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Axes Description
- I: Symptoms that cause distress
- II: Personality disorders and mental retaradation
- III: Medical conditions that may be relevant
- IV: Psychosocial and environment
- V: Global assessement of functioning
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Schizophrenia
- One of the most severe mental disorders
- Chronic severe debilitating brain disease
- Affects 1% of population
- 2 million diagnosed yearly in the US
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Epidemiology of Schiz
- Prevalence is equal in men and women
- Onset of men: 15-25 years of age
- Onset of woment: 25-35 years of age
- High population density is correlated with increased rates
- Occurs in all countries and cultures
- Over 50% of schizo's do not live with their families
- Many are not institutionalized
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Downward Drift of Schiz
- Schizo is diagnosed more in a lower socioeconomic statuses
- Increased incidence is due to "downward drift" as schizo move into poorer areas
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Etiology of Schizo
- Unknown; however the following factors has been shown to be associated with schizo
- Genetic
- Prenatal
- Social
- Substance abuse
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Biologic Etiology
- Dopaaminergic system is hyperactive in the mesolimbic pathway--> + symptoms
- Decreased GABA can lead to increased dopaminergic activity
- Increased serotonin -->(-) symptoms
- May be gross abnormalities in the frontal lobes, limbic system and basal ganglia
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Dopamine overview
- Catecholamine
- Excitatory/inhibitory
- Nigrostriatal pathway
- Meso-limbic cortico pathway
- Tuberoinfundibular system
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Nigrostriatal Pathway
- Substantia nigra: part of the basal ganglia
- Important for: Reward, addiction, movement
- Some parts are dark due to high levels of melanin in dopaminergic neurons
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Tuberoinfundibular Tract
- Inhibits the secretion of prolactin from the anterior pitituary.
- DOPAMINE INHIBITS PROLACTIN!!!
- Prolactin level may indicate overall dopamine activity
- Blockage of dopaminergic receptors by antipsychotic drugs prevents the inhibition of prolactin release therefore increasing prolactin level.
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Meso-Limbic Cortico Pathway
- Expression of mood and emotion
- Increased can cause psychosis
- Neuroleptic meds have antidopamergic effects and reduces the positive symptoms of schizo(delusions/hallucinations)
- Dopamine levels tend to be low in depression and higher in mania
- Tourette syndrome
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Neurotransmitters/metabolites
HVA and VMA, 5-HIAA, MHPG are all increased in the urine with mood + psychotic disorders
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Premorbid Personality
- Childhood: quiet, obedient, passive
- Adulthood: avoids social activities, introverted
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Characteristics
- Delusion
- illusion
- hallucinations
- bizarre behavior
- flat affect
- disorganized speech
- social isolation
- A&O x 3
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Illusion
- misperception of real external stimuli
- ex: Interpreting the appearance of a coat in a dark closet as a man
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Hallucination
- False sensory perception
- ex: Hearing voices when alone in a room
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Delusion
- False belief not shared by others
- ex: The feeling of being followed by the FBI
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Disorders of form of thought
- Word salad: incoherent
- loose associations
- mutism
- neologisms: making up new word
- echolalia: repeating a word
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Disorder of thought process
- flight of ideas
- illogical ideas
- thought blocking
- short attn. span
- def. in thought and content of speech
- impaired memory and abstraction abilities
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Negative symptoms
- Flattening of affect
- though blocking
- def. in speech content
- poor grooming
- anhedonia
- lack of motivation
- social withdrawal
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Positive symptoms
- Psychosis
- loose associations
- strange behavior
- hallucinations
- talkativeness
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Suicide
- rate in the US is about 12/100,000 with the suicide attempts being nine times more then successful attempts
- suicide in schizo: over 50% attempt, 10% die in the attempt
- Risk factors that predict suicide in schizo: male sex, college education, youth, many relapses, depressed mood, high ambitions, and living alone.
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Duration
- Schizo: symptoms lasting longer than 6 months
- schizophreniform: symptoms in b/w 1 and 6 months
- Brief psychotic disorder: symptoms lasting less than 1 month
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Brief Psychotic disorder
- delusions, hallucinations, or disoragnized speech/behavior
- 1-30 days
- return to full former functioning
- not due to substance abuse or organic use
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Schizoaffective disorder
- symptoms of schizophrenia
- symptoms of a mood disorder: depression, mania
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Subtypes of Schizo
- paranoid
- catatonic
- disorganized
- undifferentiated=mixture of above
- Residual=+symptoms at low intensity
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Paranoid Schizo
- delusional
- auditory hallucinations
- older onset compared with others
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Catatonic
- complete stupor
- mute
- rigid posture
- "statue"
- outbursts of violence
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Disorganized
- incoherent
- unorganized behaviors/speech
- poor personal appearance
- little contact with reality
- flat affect
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Antipsychotics
- aka neuroleptics
- used primarily as the treatment in schizophrenia
- takes several days to a couple of weeks to show improvement
- typical antipsychotcis: older
- atypical antipsychotics: newer
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Typical antipschotics
- aka first generation antipsychotics
- older
- associated with more adverse rxn's
- Phenothiazines:
- chlorpromazine- pigmented cornea
- thioridazine- retinitis pigmentosa
- fluphanzine
- Butyrophenones: Haloperidol (high potency)
- haloperidol- you can give this drug actuely; to calm patients down and reduce aggression
- MOA: Blocks central D-2 receptors, most affective against positive symptoms
- Treatment: for at least 4-6 weeks, relapse is common due to bad compliance, lots of adverse effects
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ADR
- Neurological ADR with the high potency drugs
- EPS
- Tardive Dyskinsia- involutary repetitive body movments
- NMS- neuroleptic malignant syndrome
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Low Potency drug ADR
- Histamine blockage: sedation
- Alpha blockage: orthostatic hyptotension
- Muscarinic blockage/anticholinergic effects: dry mouth, blurry vision, constipation
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ADR
- weight gain
- impotence
- extrapyramidal neurological signs: tremor, akinesia, rigidity, akthisia, acute dystonias
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ADR cont'd
- 4 hours: acute dystonia
- 4 days: akinisia- no movement
- 4 weeks: akathisia- restlessness
- 4 months: tardive dyskinesia- irreversible
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Tardive dyskinesia
- greater than 3 months
- serious ADR form neuroletpic meds
- uncontrolled writhing
- jerking movements often with tongue/mouth
- potentially irreversible
- women/older patients
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NMS
- commonly in men
- RARE but potentially fatal
- mortality rate of 20%
- FEVER
- AUTONOMIC DYSFUNCTION-SWEATING, INCREASE HR
- MUSCULAR RIGIDITY
- ALTERED MENTAL STATUS
- dystonia, akinesia
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Pnemonic
- F-Fever
- E-Encephalopathy-altered mental status
- V-Vitals unstable
- E-Elevated enzymes (cpk)
- R-Rigidity
Give pt. DANTROLENE to calm them down
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Atypical Antipsychotics
- aka second generation antipsychotics
- may also be used for acute mania, bipolar
- block dopamine and serotonin receptors
- less likely to cause extrapyramidal symptoms
- higher compliance
- lower suicide rate
- improved quality of life
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Atypical antipsychotics
- Clozapine
- Olazapine
- Quetiapine
- Risperiodone
sexual dysfunction, breast enlargement, and discharge, infertility in female
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Clozapine
- resistance or patients suffering from ADR from other anti-psychotics should be considered for treatment with clozapine
- blocks serotonin and dopamine receptors
- useful in treating negative symptoms
- NOT ASSOCIATED WITH TARDIVE DYSKINISIA, NMS, or EXTRAPYRAMIDAL EFFECTS
- agranulocytosis
- lowers seizure threshold
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