Advanced Pathophysiology: Concepts of Psychological Disorders

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QUESTION

Use a few sentences to answer these questions based on the scenarios
Scenario 1: Schizophrenia
A 22-year-old female student was brought to her college student health department by her boyfriend. He was concerned about the changes in her behavior. The boyfriend noted that she has been hearing voices, and seeing things that are not there. She also thinks that there are people that want to harm her. She told her family that she cannot finish college as the voices told her to quit because she is “dumb”.  The boyfriend relates episodes of unexpected rage and crying.
PMH:  noncontributory
FH: positive for a first cousin who “had mental problems”.
SH: Denies current drug abuse but states he smoked marijuana every day during junior and senior years of high school. Admits to drinking heavily on weekends at various fraternity houses.
PE: thin, anxious disheveled female who, during conversations, stops talking, tilts her head and appears to be listening to something. There is poor eye contact and conversation is disjointed.
DIAGOSIS: schizophrenia.
Questions
1.     What are known characteristics of schizophrenia and relate those to this patient.
2.    Genetics are sometimes attached to schizophrenia explain this.

3. What roles do neurotransmitters play in the development of schizophrenia?
4. Explain what structural abnormalities are seen in people with schizophrenia.

Scenario 2: Bipolar Disorder
A 44-year-old female came to the clinic today brought in by her husband. He notes that she has been with various states of depression and irritability over the past 3 months with extreme fatigue, has lost 20 pounds and has insomnia. He has come home from work to find his wife sitting in front of the TV and not moving for hours. In the past few days, she suddenly has become very hyperactive, has been talking incessantly, has been easily distracted and seems to “flit from one thing to another.”. She hasn’t slept in 3 days. The wife went on an excessive shopping spree for new clothes that resulted in their credit card being denied for exceeding the line of credit. The wife is unable to sit in the exam room and is currently pacing the hallway muttering to herself and is reluctant to talk with or be examined the ARNP. Physical observation shows agitated movements, rapid fire speech, and hyperactivity.
DIAGNOSIS: bipolar type 2 disorder.
Question
5. How does genetics play in the development of bipolar 2 disorders?

Use this to answer:

i. Positive symptoms of Schizophrenia with respect to the given case study:
Schizophrenia is characterized by plethora of positive and negative symptoms. The positive symptoms in the given case are:
• Hallucinations: The client began “hearing voices” and is of opinion from that voices that he is “not smart enough”. These are described as auditory hallucinations with voices commenting or conversing in the affected individual
• Delusions: The client is experiencing a strange feeling that “everyone is out to get him” which is a positive symptom of Delusion in Schizophrenia
• Positive formal thought disorder: Lack of logic, poor eye contact and rambling conversation are signs of positive formal thought disorder which is also a characteristic positive symptom in Schizophrenia
• Bizarre behavior: Unexpected rage, crying, appearance are all positive symptoms which can be described as Bizarre behavior
Hence, the affected individual is having all the positive symptoms of Schizophrenia
(On the other hand, poor eye contact (affective flattening), inattentiveness during testing, poor conversation are negative symptoms of Schizophrenia)
Step-by-step explanation
ii. Genetics of schizophrenia: Schizophrenia has a hereiditary predispositioin as many of the affected individuals share a family history of schizophrenia (as seen in this case)
• High susceptibility to schizophrenia in monozygotic twins and a relatively moderate (but not lower) susceptibility in dizygotic twins support the genetic predisposition of schizophrenia
• Copy number variations involving deletion of DNA sequences (especially at 22q11.2) is found to be a genetic predisposition in the development of schizophrenia
• Defective genes in the affected individual leads to reduced Reelin (a protein responsible for neuronal migration) function during the brain development in the childhood. Thus, reelin function is compromised in prefrontal cortex and hippocampus resulting in reduced Gamma Amino Butyric Acid (GABA-an inhibitory neurotransmitter) function which could also be a genetic basis of Schizophrenia
iii. Role of neurotransmitters in the development of schizophrenia:
• High concentration of Dopamine: Increased concentration of the neurotransmitter dopamine and its effects on Dopamine receptors (especially D2 receptor) in the mesolimbic dopaminergic pathway is strongly correlated with symptoms associated with Schizophrenia.
• Reduced concentration of Glutamate: Reduced glutamate concentration (an excitatory neurotransmitter) on the N-Methyl D aspartate (NMDA) Receptor also plays a role in the development of hallucinations, delusions and prefrontal cortical damage that affects the cognitive function. Thus, reduced glutamate is also a contributory factor in the development of schizophrenia
iv. Structural abnormalities are seen in people with schizophrenia:
The structural abnormalities which are associated with Schizophrenia are:
• Individuals affected with schizophrenia exhibit progressive degeneration of Cortical gray matter in temporal lobe, somatosensory and motor cortex which contributes for negative symptoms and cognitive impairment
• Lateral and third ventricles are enlarged in the affected individuals which contributes for the negative symptoms of schizophrenia and cognitive impairment.
• Frontocortical fissures and sulci are broadened.
• Reduced size of thalamus is responsible for impairment of neurotransmission between cortex and sensory, motor areas. On the other hand reduction of amygdala, hippocampus and parahippocampal gyrus are correlated with positive symptoms such as hallucinations, delusions and thought disorders
• Structural changes in Dorsolateral prefrontal cortex is also responsible for poor memory and cognition related problems in schizophrenia

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