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Flashcards in Psychosis Deck (57)
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Define psychosis?

- broadly defined as a loss of contact with reality


Why are psychotic states high risk periods?

pt is experiencing:
impulsivity (suicide)
other forms of behavioral dysfxn


Clinical manifestations of psychosis - delusions?

- strongly held false beliefs that are not part of the pt's cultural or religious backgrounds
- they may be bizarre or non-bizzare
- types:
delusions of reference
delusions of control


clinical manifestations of psychosis - hallucinations?

- wakeful experiences of content that isn't actually present
- any of the 5 senses
- auditory most common
- followed by visual, tactile, olfactory, and gustatory


clinical manifestations of psychosis - thought disorganization (speech)?

- alogia/poverty of content
- thought blocking - suddenly losing train of thought
- loosening of assoc - sequences not well connected
- tangentiality: answers to questions veering off topic
- clanging or clang association: using rhyming words
- word salad - real words linked incoherently
- perseravation - repeating words or ideas even when topic is changed


Psychotic disorders - differential?

- schizophrenia
- bipolar disorder with psychotic features
- major depression w/ psychotic features (at same time)
- schizoaffective disorder (depression or bipolar at diff time then psychosis)
- schizophreniform disorder (not long enough to be called schizophrenia)
- brief psychotic disorder
- substance induced psychotic disorder
- delusional disorder
- psychosis secondary to a medical condition


Work up of psychosis?

- thorough mental status exam - note grooming, mannerisms, reactions
- PE
- labs:
urine drug screen
more as indicated by hx


How do you dx schizophrenia?

- dx is based entirely on psychiatric hx and mental status exam
- there is no lab test for schizophrenia


epidemiology of schizophrenia?

- lifetime prevalence is 1%
- found in all societies and geographical areas
- equally prevalent in men and women
- over 50% male pts first admitted to psych hopstial b/f 25
- only 1/3 of female schizophrenic pts admitted b/f 25
- peak ages of onsets:
men - 12-25
women - 25-35
- women get it later in life than men and men tend to have worse outcome
- onset b/f 10 and after 60 extremely rare


Why is it so hard for the patient with schizophrenia?

- for most it is highly disabling
- generally persists throughout a pts life
- pts and their families often suffer from poor care and social ostracism
- only about half of all pts with schizophrenia obtain tx, in spite of the severity of the disorder


How does genetics play a role in schizophrenia?

prevalence of having schizophrenia:
- child with one affected parent - 12%
- 2 affected parents - 40%
- monozygotic twin - 47%


DSM-5 of schizophrenia?

2 or more of the following, each present for a significant portion of time during a 1 month period (or less if successfully tx):
-disorg. sppech (frequent derailment, incoherence)
-grossly disorganized or cataonic behavior
- negative sxs (affective flattening or poverty of speech)

only one of these criterion are necessary if:
- delusions are bizzare
- hallucinations consist of a voice keeping up running commetery, or 2 or more voices conversing
theses are all considered active phase sxs

more keys to dx:
- social or occupational dysfxn
- continuous signs of disturbance persisting for at least 6 months and w/in this at least 1 month of active phase sxs


Positive sxs of schizophrenia?

- dellusions
- hallucinations


Negative sxs of schizophrenia?

- affective flattening
- poverty of speech (alogia)
- blocking
- poor grooming
- lack of motivation
- anhedonia
- social withdrawal


diff b/t positive and negative sxs of schizophrenia?

- pts that predominantly have postive sxs have a relatively good response to tx
- pts that have negative sxs have poor responses to tx


What is paranoid subtype of schizophrenia?

- preoccupation with one or more delusions or frequent auditory hallucinations
- no disorganized speech, disorganized speech, disorganized or catonic behavior, or flat or inappropriate affect


What is the disorganized subtype of schizophrenia?

- disorganized speech, disorganized behavior, flat or inappropriate affect


What is the catatonic subtype of schizophrenia?

- motoric immobility
- excessive purposeless motor activity
- extreme negativism or mutism
- pecularities of voluntaray movement (bizarre posturing, stereotyped movements)
- echolalia or echopraxia: mimic what you say or do


Components of mental status examination? description, mood, feelings, affect, perception?

-General description: ranges from completely disheveled, screaming, and agitated to obsessively groomed, completely silent and immobile.
behavior: may be talkative and exhibit weird postures, may become agitated or violent in an unprovoked manner or in response to hallucinations, may be in catatonic stupor, tics, echopraxia
-mood, feelings, affect: reduced emotional responsiveness to overly active and inappropriate emotions such as extremes of rage, happiness, and anxiety
- perception: all 5 senses may be affected by hallucinatory experiences (MC: auditory and visual).
Illusions: diff from hallucinations in that illusions are distortions of real images


MSE: thought components?

- most difficult sxs to understand
- likely the CORE sxs of schizophrenia:
*thought content:
what is the person thinking (ideas, beliefs, and interpretations of stimuli)
delusion (4 components):
false belief
based on incorrect inference about external reality.
not consistent with pt's intelligence and cultural background.
can't be corrected by reasoning

*thought form and process:
how is person thinking what they're thinking?
flight of ideas
thought blocking
poverty of content
poor abstraction abilities


MSE: sensorium and cognition?

- usually oriented to person, time and place (lack of such orientation should prompt clinicians to investigate the possibility of medical or neuro brain disorder)
- memory usually intact (may be difficult however to get pt to attend closely enough to the memory tests for adequate assessment)
- classically described as having poor insight into the nature and severity of the disorder - pt doesn't understand that they are sick (fully believe in delusions)


MSE - impulsiveness?

- may be agitated and have little impulse control when ill
- along with this - may have decreased social sensitivity - may throw food on floor, grab other person's belongings


Etiology of schizophrenia?

- NOT a single disease
- likely a group of disorders with differing causes leading to somewhat similar sxs


How is dopamine affected in schizophrenia?

- decreased dopamine in prefrontal cortex (D1 receptor) may be responsible for some of cognitive and negative sxs in schizophrenia
- all drugs with antipsych properities block dopaminergic D2 receptor
- despite adequate tx many people with schizophrenia continue to exhibit positive sxs, so likely that there are other NTs involved


How is glutamate affected in schizophrenia?

- major CNS excitatory NT
- hypofxn of NMDA glutamate receptor may contribute to pathology of schizophrenia
- clinical trials with agents that enhance glutamategic NT are being done with varied results depending on the agent


GABA's role in schizophrenia?

- major CNS inhibitory NT
- GABA-ergic interneurons are impt in regulation of prefrontal cortical fxn through their modulation of glutamatergic pyramidal cells
- evidence suggests that these interneurons are dysfxnl in people with schizophrenia


Acetylcholine's role in schizophrenia?

- increased smoking in pts with schizo has led to hypothesis that nicotine which stimulates acetylcholine receptors, is correcting a fundamental neurochemical problem in schizophrenia
- tx with nicotine or nicotine cholinergic drug can tx some abnormalities in schizo
- Unsure relationship still


Serotonin's role in schizophrenia?

- antagonism at the serotonin 5-HT2 receptor has been emphasized as impt in reducing psychotic sxs
- serotonin dopamine antagonists have high affinity for serotonin 5-HT2 receptors (even higher than D2 receptors)


Course of schizophrenia?

premorbid pattern of sxs may be first evidence of illness (usually not discovered right a way):
- quiet, passive, and introverted personality
- usually few friends growing up
- adolescents may have no close friends, no dates, and may avoid team sports
- oten enjoy movies and TV or listening to music to exclusion of social activities


Prognosis of schizophrenia?

- over 5-10 yr period after 1st psych hospitalization - only approx 10-20% of pts have a good outcome
- more than 50% have poor outcome:
repeated hosp
exacerbation of sxs
episodes of major mood disorders
suicide attempts
- doesn't always run a deteriorating course - est that 20-30% of pts are able to live somehwhat normal lives