Psychotic Disorders Flashcards
1
Q
What is the definition of psychosis?
A
- A break from reality involving delusions, perceptual disturbances, and/or disordered thinking.
- Ex: schizophrenia & substance-induced psychosis
2
Q
Disorders of thought include thought ______ and _____.
A
content
process
3
Q
What are disorders of thought content?
A
- Reflect the patient’s belief’s, ideas and interpretations of his and her surroundings
- Examples
- Paranoid delusions
- Ideas of reference
- Loss of ego boundaries
4
Q
What are disorders of thought process?
A
- Involve the manner in which the patient links ideas and words together
- Examples
- Tangentiality
- Circumstantiality
- Loosening of associations
- Thought blocking
- Perseveration
5
Q
What is the definition of a delusion?
A
- Fixed, false beliefs that cannot be altered by rational arguments and cannot be accounted for by the cultural background of the individual
6
Q
What are the 5 types of delusions?
A
- Paranoid delusion
- Ideas of reference
- Thought broadcasting
- Delusions of grandeur
- Delusions of guilt
7
Q
Paranoid delusion
A
- Irrational belief that one is being persecuted
- “The CIA is after me and taps my phone”
8
Q
Ideas of reference
A
- Belief that some event is uniquely related to the individual
- “Jesus is speaking to me through TV characters”
9
Q
Thought broadcasting
A
- Belief that one’s thoughts can be heard by others
10
Q
Delusions of grandeur
A
- Belief that one has special powers beyond those of a normal person
- “I am the all-powerful son of God and I shall bring down my wrath on you if I cannot have a smoke”
11
Q
Delusions of guilt
A
- False belief that one is guilty of responsible for something
- “I caused the flood in Mozambique”
12
Q
What is the definition of a hallucination?
A
sensory perception without an actual external stimulus
13
Q
What are the 4 types of hallucinations?
When are they commonly seen?
A
- Auditory - most commonly exhibited by schizophrenic patients
- Visual - commonly seen with drug intoxication
- Olfactory - usually an aura associated with epilepsy
- Tactile - usually secondary to drug abuse or alcohol withdrawal
14
Q
What is the definition of an illusion?
A
- Misinterpretation of an existing sensory stimulus
- Ex: mistaking a shadow for a cat
15
Q
Loss of ego boundaries
A
unawareness of where one’s mind and body end and those of others begin
16
Q
What is the differential diagnosis of psychosis?
A
- Psychosis secondary to general medical condition
- Substance-induced psychotic disorder
- Delirium/Dementia
- Bipolar disorder
- Major depression with psychotic features
- Brief psychotic disorder
- Schizophrenia
- Schizophreniform disorder
- Schizoaffective disorder
- Delusional disorder
17
Q
What are 4 medical causes of psychosis?
A
-
CNS disease
- Cerebrovascular disease, MS, neoplasm, Parkinson’s disease, Huntington’s chorea, temporal lobe epilepsy, encephalitis, prion disease
-
Endocrinopathies
- Addison’s/Cushing’s disease, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism
-
Nutritional/Vitamin deficiency status
- B12, folate, niacin
-
Other
- Connective tissue disease (SLE, temporal arteritis), porphyria
18
Q
What is the DSM IV criteria for psychotic disorder secondary to a general medical condition?
A
- Prominent hallucinations or delusions
- Symptoms do not occur only during episode of delirium
- Evidence to support medical cause from lab data, history or physical
19
Q
What are the causes of medication/substance-induced psychosis?
A
- Anti-depressants
- Anti-parkinsonian agents
- Anti-hypertensives
- Anti-histamines
- Anti-convulsants
- Digitalis
- Beta blockers
- Anti-TB agents
- Corticosteroids
- Hallucinogens
- Amphetamines
- Opiates
- Bromide
- Heavy metal toxicity
- Alcohol
20
Q
What is the DSM IV criteria for psychosis secondary to medication of substance use?
A
- Prominent hallucinations or delusions
- Symptoms do not occur only during episode of delirium
- Evidence to support medication or substance-related cause from lab data, history or physical
- Disturbance is not better accounted for by a psychotic disorder that is not substance-induced
21
Q
What is Schizophrenia?
A
- Psychiatric disorder characterized by constellation of abnormalities in thinking, emotion and behavior
- No single symptom is pathognomonic
22
Q
What are the positive symptoms of Schizophrenia?
A
- Hallucinations
- Delusions
- Bizarre behavior
- Thought disorder
23
Q
What are the negative symptoms of Schizophrenia?
A
- Blunted affect
- Anhedonia
- Apathy
- Inattentiveness
24
Q
What are the 3 phases of schizophrenia?
A
- Prodromal
- Psychotic
- Residual
25
**Prodromal** phase of schizophrenia
* Decline in functioning that precedes the first psychotic episode
* The patient may become social withdrawn and irritable
* He/she may have physical complaints and/or newfound interest in religion or the occult
26
**Psychotic** phase of schizophrenia
* Perceptual disturbances
* Delusions
* Disordered thought process/content
27
Residual phase of schizophrenia
* Occurs btwn episodes of psychosis
* Marked by flat affect, social withdrawal, and odd thinking or behavior (negative symptoms)
* Patients can continue to have hallucinations even with treatment
28
What is the DSM IV Criteria for Schizophrenia?
* _2 or more_ of the following must be present for at least _1 month_:
* Delusions
* Hallucinations
* Disorganized speech
* Grossly disorganized or catatonic behavior
* Negative symptoms (flat affect)
* Must cause significant social or occupational functional deterioration
* Duration of illness for **at least 6 mo** (including prodromal or residual periods in which above crteria may not be met)
* Symptoms not due to medical, neurological, or substance-induced disorder
29
What are the 5 subtypes of Schizophrenia?
* Paranoid type
* Disorganized type
* Catatonic type
* Undifferentiated type
* Residual type
30
Paranoid type of schizophrenia
* Highest functioning type, older age of onset
* Must meet the following criteria:
* Preoccupation w/ one or more delusions or frequent auditory hallucinations
* No predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect
31
Disorganized type of schizophrenia
* Poor functioning type, early onset
* Must meet the following criteria:
* Disorganized speech
* Disorganized behavior
* Flat or inappropriate affect
32
Catatonic type of schizophrenia
* Rare
* Must meet at least 2 of the following criteria:
* Motor immobility
* Excessive purposeless motor activity
* Extreme negativism or mutism
* Peculiar voluntary movements or posturing
* Echolalia (repeats words or phrases) or Echopraxia (mimics behavior)
33
Undifferentiated type of schizophrenia
* Characteristic of more than one subtype or non of the subtypes
34
Residual type of schizophrenia
* Prominent negative symptoms
* Flattened affect or social withdrawal
* Minimal evidence of positive symptoms
* Hallucinations or delusions
35
What are the typical findings in schizophrenic patients on exam?
* Disheveled appearance
* Flattened affect
* Disorganized thought process
* Intact memory & orientation
* Auditory hallucinations
* Paranoid delusions
* Ideas of reference (references made to them by TV, newspaper, etc)
* Concrete understanding of similarities/proverbs
* Lack insight into their disease
36
Schizophrenia affects \_\_% of people over their lifetime.
Men tend to present around ___ yrs of age.
Women tend to present around ___ yrs of age.
(Men/Women) have a more severe course.
1%
20
30
Men
37
People born in these two seasons have a higher incidence of schizophrenia?
What is the explanation for this?
* Winter & early spring
* Seasonal variation in viral infections of mothers during pregnancy
38
Schizophrenia rarely presents before age ___ or after age \_\_\_.
(Strong/Weak) genetic predisposition.
Strong association with \_\_\_\_\_\_\_.
15, 45
Strong
substance use
39
What is the "downward drift hypothesis"?
* Lower socioeconomic groups have higher rates of schizophrenia
* People suffereing from schizophrenia are unable to function well in society and hence enter lower socioeconomic groups
* Ex: homeless people in urban areas
40
What is the "dopamine hypothesis"?
* Most antipsychotics that successfully treat schizophrenia are dopamine receptor antagonists
* Cocaine & amphetamines lead to schizophrenic-like symptoms
41
What are the theorized dopamine pathways affected in schizophrenia?
* **Prefrontal cortical** - responsible for negative symptoms
* **Mesolimbic** - responsible for positive symptoms
42
What are some other important dopamine pathways affected by Neuroleptics?
* **Tuberoinfundibular** - blocked by neuroleptics, causing hyperprolactinemia
* **Nigrostriatal** - blocked by neuroleptics, causing extrapyramidal side effects
43
CT scans of patients with schizophrenia show...
* Enlargement of the ventricles
* Diffuse cortical atrophy
44
What are 3 neurotransmitter abnormalities implicated in schizophrenia?
* **Elevated serotonin**
* Atypical antipsychotics antagonist serotonin
* Risperidone, clozapine
* **Elevated** **NE**
* Long-term use of antipsychotics decreases activity of noradrenergic neurons
* **Decreased GABA**
* Loss of GABAergic neurons in the hippocampus; may indirectly activate dopaminergic & noradrenergic pathways
45
**Schizophrenia**
What factors are associated with a better prognosis?
* Later onset
* Good social support
* Positive symptoms
* Mood symptoms
* Acute onset
* Female sex
* Few relapses
* Good premorbid functioning
46
**Schizophrenia**
What factors are associated with worse prognosis?
* Early onset
* Poor social support
* Negative symptoms
* Family history
* Gradual onset
* Male sex
* Many relapses
* Poor premorbid functioning (social isolation, etc)
47
**Typical neuroleptics**
* Examples
* Mechanism
* Efficacy
* Side effects
* Chlorpromazine, thioridazine, trifluoperazine, haloperidol
* Dopamine (D2) antagonists
* Positive \>\> Negative symptoms
* Side effects
* Extrapyramidal symptoms
* Neuroleptic malignant syndrome
* Tardive dyskinesia
48
**Atypical neuroleptics**
* Examples
* Mechanism
* Efficacy
* Side effects
* Risperidone, clozapine, olanzapine, quetiapine, aripiprazole, ziprosidone
* Antagonize serotonin receptors (5-HT2) & dopamine receptors
* Negative \>\> Positive symptoms
* Lower incidence of extrapyramidal side effects
49
Medications should be taken for a least _________ before efficacy is determined.
4 weeks
50
Behavioral therapy
* Attempts to improve patients' ability to function in society
* Patients helped through a variety of methods to improve their social skills, become self-sufficient, and act appropriately in public
* Family therapy & group therapy are successful adjuncts
51
What are extrapyramidal symptoms?
How is it treated?
* Caused by high potency traditional antipsychotics
* Dystonia (spasms) of face, neck, tongue
* Parkinsonism (resting tremor, rigidity, bradykinesia)
* Akathisia (feeling of restlessness)
* Treatment: antiparkinsonian agents (benztropine, amantadine), benzodiazepines
52
What are anticholinergic symptoms?
How are they treated?
* Caused by low-potency antipsychotics & atypical antipsychotics
* Dry mouth
* Constipation
* Blurred vision
* Treatment: as per symptom (eyedrops, stool softeners, etc)
53
What is tardive dyskinesia?
How is it treated?
* Caused by high potency antipsychotics
* Darting or writhing movements of face, tongue and head
* Treatment: discontinue offending agent and substitute atypical neuroleptic
* Benzodiazepines, beta blockers & cholinomimetics may be used short term
* Movements often persist despite withdrawal of the offending drug
54
What is neuroleptic malignant syndrome?
* Caused by high potency antipsychotics
* Confusion, high fever, elevated BP, tachycardia, "lead pipe" rigidity, sweating, greatly elevated CPK levels
* Can be life-threatening, not an "allergic rxn"
55
What are some additional side effects of antipsychotic medications?
* Weight gain
* Sedation
* Orthostatic hypotension
* ECG changes
* Hyperprolactinemia
* Gynecomastia, galactorrhea, amenorrhea, diminished libido, impotence
* Hematologic effects
* Agranulocytosis (clozapine)
* Ophthalmologic conditions
* Thioridazine: irreversible retinal pigmentation
* Chlorpormazine: deposits in lens & cornea
* Dermatologic conditions
* Rashes, photosensitivity
* Hyperlipidemia
* Glucose intolerance
56
What is the difference between schizophrenia & schizophreniform disorder?
* Schizophreniform disorder
* 1-6 months
* Schizophrenia
* \>6 months
57
**Schizophreniform Disorder**
\_\_\_ recover completely.
\_\_\_ progress to schizoaffective disorder or schizophrenia.
1/3
2/3
58
How is schizophreniform disorder treated?
* Hospitalization
* 3-6 month course of antipsychotics
* Supportive psychotherapy
59
What is the definition of schizoaffective disorder according to DSM-IV criteria?
* Meet criteria for either major depressive episode, manic episode or mixed episode (during which criteria for schizophrenia are also met)
* Have delusions or hallucinations **for 2 wks** in the absence of mood disorder symptoms (necessary to differentiate schizoaffective disorder from mood disorder with psychotic features)
* Have mood symptoms present for substantial portion of psychotic illness
* Symptoms not due to general medical condition or drugs
60
Prognosis of schizoaffective disorder is _____ than schizophrenia but _____ than mood disorder.
better, worse
61
How is schizoaffective disorder treated?
* Hospitalization and supportive psychotherapy
* Medical therapy
* Antipsychotics: short-term control of psychosis
* Mood stabilizers
* Antidepressants
* Electroconvulsive therapy (ECT): as needed for mania or depression
62
What is the definition of brief psychotic disorder according to DSM-IV criteria?
* Patient with psychotic symptoms as defined for schizophrenia
* Symptoms last 1 day to 1 month
* Symptoms must not be due to general medical condition or drugs
* Rare, much less common than schizophrenia
63
**Brief psychotic disorder**
\_\_\_% recovery rate
\_\_\_% may be eventually diagnosed with schizophrenia or mood disorder
50-80%
20-50%
64
How is brief psychotic disorder treated?
* Brief hospitalization
* Supportive psychotherapy
* Course of antipsychotics for psychosis itself and/or benzodiazepines for agitation
65
What is the time course of these disorders?
* Brief psychotic disorder
* Schizophreniform disorder
* Schizophrenia
* Brief psychotic disorder: \<1 month
* Schizophreniform disorder: 1-6 months
* Schizophrenia: \>6 months
66
Put these in order of prognosis from BEST to WORST:
* Schizophreniform disorder
* Brief psychotic disorder
* Schizophrenia
* Mood disorder
* Schizoaffective disorder
1. Mood disorder (BEST prognosis)
2. Brief psychotic disorder
3. Schizoaffective disorder
4. Schizophreniform disorder
5. Schizophrenia (WORST prognosis)
67
In what subset of patients is delusional disorder most common?
1. Older patients (\>40 YO)
2. Immigrants
3. Hearing impaired
68
What is the DSM-IV criteria for delusional disorder?
* Nonbizarre, fixed delusions for at least 1 month
* Does not meet criteria for schizophrenia
* Functioning in life not significantly impaired
69
What are the 6 types of delusions and their definitions?
* **Erotomanic type** - delusions revolves around love
* **Grandiose type** - inflated self-worth
* **Somatic type** - physical delusions
* **Persecutory type** - delusions of being persecuted
* **Jealous type** - delusions of unfaithfulness
* **Mixed type** - more than one of the above
70
**Prognosis of delusional disorder**
\_\_\_% full recovery
\_\_\_% decreased symptoms
\_\_\_% no change
50%
20%
30%
71
How is delusional disorder treated?
* Psychotherapy may be helpful
* Antipsychotics are often ineffective
* Course should be tried
* High potency traditional antipsychotic or one of the newer atypical antipsychotics
72
What are the fundamental differences between Schizophrenia & Delusional Disorder?
* **Schizophrenia**
* Bizarre delusions (or nonbizarre)
* Daily functioning significantly impaired
* Must have 2 or more of the following:
* Delusions
* Hallucinations
* Disorganized speech
* Disorganized behavior
* Negative symptoms
* **Delusional Disorder**
* Nonbizarre delusions (never bizarre)
* Daily functioning not significantly impaired
* Does not meet the criteria for schizophrenia as described in left column
73
What is the DSM-IV criteria for shared psychotic disorder?
* *Folie à deux*
* Diagnosed when a patient develops the same delusional symptoms as someone he or she is in a close relationship with
* Most commonly family members
74
**Shared psychotic disorder**
\_\_\_% will recover upon removal from the inducing person
20-40%
75
How is shared psychotic disorder treated?
* **Separate** the patient from the person who is the source of shared delusions (usualy a family member with an underlying psychotic disorder)
* **Psychotherapy** should be undertaken
* **Antipsychotic** medications
* If symptoms not improved in 1-2 wks after separation
76
What is Koro?
**Culture-specific psychoses**
* Patient believes that his penis is shrinking and will disappear, cuasing his death
* Culture: Asia
77
What is Amok?
**Culture-specific psychoses**
* Sudden unprovoked outbursts of violence of which the person has no recollection
* Person often commits suicide afterwards
* Culture: Malaysia, Southeast Asia
78
What is Brain fag?
**Culture-specific psychoses**
* Headache, fatigue and visual disturbances in male students
* Culture: Africa
79
**Define**
Lifelong psychotic disorder
Schizophrenia
80
**Define**
Schizophrenia for \<6 months
Schizophreniform
81
**Define**
Schizophrenia + mood disorder
Schizoaffective
82
**Define**
Paranoid, odd or maginal beliefs, eccentric, lack of friends, social anxiety. Criteria for true psychosis are not met.
Schizotypal (personality disorder)
83
**Define**
Withdrawn, lack of enjoyment from social interactions, emotionally restricted.
Schizoid (personality disorder)
