Schizophrenia

Question 1

what is the “downward drift” of schizophrenia?

Answer 1

prior to onset, patients are psychosocially fully functional (10% lead normal lives)
-as years progress, they lose social stature, income, relationships, and support networks until they become homeless

Question 2

when does schizophrenia usually start?

Answer 2

rare in children (<1/10,000)

-usually starts in young adulthood (1/100)

Question 3

what is the definition of schizophrenia?

Answer 3

“split mind” irrational divergence between behavior and thought content

• chronic, debilitating illness associated with deterioration in mental function and behavior
• -clearly involves gene (60-70 related) by environmental interaction
• -not caused by any known social or environmental factor
• -exacerbated by social stress

Question 4

what is the hallmark symptom of schizophrenia?

Answer 4

psychosis; impairment in reality testing may present as:

• alteration in sensory perceptions (hallucinations)
• abnormalities in thought content (delusions)
• abnormalities in thought process/organization

Question 5

what is an illusion?

Answer 5

misperception of real external stimuli (misheard a compliment as an insult)

Question 6

what is a hallucination?

Answer 6

sensory perceptions not generated by external stimuli (hearing someone when no one is there)

Question 7

what are ideas of reference?

Answer 7

false conviction that one is subject of attention by other people (crowds, TV, radio, internet) or feeling as though people are referring to you in conversations

Question 8

what are delusions?

Answer 8

false beliefs not correctable by logic or reason, not based on simple ignorance, and not shared by culture
-delusions of persecution are most common

Question 9

what is the loss of ego boundaries?

Answer 9

not knowing where one’s mind and body end, and those of others begin

Question 10

what is alogia?

Answer 10

lack of informative content in speech

-lacking/poverty of speech (mute or speaks few words)

Question 11

what is echolalia/echologia/echophrasia?

Answer 11

all mean clanging; repeating statements of others or associating words by their sounds, but not their meaning

Question 12

what is thought blocking?

Answer 12

abrupt halt in the train of thinking, often because of hallucinations

Question 13

what are neologisms?

Answer 13

inventing new words

Question 14

what is circumstantiality?

Answer 14

in responding to questions, one presents unnecessary and voluminous details ultimately arriving at an answer to the question posed

Question 15

what is tangentiality?

Answer 15

in responding to questions, begins in logical fashion but then gets further and further from the point, failing to answer question initially posed

Question 16

what is loose association?

Answer 16

loss of logical meaning between words or thoughts

-when asked a question, illogically jumps from one subject to another

Question 17

what are characteristic symptoms of schizophrenia?

Answer 17

at least one episode of psychosis with persistent disturbances of thought, behavior, appearance, speech, and affect (emotion) as well as impairment in occupational and social functioning

Question 18

does clouding of consciousness occur in delirium, substance abuse, or schizophrenia?

Answer 18

the first two only

• schizophrenics have intact attention and memory capacity (when not psychotic)
• -alert and oriented, don’t fluctuate in/out of consciousness/stupor

Question 19

what are DSM-5 diagnostic criteria of schizophrenia?

Answer 19

1. characteristic symptoms
   - 2+ of the following present for significant portion of time during 1 mo period (or less if successfully treated)
   - -delusions, hallucinations, grossly disorganized or catatonic behavior, negative symptoms (flat affect, alogia, avolition), disorganized speech (frequent derailment or incoherence)
2. social/occupational dysfunction
3. duration
   - continuous signs of distirbance persist for at least 6 mo, including at least 1 mo of symptoms that may include periods of prodromal or residual symptoms
4. schizoaffective and mood disorder exclusion
5. substance/general medical condition exclusion

Question 20

what are positive and negative symptoms in schizophrenia? treatment?

Answer 20

+ additional to expected behavior

• delusions, hallucinations, agitation, talkativeness, thought disorder
• respond well to most traditional and atypical antipsychotic agents
• missing from expected behavior
• amotivation, social withdrawal, flattened affect/emotion, cognitive disturbances, poor grooming, poor/impoverished speech
• sometimes a better response with atypical antipsychotics

Question 21

what is undifferentiated schizophrenia?

Answer 21

most common

-characteristics of more than one subtype

Question 22

what is paranoid schizophrenia?

Answer 22

delusions of persecution

• older age of onset
• better functioning than other types

Question 23

what is residual schizophrenia?

Answer 23

at least one psychotic episode with subsequent negative symptoms
-mild positive symptoms may occur

Question 24

what is disorganized schizophrenia?

Answer 24

onset < 25 yo
-incoherent speech, bizarre behavior (mirror gazing, facial grimacing, sterotypic movements), poor grooming, inappropriate emotional responses

Question 25

what is catatonic schizophrenia?

Answer 25

rare since introduction of antipsychotic agents | -stupor or extreme agitation, incoherent speech, blank facial expression, bizarre posturing, waxy flexibility

Question 26

why were the schizophrenia subtypes taken out of DSM5?

Answer 26

limited diagnostic stability, low reliability, poor validity | -have not been shown to exhibit distinctive patterns of treatment response or longitudinal course

Question 27

what are the phases of schizophrenia?

Answer 27

1. prodromal - prior to first psychotic break - avoidance of social activities - quiet and passive, or irritable - sudden interest in religion or philosophy - may have physical complaints - anxiety and depression common 2. psychotic/active - loss of touch with reality - associated with positive symptoms 3. residual - period between psychotic episodes, in touch with reality but doesn't behave normally - negative symptoms, peculiar thinking, excentric behavior, withdrawal from social interactions

Question 28

what is the etiology of schizophrenia?

Answer 28

- role of genetics (concordance rate in twins 50%, dizygotic 10%) - de novo mutations in advanced paternal aged germ cells - equally in men and women, but ages are 15-25 in men, 25-35 in women - -women respond better to antipsychotic medication, but have greater risk of tardive dyskinesia - -cumulative days of D2 receptor blockade can lead to permanent movement disorder: chorea, athetotic movements (orofacially)

Question 29

environmental factors of schizophrenia?

Answer 29

- viral infection and exposure to drugs during development have been implicated - increased incidence when born in cold-weather months (potentially due to seasonal viral infections) - third trimester maternal use of diuretics - -severe maternal HTN - questionably, anti-NMDA receptor Ab in adults

Question 30

what are neurological abnormalities?

Answer 30

1. abnormalities of frontal lobes (decreased use of glucose in prefrontal cortex = hypofrontality) 2. lateral and third ventricle enlargement 3. abnormal cerebral symmetry (loss of asymmetry) 4. changes in brain density - decreased volume of hippocampus, amygdala, and parahippocampal gyrus 5. abnormalities in eye movements (poor saccadic smooth visual pursuit)

Question 31

what is the dopamine hypothesis in schizophrenia?

Answer 31

excessive DA activity in mesolimbic tract - stimulant drugs, amphetamines, and cocaine can cause psychotic symptoms by amplifying this tract/pathway - negative symptoms: may involve different abnormality of DA mech; hypoactivity of mesocortical DA tract - elevated levels of homovanillic acid (DA metabolite) in bodily fluids

Question 32

describe DA hypothesis for negative symptoms? aims of treatment?

Answer 32

mesocortical (bad executive functioning; negative and cognitive symptoms) and tuberoinfundibular (increased PRL) pathway are inactive -aim to increase DA neurotransmission

Question 33

describe DA hypothesis for positive symptoms? aims of treatment?

Answer 33

mesolimbic (psychosis) and nigrostriatal (controls movement) are too active - aim is to slow down DA neurotransmission, but can cause extrapyramidal symptoms in NS system - -Parkinsonism, dystonia, akathisia, neuroleptic malignant syndrome

Question 34

how active is serotonin in schizophrenia?

Answer 34

hyperactive - hallucinogens like LSD that increaser serotonin cause hallucinations and delusions - newer atypical antipsychotics have anti-5HT2A receptora ctivity

Question 35

how active is NE in schizophrenia?

Answer 35

hyperactive | -paranoid subtype may have increased metabolites

Question 36

what is the glutamate hypothesis in schizophrenia?

Answer 36

as GLU is the major excitatory nt in CNS, think NMDA receptor hypoactivity - mutated NMDAR proteins are ineffective or underactive - sit on GABA interneurons between octical GLu pyramidal neuron and its secondary neuron, thus inhibition at second GLU allowing excessive firing and increase in firing of VTA, sending extra DA into limbic system to cause psychosis - likely causes DA hypothesis

Question 37

explain normally functioning VS psychotic mesolimbic system

Answer 37

glu-GABA-glu-DA - normal: glu1 tone high --> GABA tone high --> glu2 tone low --> normal DA - psychosis (positive symptoms): glu1 tone high --> GABA interneuron low --> glu2 tone hyperactive --> DA hyperactive in limbic system - -due to hypofunctioning NMDA receptors in prefrontal cortex

Question 38

explain normally functioning VS psychotic mesocortical system

Answer 38

glu-GABA-glu-GABA-DA - normal: glu1 tone high --> GABA tone high --> glu2tone low --> GABA2 tone low --> DA high - psychosis (negative symptoms): glu1 tone high --> GABA interneuron very high --> glu2 tone low --> GABA2 tone very high --> DA tone low

Question 39

differential diagnoses for schizophrenic patients?

Answer 39

1. psychotic disorder caused by general medical condition - B12/folate deficiency, temporal lobe epilepsy, cortico-steroid induced 2. manic phase of bipolar disorder 3. substance-induced psychotic disorder - cocaine, crystal meth, ritalin/adderall (stimulants), ketamine, PCP, LSD, bath salts 4. other psychotic disorders - brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, shared psychotic disorder

Question 40

what is brief psychotic disorder?

Answer 40

1-29 days of schizophrenia symptoms

Question 41

what is schizophreniform disorder?

Answer 41

1 mo to 6 mo of symptoms

Question 42

what is schizoaffective disorder?

Answer 42

schizophrenia + mania and/or depression

Question 43

what is delusional disorder?

Answer 43

delusions, but no other schizophrenia symptoms

Question 44

what is shared psychotic disorder?

Answer 44

one person is delusional, and a second person develops the same delusion

Question 45

what is management for schizophrenia?

Answer 45

all effective antipsychotics block D2 receptors in the mesolimbic DA path - life long treatment that doesn't lower DA availability, but blocks neurons from excessively firing at high [DA] - traditionally high and low potency (D2 receptor affinity) typical first generation antipsychotics

Question 46

what is given if there is low compliance due to FGAs and SGAs?

Answer 46

long acting injectable depot (shots that last 2-4 mo) - Haloperidol decanoate, fluphenazine decanoate are FGAs - risperidone, paliperidone, aripiprazole are SGAs

Question 47

how can psychotherapy manage schizophrenia?

Answer 47

- provide long-term support for patient and family - foster compliance with drug regimen - cognitive behavioral therapy (CBT) - -improve executive dysfunction (memory, concentration, planning, prioritizing) - family therapy - peer and mentor support or social skills group

Question 48

why is compliance rate of antipsychotics low?

Answer 48

unpleasant side effects (fatigue, grogginess, sedation) and poor patient insight

Question 49

difference in action between typical and atypical ant?

Answer 49

typical: high potency/affinity drugs are better at binding and sticking to D2 receptors, and may cause more side effects in nigrostriatal and tuberoinfundibular pathway atypical: also block 5HT2a receptors, allowing DA to more freely flow in nigrostriatal path