  • poverty of speech
  • poverty of motor activity
26
Q

cognitive symptoms of schizophrenia

A
  • deficit in attention
  • deficit in memory
  • deficit in learning
27
Q

active types of schizophrenia

A
  1. disorganized (hebephrenic) (more difficult to spot)
  2. catatonic (easier to spot)
  3. paranoid (easier to spot)
  4. undifferentiated (more difficult to spot)
28
Q

disorganized (hebephrenic) schizophrenia

A

active type

  • incoherence
  • lack of systemized delusions/absence of a fully organized delusional system
  • disorganized behavior that is not catatonic
29
Q

catatonic schizophrenia

A

active type

  • excitement or stupor
  • mutism - refusal to speak
  • negativism - refusal to do stuff/do opposite
  • motor rigidity and posturing
30
Q

paranoid schizophrenia

A

active type

  • well formalized and systematic delusions
  • fewer negative symptoms
  • less of personality and social deterioration
31
Q

undifferentiated schizophrenia

A

active type

  • does not meet criteria for other 3 active types
  • grossly disorganized behavior
  • hallucinations
  • incoherent behavior
  • delusions
32
Q

residual type of schizophrenia

A
  • positive hx for more of the positive sxs but individual is not demonstrating positive symptoms at this time
  • burnt out schizophrenic
  • met criteria at one point, but is not meeting it now
33
Q

Criteria for schizophrenia

A
  • must have met criteria for 6 months total
  • stages of diagnosis based on length of episode
  • brief psychotic disorder (one day to one month)
  • schizophreniform disorder (one month to 6 months)
  • schizophrenia (at least 6 months)
34
Q

good prognostic signs for schizophreniform disorder

A
  • onset of psychotic symptoms w/in 4 weeks of 1st noticeable change in usual behavior
  • confusion or perplexity at height of psychotic episode
  • good premorbid social and occupational functioning
  • absence of blunted or flat affect
35
Q

percent of individuals that have an episode of psychosis, recover, and never have another episode

A

25%

36
Q

percent of people with schizophrenia who attempt to commit suicide

A

50%

10-15% of people succeed

37
Q

prodromal sxs of schizophrenia

A

negative and on a continuum with normal behaviors so they are difficult to identify

  • depression
  • anxiety
  • suspiciousness
  • social withdrawal
  • triggering events
38
Q

genetics of schizophrenia

A
  • general pop (no family member with the disorder = 1-2%
  • siblings 8%
  • one parent 12%
  • dizygotic twins 14%
  • both parents 37%
  • monozygotic twins 47% (identical genetic material, therefore must be environmental contributions) (if a monozygotic twin develops schizophrenia, 80% of the time it is with the low birth weight twin
39
Q

modal time of onset of schizophrenia to treatment

A

6-7 years

40
Q

dysexecutive syndrome

A

problems with error correction, problem solving, management of basic level functions (memory, perception, etc.) seen in schizophrenia
-intrinsic part of the disorder; overlaps in presentation with negative s/s

41
Q

declarative memory

A

you can declare it - available to introspection

  • episodic: memory of individual discreet events - temporal and perceptual correlates to them; most prone to damage from schizophrenia
  • semantic: knowledge of world facts and dates - dont have temporal and perceptual correlates (i.e. 4th of July)
42
Q

nondeclarative (procedural) memory

A
  • not available for introspection

- includes habit learning, classical conditioning, etc.

43
Q

relationship of dopamine with schizophrenia

A

meds that block dopamine affect the POSITIVE s/s of schizophrenia (phenothiazines were the 1st class to do so)

44
Q

4 key dopamine pathways

A

mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular

45
Q

Mesolimbic pathway

A
  • dopamine axons in brain stem go to limbic system
  • role in emotional behaviors, auditory hallucinations, delusions, and thought disorder
  • the system for the POSITIVE s/s of schizophrenia (too much dopamine here = + s/s)
  • cause of too much dopamine = schizophrenia, amphetamines/cocaine, giving someone with Parkinson’s too much levodopa
46
Q

mesocortical pathway

A
  • starts at cell bodies in brain stem and terminates near cerebral cortex
  • mediates NEGATIVE and COGNITIVE s/s of schizophrenia
  • degeneration in this system may account for worsening s/s in schizophrenia
  • too much dopamine causes the cognitive s/s
  • if we block D2, we worsen negative s/s
47
Q

nigrostriatal pathway

A
  • cell bodies in substantia nigra (death of these cell bodies results in decrease of dopamine (parkinsons))
  • blockade of this in persons with schizophrenia will produce pseudo-parkinsonian syndrome
  • prolonged blockade of dopamine can lead to overproduction of receptors - hypersensitivity syndrome (reverse of parkinsonian)
48
Q

tuberoinfundibular pathway

A
  • from hypothalamus to anterior pituitary

- if we block D2 we increase prolactin (dopaminergic neurons inhibit prolactin release)

49
Q

hypothesis for etiology of schizophrenia

A
  • neurodevelopment problem hypothesis - schizophrenia originates from abnormalities in fetal brain development during neuronal selection and migration (s.s cant be seen until adolescence when brain recognizes synapses); frontal lobe problem - they cant bring behavior under control
  • neurodegenerative disorder hypothesis - subtle negative s/s in late teens, early 20s and have destructive positive s/s that causes further brain damage (each acute exacerbation leads to further brain damage)

These hypotheses are not mutually exclusive

50
Q

Typical antipsychotics

A
  • most typical APs also block muscarinic cholinergic receptors (cause dry mouth, constipation, urinary retention, blurred vision, cognitive blunting)
  • Ach and dopamine act in opposition of each other
  • block dopamine but not Ach - get more extrapiramidal symptoms
  • dopamine blockers that also block Ach get decreased EPS s/s
51
Q

neuroleptic malignant syndrome

A

from typical antipsychotics
-muscle rigidity, elevated temp, autonomic instability and cognitive changes such as altered mental state and is associated with elevated creatine phosphokinase

52
Q

Atypical antipsychotics (2nd gen)

A
  • address D2 but address other neurotransmitters more than D2
  • all atypical APs work to exploit the different ways that serotonin and dopamine interact with each other in the 4 pathways
  • benefits derived from serotonin and dopamine interacting with each other
  • increased compliance b/c fewer and less extreme side effects but also increased weight gain, diabetes, and hypercholesterimia
53
Q

atypical antipsychotics (3rd gen)

A
  • more actions on the negative and cognitive s/s
  • more benign SEs and mvmt disorder SEs
  • weight gain, diabetes, elevated cholesterol, cardiac effects (prolonged QT interval)
  • Aripiprazol actons on either D2 as a partial agonist, or D2 functional selectivity (meaning that the drug causes markedly different signaling through a single receptor)
54
Q

interactions in the 4 pathways

A
  • serotonin-dopamine interactions
  • nigrostriatal: presence of serotonin inhibits dopamine release both at cell body and at axon terminal (typical APs = 60-70% reduction in dopamine, atypical APs = 20-40% reduction in dopamine which reduces likelihood and severity of typical side effects); mvmt disorders are hugely reduced with atypical APs
  • mesocortical: same effect as nigrostriatal system except net increase in amount of dopamine available.
  • tuberoinfundibular: reciprocal effect of serotonina nd dopamin on prolactin release balancing blocked decreased hyperprolactemia
  • mesolimbic: serotonin antagonism fails to reduce the dopamine blockade here. We want dopamine reduced here
55
Q

Treatment using antipsychotics

A

-choose AP based on pt hx, poor response to different trial, side effect profile, cost, and dosing

56
Q

most typical looking atypical drug

A

Risperdal

-most likely to cause typical like side effects and least likely to cause weight gain and diabetes etc.

57
Q

drug for first episode where a hx of AP response is not known

A

Second generation AP (other than clozapine)

Second generation is FIRST LINE

58
Q

side effect: weight gain

A
  • important liability and can be 5-10 lbs per month in some individuals
  • clozapine and olanzapine have most weight gain
  • weight gain increases nonadherence, relapse, and decreases quality of life
  • more weight gain with atypicals
59
Q

progression of trying APs

A

second generation, first generation, clozepine

60
Q

when is clozapine indicated?

A
  • severely ill treatment refractory patients with problems or continuing symptoms with multiple trials
  • no patient should be considered non or partial responders until they have had a trial of clozapine
61
Q

what should a clinician monitor?

A
  • newer antipsychotic
  • weight
  • blood pressure particularly in the elderly
  • diabetes in the family
  • measure of triglycerides and cholesterol
  • people with schizophrenia tend to be extremely high in their CV risk factors (overweight, poor diet)
62
Q

managing s/s of schizophrenia

A
  • pharmacologic
  • life skills - do this in a way that is not dependent on short term memory
  • pt education - negotiate how to talk about the problem
  • family education (longer the better)

Behavioral Medicine (4 decks)

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