Chapter 3_Psychotic Disorders Flashcards
Define psychosis in a nutshell
DISTORTED PERCEPTION OF REALITY
Two types of delusions of control
- thought broadcasting - “other people can read my mind”
2. thought insertion - “people are putting thoughts in my head”
delusion vs. illusion vs. hallucination
delusion is a fixed false belief that remains despite evidence to the contrary
illusion is a misinterpretation of an existing stimuli (ex: thinking a shadow is a cat)
hallucination is a sensory perception WITHOUT an actual stimulus. Can be visual, auditory, tactile, olfactory
Differential dx of psychosis (hint: there’s a bunch)
- psychotic d/o due to another medical conditions
- substance/medication induced psychotic d/o
- delirium/dementia
- bipolar diosrder, manic/mixed episode
- major depression with psychotic features
- brief psychotic disorder
- schizophrenia
- schizophreniform
- schizoaffective
- delusional disorder
What CNS diseases can cause psychosis?
cerebrovascular disease, multiple sclerosis, neoplasm, Alzheimer’s, Parkinson’s, Huntington’s, tertiary syphilis, epilepsy (often temporal lobe), encephalitis, prion disease, neurosarcoidosis, AIDS
What endocrinopathies can cause psychosis?
Addison/Cushing’s disease, hypo/hyperthyroidism, hyper/hypocalcemia, hypopituitarism
What nutritional/vitamin deficiencies can cause psychosis?
b12, folate, niacin (pellagra)
SLE, temporal arteritis, and porphyrias can cause…
PSYCHOSIS
Broad categories of medical causes ofpsychosis
CNS disease, endocrinopathies, vitamin/nutritional states, other
Criteria for psychotic disorder due to medical condition? (Name 3)
- prominent hallucinations/delusions
- symptoms do not occur exclusively in an episode of delirium
- clinical evidence (labs, history, physical) to support medical cause (non-psych cause)
Name some classes of medications that can cause psychosis
anesthetics, antimicrobials, NSAIDS, anticholinergics, antihistamines, corticosteroids, antihypertensives, methylphenidate, chemotherapeutic agents, , anticonvulsants, antiparkinsonian agents
PRETTY MUCH EVERYTHING
Examples of positive symptoms of schizophrenia
hallucinations, delusions, bizarre behavior, disorganized speech. Tend to respond well to medication
Examples of negative symptoms of schizophrenia
Anhedonia, flat/blunted affect, apathy, alogia (poverty of speech), lack of interest in socialization. Don’t respond as well to treatment, contribute to social isolation
Examples of cognitive symptoms of schizophrenia
impairments in attention, executive function, and working memory (lead to poor work/school function)
Three phases of schizophrenia symptom presentation
- prodromal - decline in function, social withdrawal, more irritable. New bizarre interests, declining work/school performance
- psychotic - active psychosis
- residual - follows psychotic episode. socially withdrawn, negative symptoms, psychosis
Physical/movement symptoms of schizophrenia
catatonia, stereotyped/repetitive movement, bizarre posturing, muscle rigidity
DSM-5 criteria for schizophrenia
- 2 or more of the following must be present: hallucinations, delusions, disorganized speech, negative symptoms, grossly disorganized/catatonic behavior (at least one must be one out of 1st three)
- significant social, functional, occupational impairment
- must be present for at least six months
- symptoms not due to effect of substance or medical condition
What are the 5 A’s of schizophrenia (negative symptoms)
Apathy Anhedonia Alogia Affect (flat) Attention (poor)
What is the LAST RESORT antipsychotic?
Clozapine. Use if patient fails atypical and typical antipsychotics. Watch out for AGRANULOCYTOSIS (monitor WBC and ANC)
Difference between brief psychotic disorder, schizophreniform, and schizophrenia
Brief = 6months
Typical age of presentation of schizophrenia
Men: early-mid 20s
Women: late 202
men tend to have more negative symptoms and have poorer outcomes than women
T/F Substance use is comorbid with many schizophrenic patients
TRUE! nicotine, alcohol, cannabis, cocaine
downward drift hypothesis
postulates that people suffering from schizophrenia are unable to function well in society and therefore end up in lower socioeconomic groups.
What neurotransmitter likely plays a role in pathophysiology of schizophrenia?
DOPAMINE! (most antipsychotics are dopamine ANTAGONISTS, and many drugs like cocaine/amphetiamines increase dopamine activity)
In theory, which two dopamine pathways are involved in schizophrenia?
Prefrontal cortical - not enough dopaminergic activity leads to negative symptoms
Mesolimbic - excessive dopaminergic activity leads to positive symptoms
Which two additional pathways do antipsychotics affect and how are they affected?
tuberoinfundibular - blocked my antipsychotics, causes hyperprolactinemia leading to gynecomastia, sexual dysfunction, and menstrual irregularities
nigrostriatal - blocked by antipsychotics, causes EPS (ex: parkinsonism, tremor rigidity, slurred speech, akathisia, dystonia, and other abnormal movements)
What other NT’s are involved in schizophrenia and how are they affected?
elevated serotonin, elevated norepi, decreased GABA, decreased glutamate (less NMDA receptors in schizophrenic patients)
What are some good prognostic factors for schizophrenia?
later onset, good social support, positive symptoms, mood symptoms, acute onset, FEMALE, good premorbid functioning
What are some bad prognostic factors for schizophrenia?
earlier onset, MALE gender, negative symptoms, poor premorbid functioning, lack of social support, family history, gradual onset, many relapses, comorbid substance use
What can a head CTI/MRI show in schizophrenia?
Enlarged ventricles, diffuse cortical atrophy, and reduced brain volume
Examples of first generation/typical antipsychotics
haloperidol, chlorpromazine (thorazine), fluphenazine, perphrenazine
Mechanism of first generation antipsychotics
Primarily dopamine (mostly D2) antagonists, treat positive symptoms with little impact on negative
Side effects to watch out for on first generation antipsychotics
EPS, tardive dyskinesia, neuroleptic malignant syndrome
Examples of second generation antipsychotics
aripiprazole (abilify), asenapine, clozapine (clozaril), iloperidone, lurasidone (latuda), olanzapine (zyprexa), quetiapine (seroquel), risperdone (risperdal), ziprasidone (geodon)
Mechanism of second generation antipsychotics?
Antagonize serotonin receptors (5HT2) and dopamine (D4>D2) receptors. No significant difference in efficacy between typical and atypicals.
T/F Second generation antipsychotics work immediately
False. must take for at least 4 weeks before effect is seen
What are some EPS symptoms due to typicals and how are they treated?
Dystonias (spasms) of face, neck, and tongue
Parkinsonism (resting tremor, rigidity, bradykinesia)
akathisa (restlessness)
Treat with anticholinergics, benzos/beta blockers (esepcially for akathisia)
Dry mouth, constipation, blurred vision, hyperthermia
Anti-cholinergic symptoms that can be caused by low potency typicals and atypicals
What are some components of metabolic syndrome and how to treat these?
hypertension, high blood sugar, excess central body fat, hyperlipidemia ( all increase the risk for CV disease and T2DM).
Treatment: switch to typical antipsychotic, or more “weight neutral” atypical (aripriprazole, ziprasidone). Make sure to monitor lipid and blood glucose. Always encourage good diet/exercise/smoking cessation
What is tardive dyskinesia, which class more likely to cause, and how to treat?
choreoatheoid movements (tongue, face, head), more likely with typical antipsychotics.
Treatment: D/c or lower dose, consider switching to atypical. Benzos, botox, vitamin E may be used.
What is neuroleptic malignant syndrome?
Change in mental status, autonomic instability (vital signs all over the place; fever, fast breathing, labile BP), “lead pipe” rigidity, elevated CPK, leukocytosis, metabolic acidosis.
Medical emergency that requires PROMPT withdrawal of all antipsychotics and immediate treatment. More frequently associated with initiation fo treatment and at higher IV/IM dosing of high-potency neuroleptics. Prior history of NMS = higher chance for recurrent NMS.
Which typical antipsychotic can cause deposits in lens and cornea?
chlorpromazine
Treatment for schizophreniform
Hospitalization (if necessary), 6 months antipsychotics, supportive psychotherapy if necessary
DSM-5 criteria for schizoaffective disorder
- Meet criteria for either major depressive or major manic episode while criteria in which psychotic symptoms consistent with schizophrenia are also met
- Hallucinations/delusions occur for 2 weeks in the absence of mood disorder (distinguishes this from mood disorder with psychotic features)
- Mood symptoms are present for majority of psychotic illness
- Symptoms must not be due to substance/other medical condition
Treatment options for schizoaffective
Antipsychotics (atypicals can target both psychosis and mood), mood stabilizers, ECT, antidepressants
DSM-5 criteria for brief psychotic disorder (rare)
- Psychotic symptoms consistent with schizophrenia lasting 1day-1month.
- Must make full recovery from psychosis and return to full premorbid functioning
- Not due to another substance/ medical condition
Main differences between delusional disorder and schizophrenia
- delusion only has to be present for at least 1 month
- delusions aren’t necessarily bizarre
- daily functioning NOT SIGNIFICANTLY impaired
- does not meet criteria for schizophrenia (even though delusions can occur in schizophrenia)
- Typical presents later in life (middle-late age)
Erotomanic delusion
delusion that another is in love with the individual
Grandiose type delusion
delusion of having great talent/special powers
Somatic type delusion
physical delusion (I’m pregnant)
Persecutory type delusion
delusion that an individual is being persecuted
jealous type
delusions of unfaithfulness
How to treat delusional disorder
difficult to treat given patient’s lack of insight and impairment, antipsychotics recommended (but limited evidence). NO GROUP therapy, but can try supportive therapy
Sudden unprovoked outburts of violence, often followed by suicide
Amok (malaysia)
intense anxiety that penis with recede into body and lead to death
Koro (southeast asia)
headache, fatigue, eye pain, cognitive difficulties, and other somatic disturbances in male students (Africa)
brain fag
Order these disorders in order of worsening prognoses
schizoaffective, schizophrenia, mood disorder with psychotic features, schizophreniform diosrder
mood disorder with psychotic features, schizoaffective, schizophreniform, schizophrenia
Difference between schizophrenia and schizotypal/schizoid
schizotypal/schizoid are personality disorders that don’t have psychosis
