4. Psychotic Disorders

Question 1

Define psychotic disorders (2)

Answer 1

• characterized by a significant impairment in reality testing
• positive and negative symptoms

Question 2

Name positive symptoms (3)

Answer 2

• delusions or hallucinations (with or without insight into their pathological nature)
• disorganized behaviours
• formal thought disorder

Question 3

Name negative symptoms (5)

Answer 3

• affective flattening
• anhedonia
• avolition
• alogia
• asociality

Question 4

Differentiate delusions vs hallucinations

Answer 4

• Delusions: fixed, false beliefs
• Hallucinations: perceptual experiences without an external stimulus

Question 5

Duration of Time Differentiates the following 3 Psychotic Disorders:

• Brief Psychotic Disorder
• Schizophreniform Disorder
• Schizophrenia

Answer 5

• Brief Psychotic Disorder: < 1 month
• Schizophreniform Disorder: 1-6 month
• Schizophrenia: >6 month

Question 6

Describe the approach to psychosis (5)

Answer 6

• differentiate among psychotic disorders and distinguish them from other primary diagnoses with psychotic features
• consider symptoms, persistence, and time
• symptoms: the primary diagnosis needs full criteria to be met
  
  • mood: depressive episodes with psychotic features, manic episodes with psychotic features
  • psychotic: consider symptoms in Criterion A of schizophrenia
• persistence: is there a time when certain symptom clusters are present without other clusters?
  
  • i.e. if there is a period of time with mood symptoms but not psychotic symptoms, consider mood disorder
  • i.e. if two weeks during which psychotic symptoms persist in the absence of mood symptoms, consider schizoaffective disorder
  • i.e. if long periods with psychotic symptoms and brief or rare mood symptoms, consider schizophrenia
• time: how long have the symptoms been present?

Question 7

Differentiating Psychotic Disorders

Answer 7

Question 8

Name relevant investigations for psychosis (4)

Answer 8

• CBC, electrolytes (including extended lytes), creatinine, glucose, urinalysis, urine drug screen, TSH, Vit B12
• Liver function tests, fasting lipids, HbA1C to obtain baseline levels prior to antipsychotic initiation
• ECG (several antipsychotics affect cardiac conduction)
• If clinically indicated, order infectious work-up, inflammatory markers, brain imaging

Question 9

Name DDX for psychosis (23)

Answer 9

• Primary psychotic disorders:
  
  • schizophrenia
  • schizophreniform
  • brief psychotic
  • schizoaffective
  • delusional disorder
• Mood disorders:
  
  • major depressive disorder with psychotic features,
  • bipolar disorder (manic or depressive episode with psychotic features)
• Personality disorders:
  
  • schizotypal
  • schizoid
  • borderline
  • paranoid
  • obsessive-compulsive (they predispose to psychosis but presence of psychotic symptoms require another diagnosis)
• General medical conditions:
  
  • tumour
  • head trauma
  • dementia
  • delirium
  • metabolic
  • infection
  • stroke
  • temporal lobe epilepsy
• Substance-induced psychosis:
  
  • intoxication or withdrawal
  • prescribed medications
  • toxins

Question 10

Describe: Management of Acute Psychosis and Mania (7)

Answer 10

• Ensure safety of self, patient, and other patients
• Have an exit strategy
• Decrease stimulation
• Assume a non-threatening stance
• IM medications (benzodiazepine + antipsychotic) often needed as patient may refuse oral medication
• Physical restraints may be necessary
• Do not use antidepressants or stimulants

Question 11

Name DSM-5 diagnostic criteria for schizophrenia (7)

Answer 11

1. two (or more) of the following, each present for a significant portion of time during a 1 mo period (or less if successfully treated). At least one of these must be (1), (2), or (3)
   
   1. delusions
   2. hallucinations
   3. disorganized speech (i.e. frequent derailment or incoherence)
   4. grossly disorganized or catatonic behaviour
   5. negative symptoms (i.e. diminished emotional expression or avolition)
2. decreased level of function: for a significant portion of time since onset, one or more major areas affected (i.e. work, interpersonal relations, self-care) is markedly decreased (or if childhood/adolescent onset, failure to achieve expected level)
3. at least 6 mo of continuous signs of the disturbance. Must include at least 1 mo of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms, during which, disturbance may manifest by only negative symptoms or by two or more Criterion A symptoms present in an attenuated form (i.e. odd beliefs, unusual perceptual experiences)
4. rule out schizoaffective disorder and depressive or bipolar disorder with psychotic features because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness
5. rule out other causes: GMC, substances (i.e. drug of abuse, medication)
6. if history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 mo (or less if successfully treated)

• specifiers: type of episode (i.e. first episode, multiple episodes, continuous), with catatonia, current severity based on quantitative assessment of primary symptoms of psychosis (in acute episode, in partial remission, in full remission)

Question 12

Describe epidemiology: Schizophrenia (3)

Answer 12

• prevalence: 0.3-0.7%, M:F = 1:1
• mean age of onset: females late-20s to 40s; males early- to mid-20s (some cases with late onset)
• suicide risk: 10% die by suicide, 30% attempt suicide

Question 13

Describe Disorganized Behaviours in Schizophrenia (8)

Answer 13

• Catatonic stupor
• Catatonic excitement
• Stereotypy
• Mannerisms
• Echopraxia:
• Automatic obedience
• Negativism
• Inappropriate affect, neglect of self-care, other odd behaviours (random shouting)

Question 14

Describe: Catatonic stupor (1)

Answer 14

fully conscious, but mute, and unresponsive, immobile, maintaining bizarre positions for a long time

Question 15

Describe: Catatonic excitement (1)

Answer 15

uncontrolled and aimless motor activity, extreme agitation

Question 16

Describe: Stereotypy (1)

Answer 16

repeated but non-goal- directed movement (i.e. rocking)

Question 17

Describe: Mannerisms (1)

Answer 17

goal-directed activities that are odd or out of context (i.e. grimacing)

Question 18

Describe: Echopraxia (1)

Answer 18

imitates movements and gestures of others

Question 19

Describe: Automatic obedience (1)

Answer 19

carries out simple commands in robot-like fashion

Question 20

Describe: Negativism (1)

Answer 20

refuses to cooperate with simple requests for no apparent reason

Question 21

Describe epidemiology: Schizophrenia (3)

Answer 21

• prevalence: 0.3-0.7%, M:F = 1:1
• mean age of onset: females late-20s to 40s; males early- to mid-20s (some cases with late onset)
• suicide risk: 10% die by suicide, 30% attempt suicide

Question 22

Describe etiology: Schizophrenia (6)

Answer 22

multifactorial: disorder is a result of interaction between both biological and environmental factors

• genetic: 40% concordance in monozygotic (MZ) twins; 46% if both parents have schizophrenia; 10% of dizygotic (DZ) twins, siblings, children affected; vulnerable genes include Disrupted-in-Schizophrenia 1 (DISC1); neuregulin 1 (NRG 1); dystrobrevin binding protein / dysbindin (DTNBP1); catechol-O-methyltransferase (COMT); d-amino acid oxidase activator (DAOA); metabotropic glutamate receptor 3 (GRM3); and brain-derived neurotrophic factor (BDNF)
• neurochemistry (“dopamine hypothesis”): excess activity in the mesolimbic dopamine pathway may mediate the positive symptoms of psychosis, while decreased dopamine in the prefrontal cortex may mediate negative and cognitive symptoms. GABA, glutamate, and ACh dysfunction are also thought to be involved
• neuroanatomy: decreased frontal lobe function; asymmetric temporal/limbic function; decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities
• neuroendocrinology: abnormal growth hormone, prolactin, cortisol, and ACTH
• neuropsychology: global defects seen in attention, language, and memory suggest disrupted connectivity of neural networks
• environmental: indirect evidence of cannabis use, geographical variance, winter season of birth, obstetrical complications, and prenatal viral exposure

Question 23

Describe pathophysiology: Schizophrenia (2)

Answer 23

• neurodegenerative theory: natural history may be a rapid or gradual decline in function and ability to communicate
  
  • glutamate system may mediate progressive degeneration by excitotoxic mechanism which leads to production of free radicals
• neurodevelopmental theory: abnormal development of the brain from prenatal life
  
  • neurons fail to migrate correctly, make inappropriate connections, and apoptosis in later life

Question 24

Name comorbidities: Schizophrenia (3)

Answer 24

• substance-related disorders
• anxiety disorders
• reduced life expectancy secondary to medical comorbidities (i.e. obesity, diabetes, metabolic syndrome, CV/pulmonary disease)

Question 25

Describe Management of Schizophrenia (7)

Answer 25

• biological / somatic
  
  • acute treatment and maintenance: antipsychotics (risperidone, aripiprazole, haloperidol, paliperidone; clozapine if resistant); regimens of IM q2-4 wk used in severe cases to improve adherence
  • adjunctive: ± mood stabilizers (for aggression/impulsiveness - lithium, valproate, carbamazepine) ± anxiolytics ± ECT
  • treat for at least 1-2 years after the first episode, at least 5 years after multiple episodes (relapse causes severe deterioration)
• psychosocial
  
  • psychotherapy (individual, family, group), supportive, CBT (see Table 14, PS41)
  • ACT (Assertive Community Treatment): mobile mental health teams that provide individualized treatment in the community and help patients with medication adherence, basic living skills, social support, job placements, ressources
  • social skills training, employment programs, disability benefits
  • housing (group home, boarding home, transitional home)

Question 26

Describe course and prognosis: Schizophrenia (4)

Answer 26

• majority of individuals display some type of prodromal phase
• course is variable: some individuals have exacerbations and remissions while others remain chronically ill; accurate prediction of the long-term outcome is not possible
• positive symptoms typically diminish with treatment; negative symptoms may be prominent early in the illness or may become more prominent and more disabling later on
• over time: 1/3 improve, 1/3 remain the same, 1/3 worsen

Question 27

Name good prognostic factors of schizophrenia (10)

Answer 27

• Acute onset
• Shorter duration of prodrome
• Female gender
• Good cognitive functioning
• Good premorbid functioning
• No family history
• Presence of affective symptoms
• Absence of structural brain abnormalities
• Good response to drugs
• Good support system

Question 28

Describe diagnosis: Schizophreniform Disorder (3)

Answer 28

• criteria A, D, and E of schizophrenia are met; an episode of the disorder lasts for at least 1 mo but less than 6 mo
• if the symptoms have extended past 6 mo the diagnosis becomes schizophrenia
• specifiers:
  
  • with/without good prognostic features (i.e. acute onset, confusion, good premorbid functioning, absence of blunt/flat affect)
  • with catatonia
  • current severity based on quantitative assessment of primary symptoms of psychosis

Question 29

Describe tx: Schizophreniform Disorder (1)

Answer 29

• similar to acute schizophrenia

Question 30

Describe prognosis: Schizophreniform Disorder (1)

Answer 30

• better than schizophrenia; begins and ends more abruptly; good pre- and post-morbid function

Question 31

Describe diagnosis: Brief Psychotic Disorder (3)

Answer 31

• criteria A1-A4, D, and E of schizophrenia are met;
  
  • an episode of the disorder lasts for at least 1 d, but less than 1 mo with eventual full return to premorbid level of functioning
• specifiers: with/without marked stressors, with postpartum onset, with catatonia, current severity
• can occur after a stressful event or postpartum

Question 32

Describe tx: Brief Psychotic Disorder (1)

Answer 32

• secure environment, antipsychotics, and anxiolytics

Question 33

Describe prognosis: Brief Psychotic Disorder (1)

Answer 33

good, self-limiting, should return to pre-morbid function within 1 mo

Question 34

Name DSM-5 diagnostic criteria for schizoaffective disorder (4)

Answer 34

1. concurrent psychosis (criterion A of schizophrenia) and major mood episode - uninterrupted period of illness
2. delusions or hallucinations for 2 or more wk in the absence of a major mood episode during the lifetime duration of the illness
3. major mood episode symptoms are present for the majority of the total duration of the active and residual periods of the illness
4. the disturbance is not attributable to the effects of a substance or another medical condition

• specifiers: bipolar type, depressive type, with catatonia, type of episode, severity

Question 35

Describe epidemiology: Schizoaffective disorder (2)

Answer 35

• one-third as prevalent as schizophrenia; schizoaffective disorder bipolar type more common in young adults, schizoaffective disorder depressive type more common in older adults
• depressive symptoms correlated with higher suicide risk

Question 36

Describe tx: Schizoaffective disorder (1)

Answer 36

• antipsychotics, mood stabilizers, and antidepressants

Question 37

Describe prognosis: Schizoaffective disorder (1)

Answer 37

• between that of schizophrenia and of mood disorder

Question 38

Name DSM-5 diagnostic criteria: Delusional Disorder (7)

Answer 38

1. the presence of one (or more) delusions with a duration of 1 mo or longer
2. criterion A for schizophrenia has never been met

Note: hallucinations, if present, are not prominent and are related to the delusional theme

1. apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour is not obviously bizarre or odd
2. if manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods
3. the disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder

• subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified
• further specify: bizarre content, type of episode (i.e. first episode, multiple episode), severity

Question 39

Describe tx: Delusional Disorder (3)

Answer 39

• antipsychotics, psychotherapy, and antidepressants

Question 40

Describe prognosis: Delusional Disorder (1)

Answer 40

• may respond well to antipsychotics but most patients refuse them and have chronic, unremitting course; some maintain a high level of functioning; some progress to schizophrenia