Psychotic Disorders. Source of answers, unless otherwise noted are DSM-IV-TR or APA Practice Guideline on schizophrenia, Supplement to AJP, February, 2004. As of 10July2012. Dx criteria. Q. What are the dx criteria for schizophrenia?. Dx criteria. Ans. Two or more of five: 1] delusions
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Source of answers, unless otherwise noted are DSM-IV-TR or APA Practice Guideline on schizophrenia, Supplement to AJP, February, 2004.
As of 10July2012
Q. What are the dx criteria for schizophrenia?
Ans. Two or more of five:
3] disorganized speech
4] disorganized behavior or catatonia
5] deficit signs of flat affect, apathy, alogia, and so on [“negative” signs].
Q. Under what circumstances can you give a person a dx of schizophrenia when delusions is the only one of the five supra that the pt has?
Ans. When the delusions are “bizarre.” By bizarre, DSM means that the idea could not be true. It could be true, for example, that someone is poisoned, but it could not be true that the pt’s father lives on the planet Jupiter. [Thus, one does not need to dx psychotic disorder NOS when faced with a six month illness that only has bizarre delusions, but can dx “schizophrenia.”]
Q. What characteristics of hallucination allows one to dx a person with schizophrenia even when the individual lacks any of the other four signs of schizophrenia listed supra?
Ans. Two exceptions:
1] “Hearing” a voice constantly reflecting on the pt’s behavior or thoughts.
2] “Hearing two voices conversing with each other.
Q. Your pt has the signs of catatonic type and has the signs of the paranoid type, what is the dx?
Ans. Catatonic Type. The catatonic type trumps all the other types. Disorganized type also trumps paranoid type.
[These slides avoid the terms “positive” and “negative” and instead use “psychotic” and “deficit.”]
Ans. While the list could be long, two will probably reach the exam question:
Ans. Someone who has:
Q. Most consistent structural neuro-imaging finding of these pts with schizophrenia in comparison to general population?
Ans. Enlargement of lateral ventricles.
Q. What has been the most consistent finding as to functional neuroimaging studies in pts with schizophrenia?
Ans. Die a decade or more earlier. [since 2007, “25 years” has become a common figure.]
Q. List the three reasons why the death rate is higher.
Q. What is rate of suicides?
Ans. DSM-IV says 10%. More recent studies say 5%.
Ans. Risk factors that are different from the general population include:
Ans. Not able to predict.
[This will be correct answer to almost any question as to ability to predict suicide, not just the psychotic disorders.]
Ans. A family hx that has a mood disorder has a better prognosis.
Ans. Women have a better prognosis.
Ans. The later the onset of the illness, the better the prognosis.
[If neither of the above two are among the choices, seems confused may be the correct answer.]
List two as to onset.
List one as inter-episode functioning.
Ans. The following suggest a relatively good prognosis:
Ans. Beginning with the onset of the episode until the pt reaches what the clinician believes is to be the pt’s baseline.
Severity of signs of delusion and hallucinations
Duration of untreated psychosis
EPS side effects
a. persistent, severe psychosis
Q. List four causes of relapse in schizophrenia?
Ans. Causes include:
[This is politically correct answer for all dual dx pts, not just those with schizophrenia.]
Ans. All atypicals except clozapine.
[This answer is pre-CATIE. Would be hard to justify this post-CATIE if someone preferred perphenazine.]
Ans. Pt is less sensitive as to the therapeutic effects AND less sensitive as to the side effects. You will probably need to use higher dose that 1 mg BID for the second hospitalization and the side effects might be less prominent.
Q. How does clozapine compare with other antipsychotics for naïve-medication patient? Will it perform better, for example, than chlorpromazine?
Ans. Will not do better. So, in addition to the usual side effect concerns, there is no evidence that clozapine is superior in pts in their first acute episode. Clozapine might be the correct answer in highly suicidal pt.
Ans. Meds blocking
Ans. Usually, no further weight gain, but what has been gained will not be automatically loss. If pt has gained 25 pounds, losing that weight is not going to take place simply because the med has been discontinued. Still, some pts have had dramatic weight loss on ziprasidone and aripiprazole after being switched from olanzapine.
Q. What is action site of typical antipsychotics?
Ans. Prolonged QTc leading to malignant ventricular arrhythmia. Sometimes fatal.
Ans. Signs include:
[TD, of course, would be the answer as to long-term use.]
Q. Which antipsychotic has the highest rate of TD?
[There are others, but these two probably reach the answers.]
Ans. All to the good:
Ans. Like all of us:
Q. What does AIMS = ?
Ans. Abnormal Involuntary Movement Scale.
Q. In using antipsychotic meds, how often should you do the AIMS? Two answers:
1] If your pt is on typical.
2] If on atypical.
Q. How often to do an AIMS in the elderly?
Typical: every 3 months
Atypical: every 6 months.
*In 2007, some began championing 2 hour post-prandial blood sugar as more meaningful.
Ans. Reducing over-stimulation and reducing stress.
*Psychotic = “positive”
**Deficit = “negative”
Q. Pt has hx of untoward sensitivity to prolactin elevation with typical antipsychotics. Atypical antipsychotic choices for such a pt ?
Ans. Any atypical except risperidone.
Shortest, loxapine, 4 hours.
Q. Which antipsychotic has the longest half-life?
Ans. Aripiprazole, 75 hours.
Q. Treatment for akathisia? Practice Guideline lists 6.
Q. Treat parkinsonism reaction to an antipsychotic with? Practice Guideline list 4.
Ans. Not recommended because results 1] in more relapses and 2] more TD.
Ans. Consider an antidepressant if obsessions and compulsions are still present after antipsychotics have failed to improve these signs.
Q. Key aspects to DSM-IV criteria for delusional disorder?
1. Nonbizarre delusions.
2. Not part of another disorder, especially doesn’t meet criteria for schizophrenia.
3. Distressing to the pt or has led to pt’s becoming socially, educationally or occupationally dysfunctional.
Q. Which is most common subtype of delusional disorder?
Q. Mean age of onset of delusional disorders?
Ans. About 40 y/o
Ref: Kaplan & Sadock Synopsis
Q. Which gender is more common?
[First & Tasman, p 716]
Q. Place of confrontation to the delusion within the physician-patient relationship?
Ans. Is not helpful at best and destroys physician-pt relationship at worst.
[First & Tasman, 717]
Q. Name meds for this disorder.
Ans. While antipsychotics and antidepressants have anecdotal support, exam question may be looking for pimozide.
[First and Tasman, p 717]
Q. Basic criteria for shared psychotic disorder?
Ans. Delusion develops in an individual who has a close relationship with another person who already had that delusion – and not part of another disorder. Commonly, parent and child.
Q. What is the treatment plan for this disorder?
1. Separate the two people.
2. If the second person is still delusional after a week of separation, begin an antipsychotic.
3. Supportive psychotherapy
4. Steps to avoid social isolation may help prevent reemergence.
Treating the first person is obviously a need and family therapy may be important if within a family.
[First & Tasman, p 719]
Q. Another name for Shared Psychotic Disorder?
Ans. Folie a Deux.