1. Charles Camp, MS IV ctcamp@buffalo.edu
Psych Review I

2. Use these reviews as a guideline for your studying!
Goals
Give a broad overview of preceding material
Distill content to the most important, exam-relevant information
Provide an open forum for questions and clarifications
Use these reviews as a guideline for your studying!

3. Topics Mental Status Exam Psychosis and Psychotic Disorders
Schizophrenia
Antipsychotics

4. Mental Status Exam
Appearance – age, hygiene, physical characteristics, dress
Attitude/Activity – cooperativity, eye contact, calm/agitated, movement
Mood – predominant internal emotional state, quoted from the patient
Affect – expression of that emotional state, as observed by the clinician
Speech – volume, rate, spontaneity, articulation, semantics
Thought Form – thought organization
Thought Content – thought substance
Perception – illusions, hallucinations, depersonalization, autoscopy, déjà vu, jamais vu
Cognition – AOx3, concentration, registration, short/long-term memory, construction, abstraction
Insight – patient’s understanding of their illness, behavior, and benefits of treatment
Judgment – consideration before action

5. Mental Status Exam
Affect – emotional expression as observed by the clinician
Congruency with stated mood
Appropriateness with conversation content
Intensity – level of expression
Blunted = minimal expression
Flat = no expression
Range – emotional spectrum displayed by the patient
Full or restricted
Mobility – fluidity/ease of movement through that spectrum
Labile > Mobile > Fixed
Reactivity – responds appropriately to shifts in conversation content

6. Loosening of Associations
Mental Status Exam
Thought Form – thought organization
Organized
Circumstantial
Tangential
Flight of Ideas
Loosening of Associations
Word Salad
Peculiarities of Form
Clang Associations
Echolalia/Palilalia
Neologisms
Thought blocking
Perseveration

7. Mental Status Exam Thought Content – thought substance
Delusions – fixed, false beliefs not shared by peer group
Bizarre – couldn’t happen within our current reality
Non-bizarre – could happen within our current reality
Overvalued Ideas – “delusions” you can reason with
Suicidal/Homicidal Ideations
Obsessions – intrusive, persistent ego-dystonic thoughts
Preoccupations
Magical (“superstitious”) thinking
Ideas of reference – believing innocuous events have strong personal significance

8. A symptom of an underlying disorder or substance.
Psychosis
Impaired sense of reality characterized by:
Hallucinations
Delusions
Disorganized thought/speech
Disorganized behavior
Not a diagnosis!
A symptom of an underlying disorder or substance.

9. Schizophrenia Chronic or recurrent disorder characterized by:
Sustained periods of psychosis, a.k.a. “positive symptoms” (~1 month)
Negative symptoms
Long-term deterioration in functional ability
Symptom duration of at least 6 months
Risk Factors
Family Hx (genetics)
Obstetric complications
Infection, winter birth
Immune factors
Nutritional factors
Cannabis/drug use
Immigration
Advanced paternal age
Epidemiology
~1% prevalence
1.4 Men : 1 Women
Starts in 20’s
Suicide:
20-50% attempt
5-6% succeed
Concordance Rates
Twins, both parents – 50%
Siblings, 1 parent – 10%

10. Schizophrenia Positive Symptoms Negative Symptoms Delusions
Hallucinations
Thought/speech disorganization
Disorganized behavior/Catatonia
Negative Symptoms
Blunted Affect
Anhedonia/Asociality
Alogia
Inattention
Avolition/Apathy
↑ dopamine in mesolimbic tract
Occur late, wax and wane
Cause hospitalization
Respond well to antipsychotics
↓ dopamine in mesocortical tract
Occur early (prodrome), progressive
Impair function
Less response to antipsychotics

11. Schizophrenia A. 2+ of the following symptoms for at least 1 month:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
B. Social/Occupational Dysfunction
C. Overall duration of at least 6 months
D. Not attributable to schizoaffective or mood disorder, substance use, general medical condition, pervasive developmental disorder
Need at least 1
Positive symptoms (psychosis)

12. Schizophrenia Cognitive Deficits Mood Symptoms
Memory
Language
Attention
Executive function
Mood Symptoms
Depression
Dysphoria
Common comorbidities – substance abuse, anxiety disorders, personality disorders, diabetes, metabolic syndrome, heart/lung disease (reduced life expectancy)
Involves all cognitive domains
Progressive
Highly correlated with functional impairment
Poor response to antipsychotics
Disabling/distressing
Contributes to suicidality risk

13. Schizophrenia
Good Prognosis Acute and/or late onset Positive symptoms Family Hx of affective disorder Supportive family Good premorbid functioning
Poor Prognosis
Insidious and/or early onset
Negative symptoms
Family Hx of schizophrenia

14. Schizophrenia Neuroscience points: ↓ brain volume, ↑ ventricle size
↓ size of medial temporal cortex, hippocampus, amygdala, parahippocampal gyrus
Temporolimbic structures involved in positive symptoms
Frontal structures involved in negative symptoms

15. DDx of Psychosis Primary Psychotic Disorders
Brief Psychotic Disorder, < 1 month
Sudden onset (develops within 2 weeks)
No negative symptoms
Intact function
Schizophreniform Disorder, 1-6 months
Same criteria as schizophrenia EXCEPT function is intact
Schizophrenia, >6 months
Function must be impaired

16. DDx of Psychosis Primary Psychotic Disorders (continued)
Schizoaffective Disorder – concurrent symptoms of schizophrenia and major mood disorder
Mood symptoms present for the majority of illness, other than a period of at least 2 weeks with delusions or hallucinations alone
Impaired function not required (though common)
Delusional Disorder – 1+ delusions for ≥ 1 month
Types – erotomanic, jealous, grandiose, persecutory
Intact function

17. DDx of Psychosis Mood disorders – MDD, bipolar disorder Dementia
Delirium
Personality disorders
PTSD
Post-partum psychosis or mood disorder
Medications/Substances – steroids, amphetamines, cocaine
General Medical Condition – encephalitis, seizures, thyrotoxicosis

18. Antipsychotics 4 Dopamine (DA) Tracts Mesolimbic Mesocortical
↑DA  Positive Symptoms
Mesocortical
↓DA  Negative Symptoms
Nigrostriatal (movement)
DA competes with Ach in basal ganglia
Tuber0infundibular (endocrine)
DA inhibits prolactin release

19. Antipsychotics
Typical (1st Generation) Antipsychotics – Mechanism of Action
Dopamine (D2) blockade – therapeutic action (as well as side effects)
Muscarinic (M1) blockade – anticholinergic effects
Alpha1 blockade – orthostatic hypotension/dizziness/drowsiness
Histamine (H1) blockade – drowsiness, weight gain

20. Antipsychotics Mesolimbic Mesocortical Nigrostriatal
Universal D2 blockade (Typicals)
↓ DA  ↓ Positive Symptoms
↓ DA  ↑ Negative Symptoms
↓ DA  ↑ Ach  EPS
↓ DA  ↑ Prolactin  galactorrhea amenorrhea
Mesolimbic
↑DA  Positive Symptoms
Mesocortical
↓DA  Negative Symptoms
Nigrostriatal
DA competes with Ach in basal ganglia
Tuber0infundibular
DA inhibits prolactin release

21. Antipsychotics Extrapyramidal Symptoms (EPS):
Parkinsonism – bradykinesia, masklike facies, cogwheeling, pill-rolling tremor
Tx = anticholinergics – benztropine, trihexyphenidyl, diphenhydramine
Akathisia – unpleasant urge to move, inner restlessness
Tx = propranolol
Dystonia – painful, involuntary muscle spasms (usually head or neck)
Tx = anticholinergics – benztropine or diphenhydramine
Tardive Dyskinesia – involuntary movements of face/neck/extremities (chewing, tongue protrusions, grimacing)
Arise after long term use
Often irreversible, switch to lower risk antipsychotic

22. Antipsychotics Neuroleptic Malignant Syndrome (NMS)
Muscle rigidity, fever, autonomic instability, ↑ CPK
Immediately STOP antipsychotic (potentially fatal)
Tx = dantrolene (inhibits calcium release from SR and allows muscles to relax)

23. Antipsychotics
Low Potency Typicals (lower D2 affinity) – Chlorpromazine
↑ dose needed  ↑ anticholinergic effects  ↓ Ach  ↓ EPS
Predominant side effects: anticholinergic, drowsiness, orthostatic hypotension
High Potency Typicals (higher D2 affinity) – Haloperidol, Fluphenazine, Trifluoperizine
↓ dose needed  ↓ anticholinergic effects  ↑ Ach  ↑ EPS
EPS symptoms predominate, hyperprolactinemia
Bottom Line: improve positive sx, worsen negative sx, cause EPS, anticholinergic sx, drowsiness, orthostasis

24. The result? – SELECTIVE D2 blockade focused on mesolimbic tract
Antipsychotics
Atypical (2nd Generation) Antipsychotics – Mechanism of Action
Dopamine (D2) Blockade, but with faster dissociation from D2 receptors
Serotonin (5-HT2A) Blockade
↓ 5-HT  ↑ DA (antagonistic relationship) – counteracts D2 blockade
5HT-2A receptor levels differ in different brain locations:
Mesolimbic tract = low levels
Mesocortical, nigrostriatal, tuberoinfundibular tracts = high levels
The result? – SELECTIVE D2 blockade focused on mesolimbic tract

25. Antipsychotics Mesolimbic (few 5-HT2A receptors)
5-HT2A and D2 blockade (Atypicals)
↓ DA  ↓ Positive Symptoms
↓ 5-HT  ↑ DA  ↓ Negative Symptoms
↓ 5-HT  ↑ DA  ↓ Ach  ↓ EPS
↓ 5-HT  ↑ DA  ↓ Prolactin  ↓ galactorrhea
↓ amenorrhea
Mesolimbic (few 5-HT2A receptors)
↑DA  Positive Symptoms
Mesocortical (many 5-HT2A receptors)
↓DA  Negative Symptoms
Nigrostriatal (many 5-HT2A receptors)
DA competes with Ach in basal ganglia
Tuber0infundibular (many 5-HT2A receptors)
DA inhibits prolactin

26. Antipsychotics
Risperidone – hyperprolactinemia (most similar to typicals)
Olanzapine – weight gain
Quetiapine – sedation
Ziprasidone – ↓ weight gain, ↑ QTc
Aripiprazole (D2 partial agonist) – akathisia
Colazpine – agranulocytosis (needs monitoring)
Only antipsychotic with ↑ efficacy
No EPS, TD, or Hyperprolactinemia
Use in cases of 2x failed treatment
All Atypicals
↑ weight
Metabolic syndrome risk
Varying degrees of anticholinergic sx, sedation, orthostasis
All Antipsychotics
↓ seizure threshold

27. Questions?