Chapter 3: Psychotic disorders Flashcards
delusional themes
persecution/ paranoid
reference (cues in the external environment are uniquely related to individual)
control (includes thought broadcasting, thought insertion)
grandeur
guilt
somatic
illusion
misinterpretation of an existing sensory stimulus
medical causes of psychosis include
CNS disesase (MS, alzheimers, parkinson's, etc) endocrinopathies nutritional/ vitamin deficiency states (B12, folate, niacin) Other (connective tissue disease, porphyria)
positive symptoms of schizophrenia
hallucinations, delusions, bizarre behavior, disorganized speech. Tend to respond more robustly to antipsychotic meds
negative symptoms of schizophrenia
flat or blunted affect, anhedonia, apathy, alogia, lack of interest in socialization.
tend to be treatment resistant
3 phases of schizophrenia
prodromal (decline in functioning preceding first psychotic episode). Socially withdrawn/ irritable
psychotic (perceptual disturbances, delusions, and disordered thought process/ content
residual (occurs following an episode of active psychosis. Marked by mild hallucinations or delusions, social withdrawal, and negative symptoms.
5 As of schizophrenia
anhedonia affect (flat) alogia (poverty of speech) avolition (apathy) attention (poor)
DSM-5 criteria for schizophrenia
2 or more for at least 1 month: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. grossly disorganized or catatonic behavior 5. Negative smptoms Note: at least one must be 1, 2, or 3
must cause significant social, occupational or self-care functional deterioration
duration of illness for at least 6 months (including prodromal or residual periods)
symptoms not due to substance/ other med condition
clozapine and schizophrenia
typically considered when a pt fails both typical and other atypical antipsychotics; due to poetential rare adverse event: agranulocytosis
pts must be monitored (WBC and ANC counts) regularly
typical finding in schizophrenic patients include
disheveled appearance
flat affect
disorganize thought process
brief psychotic disoder vs schizophreniform vs schizophrenia
brief: less than 1 month
schizophreniform - 1-6 months
schizophrenia: > 6 months
Side effects of antipsychotic meds
Extrapyramidal (esp high-potency first gen)
Anticholinergic (esp low-potency first gen, atypicals)
Metabolic syndrome (2nd gen)
Tardive dyskinesia (more likely with first gen)
Neuroleptic malignant syndrome (high potency first gen)
prolonged QT interval and ECG changes, hyperprolactinemia, hematologic, opthalmologic, dermatologic
Extrapyramidal symptoms
side effect w/ high-potency first gen antipsychotics
- dystonia (spasms) of face, neck, tongue
- Parkinsonism (resting tremor, rigidity, bradykinesia)
- Akathisia (feeling of restlessness)
Treat with anticholinergics (benztropine, diphenhydramine), benzos/ beta-blockers (specifically for akathisia)
Anticholinergic symptoms
esp w/ low-potency first gen antipsychotics, atypical antipsychotics:
Dry mouth, constipation, blurred vision, hyperthermia
Metabolic syndrome
side effect of 2nd gen antipsychotics:
constellation of conditions. Increased BP, blood sugar, body fat around waist. Abnormal cholesterol levels. Increased risk for developing cardiovascular disease, stroke, type 2 diabetes.
Consider switching to a 1st gen antipsychotic or a more weight neutral 2nd gen one such as aripiprazole or ziprasidone. Monitor lipids and blood glucose measurements. Refer to PCP for rx of hyperlipidemia, diabetes, etc. Encourage diet, exercise, smoking cessation.
Tardive dyskinesia
more likely with 1st gen antipsychotics
choreoathetoid mvmts, usually seen in the face, tongue, and head.
Treatment: discontinue or reduce med. Consider substituting atypical antipsychotic (if appropriate). Benzos, Botox, vitamin E may be used. Movements may persist despite withdrawal of the drug.
atypicals can also cause.
Neuroleptic malignant syndrome
side effect in high potency first gen antipsychotics
- change in mental status, autonomic instability (high fever, labile BP, tachycardia, tachypnea, diaphoresis), “lead pipe” rigidity, elevated creatine phosphokinase (CPK) levels, leukocytosis, and metabolic acidosis.
- medical emergency that requires prompt withdrawal of all antipsychotic meds and immediate medial assessment and treatment.
cumulative risk of developing tardive dyskinesia from antipsychotics, esp first gen
5% per year
schizophreniform disorder
same criteria as schizophrenia, between 1-6 months
schizoaffective disorder
- meet criteria for either a major depressive or manic episode during which psychotic symptoms consistent with schizophrenia are also met.
- delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms (necessary to differentiate schizoaffective disorder from mood disorder with psychotic features)
- mood symptoms present for majority of the illness
prognosis for schizoaffective disorder
worse with poor premorbid adjustment, slow onset, early onset, predominance of psychotic symptoms, long course, and family history of schizophrenia
Treatment for schizoaffective disorder
hospitalization if necessary, supportive psychotherapy
medical therapy: antipsychotics (2nd gen may target both psychotic and mood symptoms), mood stabilizers, antidepressants, or ECT.
Brief psychotic disorder
psychotic symptoms as in schizophrenia; however, 1 day to 1 month. Eventual full return to pre-morrbid level of functioning. Not due to effects of a substance or other med condition. rare dx.
may be seen in reaction to extreme stress such as bereavement, sex assault,e tc.
prognosis: high rates of relapse, but almost all completely recover.
treatment: brief hospitalization, supportive therapy, course of antipsychotics for psychosis, and/or benzodiazepines for agitation
Delusional disorder
more often in middle aged or older patients. Immigrants, hearing impaired, and with fam history of schizophrenia at increased risk.
- one or more delusions at least 1 month
- not meeting criteria for schizophrenia
- functioning in life not significantly impaired; not obviously bizarre behavior
