Psychosis Flashcards
(125 cards)
1
Q
What percentage refractory?
A
25%
2
Q
What percentage functional remission?
A
12-15%
3
Q
Most common delusion?
A
Persecutory
4
Q
How long for delusional disorder?
A
1 month
5
Q
Other name for erotomania delusion?
A
Clérambeault
6
Q
Other name for jealousy delusion?
A
Othello
7
Q
Delusional disorder specifiers?
A
With bizarre content
Severity (0-4, 5-point scale)
Course (after 1 year, first episode, multiple episodes, continuous, unspecified)
8
Q
Delusional disorder epidemiology?
A
Prevalence 0.2%
M=F for most part
Onset around 40yo
9
Q
What is NOT a risk factor for delusional disorder?
A
DEPRESSION
10
Q
Delusional disorder is not a risk for developing what?
A
SCHIZOPHRENIA
Stable diagnosis, 50% remission, 30% no change
11
Q
How long for brief psychotic disorder?
A
24 hours to 1 month
Only need ONE symptom (at least delusion, hallucination or disorganized speech)
12
Q
Brief psychotic disorder specifiers?
A
With marked stressors
Without marked stressors
With postpartum onset (max 4 weeks PP)
With catatonia
13
Q
Brief psychotic disorder epidemiology?
A
Prevalence 9% of first episode psychosis
2F : 1M
More in developing countries
Onset in mid 30s
14
Q
Brief psychotic disorder prognosis?
A
50% will have a final diagnosis of something chronic (like schizophrenia or mood d/o)
15
Q
How long for schizophreniform?
A
1 month at least but less than 6 months
At least TWO symptoms
No need for functional decline
16
Q
Schizophreniform specifiers?
A
With good prognostic features = at least TWO of
- prominent psychotic symptoms within 4 weeks of first noticeable change in behaviour
- confusion or perplexity
- good pre-morbid functioning
- absence of blunted or flat affect
Without good prognostic features
With catatonia
17
Q
Schizophreniform epidemiology?
A
Prevalence 0.3-0.7% similar to schizophrenia
Common in DEVELOPING countries
5M : 1F
Higher likelihood of a family history of mood disorder vs. schizophrenia
18
Q
Schizophreniform prognosis?
A
1/3 remain with schizophreniform
2/3 eventually schizophrenia or schizoaffective
RESPOND QUICKER TO RX than schizophrenia
Higher risk of schizophrenia in relatives if dx
19
Q
How long for schizophrenia?
A
At least 1 month and more than 6 months (including prodromal and residual phases)
At least TWO symptoms
Marked decrease level of functioning
20
Q
Most common predictor of non-adherence to treatment?
A
Anosognosia (symptoms NOT coping strategy)
21
Q
Schizophrenia specifiers?
A
Course (after 1 year)
With catatonia
Early onset = 18 years old
Very early onset = 13 years old
22
Q
Schizophrenia epidemiology?
A
Prevalence 0.3-0.7% Higher INCIDENCE in men Prevalence M = F Mid to late 20s for FEP Late teens and mid-30s for symptom emergence
23
Q
Which symptoms are more closely related to prognosis in schizophrenia?
A
Negative symptoms
24
Q
Schizophrenia risk factors?
A
Male gender
Winter birth
Urban environment
Hypoxia at birth, perinatal complications
Advanced paternal age (>60yo in K&S)
Migration (2nd generation > 1st generation)
** MOST INDIVIDUALS WITH SCHIZOPHRENIA HAVE NO FAMILY HISTORY**
25
Suicide in schizophrenia?
```
5-6% complete
20% attempt
Young males with substance use
Following discharge from hospital
Depression MOST SIGNIFICANT
Unemployed
NEGATIVE SYMPTOMS ARE PROTECTIVE
CLOZAPINE IS PROTECTIVE
```
26
Criteria for schizoaffective disorder?
Major mood episode concurrent with criterion A of schizophrenia.
Psychotic sx in absence of mood episode for at least 2 WEEKS.
Mood sx present for majority of total duration of illness
No need for functional decline or to r/o ASD
27
Schizoaffective disorder specifiers?
Depressive type
Bipolar type
With catatonia
Course (after 1 year)
28
Schizoaffective disorder symptoms compared to schizophrenia?
Less negative symptoms
Less anosognosia
Better prognosis overall, but not as good as pure mood disorder
29
Schizoaffective disorder gene?
DISC1 gene on 1q42
30
Schizoaffective disorder epidemiology?
Prevalence 0.3% (1/3 as likely as schizophrenia)
F > M
Early adulthood age of onset
31
Suicide in schizoaffective disorder?
5%
| Higher risk with depressed type and North Americans
32
What percentage of FEP is substance-induced?
7-25%
33
Alcohol-induced hallucinations are generally what kind?
Auditory
34
What to rule out if olfactory hallucinations?
Temporal lobe epilepsy
35
Most common psychosis due to medical condition?
Post-ictal psychosis in 2%-7.8% epilepsy patients
36
What are the other-specified schizophrenia spectrum disorders?
Persistent auditory hallucinations
Delusions with significant overlapping mood episodes
Attenuated psychosis syndrome
Delusional symptoms in partner of individual with delusional disorder
37
Catatonia most common with?
Mood disorders (25-50%, bipolar especially)
Less with schizophrenia (10%)
Need to r/o NMS
38
How many patients with schizophrenia have catatonia?
35%
39
Types of catatonia?
1. Malignant
2. Stuperous
3. Excited
NMS presents with malignant and stuperous
Mania presents with excited
Periodic catatonia presents with stuperous and excited
40
Cannabis and psychosis
Association ++ at younger than 15yo
Earlier disease onset by 2.7-6.9 years
2-3x increased risk for schizophrenia but inverse NOT TRUE (adolescent psychosis does not increase cannabis use risk)
41
Schizophrenia and physical co-morbidities
Cigarettes, CAD, DM2, HIV, Hep C
Life expectancy decreased by 10-20 years!
LOWER RISK OF RHEUMATOID ARTHRITIS
42
Schizophrenia and psychiatric co-morbidities
Substance use 44-47%
Anxiety 50%
Mood disorder 50%
PTSD
43
Schizophrenia and elderly
Less positive symptoms
20% have no active symptoms over 65yo
Respond WELL to antipsychotics
Need smaller doses
44
Bleuler
Associational disturbances
Affective disturbance
Autism
Ambivalence
Secondary symptoms of hallucinations, mood changes, delusions and perplexity
45
Schneider first rank symptoms?
Auditory hallucinations (audible thoughts, arguing voice, commentating voice)
Broadcasting of thoughts (insertion, withdrawal)
Control of thoughts (forced feelings/impulses, forced actions, passivity experiences)
Delusional perception
46
Negative symptoms?
```
Anhedonia
Asociability
Alogia
Avolition
Decreased emotional expression
```
NOT APATHY (don't have loss of concern)
47
Hallucination outside normal perceptual field (such as seeing behind your back)
Extracampine hallucination
48
Fantom mirror
Autoscopic
| in depression
49
Don't see self in mirror
Negative autoscopic
50
Image persists despite stimulus gone
Palinopsia
| in LSD, trauma, migraine, epilepsy
51
Seeing small people or animals
Lilliputian
| delirium tremens, LBD
52
Perceiving shapes (such as in clouds)
Pareidolia
53
Mixed up sense (seeing doors)
Synesthesia
54
Altered internal state (such as "brain on fire")
Cenesthetic hallucination
55
Imposter syndrome (hypo identification)
Capgras
56
Stranger is a loved one (hyper identification)
Fregoli
57
Other created physically similar
Subjective double
58
Inanimated double
Doppleganger
59
Others interchange physically and psychologically
Intermetamorphosis
60
Places have been duplicated
Reduplicative paramnesia
61
People living in house
Phantom boarder syndrome
62
Nihilistic delusion
Cottard
63
Schizophrenia heritability?
80%
Multi loci gene with incomplete penetrance
```
22q11 = PRODH (Di George) 1-2% of schizophrenia but 25x increased risk in those with Di George
22q1 = COMT
```
9 linkage sites: 1q, 5p, 6p, 8p, 10p, 13p, 15q, 22q
```
Pyknic type (short, stalky) = good
Aesthenic/athletic types = bad
```
64
Genetic risk if MZ twin
47%
65
Genetic risk if both parents
40%
66
Genetic risk if DZ twin
12%
67
Genetic risk if 1 parent
12% (or 6% in KS)
68
Genetic risk if sibling
8%
69
Di George characteristics
22q11
Nasal voice, long narrow face, narrow palpebral fissures, flat cheeks, proeminent nose, small ears, small mouth, learning d/o, ++ otitis, cardiac malformation, hypocalcemia, platelet dysfunction
70
Genetics of negative symptoms in schizophrenia?
Mutations in DTNBP1 + NEUREGLIN1
71
Ultra high risk psychosis groups?
1. 1st degree relative or significant decrease in functioning in last year
2. Attenuated positive symptoms (MOST COMMON)
3. Brief and intermittent positive symptoms
72
Ultra high risk group conversion to psychosis?
10-18% / year
35% / 10 years
73% have co-morbidity
DEPRESSION most common
73
What should be monitored at all check-ins (baseline, 1 month, 3 months, annually?)
BMI/weight
| EPS
74
What should be monitored only as clinically indicated?
Prolactin
75
Dopamine signaling in schizophrenia?
Phasic INCREASES
| Tonic DECREASES
76
Neuropsychiatry and schizophrenia
White matter loss STABLE
Grey matter loss PROGRESSES
Cognitive deficits often precede diagnosis
Become more severe with 1st episode then stable
Decreased dendritic arborization and spines
77
Neuropathology and schizophrenia
INCREASED lateral ventricles (80%)
INCREASED 3rd ventricle
INCREASED basal ganglion
INCREASED asymmetry
HYPOFRONTALITY on functional imaging (decreased frontal metabolism)
```
DECREASED thalamus
DECREASED cerebellum
DECREASED temporal, frontal, occipital lobes
DECREASED amygdala
DECREASED hippocampus
```
ATROPHY = poor prognostic sign
78
Acute intermittent porphyria
Abdominal pain, psychosis, polyneuropathy
Increased urinary aminolevulinic acid (while symptomatic)
Treat with IV hemin
79
Which neurotransmitter has a possible role in anhedonia?
Norepinephrine
80
Positive symptom circuit?
Anterior cingulate basal ganglia thalami-cortical circuit
81
Negative symptom circuit?
Dorsolateral-prefrontal
| Correlate with decrease DA1 receptor concentration in prefrontal cortex
82
EEG in psychosis
Abnormal in 15-25%
Worst prognosis if abnormal in FEP
Similar to complex partial epilepsy picture
83
Eye movements in schizophrenia
Decreased smooth visual pursuit
| Disinhibition of saccadic movements
84
Endocrinology and schizophrenia
Abnormal dexamethasone suppression test which predicts poor outcome
Decreased concentrations of LH and FSH
luted release of prolactin and HG or GRH/TRH
85
Percentage of post-psychotic depressive disorder?
25%
| Increased suicide risk
86
LAI trial?
6 weeks post achieving steady state
87
Clozapine trial?
8-12 weeks
| More than 400mg or Clozapine level more than 1100nm/L
88
CATIE trial findings?
SGA = FGA except Zyprexa which was mildly superior but had high incidence of metabolic syndrome
89
Relapse?
15-23% per year if treated vs. 79% if untreated
90
Clozapine response rate?
30-60%
91
Treatment resistance?
At least 2 moderate + symptoms OR at least 1 severe + symptom after trial of 2 different APs
92
Clozapine resistance tx?
```
NOT Tegretol (agranulocytosis risk)
NOT Gabapentin
```
93
Metabolic syndrome?
Abdominal obesity (WC 80cm women or 94cm men) + 2 others
- Trigs > 1.7mol/L
- Hypertension >130/85mmHg
- HDL <1.3 mol/L
- Fasting glucose > 5.6mmol/L
94
Mesocortical
Negative symptoms
Hypoactivity
D1 receptors
Motivation and cognition
95
Mesolimbic
Positive symptoms
Memory, emotional behaviours
Reward pathway
D2 receptors
96
Tuberoinfundibular
Decreased dopamine secretion by hypothalamus with decreased inhibition of prolactin aka indirect prolactin increase
DOPAMINE INHIBITS PROLACTIN
97
Serotonin and dopamine?
SEROTONIN INHIBITS DOPAMINE
98
D2 blockade percentages?
```
68% = efficacy
72% = prolactin increase
80% = EPS
```
Clozapine = 38-68%
Clozapine and Quetiapine most loose binding
Haldol, paliperidone and risperidone higher blockade
99
Abilify
```
5HT1a partial agonist
5HT2a antagonism
CYP 2D6 and 3A4
Least QT prolongation
No effect or even decreases prolactin
```
100
Anticholinergic APs
Clozapine > Zyprexa > Seroquel > Abilify > Risperdal
Least risk NMS
Tx with Physostigmine
DOPAMINE INHIBITS CHOLINERGIC ACTIVITY
Low potency APs have higher anticholinergic activity
101
EPS risk factors?
High potency APs
Women
Elderly
Symptoms can last 2 weeks to 3 months after stopping AP
102
Akathisia
Middle aged women most at risk
Risk factors include iron deficiency, caffeine, SSRIs, anxiety, co-morbid mood d/o
Beta-blocker
ANTICHOLINERGIC NOT HELPFUL
103
Indications for B-blocker use?
```
Akathisia
Performance anxiety
Tremor due to Lithium
Alcohol withdrawal
Aggressive/violent especially secondary TBI
```
104
Acute dystonia
Risk factors include young man, hypocalcemia, hypothyroidism, hypoparathyroidism, recent cocaine use
Treat with anticholinergic, benzo SL or Benadryl IM
BETA BLOCKERS NOT HELPFUL
105
Most frequent TD symptom?
Peri-oral
106
TD
Rarely in first 6 months of treatment
Decreased by sleep, movement of affected areas, voluntarily
ANTICHOLINERGIC MAY WORSEN
107
Clozapine CBC monitoring?
CBC weekly x 6 months
every 2 weeks x 6 months
every month afterwards
108
Which anticholinergic may cause depression?
Tetrabenazine
109
Which meds can cause agranulocytosis?
Clozapine
Tegretol
Seroquel
Mirtazapine
110
Predictor sign of seizures?
Myoclonus
111
Missed Sustenna injection?
Less than 6 weeks, give dose
Less than 6 months, give loading dose again
More than 6 months, start over
112
Missed Abilify Maintena?
More than 6 weeks, need to supplement with PO again (usually have to supplement with PO Abilify x 2 weeks when starting)
113
Missed Risperdal Consta?
If missed 2nd dose or more than 6 weeks, need PO supplementation again (usually have to supplement with PO Risperdal x 3 weeks when starting)
114
Side effect frequency?
1. Parkinsonism
2. Dystonia
3. Akathisia (most common in another source??)
4. TD
115
NMS criteria
```
0.01-0.02%
Fever
Rigidity
Tachycardia
Autonomic dysfunction
Altered mental state
Elevated CK, LFTs, WBC
```
116
NMS risk factors
```
Young male (compared to elderly women for almost all other side effects except for acute dystonia)
Neurological dysfunction
Dehydration
Exhaustion
Agitation
Fast administration/titration
```
117
NMS treatment
Dantrolene
Bromocriptine
Amantadine
118
Which receptors mediate weight gain?
5HT2C
H1
Alpha 1
119
Black box warning for SGA?
Increased stroke risk in dementia-related psychosis
120
Which antipsychotic can cause cataracts?
Quetiapine
121
Which cognitive task is most affected in schizophrenia?
Processing speed
122
Perseveration is common in which illnesses?
```
SCHIZOPHRENIA
Organic causes (delirium)
```
123
Genes of negative symptoms?
DTNBP1
| Neureglin 1
124
Who coined the term "schizophrenia"?
Bleuler
125
Who coined the term "dementia praecox"?
Kraepelin
