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Psychiatry > Psychotic Disorders > Flashcards

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
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2
Q

Disorders of thought include thought ______ and _____.

A

content

process

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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
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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
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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
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6
Q

What are the 5 types of delusions?

A
  • Paranoid delusion
  • Ideas of reference
  • Thought broadcasting
  • Delusions of grandeur
  • Delusions of guilt
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7
Q

Paranoid delusion

A
  • Irrational belief that one is being persecuted
  • “The CIA is after me and taps my phone”
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8
Q

Ideas of reference

A
  • Belief that some event is uniquely related to the individual
  • “Jesus is speaking to me through TV characters”
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9
Q

Thought broadcasting

A
  • Belief that one’s thoughts can be heard by others
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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”
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11
Q

Delusions of guilt

A
  • False belief that one is guilty of responsible for something
  • “I caused the flood in Mozambique”
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12
Q

What is the definition of a hallucination?

A

sensory perception without an actual external stimulus

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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
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14
Q

What is the definition of an illusion?

A
  • Misinterpretation of an existing sensory stimulus
  • Ex: mistaking a shadow for a cat
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15
Q

Loss of ego boundaries

A

unawareness of where one’s mind and body end and those of others begin

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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
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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
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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
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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
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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
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21
Q

What is Schizophrenia?

A
  • Psychiatric disorder characterized by constellation of abnormalities in thinking, emotion and behavior
  • No single symptom is pathognomonic
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22
Q

What are the positive symptoms of Schizophrenia?

A
  • Hallucinations
  • Delusions
  • Bizarre behavior
  • Thought disorder
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23
Q

What are the negative symptoms of Schizophrenia?

A
  • Blunted affect
  • Anhedonia
  • Apathy
  • Inattentiveness
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24
Q

What are the 3 phases of schizophrenia?

A
  • Prodromal
  • Psychotic
  • Residual
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25
Q

Prodromal phase of schizophrenia

A
  • 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
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26
Q

Psychotic phase of schizophrenia

A
  • Perceptual disturbances
  • Delusions
  • Disordered thought process/content
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27
Q

Residual phase of schizophrenia

A
  • 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
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28
Q

What is the DSM IV Criteria for Schizophrenia?

A
  • 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
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29
Q

What are the 5 subtypes of Schizophrenia?

A
  • Paranoid type
  • Disorganized type
  • Catatonic type
  • Undifferentiated type
  • Residual type
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30
Q

Paranoid type of schizophrenia

A
  • 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
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31
Q

Disorganized type of schizophrenia

A
  • Poor functioning type, early onset
  • Must meet the following criteria:
    • Disorganized speech
    • Disorganized behavior
    • Flat or inappropriate affect
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32
Q

Catatonic type of schizophrenia

A
  • 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)
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33
Q

Undifferentiated type of schizophrenia

A
  • Characteristic of more than one subtype or non of the subtypes
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34
Q

Residual type of schizophrenia

A
  • Prominent negative symptoms
    • Flattened affect or social withdrawal
  • Minimal evidence of positive symptoms
    • Hallucinations or delusions
35
Q

What are the typical findings in schizophrenic patients on exam?

A
  • 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
Q

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.

A

1%

20

30

Men

37
Q

People born in these two seasons have a higher incidence of schizophrenia?

What is the explanation for this?

A
  • Winter & early spring
  • Seasonal variation in viral infections of mothers during pregnancy
38
Q

Schizophrenia rarely presents before age ___ or after age ___.

(Strong/Weak) genetic predisposition.

Strong association with _______.

A

15, 45

Strong

substance use

39
Q

What is the “downward drift hypothesis”?

A
  • 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
Q

What is the “dopamine hypothesis”?

A
  • Most antipsychotics that successfully treat schizophrenia are dopamine receptor antagonists
  • Cocaine & amphetamines lead to schizophrenic-like symptoms
41
Q

What are the theorized dopamine pathways affected in schizophrenia?

A
  • Prefrontal cortical - responsible for negative symptoms
  • Mesolimbic - responsible for positive symptoms
42
Q

What are some other important dopamine pathways affected by Neuroleptics?

A
  • Tuberoinfundibular - blocked by neuroleptics, causing hyperprolactinemia
  • Nigrostriatal - blocked by neuroleptics, causing extrapyramidal side effects
43
Q

CT scans of patients with schizophrenia show…

A
  • Enlargement of the ventricles
  • Diffuse cortical atrophy
44
Q

What are 3 neurotransmitter abnormalities implicated in schizophrenia?

A
  • 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
Q

Schizophrenia

What factors are associated with a better prognosis?

A
  • Later onset
  • Good social support
  • Positive symptoms
  • Mood symptoms
  • Acute onset
  • Female sex
  • Few relapses
  • Good premorbid functioning
46
Q

Schizophrenia

What factors are associated with worse prognosis?

A
  • Early onset
  • Poor social support
  • Negative symptoms
  • Family history
  • Gradual onset
  • Male sex
  • Many relapses
  • Poor premorbid functioning (social isolation, etc)
47
Q

Typical neuroleptics

  • Examples
  • Mechanism
  • Efficacy
  • Side effects
A
  • Chlorpromazine, thioridazine, trifluoperazine, haloperidol
  • Dopamine (D2) antagonists
  • Positive >> Negative symptoms
  • Side effects
    • Extrapyramidal symptoms
    • Neuroleptic malignant syndrome
    • Tardive dyskinesia
48
Q

Atypical neuroleptics

  • Examples
  • Mechanism
  • Efficacy
  • Side effects
A
  • Risperidone, clozapine, olanzapine, quetiapine, aripiprazole, ziprosidone
  • Antagonize serotonin receptors (5-HT2) & dopamine receptors
  • Negative >> Positive symptoms
  • Lower incidence of extrapyramidal side effects
49
Q

Medications should be taken for a least _________ before efficacy is determined.

A

4 weeks

50
Q

Behavioral therapy

A
  • 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
Q

What are extrapyramidal symptoms?

How is it treated?

A
  • 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
Q

What are anticholinergic symptoms?

How are they treated?

A
  • Caused by low-potency antipsychotics & atypical antipsychotics
  • Dry mouth
  • Constipation
  • Blurred vision
  • Treatment: as per symptom (eyedrops, stool softeners, etc)
53
Q

What is tardive dyskinesia?

How is it treated?

A
  • 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
Q

What is neuroleptic malignant syndrome?

A
  • 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
Q

What are some additional side effects of antipsychotic medications?

A
  • 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
Q

What is the difference between schizophrenia & schizophreniform disorder?

A
  • Schizophreniform disorder
    • 1-6 months
  • Schizophrenia
    • >6 months
57
Q

Schizophreniform Disorder

___ recover completely.

___ progress to schizoaffective disorder or schizophrenia.

A

1/3

2/3

58
Q

How is schizophreniform disorder treated?

A
  • Hospitalization
  • 3-6 month course of antipsychotics
  • Supportive psychotherapy
59
Q

What is the definition of schizoaffective disorder according to DSM-IV criteria?

A
  • 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
Q

Prognosis of schizoaffective disorder is _____ than schizophrenia but _____ than mood disorder.

A

better, worse

61
Q

How is schizoaffective disorder treated?

A
  • 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
Q

What is the definition of brief psychotic disorder according to DSM-IV criteria?

A
  • 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
Q

Brief psychotic disorder

___% recovery rate

___% may be eventually diagnosed with schizophrenia or mood disorder

A

50-80%

20-50%

64
Q

How is brief psychotic disorder treated?

A
  • Brief hospitalization
  • Supportive psychotherapy
  • Course of antipsychotics for psychosis itself and/or benzodiazepines for agitation
65
Q

What is the time course of these disorders?

  • Brief psychotic disorder
  • Schizophreniform disorder
  • Schizophrenia
A
  • Brief psychotic disorder: <1 month
  • Schizophreniform disorder: 1-6 months
  • Schizophrenia: >6 months
66
Q

Put these in order of prognosis from BEST to WORST:

  • Schizophreniform disorder
  • Brief psychotic disorder
  • Schizophrenia
  • Mood disorder
  • Schizoaffective disorder
A
  1. Mood disorder (BEST prognosis)
  2. Brief psychotic disorder
  3. Schizoaffective disorder
  4. Schizophreniform disorder
  5. Schizophrenia (WORST prognosis)
67
Q

In what subset of patients is delusional disorder most common?

A
  1. Older patients (>40 YO)
  2. Immigrants
  3. Hearing impaired
68
Q

What is the DSM-IV criteria for delusional disorder?

A
  • Nonbizarre, fixed delusions for at least 1 month
  • Does not meet criteria for schizophrenia
  • Functioning in life not significantly impaired
69
Q

What are the 6 types of delusions and their definitions?

A
  • 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
Q

Prognosis of delusional disorder

___% full recovery

___% decreased symptoms

___% no change

A

50%

20%

30%

71
Q

How is delusional disorder treated?

A
  • Psychotherapy may be helpful
  • Antipsychotics are often ineffective
    • Course should be tried
    • High potency traditional antipsychotic or one of the newer atypical antipsychotics
72
Q

What are the fundamental differences between Schizophrenia & Delusional Disorder?

A
  • 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
Q

What is the DSM-IV criteria for shared psychotic disorder?

A
  • 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
Q

Shared psychotic disorder

___% will recover upon removal from the inducing person

A

20-40%

75
Q

How is shared psychotic disorder treated?

A
  • 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
Q

What is Koro?

A

Culture-specific psychoses

  • Patient believes that his penis is shrinking and will disappear, cuasing his death
  • Culture: Asia
77
Q

What is Amok?

A

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
Q

What is Brain fag?

A

Culture-specific psychoses

  • Headache, fatigue and visual disturbances in male students
  • Culture: Africa
79
Q

Define

Lifelong psychotic disorder

A

Schizophrenia

80
Q

Define

Schizophrenia for <6 months

A

Schizophreniform

81
Q

Define

Schizophrenia + mood disorder

A

Schizoaffective

82
Q

Define

Paranoid, odd or maginal beliefs, eccentric, lack of friends, social anxiety. Criteria for true psychosis are not met.

A

Schizotypal (personality disorder)

83
Q

Define

Withdrawn, lack of enjoyment from social interactions, emotionally restricted.

A

Schizoid (personality disorder)

Psychiatry (18 decks)

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