Schizophrenia Flashcards
(36 cards)
1
Q
Why is SCZ important?
A
- economic cost to society: $30-65 billion/yr
- 22% of all mental illness costs
- 1/3 of all psych hospital beds occupied by schizophrenic pts
2
Q
Diagnosing Schizophrenia
A
- Criteria A: Active Phase signs and symptoms
- Criteria B: Social Occupational Dysfunction: How bad is it?
- Criteria C: Time Duration
- Criteria D: Another Diagnostic Explanation
3
Q
Criteria A: S&S
A
- Hallucinations
- Delusions
- Disorganized thinking
- Disorganized Behavior
- Negative Symptoms
4
Q
Psychosis
A
- Grossly impaired reality testing.
- Persons incorrectly evaluate the accuracy of their perceptions and thoughts and make incorrect inferences about external reality, even in the face of contrary evidence.
- Psychosis = pt is experiencing delusions and hallucinations. These are also called the “positive” symptoms of schizophrenia.
- Disorganized thinking is also referred to as psychotic thinking, or psychosis, and is a positive symptom.
5
Q
Hallucinations
A
- perceptions WITHOUT stimuli
- Auditory hallucinations-“hearing voices”; most common type
- Visual hallucinations-“seeing things that aren’t there”; 2nd most common type
-
Tactile hallucinations-feeling things that aren’t there, like bugs on or under one’s skin
- less common, may be seen in context of various substance withdrawal syndromes
- olfactory & gustatory hallucinations- smelling, tasting things; rare
6
Q
Delusions
A
- unfounded, unrealistic belief that is held without supporting evidence and are not amenable to change
- when conflicting evidence is presented; the person is totally convinced that what they believe is true; will often lead to conflicts with others
- Non-bizarre delusions-have a certain amt of plausibility when you first hear about it, as you get more details it becomes less plausible
- Bizarre delusions-clearly implausible, not understandable, and/or do not derive from ordinary life experiences. Usually easy to identify though can be difficult to judge situations involving different cultures
7
Q
Disorganized Thinking
A
- Symptom must substantially impair effective communication
- Inferences about thinking are based primarily on the individual’s speech; one’s speech may be disorganized in various ways:
- Derailment—person talking about a topic…derails (stops)…resumes on a different topic
- Loose associations—person slips off track from one topic to another topic; association between topics is weak or unclear
- Tangential speech-answers are unrelated or only vaguely related to the question
- Incoherence or word salad-severely disorganized speech, nearly incomprehensible
8
Q
Disorganized behavior
A
- Grossly disorganized; may be seen in wide range of possible behaviors.
- Childlike silliness to unpredictable agitation
- Problems with any form of goal directed behavior; leads to difficulties performing activities of daily living (meal preparation, maintaining personal hygiene)
- inappropriate sexual behavior
- shouting, swearing
- catatonic behavior
9
Q
Schizophrenia A Criteria-Negative Symptoms
A
- affective flattening-lack of emotion; interpersonal emotional cues (facial expression, eye contact, body language) are lacking
- alogia-poverty of speech; brief, laconic, empty replies
- avolition-lack of motivation; inability to initiate and persist in goal directed activities
- anhedonia-lack of pleasure; unable to enjoy activities
- onyl need to have any ONE of the 4 negative symptoms to qualify as having negative sym
10
Q
Meeting the Schizophrenia A Criteria
A
- must have TWO of the S&S to meet A criteria
- ONE of the TWo must be:
- Positive symptom: hallucination, delusion, disorganized thinking
11
Q
Criteria B: Social Occupational Dysfunction, How Bad Is It?
A
- usually why they present
- For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning–work, interpersonal relations, or self-care– are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
- Downward Drift Hypothesis
- disproportionate number of people with schizophrenia are in the low socioeconomic group.
- WHY?…ppl who start out with resources available to them gradually lose them and drift downward into the low socioeconomic group.
- 33%, of the homeless pop. have schizophrenia
12
Q
Criteria C: Time Duration
A
- Continuous signs of the disturbance that persist for at least 6 months—Criteria A does not need to be met for the entire time
- At least 1 month where Criteria A (active phase symptoms) is met
- If duration of symptoms < 1 month—diagnosis of brief psychotic disorder or psychosis nos (not otherwise specified)
- If total duration of symptoms > 1 mo, < 6 mo—diagnosis of schizophreniform disorder
- Onset of illness-most commonly there is a gradual onset and building of the symptoms of schizophrenia, a prodromal phase.
- Often not realized until after the symptoms have gotten serious (the first break of psychosis)
13
Q
What are other diagnostic explanations?
A
- another psychotic disorder
- affective disorder with psychosis
- psychosis due to a substance
- general medicine condition (delirium)
- developmental disorder
- personality disorder
14
Q
Another psychotic disorder
A
- Schizoaffective disorder (DSM-5)-a major mood episode (MDD, bipolar disorder) is concurrent with Schizophrenia Criterion A
- Major mood symptoms are present for majority of the total duration of the illness; at least one TWO WK pd of hallucinations or delusions (psychosis episode) without mood symptoms
-
Delusional Disorder—bizarre* or non-bizarre delusion (for 1 mo); most common: persecutory, jealousy
- doesnt meet Criteria A for Schizophrenia
- social-occupational fxn okay
- not due to substances or medical illness
15
Q
Mood disorder with psychosis…AFFECTIVE DISORDER
A
-
Bipolar disorder with psychosis
-
depression-overlap with negative symptoms
- anhedonia, avolution (lack of energy), affective flattening
- Mania-grandiosity (delusions?), flight of ideas (disorganized speech)
-
depression-overlap with negative symptoms
- Major depression with psychosis-symptom overlap with negative symptoms: anhedonia, avolution (lack of energy), affective flattening (disturbed mood?)
16
Q
What are the 6 illnesses with psychosis
A
- another psychotic disorder
- schizoaffective disorder
- delusional disorder
- schizophreniform disorder
- brief psychotic disorder
- psychosis N.O.S.
- Mood disorder with psychosis
- bipolar disorder w/ psychotic features
- major depression w/ psychotic features
- Psychosis due to a substance
- substance intoxication/withdrawal
- psychosis secondary to medication reaction
- General Medical condition
- any medical illness that affects the CNS-neuroloficao, endocrine, metabolic
- Developmental Disorders
- autism
- Rhett’s disorder
- Asperger’s disorder
- Personality disorders
- cluster A-paranoid, schizoid, schizotypal
17
Q
Psychosis due to a substance
A
- Intoxication
- Alcohol, any illicit drug (amphetamines, cannabis, cocaine, hallucinogens (LSD), inhalants, opioids, PCP, sedatives, hypnotics, other unknown substances
- Withdrawal: alcohol, sedatives, hypnotics, anxiolytics
- Medications:
- anesthetics, anti-cholinergics, anti-convulsants, anti-histamines, anti-hypertensive, cardiovascular meds, anti-microbial meds, anti-parkinsonian meds, chemotherapeutic agents, STEROIDS!!!, GI meds, muscle relaxants, NSAIDS, OTC, anti-depressants, disulfiram
18
Q
General medical condition
A
-
Neurological
- neoplasms, dementia, CVA’s, epilepsy, CNS infection, Huntington’s disease
-
Endocrine
- hyperthyroid, hypothyroid, hyperparathyroid, hypoparathyroid, hypoglycemia
-
Metabolic-delirium:
- hypoxia, hypercarbia, hepatic diseases, renal diseases, fluid or electrolyte imbalances
19
Q
Developmental disorder
A
Autism, Rhett’s, Asperger’s: symptom overlap:
- poor communication skills (disorganized thinking/speech)
- poor reciprocal social skills (affect is flat, anhedonia?)
- diagnosed in childhood (autism at 3yo)
- kid with schizo is rare, autism is more common
20
Q
Personality Disorders
A
- symptoms milder than schizophrenia, wwill be pronounced under STRESS (in the ER, or sick)
- Paranoid-pattern of distrust and suspiciousness of others (delusion?)
- Schizoid-social detachment & restricted affect (negative symptoms?)
- Schizotypal-ODD-odd beliefs/unusual perceptual experiences (psychosis?), odd speech (disorganized thinking?), odd/eccentric behavior (disorganized behavior)
21
Q
Schizophrenia epidemiology
A
- incidence of schizophrenia in the U.S.: 0.3 - 0.6 per 1000 individuals.
- lifetime prevalence = 1%.
- M = F
- US pop of ~ 300 million; ~ 2.2 million ppl in the country have schizophrenia
22
Q
Where do ppl with schizophrenia live?
A
- 33 independently
- 67 need support
- 25 with family
- 18 group home
- 7.5 nursing home
- 6 jail/prison
- 4.5 hospitals
- 4.5 homeless
23
Q
course of illness-THREE phases
A
- A. Prodromal phase: vague symptoms-social isolation/withdrawal, peculiar behavior, impaired personal hygiene, in
- inappropriate affect, abnml speech, odd beliefs
- often prodromal phase not identified until after the first active phase (psychotic break) takes place;
- B. Active phase (relapse): Patient meets the “A” criteria for schizophrenia
- C. Residual phase (remission): after active phase(s) have taken place; no longer clearly meets the “A” criteria;
- much overlap with the Prodromal phase
- 10-15 single active phase
- 25-30 intermitten active phases
- 50-55 chronic course of illness
- M>F
24
Q
Peak age of onset of the FIRST time in active phase
A
- Male-earlier age 15/18-25 years; > 50% have 1st hospitalization by age 25
- Female-later, age 25-35/45; ~33% have 1st hospitalization by age 25
- also have a second post-menopausal peak (a/r 50 yo)
- Childhood onset-rare; ~1% of pts w/ schizophrenia have a childhood onset
25
Suicide Risk
* Completed suicide: different studies give range of 6-8%
* General population complete suicide rate 1%
* Attempted suicide: different studies give different ranges, but ~20% make suicide attempts
* ~50x’s higher than general population risk for suicide attempts
* Risk factors
* Suicide risk remains present over the entire lifespan for both males & females
* Especially high for younger males with comorbid substance abuse
* Depressive symptoms, feelings of hopelessness, being unemployed;
* **Higher risk: pd after psychotic episode or hospital discharge**
26
Cognitive impairment
* occus early in PRO-DROME and worsens in active phase
* SMART acronym
* Speed
* Memory (working, visual, verbal)
* Attention
* Reasoning
* Tact (social cognition)
* pts are moderately to severely impaired compared to the gen pop
* Wisconsin card sort
* Anosognosia-poor insight into illness
* lack of/partial awareness/insight
* varies w/ phase of illness, awareness decreases as the illness progresses
* Cognition deficits
* appears early
* persists
* stable
* worsens in active phase
27
Course of illness-substance abuse
* 30-50% alcohol abuse/dependence
* 10-15% marijuana abuse/dependence
* 5-10% cocaine abuse/dependence
* About 50% of pts with schizophrenia have, or have had, a problem with alcohol or illicit drugs
28
Prognosis/Outcome Predictors
* Course is favorable for ~20% of patients; small number of individuals recover completely
* Course is unfavorable for the great majority of patients
* 75% can’t work, are unemployed; schizophrenia is among the top 10 causes of disability
* 60-70% do not marry, most have limited social contacts
* Only about 33% live independently
* Quality of life associated with schizophrenia ranks among the worst of chronic medical illness
* Prognosis
* **better**: *older female* with no negative symptoms, no FHx, sudden onset, good initial tx response
* **worse**: *young male*, negative symptoms and substance use, FHx, gradual onset, poor initial tx response
29
Ongoing tx issues
* Medication compliance
* 2 yrs post-hospitalization, 70% non-compliant
* Psychosocial tx needs
* handling of money
* food
* housing
* employment
* social skills training
* medical/dental care
* sex, pregnancy, parenthood
* ability to consent, use contraception, prenatal care
* **33% mothers lose custody of kids**
* legal issues
* pt autonomy and right to privacy vs. beneficence and paternalism
* confidentiality-prevention of family from helping pts
* concerns about assaultive/violent behavior
* risk to others no diff from gen pop (except for small subset)
* much greater risk for self harm
* Risk of Victimization
* pts vulnerable to criminals
* contribution to stigma
30
Outcome
* Life expectancy
* gen pop: 78 yrs
* schizophrenia: 48-53
* suicide risk vs. CVD
* smoking, diabetes, HTN, increased lipids
* difficulty treating for medical illnesses
* 75% cant work
* 60-70% dont marry, most limited scial contacts
* 33% live independently
31
What causes schizophrenia (5 theories)
1. neurochemical theory
2. infection/viral theory
3. nutritional theory
4. endocrine theory
5. genetics theory
32
Schizophrenia neurochemical disorder
* dopamine hypothesisi
* anti-psychotics are dopamine antagonists
* other hyper-dopaminergic states cause psychosis
* glutamate
* often paired with GABA
* PCP blocks glutamate and causes psychosis
33
Schizophrenia slow virus cause
* Viral cause-slow virus? May remain latent for long period of time before causing illness
* infecteed in utero, dz symptoms decades later
* idea of interaction of infectious agents (viruses) and genes (susceptible ppl)
* Many viruses are seasonal, could account for seasonality of births in schizophrenia
* Many studies consistently show more patients (~5-8%) with schizophrenia were born in the winter or spring months.
34
Genetics theory
* Risk if no family history of schizophrenia 1 : 100, 1%
* Risk if parent or sibling has schizophrenia 1 : 10, 10%
* Risk if both parents have schizophrenia 4 : 10, 40%
* Risk if identical twin has schizophrenia 1 : 2, 50%
* genetics play a big role, but are not the only component
35
Schizophrenia process of development
* genetic predisposition
* early environmental insults-prenatal, perinatal
* environmental exposures leads to neurodevelopmental abnormalities
* substance abuse, psychosocial stressors, late adolescence neuronal pruning mistakes
* active phase of illness
* periods of psychosis
* neurodgeneration
* cause of schizophrenia/how it develops-not known
36
treating psychotic illnesses
* Mood disorder with psychosis
* **Major depression with psychosis**-tx with anti-depressant & anti-psychotic; when pt no loger psychotic may eventualy stop anti-psychotic;
* continue anti-depressants indefinitely
* **Bipolar disorder with psychosis**-tx with mood stabilizer & anti-psychotic, when patient no longer psychotic, may discontinue anti-psychotic
* note 2nd generation/atypical anti-psychotics can be used as mood stabilizers
* **Medical illness with psychosis (delirium)**-tx with anti-psychotic to help with psychosis and agitation/prevent unintentional patient injury; ultimately must find & tx underlying medical illness
* discontinue anti-psychotic once delirium resolved
* **Dementia with psychosis**-tx with low dose anti-psychotic, ideally treat only temporarily
* **Substance induced psychosis**-tx acutely with anti-psychotic; most commonly psychosis
* resolves in 24-48 hours once substance is out of patient’s system
* when no longer psychotic, discontinue anti-psychotic
* **Schizoaffective disorder**-typically the patient is treated indefinitely with anti-psychotic medications
* **Schizophrenia**-typically the patient is treated indefinitely with anti-psychotic medications
