NRNP 6635 Schizophrenia Final Exam 2025

A psychological disorder characterized by delusions, hallucinations, disorganized speech, and/or diminished inappropriate emotional expression. - -Schizophrenia The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). - -signs and symptoms of schizophrenia A decline in both cognitive and social functioning that often precedes the development of florid psychosis. - -Schizophrenia is associated with The exact etiology of schizophrenia is unknown, although it is thought to be linked to an increase in dopaminergic activity. No single etiological factor is responsible for schizophrenia. - -Etiology of Schizophrenia Treatment includes antipsychotics in conjunction with behavioral therapy. - -Treatment of Schizophrenia Schizophrenia is a chronic serious mental disorder characterized by loss of contact with reality and manifested by two main symptoms: hallucinations and delusions. - Schizophrenia definition Men and women are equally affected, but with a slight difference in the age of onsetmen: average age of onset = 23 years Women: average age of onset = 26 years - -onset of schizophrenia The disorder manifests when a person with a genetic predisposition is exposed to one of many environmental stressors. - genetic predisposition - environmental stressors - -Etiological factors of schizophrenia Environmental stressors are believed to be triggers of schizophrenia rather than true causes of the disorder. -Childhood trauma - Residence in an urban area - Social isolation -Frequent cannabis use in early adolescence - Migration - Poverty - Stress and psychosocial factors NRNP 6635 NRNP 6635 - Birth in late winter or early spring -Advanced paternal age at conception - -Environmental Stressors of Schizophrenia Genetic and environmental risk factors appear to act via a common pathway Of disrupting the function of 1 or more neurotransmitter components. Dopaminergic theory: Almost all drugs with antipsychotic properties block the dopaminergic D2 receptor. However, antipsychotics are only 70% effective and clozapine, the most effective antipsychotic for treating schizophrenia, is a weak D2 antagonist. Hyperactivity of dopamine D2 receptor neurotransmission in subcortical, and limbic brain regions contribute to the positive symptoms of schizophrenia. Hypo functionality of dopamine D1 receptor neurotransmission in the prefrontal cortex contributes to both negative and cognitive symptoms. - -Pathophysiology of schizophrenia part 1 Other theories: Hypofunction of the N-methyl-D-aspartate (NMDA) glutamate receptor. Dysfunctional gamma-amino-butyric acid (GABA) interneurons. Dysfunctional nicotinic acetylcholine receptors. - -Pathophysiology of schizophrenia part 2 Patients with schizophrenia also have physical abnormalities of the brain tissue, which can be seen in neuroimaging studies. Loss of cortical tissue volume, including the limbic system, prefrontal cortex, thalamus, hippocampus, and amygdala. Ventricular enlargement (third and lateral). Decreased symmetry. Hypoactivity of the frontal lobes and hyperactivity of the basal ganglia. - -Physical abnormalities of the brain in schizophrenia Impairment of thoughts and affect, characterized by a distorted perception of reality. The impairments are severe enough to affect the patient's ability to participate in social events or to form relationships. Patients with schizophrenia often lack awareness about their illness (insight). Co-existing substance use disorder and dependence is common ("dual diagnosis"). Symptoms can be classified into premorbid, positive, negative, and cognitive. - -Clinical Presentation of schizophrenia Easy to recognize. Delusions: 1. False, fixed beliefs maintained by the patient despite being contradicted by reality or logical arguments. 2. Can include grandiosity, ideas of reference, paranoia, persecutory, erotomania, jealousy, and somatic delusions. Hallucinations: NRNP 6635 NRNP 6635 1. Perceptual abnormalities in which sensory experiences occur in the absence of external stimuli. 2. Can be auditory (most common), visual, somatic, gustatory, and olfactory. Illusions: 1. Distinguished from hallucinations by the presence of real external stimuli that is simply misinterpreted by the patient. Disorganized speech and/or behavior: 1. Can include neologisms, echolalia, flight of ideas, pressured speech, and loose associations, among others. - -Positive (psychotic phase) - Potentially difficult to recognize because of similarities to depression. - Flat affect (diminished emotional expression). - Avolition (lack of initiative). - Alogia (poverty of speech). - Poor attention. - Anhedonia. - -Negative (residual phase) - Usually nonspecific; related to the impact on the patient's quality of life. - Poor executive functioning, represented by disorganized speech and/or thought that results in impaired communication. - Inattention - Impaired memory - -Cognitive Diagnosis is made by clinical observations based on the type of symptoms presented, their severity and duration, and how the patient's life is affected by their presence. A total duration of symptoms of at least 6 months, including a period of positive symptoms lasting at least 1 month. The presence of a mix of positive and/or negative symptoms, especially delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. The presence of these symptoms must disturb the patient's daily functioning, including the social, personal, and professional areas of life. - -Diagnosis of Schizophrenia Other conditions must be ruled out to make a definitive diagnosis: - Schizoaffective, brief psychotic, and schizoaffective disorders. - Mood disorders (e.g., major depressive disorder, bipolar disorder). - Substance use disorder (requiring urine and blood toxicology tests). - -Other conditions to rule out when diagnosing schizophrenia Antipsychotic medications form the centerpiece of treatment for schizophrenia, especially the positive symptoms. Only caroprazine has been shown to have significant effects on negative symptoms. The choice of a specific agent is mostly based on the adverse effect profile, the required route of administration, and the patient's previous response to the drug. NRNP 6635 NRNP 6635 Patients who respond usually show the most rapid improvement in the 1st 2 weeks and will often continue to improve during the following weeks. While there is a wide variety of mechanisms of action, most antipsychotics block postsynaptic dopamine receptors. - -Pharmacological treatment for schizophrenia Older medications before 1989. Dopamine receptor antagonist Common side effects include EPS (which may become irreversible), hyperprolactinemia, neuroleptic malignant syndrome, QT prolongation, sudden death, and an increased risk of mortality in older adult patients with dementia. Examples include haloperidol, fluphenazine, and chlorpromazine. - -1st-generation antipsychotics Newer medications, starting with clozapine (approved in 1989). Associated with a lower risk for EPS compared with fgas and therefore the 1st-line drugs to use (although the risk of metabolic syndrome is increased with sgas). The decreased risk for EPS is the most important distinction from fgas, as the pharmacologic properties, therapeutic effects, and adverse effects are not distinct between the 2 groups. Serotonin and dopamine antagonists. Common side effects include metabolic syndrome, hypotension, sedation, anticholinergic symptoms, hyperprolactinemia, EPS, cardiac effects, cardiomyopathies, cataracts, and sexual dysfunction. Examples are risperidone, aripiprazole, quetiapine, olanzapine, ziprasidone, clozapine. - -2nd-generation (atypical) antipsychotics Requires immediate attention. Use oral antipsychotic and benzodiazepine (may require intramuscular due to noncompliance or for more rapid effect). Usually lasts 4-6 weeks. - -treatment of acute psychosis in schizophrenia - Obtain laboratory tests: CBC (including differential if clozapine used), electrolytes, fasting glucose, lipid profile, liver, renal, and thyroid function tests, and a pregnancy test in females of fertile age. - ECG if history of heart disease or if using drugs that may prolong the QT interval (clozapine, thioridazine, iloperidone, ziprasidone). - Monitor for the 1st few weeks and then regularly for involuntary movement disorders/EPS, since they may become irreversible. NRNP 6635 NRNP 6635 - The goal is to minimize symptoms, avoid relapses, and promote recovery that allows integration into society. - Minimize side effect profile. - Recommended maintenance treatment is 5 years. - May use long-acting injectable antipsychotics for non-compliant patients after checking for tolerability/efficacy with an oral agent. - -treatment of Maintenance phase in schizophrenia - Roughly 40% of treated patients will demonstrate positive symptoms that are resistant to treatment. - Assess proper dosage and duration of treatment. - Do not use 2 antipsychotics at the same time as studies show no benefits. - Consider the use of clozapine, which can be an effective treatment in persons with schizophrenia that is resistant to treatment with other antipsychotic drugs. Also reduces suicide risk. However, clozapine is associated with a risk for agranulocytosis and requires frequent, intense blood monitoring. - -Treatment for individuals with schizophrenia that are poor responders 1. EPS 2. Tardive dyskinesia 3. Elevated prolactin 4. Metabolic 5. Neuroleptic malignant syndrome - -side effects to antipsychotics (both) Definition/ treatment: - Movement disorders secondary to drugs that block dopamine receptors. - Movement phenotypes include: dystonia (involuntary muscle contractions), akathisia (inner restlessness), parkinsonism. - Treatment options include decreasing dosage, changing to a drug having a lower risk of EPS, or adding an antimuscarinic agent such as benztropine or diphenhydramine; propanolol and benzodiazepines are also used, and botulinum toxin injections are used for focal dystonia. - -extrapyramidal symptoms - A subset of EPS. - Associated with long-term treatment with 1st-generation antipsychotics Movement phenotypes include: torticollis (involuntary contraction of neck muscle, causing head tilt), dystonia of lips, tongue, oromandibular, or pharynx. - Treatment includes drugs (valbenazine and deutetrabenazine) that block vesicular monoamine transporter 2 protein, which then prevents presynaptic dopamine release; injection of botulinum toxin is also used. - -tardive dyskinesia - Caused by almost all antipsychotics. - Can result in irregular menses, galactorrhea, and sexual dysfunction. - Treatment includes dosage reduction/medication changes. - -Elevated prolactin NRNP 6635 NRNP 6635 - Weight gain, hyperlipidemia, hyperglycemia, and hypertension → increased cardiovascular risk. - Treatment: Change from high-risk drug (e.g., olanzapine, quetiapine, risperidone) to an antipsychotic with lower metabolic risk (e.g., aripiprazole or ziprasidone) if possible. - Monitor and treat each cardiovascular risk factor appropriately. - -Metabolic - Idiosyncratic reaction to antipsychotics. - This is a life-threatening emergency. - Symptoms include at least 2 of the following cardinal symptoms: fever, altered mental status, muscle rigidity, and autonomic dysfunction. - Treatment includes immediate discontinuation of the antipsychotic medication and aggressive supportive care. - -Neuroleptic Malignant Syndrome Nonpharmacological treatments are known to be partially effective in treating the negative and cognitive symptoms of the disorder and increase patient adherence to medications. 1. Hospitalization: May be required to ensure the safety of patients. In certain cases, isolation may be required for a short period of time. 2. Psychosocial therapy: - Cognitive-behavioral therapy - Compliance therapy Individual psychotherapy - Group therapy 3. Electroconvulsive therapy: mostly treatment-resistant cases for augmentation to pharmacotherapy. - -Nonpharmacological treatments for schizophrenia 1. Brief psychotic disorder 2. Schizophreniform disorder 3. Schizoaffective disorder 4. Delusional disorder 5. Substance induced psychotic disorder 6. Psychotic disorder d/t medical condition 7. Mood disorder with psychotic features - -Differential Diagnosis (ddx) for