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Block 3 PSYCH Exam -- Shizo & Psychotic Disorders (# 11-12)


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% of U.S. population w/ Schizophrenia
% of schizo pts. that attempt suicide

% of schizo pts. that die by suicide

DSM (short) definition of Schizophrenia
Decline in functioning
6 months or greater of symptoms (at least 1 month active)
Schizophreniform Disorder
Same criteria as schizophrenia, BUT SHORTER

1 - 6 MONTHS
Brief Psychotic Disorder
Schizoaffective Disorder
Criteria for BOTH schizo and Mood disorder
Symptoms occur together

Preceded/followed by >= 2 weeks of delusions W/O mood symptoms
Delusional Disorder
NON-bizarre delusions >= 1 month

ABSENCE of other active-phase Schizo symptoms

NOTE: this is often MORE REFRACTORY to anti-psych meds
Shared psychotic disorder (Folie a deux)
Disturbance in individual influenced by someone w/ an established delusion

Disturbances have similar content
What is a positive symptom
Symptom that is present in schizophrenia, but NOT seen in normal people
What is a negative symptom
Area where schizo pt. is lacking normal abilities

Also called "deficit" symptom
Which type of schizo symptom do traditional anti-psychotics affect LESS?
Negative symptoms
Prevalence of positive symptoms in Type I vs Type II schizo
Type 1 -- Prominent positive symptoms

Type 2 -- LESS prominent positive symptoms
Premorbid functioning in Type I vs. Type II schizo
Type 1 -- GOOD premorbid functioning

Type 2 -- POOR premorbid functioning
Onset in Type I vs. Type II schizo
Type 1 -- ACUTE

Efficacy of traditional antipsychotics in Type I vs Type II schizo
Type 1 -- responds to traditional anti-psychotics

Type 2 -- poor response
Cognition in Type I vs. Type II schizo
Type 1 - Good cognition between episodes

Type 2 - Prominent cognitive impairment
Neuroimaging in Type I vs. Type II schizo
Type 1 -- Normal

Type 2 -- Atrophy & enlarged ventricles
Three Dimensions of the 3-D model os Schizo
Time frame of disturbance/symptoms to qualify as Schizo
6 MONTHS of signs of the disturbance

At least 1 MONTH of two or more of following:
Delusions, hallucinations, disorganized speech
Disorganized/catatonic behavior
Negative symptoms
When is only ONE Criterion A symptom required for a diagnosis of Schizo?
When delusions are bizarre


Hallucinations are a running commentary or >= 2 voices conversing
Does Schizophrenia have any mood components?
When can Schizo be classified in terms of its longitudinal course?
Only after at leat 1 year has elapsed since onset
Paranoid Type Schizo
One or more delusions or frequent auditory hallucinations

Doesn't meet criteria for other types
Disorganized Type Schizo
ALL of the following are prominent:

Disorganized speech
Disorganized behavior

Criteria is not met for Catatonic Type
Catatonic Type Schizo
AT LEAST TWO of the following:

Motoric immobility
Excessive motor activity
Extreme negativism
Peculiarities of voluntary movment
Echolalia or echopraxia
Undifferentiated Type Schizo
Criterio A Schizo symptoms are present
BUT, doesn't fit any subtype
Residual Type Schizo
Continued evidence of the disturbance
Indicated by negative symptoms OR two or more Criterion A symptoms
Criterion A symptoms for Schizo (5)
Negative symptoms

Disorganized speech
Disorganized/catatonic behavior
Age of onset of Schizo in men? women?
Men - early to mid 20s

Women - late 20s
Prodromal phase of Schizo
Gradual development of NEGATIVE symptoms
Active phase of Schizo
Development of POSITIVE symptoms
Often occurs abruptly -- PSYCHOTIC BREAK
Akinetic Depression
Depression presenting in Schizo from anti-psychotic-induced Parkinsonism
Typical course of Schizo
EPISODIC exacerbations
CHRONIC social disability

Negative symptoms get worse with time
Positive symptoms often lessen with time
Good prognostic factors in Schizo
Good premorbid adjustment
Acute onset
Precipitating events
NO family history of Schizo
Relapse rate if pts. stop taking their meds
Ultimate relapse rate w/o meds
Relapse rate for pts. who are compliant w/ meds
30 - 50%

15% in the 1st yr.
Family risks of Schizo
One parent - 5-6%
One sibling - 10%

One sibling & parent - 17%
Two parents - 46%
Risk in twins for Schizo
Dizygotic - 15%
Monozygotic - 50%
What does Dopamine Theory of Schizo postulate?
That Schizo is due to EXCESS Dopamine
Problems w/ "classic" DA theory
NOT cofirmed by CNS studies
Doesn't explain negative symptoms
Cocaine psychosis resembles POSITIVE symptoms, NOT NEGATIVE
D2 blocking antipsychotics may actually exacerbate negative symptoms
In addition to being weak D2 blockers, what do ATYPICAL antipsychotics block
They are serotonin antagonists
How do atypical antipsychotics compare to traditional ones?
(in terms of symptoms they treat)
More effective against positive symptoms
(PSYCH notes)

More effective against negative symptoms
(PHARM notes)
Mesolimbic tract
Involved in "reward circuitry"

Overstimulation may lead to hallucinations/delusions

D2 blockers may work here to treat POSITIVE symptoms
Nigrostriatal tract
Degeneration of this --> Parkinson's

Increased DA activity --> choreoform, dystonic movements

Increased D2 sensitivity here is responsible for Tardive Dyskinesia
Mesocortical tract
Mediates effects of DA on attention & planning

Involved in GABA-mediated feedback on brainstem DA neurons
Neuroimaging in Schizo shows decreased activity where?
Frontal lobe
Tuberoinfundibular tract
DA here INHIBITS prolactin release
SO, blockade --> Increased prolactin --> galactorrhea

Antipsychotics suppress LH & FSH (can cause amenorrhea, anorgasmia)
Efficacy wise, how do traditional antipsychotics stack up against each other?
They are all equally efficiacious
Receptor types that traditional anti-psychotics interact with
M1 ACh

D2 - blockade causes EPS, Inc. prolactin
Type of relationship between ACh and DA in nigrostriatal pathway

DA neurons synapse on ACh neurons --> Decr. ACh release
D2 blockade --> Inc. ACh --> EPS
Benztropine or Trihexyphenidyl
Anti-cholinergic drugs that reduce Parkinsonism

Do so, W/O affecting anti-dopaminergic effect
Severe motor restlessness

Very common
LESS responsive to anti-cholinergic medication
Acute Dystonia
Sustained, involuntary muscle spasms

Most often involves muscles of face/neck
When does acute dystonia usually occur?
During 1st week of treatment with previously unexposed pts.
In what situation(s) is acute dystonia more common (2)?
Young male patients
High potency medications
How is acute dystonia treated (2)?
Anticholinergic (benztropine)


Antihistamine (diphenhydramine)

Many clinicians start antichilinergics before antipsychotics
What parts of body are most likely involved in tardive dyskinesia?
Tongue & Jaw
Limbs (50%)
Incidence of tardive dyskinesia
(age groups)
Younger pts. - 5% per yr.; 20-30% after several yrs.

Older pts. - 30% 1st yr.; 50% w/ long-term treatment
Who usually first notices TD?

TD is subtle, so if often missed by patients and their families

TD is usually NOT progressive
Risk factors for TD
Greater number of drug holidays
Mood Disorder > Schizophrenia
What can TD be masked by
INCREASED dose of anti-psychotic
Which pts. is spontaneous dyskinesia more common in?
Pts. w/ prominent negative symptoms and cognitive dysfunction
What can you do to resolve TD?
Gradual taper off of traditional anti-psychotics

Switch to atypical antipsychotics
Sex predilection for TD
Equal prevalence among young men and women

More common in elderly women than in men
When does neuroleptic malignant syndrome usually develop?
Within a month of first starting on antipsychotics

Most often within the first week
Treatment for NMS
Sepsis workup
Discontinuation of meds
Anitpyeretics, IV fluids, COOLING BLANKETS

DA agonists (bromocriptine)
Muscle relaxants (dantrolene)

ECT is primary treatment strategy
How long does neuroleptic malignant syndrome take to resolve?
Typically about 2 weeks
How do traditional antispychotics worsen symptoms?
(pathway effects)
DECREASED nigrostriatal DA --> Parkinsonism

DECREASED mesocortical DA --> problems w/ attention and planning
What relationship does 5-HT have to the nigrostriatal DA system?
It inhibits it
What relationship does 5-HT have to the mesocortical DA system?
Inhibits it
What relationship does 5-HT have to the mesolimbic system?
Does NOT play a role in it
Key points about Clozapine
Atypical antipsychotic

WEAK D2 blocker
STRONG 5HT2 blocker

Virtually NO EPS
Effective against negative symptoms
More effective for positive symptoms
Problems w/ Clozapine (6)
Anti-histaminergic -- WEIGHT GAIN, Sedation

When is clozapine used?
In treatment-resistant cases
Risperidone key points
Lower weight gain

MORE D2 antagonism
--- Greater risk of EPS (esp. > 6 mg/day)
--- Greater likelihood of prolactin elevation
Olanzapine (Zyprexa) key points
Most likely to cause significant weight gain

Lower EPS than Risperidone

Also approved for treatment of mania (acute)
Quetiapine (Seroquel) key points
Very low rate of EPS
Very little weight gain
Ziprasidone (Geodon)
Lowest risk of weight gain
Very low rate of EPS

NOTE: can lengthen QTc interval
--- Need to examine ECG and other meds
Atypical antipsychotic (non-clozapine) w/ most significant weight gain
Atypical antipsychotic w/ least significant weight gain
What (pathway wise) are positive symptoms mostly due to?
Overactivity in the mesolimbic pathway
What (pathway wise) are negative symptoms mostly due to?
Underactivity in the mesocortical pathway
Aripiprazole (Abilify) key points
Dopamine System Stabilizer

5HT2A antagonist
5HT1A partial agonist

Like adding lukewarm water to a tub
Most consistent CT/MRI finding in Schizo
Ventricular enlargment & sulcal dilatation

NOTE: non-specific
Remember, also found in Stage 3 Alzheimer's

NOTE: statistical finding; scans can also be normal
What brain finding in Schizo pts. correlates w/ auditory hallucinations?
Temporal lobe atrophy
Especially in superior temporal gyrus
Common EEG finding in Schizo pts.
Blunting and delay of P300 wave
In Northen latitudes, Schizo is more common in what people?
Those born in the winter
Progression of symptomology after insult to mesocortical pathway
Negative symptoms first

Ultimately, decreased negative feedback to limbic system
Decreased feedback --> positive symptoms
Erotomanic subtype of delusional disorder
Believes another person, of higher status, is in love with them
Persecutory subtype of delusional disorder
Pt. is being malevolently treated somehow
Somatic subtype of delusional disorder
Pt. has some physical defect or medical condition
Which atypical anti-psychotic can lengthen the QTc interval?

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