10/19 Psychosis - Tobia Flashcards
psychosis
how to approach deciding if someone has psychosis
rule out life threatening causes:
- stat EKG
- vital signs
- consider withdrawal syndromes (esp from alcohol, sedative hypnotics)
then, make sure psychosis isnt caused by an underlying medical condition
which neurotransmitter is implicated in all psychoses
dopamine
Hibernotherapie
compound used by French anesthesiologist who noticed that using it allowed for significantly less anesthesia intraoperatively
- as a result: pts experienced drop in all-cause mortality
psychiatrist friend decided to try on psych patients to reduce agitation
- as a result: pt reported less agitation AND improvement of psychotic sx
FDA approved as clorpromazine
- hits DA receptors in CNS
- first antipsych!
role of dopamine in psychoses
final common pathway for all psychoses
- substance-induced (ex. stimulants)
- resulting from general medical condition
- deliriums
DA neuroanatomy
long tracts
short tracts
long tracts:
- nigrostratal tract
- mesolimbic tract
- mesocortical tract
short tracts:
- tubero-infundibular tract
- retina and adrenal medulla
nigrostriatal tract
fxs
cell bodies/projections
what does DA excess in this tract look like?
- synthesizes most of CNS dopamine
- influences fx of extrapyramidal motor system
- cell bodies found in substantia nigra pars compacta → project to D2 receptors in striatum (caudate and putamen)
dopaminergic excess in nigrostriatal tract
- neurocognitive deficits: speech, memory, attn/conc
- increase in DA in striatum thought to be related to neurocog deficits in schizophrenia
- movement disorders (hyper/brady/akinesis)
common side effect of antipsychotics and why?
Parkinsonism (hypokinetic movement disorders)
- psychosis is resulting from relative or absolute high level of DA in CNS
- antipsychotics reduce DA → drop DA that would hit inhibitory D2 receptors in the indirect pathway (basal ganglia) → overall bradykinetic
mesolimbic tract
cell bodies in VTA of midbrain → project to D4 receptors in limbic system
hyperactivity?
- positive sx of schizophrenia
mesocortical tract
cell bodies in VTA of midbrain → project to frontal cortex, cigulate and prefrontal gyri
hypoactivity via D2 receptor antagonism
- negative sx
- mood and cognition effects
schizophrenia and the DA shunt
conditions like schizophrenia have both positive and negative sx
- potentially explained by thinking of a “dopamine shunt” moving DA from mesocortical tract → mesolimbic tract
- hypoactivity in mesocortical tract → negative sx
- hyperactivity in mesolimbic tract → positive sx
tuberoinfundibular tract
links ___ & ___
function
effect of antipsychotics
TI tract (short pathway)
links hypothalamus → pituitary
- chronic DA secretion → decr prolactin secretion
- therefore…one side effect of medications that lower CNS DA concentration is: HYPERPROLACTINEMIA
common side effects of medications to decrease CNS DA
- reduction of positive sx (mesolimbic)
- aggravation of negative sx (mesocortical)
- hyperprolactinemia (TI tract)
retina DA
believed that excess DA here → visual hallucinations associated with psychosis
psychotic disorders
2 groups, disorders within them
schizophrenia spectrum
- brief psychotic disorder
- schizophreniform disorder
- schizophrenia (schizoaffective disorder)
other psychotic disorders
- delusional disorder
- catatonia
schizophrenia
two or more for a 1-month period
- positive sx
- delusions
- hallucinations
- disorganized speech
- disorganized or catatonic behavior
- negative sx
(formerly) Schneider’s First Rank sx
1. delusional perceptions (aka ideas of reference): thought or belief that is 1. not bound in reality and 2. fixed/rigid
- two-stage phenomenon consisting of a normal perception followed by a delusional interpretation
- special and highly personalized significance
2. somatic passivity → belief that:
- pt is a passive recipient of bodily sensations that are imposed from the outside
- affect, impulses, and/or motor activities are controlled by an outside force
3. thought insertion: belief that thoughts are put into mind by external force
4. thought withdrawal: belief that thoughts are being removed from mind by external force
5. thought broadcast: belief that thoughts are somehow transmitted to others
6. hallucinations: perceptual disturbances that have no environmental cue
7. illusions: misinterpretation in response to an environmental cue
negative sx of schizophrenia
5 A’s
- aPathy/avolition
- aLogia (poverty of speech/thought)
- Affective flattening
- aNhedonia/asociality (withdrawal)
- aTtention deficit
due to mesocirtical tract (DA hypoactivity → neg sx)
schizophrenia
social/occupational dysfx
6mo
exclusionary criteria:
- schizoaffective and mood disorder
- autism spectrum disorder
- substance/GMC
defense mech that best characterizes sx of schizophrenia
how do we distinguish between plain old personality disorder and psychosis (ex. schizophrenia)
projection
distinguish between personality disorder (ex. paranoid PD) and psychosis (ex. schizophrenia) by looking at frontal lobe fx
- loss of the protective override between 18-35 → psychosis
psychological determinants of schizophrenia
unconscious process through which individual attributes his/her unacceptable feelings, impulses or thoughts to another
- ego process
- characterized by impaired frontal lobe fx
social determinants of schizophrenia
myths and accepted social theories
myths
- schizophrenogenic mom
- double bind (family dynamic theory that said individ gets two opposing messages from same communication)
accepted social theories
- downward drift: schizophrenia causes poverty
- stress-diathesis model: genetic/biological factors can predispose but psych/social factors are precipitants
- i.e. anyone can be made psychotic with enough psych/social stressors…the level req is determined by genetic predisp
schizophreniform disorder
schizophrenia that lasts between 1-6 months
past 6mo → schizophrenia
brief psychotic disorder
ONE or more schizophrenia sx for 1-mo
- NOT INCLUDING NEGATIVE SX
duration: 1day-1mo
recovery: full return to premorbid fx
usually precipitated by a stressor:
- witness to catastrophic event
- childbirth → postpartum onset
how do you determine if BPD or early schizophrenia?
presence of negative sx will point towards schizophrenia!
schizophrenia spectrum disorders
differentiation based on timecourse and sx
1day-1mo : brief psychotic disorder
- negative sx NOT part of dx criteria
1mo-6mo : schizophreniform disorder
6mo + : schizophrenia
schizophrenia
need to rule out:
- schizoaffective and mood disorder
- autism spectrum disorder
- substance/GMC
if you see co-occuring psychotic AND mood sx, consider something other than schizophrenia
- MDD w/ psychotic features
- sx of mood sx concurrent with sx of schizophrenia BUT NOT DURING WHOLE DURATION OF ILLNESS
- schizoaffective disorder
- sx of mood episode concurrent with sx of schizophrenia through whole duration of illness
- delusions or hallucinations for 2 or more weeks in absence of mood sx
schizophrenia
need to rule out:
- schizoaffective and mood disorder
- autism spectrum disorder
- substance/GMC
first dx’d in infancy, childhood, or adolescence
- severe impariment in several areas of devpt
- social interaction, communication deficits also seen in schizophrenia SO might be tempted to re-classify them →→→ NO.
how can you dx someone with schizophrenia in addition to ASD?
- disorganized social interaction + disorganized communication PLUS delusions or hallucinations
delusional disorder
individ suffers from a fixed belief → significant impairment
- 1 or more delusions for 1+ month in individual with no prior hx of schizophrenia
- fx is NOT markedly impaired (minus impact of delusion)
- if there was signif impairment…schizophrenia!
- mood episodes are brief
need to rule out other substance/gen med condition
topography of delusions and hallucinations
5 general themes of thought content in delusional disorder
- jealousy
- persecutory
- erotomanic (de Clerambault’s)
- fixed belief that an individual adores/is in love w you
- grandiose
- somatic
mixed, unspecified
Capgras syndrome
unspecified form of delusional disorder
- individ believes that someone close to them has been replaced by an imposter
- imposter isk ey figure for pt at time of sx onset
- ex. if married, almost always spouse
- may accompany fxal psychoses other than schizophrenia (affective, organic disorder)
Fregoli’s syndrome
variant of Capgras syndrome
- delusion that persecutors or familiar persons can assume guise of strangers
- familiar persons can change themselves into other persons at will (intermetamorphosis)
- ex. The Matrix
Cotard syndrome
- complaint of having lost possessions and status
- ex. loss of heart, blood, intestines (Wizard of Oz)
catatonia
marked behavioral (psychomotor) disturbance
abnormal motor activity
- decreased
- excessive (or peculiar)
decreased engagement
substance-induced psychotic disorder
intoxication from ALL SUBSTANCES EXCEPT
- caffeine
- nicotine
- opioids
withdrawal FROM
- alcohol
- sedatives
- hypnotics
exam tip: if substance prescription or use within past 30 days, it is highly likely that psychosis is linked to substance use!
evaluation of psychosis:
general medical conditions
complete H&P
- neuro exam
- MSE
- focal deficits? → head CT or MRI
- screening lab exams
- IheartLADYMACBETH
ABC STAMP LICKER
positive sx of psychosis/schizophrenia
negative sx of psychosis/schizophrenia
+++++
Behavior
Speech
Thought
Perceptions
- disorganized behavior
- disorganized speech
- delusions
- hallucinations
Speech (possibly alogia)
Affect (flattened affect)
Cognitive fx (attn deficit)
