Chapter Eight
Summary
Schizophrenia and other psychotic disorders affect more than 1% of the general population. It is key to
assess and treat schizophrenia in its early stages and to prevent relapse. Patients left untreated in the first year of an
episode can be as much as a 15% suicide risk.
Schizophrenia is not caused by poor parenting, trauma, or other “demonic” possession. Schizophrenia is
first and foremost a brain disorder with numerous abnormalities in structure, function and neurochemistry. With
regard to structure, we find an enlargement of the lateral ventricles followed by decreased volume of gray and white
matter. The medial temporal structures such as the hippocampus and amygdala have also been found to be smaller in
size to non-schizophrenic controls.
The most common neurochemical abnormality involves the “hyperdopaminergic” theory in which refers to
the idea that too much dopamine causes psychotic symptoms. Medications used in the treatment of these conditions
block dopamine D2 receptors at the post-synaptic membrane. Newer atypical antipsychotics block D2 and 5HT
receptors as well, but produce less side effects than the older neuroleptics.
Schizophrenia has a strong familial link with high concordance rates among first-degree relatives. We also
find that the disorder is much more prevalent among those in urban areas, those born in colder months in colder
climates, and among those whose mothers may have had a viral infection during their second trimester of pregnancy.
Specific Discussion Questions:
1. Explain the difference between positive and negative symptoms of schizophrenia.
2. Summarize the various causes of schizophrenia and other psychotic disorders.
3. What are some of the advantages of the newer antipsychotic medications over the older neuroleptics?
4. Explain tardive dyskinesia and why it is problematic.
5. Summarize both the medical and chemical causes of psychoticism.
6. What can be done to reduce the side effects of anti-psychotic medications?
7. Why are the newer atypical antipsychotics better for most patients?
8. Explain how the disease exposes one to higher mortality risk and higher rates of chronic illness.
Possible True/False Questions:
1. Schizophrenia is typically caused by environmental trauma.
2. Concordance rates for monozygotic twins is about 40-50%.
3. The “social drift” phenomenon refers to where most schizophrenics end up living as a result of
occupational/financial loss.
4. Clozaril is the only atypical antipsychotic medication with no real extra-pyramidal risk.
5. Resperidone requires weekly blood monitoring.
6. Expert consensus suggests that a prescriber wait at least three weeks before switching from one anti-psychotic
medication to another.
7. Symbyax is a new medication that consists of both Zyprexa and Prozac.
8. Schizophrenia affects nearly 3% of the general population.
9. Schizophrenia can be detected on brain scans.
10. For patients with multiple-episodes, Risperdol or Invega are the drugs of choice.
11. Seroquel has been studied to determine if it is a popular drug of abuse.
Possible Multiple Choice Questions:
1. All of the following are atypical antipsychotics except:
a. Zyprexa
b. Fanapt
c. Abilify
d. Navane
2. The treatment of choice for the first episode psychotic patient is:
a. Risperdal
b. Abilify
c. Haldol
d. None of these
3. The advantages of the newer atypicals include:
a. Minimal EPS
b. Efficacy for reducing the positive symptoms.
c. Improving patient cognition.
d. All of the above.
4. The best medication for treatment refractory schizophrenia is:
a. Seroquel
b. Abilify
c. Clozaril
d. Orap
5. Which medication does not belong with the others?
a. Artane
b. Benadryl
c. Cogentin
d. Stelazine
6. Which of the following is most associated with weight gain?
a. Geodon
b. Zyprexa
c. Clozaril
d. Saphris
Alternative Class Assignments and Essay Questions:
1. Have the class make a list of all the medications currently available to treat schizophrenia and other psychotic
disorders. Discuss which can be used to address positive symptoms, which can be used to address negative,
and which can be used to address both.
2. Describe tardive dyskinesia. What types of warning signs should one look for?
3. Review the four treatment steps proposed by the authors. What is a reasonable first step for the typical
patient? What should be done next if the patient does not respond?
4. Explain the concept of expressed emotion (EE) and how this affects relapse and course of the illness.
5. Explain the difference between extra pyramidal side effects and the anticholinergic side effects.
Read the Case Vignette in this chapter and answer the following questions:
Case Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in the case?
2. Is there another disorder that may apply or should be ruled-out?
3. Do you agree with the medication suggestions made in this case?
4. Any other medications that might be considered…what is the rationale?
5. If you were asked to follow-up on this case as the treating therapist, would you offer any additional
suggestions or approaches?
Chapter Eight
Answer Key
True/False Questions:
Multiple Choice Questions: