Schizophrenia Spectrum Snd Other Psychotic Disorders

Question 1

What are the 5 psychotic symptom disorders?

Answer 1

1. Delusions
2. Hallucinations
3. Disorganized speech

Above 3 are “core” domains

4. Disorganized or catatonic behavior
5. Negative symptoms

Question 2

Explain the psychotic DELUSION symptom domain

Answer 2

Delusion(core)- A fixed belief that is not amenable to change, even with conflicting evidence

• delusion of grandeur(grandiose)
• delusion of persecution (paranoid)
• Delusion of control(external force controlling behavior)
• Delusion of reference (belief that outside action refers directly to the person or has special personal meaning’
• Thought broadcasting delusion (thoughts being transmitted to others)

Question 3

Explain the psychotic HALLUCINATION symptom domain

Answer 3

A sensory perception without an external stimulus (auditory are the most common)

Question 4

Describe the psychotic symptom domain : disorganized speech (core)

Answer 4

Speech (thinking) lacks the normal, logical connections between thoughts. Patients who exhibit this symptom are described as having m

A formal thought disirder

Loose associations in thinking

Question 5

Describe symptoms of the psychotic domain: disorganized or catatonic behavior

Answer 5

Disorganized: non-goal oriented behavior (e.g., wandering aimlessly)

Catatonic: multiple motor/behavioral abnormalities thatreflect diminished reactivity to the environment:

• posturing
• waxy flexibility
• stereotypes
• Non-responsiveness
• mutism

Question 6

Describe symptoms os the psychotic domain: negative symptoms

Answer 6

Diminished emotional expression

Avolition(decrease in motivated self-initiated purposeful activities

Alogia(diminished speech output)

Anhedonia(inability to feel pleasure)

Asociality (lack of self interactions)

Question 7

What are the diagnostic criteria of schizophrenia?

Answer 7

At least 2 psychotic domain symptoms :

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized behavior
5. Negative symptoms

Atleast 1 core symptom domain (1, 2 or 3)

Question 8

Give the schizophrenia diagnosis timeline

Answer 8

Signs of the disturbance for 6+ months (including any prodromal and/or residual phases)

6+ months of prodromal phase, active phase (must be 1+ month). And residual phase

Prodromal and residual phases often manifest as only negative symptoms and/or do,Ian symptoms in subthreshold forms

Question 9

What are the subtypes of schizophrenia?

Answer 9

DSMno longer subtypes schizophrenia except to specify “with catatonia”

Presentation of schizophrenia varies depending on which psychotic domain symptoms are most important

Question 10

Give the differential of schizophrenia

Answer 10

Substance-induced psychosis, (e.g., consider psychomotomimetic drugs such as stimulants and dissociative anesthetics)

Question 11

What are the associated features of schizophrenia?

Answer 11

• nicotine dependence(self medication)
• increased suicide risk

Aggression

• patient may be aggressive to protect himself/herself
• If command hallucinations(or uses drugs), patient is at greater risk 9f being violent
• Despite publicity, schizophrenics are not at higher risk of homocide

Question 12

Give the epidemiology of schizophrenia

Answer 12

1% of general population with no gender bias(though males have greater illness severity)

There is a higher prevelance of schizophrenics with low socioeconomic status (SES): “downward drift” phenomenon

High number of schizophrenics amongst the homeless, largely as a result of de institutionalization

Question 13

Describe schizophrenic onset

Answer 13

• typical onset: late teens, slightly later onset in women
• A negative symptom prodrome often precedes the onset of positive symptoms by a few weeks to months
• Late-onset(40+ years): More in women and characterized by positive symptoms and less severe course
• childhood onset (+13 years): severe form of disorder associated with more pronounced deficits in neurodevelopment

Question 14

Give the course and outcome of schizophrenia

Answer 14

Slow gradual decline in function, or one characterized by fluctuating symptoms

The disorder is chronic

Majority of patients have a moderate to severe disability with need for periodic hospitalization

Question 15

Give the etiology of schizophrenia

Answer 15

Dopamine(DA) pathway and consequent neuromodulation disruption

• Too much DA= positive symptoms
• Disconnect between “normal” cognition (I.e., internal dialogue ) and perception of that dialogue
• Too little DA in frontalbareas = negative symptoms and cognitive impairment

Question 16

What are dopamine pathways?

Answer 16

Mesolimbic pathway(positive symptoms)

Mesocortical pathway(negative symptoms)

Nigrostriatal pathway(extrapyramidal syndrome)

Tuberoinfundibular pathway (increased prolactin release)

Question 17

Explain the dopamine pathway: mesolimbic pathway

Answer 17

Positive symptoms

• projections from ventral tegmental area (VTA) to nucleus acumbens(NA)
• reward, reinforcement, motivation, motor function

Question 18

Explain the dopamine pathway: mesocortical pathway

Answer 18

Negative symptoms

• projections from VTA to DLPFC
• Executive functions
• projections from VTA to VMPFC
• emotions and affect

Question 19

Explain the dopamine pathway: nigrostrital pathway

Answer 19

Extrapyramidal syndrome

• Projectiond from substantia nigra to striatum (caudate and putamen)
• stimulation of purposeful movement

Question 20

Explain the dopamine pathway: tuberoinfundibular pathway(increased prolactin pathway )

Answer 20

Increased prolactin release

• projections from the hypothalamus to the infundibulum region
• normally inhibits prolactin release

Question 21

Give the schizophrenia etiology with dopamine not being the whole story

Answer 21

Dopamine not the entire story
-33% of patients do not respond to “typical” antipsychotics

• more than just dopamine this excess
• Non-dopaminergic sub-type of schizophrenia
• reduced glutamate in frontal lobes and glutamine increase= cognitive impairment
• viral infection in uterus increases risk

Question 22

How can neuroanatomical chang3s lead to schizophrenia?

Answer 22

Enlarged cerebral ventricles(ventriculomehaly)

Cortical atrophy

Smaller size and cellular disorganization of temporal lobe

Cellular disorganization suggests that schizophrenia is a neurodevelopmental disorder

Question 23

What are the neuropsychological effects of schizophrenia?

Answer 23

-Impairments are seen in a variety of cognitive functions such as attention, memory, verbal fluency and “executive “ functions (I.e., initiating, planning, shifting, following though)

List as many words as you can think of that start with the letter “D”. Schizophrenics would have a difficult time searching their “lexicon” to generate words

Question 24

How can schizophrenia be treated?

Answer 24

First generation (typical) antipsychotics

• thorazine(chlorpromazine)
• Haldol(haloperidol)

Dopamine (DA) receptor blockers(antagonists)

Alleviates positive symptoms (hallucinations, delusions)

Side effects: extrapyramidal syndrome (ES) due to blockage of nigrostriatal (motor system) dopamine

Question 25

What is extrapyramidal syndrome?

Answer 25

1. Dystonia- sustained muscle contractions of the head and neck, often develops first week 2. Parkinsonism- tremor and shuffling , often develops in first few months 3. Akathisia -excessive movements dye to “inner restlessness”, often develops in the first few months 4 tar dive Dyskinesia- repetitive, involuntary, purposelessness movements of the face and extremities - comes due to long term side eff3cts of meds

Question 26

What is neuroleptic malignant syndrome?

Answer 26

- Tachycardia, hypertension, rapid respiration, fever, extreme rigidity, delirium, and death - Within 2 weeks of starting medication or increasing dosage - Results from a previous drop in dopamine that impacts hypothalamic function (autonomous nervous. System )

Question 27

How can schizophrenia be treated( 2nd generation)?

Answer 27

``` 2nd generation(atypical treatments) antipsychotics Clozaril (clozapine) Risperdal(risperidone) ``` -dopamine (DA) receptor blockers (antagonists ) and serotonin antagonist Alleviates positive(hallucinations) and negative (anhedonia) symptoms Side effects: Agranulocytosis is seen in 1-2% of patients taking clozapine

Question 28

How can schizophrenia be treated without antipsychotics?

Answer 28

Psychotherapy- for secondary effects, not primary effects - behavioral therapy to increase activities of daily living - supportive psychotherapy (if indicated) - family education with the goal of diminishing household/environmental stress Electroconvulsive therapy Not usually as effective as medications but may be more useful for catatonic subtype

Question 29

What are the diagnostic criteria of schizophreniform ?

Answer 29

- identical symptoms to schizophrenia, distinguished by duration - 1+ month but less than 6. Months of active phase symptoms Sometimes provisional fir schizophrenia until 6-month symptom duration is reached - delusions - hallucinations - Disorganized speech - Disorganized or catatonic behavior - diminished range of emotional expression

Question 30

What are the diagnostic criteria of Brief psychotic disorder symptoms?

Answer 30

- Atleast 1 core psychotic domain symptom (I.e., delusions, hallucinations, disorganized speech) - episode lasts less than 1 month - Person returns to full premorbjd functioning - specify trigger of episode: - with marked stressor - without marked stressor

Question 31

Give diagnostic criteria if delusi9n dusirder

Answer 31

The presence of a delusion Symptoms must last 1+ month No other psychotic domains No functional impairment aside from the direct impact of the delusion Specify: Non-bizarre delusion: a belief that involves something that could occur in real life, is physically possible Bizzare delusion: A belief that is clearly implausible and not derived from ordinary life experiences

Question 32

How may delusional disorder occur?

Answer 32

A delusion may develop in the context of a close relationship with a psychotic individual - Partner comes to believe the same delusion as the psychotic individual - The person is also diagnosed with Delusional disorder(formerly “shared psychotic disorder”)

Question 33

What are the delusional disorder subtypes ?

Answer 33

Persecutory type: belief of malevolent treatment Grandiose type: belief of having some great (but unrecognized ) talent or insight or having made some important discovery Erotomatic type: belief that someone else is in love with the individual Jealous type : belief of infedility of partner Somatic type: belief involving bodily functions/sensations, such as parasitosis, maldorous, organ dysfunction Unspecified type- theme of none above

Question 34

What are the differentials of delusional disorder?

Answer 34

- bidy Dysmorphic disorder (BDD) with absent insught(delusional belief): in BDD, delusion is appearance-related - illness anxiety disorder (IAD): IAD patients worry about health but they are not delusional Unspecified(theme is none of the above)

Question 35

Briefly describe schizoaffective

Answer 35

Active phase of schizophrenia occurs concurrently with a Major mood episode (MDE or manic episode) Active phase lasts 2+ weeks without mood Mood symptoms are present for “the majority of the total durstion” of symptomatic periods of illness

Question 36

How can schizoaffective disorder be diagnosed?

Answer 36

- concurrent psychosis and mood - psychosis alone - mood symptoms duration proportional with psychotic symptoms duration Subtypes: - Bipolar type (if mania is experienced) - depressive type(if depression is experienced without mania)

Question 37

Give the etiologies of delusional disorder and schizoaffective disorder

Answer 37

``` Delusion disorder (DD) -Genetic-DD is more common in people who have family members with DD or schizophrenia ``` - dopamine and serotonin imbalance - environmental/psychologica- triggered by stress, isolation, alcohol and drug abuse might contribute Schizoaffective disorder -unknown but thought to overlap with schizophrenia

Question 38

How can schizoaffective and delusional disorders be affected?

Answer 38

- antipsychotic medications - individuals psychotherapy to identify underlying distorted thoughts - CBT to recognize and change thought patterns and behaviors - psychosocial therapy to assist with employment, living arrangements - family therapy to help families deal more effectively with a loved one