Psychosis (incl. Catatonia)

Question 1

What is catatonia?

Answer 1

Catatonia - reduced reaction to external environment

Question 2

How do you diagnose catatonia via DSM 5?

Answer 2

3 or more of 12 psychomotor features

• stupor (no psychomotor activity, not actively relating to environment)
• catalepsy (passive induction of a posture held against gravity)
• waxy flexibility (slight, even resistance to positioning by examiner)
• mutism (no or very little verbal response)
• negativism (opposition or no response to instruction or external stimuli)
• posturing (spontaneous and active maintenance of a rigid posture against gravity)
• mannerism (odd, circumstantial caricature of normal actions)
• stereotypy (repetitive, abnormally frequent, non-goal-directed movements)
• agitation, not influenced by external stimuli
• grimacing
• echolalia (mimicking speech)
• echopraxia (mimicking another’s movements)

motoric immobility may be severe (stupor) or moderate (catalepsy and waxy flexibility); decreased engagement may be severe (mutism) or moderate (negativism); expessive and peculiar motor behavours can be complex (stereotypy) or simple (agination) and may include echolalia and echopraxia.

Question 3

DDx for catatonia?

Answer 3

Ddx: catatonic disorder due to another medical condition, unspecified catatonia

Catatonia – decreased reactivity to environment

Question 4

In which conditions can catatonia occur?

Answer 4

Can occur in psychosis, depression, bipolar,neurodevelopmental and other mental disorders.

Question 5

What are some differentiating features between psychotic disorders (ex. brief psychotic d/o vs szhizoaffective)?

Answer 5

Brief psychotic d/o >1 day <1 month

Schizophreniform (light Form of schizophrenia) >1 month <6 months, no reqd decline in function

Schizophrenia >6 months, at least 1 month of active-phase symptoms

Schizoaffective = mood+psychosis together and also either preceded or followed by at least 2 weeks of delusions or hallucinations without mood symptoms (vs mood disorder with psychosis

Question 6

What is delusional disorder, how do you diagnose?

Answer 6

1+ delusions 1+ month in duration

schizophrenic criteria not met

hallucinations if present are not prominent and related to delusional theme

functioning not markedly impaired, behavior not bizzare

0.2% of population 1:1 M:F

Question 7

What are types of delusions?

Answer 7

Erotomanic type: another person is in love with the individual

Grandiose type: great (but unrecognized) talent or insight or important discovery

Jealous type: spouse or lover unfaithful

Persecutory type: being conspired against, cheated, spied on, followed, poisoned, harassed, obstructed in pursuit of goals – most frequent

Somatic type: bodily functions/sensations

Mixed type: no one delusional theme predominates

Unspecified: if cannot be determined

Specify if with bizarre content (ex. chip instead of brain)

Question 8

DDx for delusions?

Answer 8

Neuro/psychotic: delirium, psychotic disorder due to another medical condition, substance/medication induced psychotic disorder, schizophrenia and schizophreniform d/o

Mood: depressive and bipolar disorders and schizoaffective d/o

Question 9

How do you diagnose brief psychotic disorder?

Answer 9

Brief psychotic d/o
1 or more of: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior

>1 day <1 month

specifiers: with marked stressor(s), without marked stressors, with postpartum onset (within 4 weeks), with catatonia

Question 10

How do you diagnose schizophreniform disorder?

Answer 10

2 or more, each present for significant portion of time during 1 month, at least 1 from top 3

• delusions
• hallucinations
• disorganized speech (derailments, incoherence)
• grossly disorganized or catatonic behavior
• negative symptoms

>1 month < 6 months

may not cause significant decrease in function

Question 11

How do you diagnose Schizophrenia?

Answer 11

Schizophrenia

2 or more of the following (criteria A), present for a significant portion of time during 1 month, one of these must be in top 3

• delusions
• hallucinations
• disorganized speech (derailment, incoherence..)
• grossly disorganized or catatonic behavior
• negative symptoms

level of functioning in one or more major areas, such as work or interpersonal relationships or self-care is markedly below

continuous signs persist for at least 6 month, with 1+ month meeting bullets above (active-phase symptoms)

Question 12

Ddx for schizophrenia?

Answer 12

Ddx for schizophrenia:

Mood: major depressive or bipolar disorder with psychotic or catatonic features, schizoaffective disorder

Psychotic: delusional disorder, schizophreniform and brief psychotic disorders

Personality: schizotypal, but persistent

Anxiety: OCD – preoccupations that reach delusional proportions

PTSD – flashbacks of hallucinatory quality, hypervigilence can reach paranoia

Neurocognitive: autism spectrum or communication – disorganized speech, but will have difficulty in social interactions

Question 13

What is substance/medication induced psychotic disorder?

Answer 13

Substance/Medication-Induced Psychotic disorder

One or both : delusions

hallucinations

Evidence from the history/physical or labs of both 1) and 2):

symptoms in criterion A (delusions, hallucinations etc) developed during or soon after substance intoxication or withdrawal or after exposure to a medication

involved substance/medication is capable of producing the symptoms in criterion A

Question 14

How do you diagnose psychotic disorder due to another medical condition?

Answer 14

Psychotic Disorder Due to another medical condition

~ prominent hallucinations or delusions

~ evidence form the history, physical or labs that it is direct pathophysiological consequence of another medical condition

Question 15

What are four types of extrapyramidal symptoms of antipsychotics?

Answer 15

• tardive dyskinesia
• dystonia
• pseudo-parkinsonian
• akathisia

Question 16

What would tardive dyskinesia look like, how do you treat?

Answer 16

Tardive dyskinesia - involuntary movements of face, eyes, tongue

examples: grimacing, tongue protrusions, lip smacking, REMs
onset: tardive >90 days

tardive EPSs hard to reverse

try: clozapine (last resort), discontinue drug/lower dose

Question 17

What would pseudoparkinsonism look like? how do you treat?

Answer 17

pseudoparkinsonism - EPS s/e of antipsychotic drugs

acute onset usually, within 30 days

parkinsonian features - resting tremor, masked facies, bradykinesia, pill rolling tremor, shuffling gait, difficulty turning, rigidity (cogwheeling), akinesia (loss of impairment of power in voluntary movement)

Tx: benzotropine “Cogentin” (anti-cholinergic), reduce or change to lower potency drug

“taking benzos trip in the park”

or “go gentle on pseudoparkinsonianism”

Question 18

What is akathisia in the context of psychiatry? how do you treat?

Answer 18

akathisia - motor restlessness, sometimes crawling sensation in legs releaved by walking, very distressing

acute - can be treated

“STOP - LAPD”

stop akathisia/restlessness - Lorazepam, propanolol, diphenhydramine = Benadryl (25-50 mg po/IM QID)

Question 19

What is dystonia in th econtext of EPS?

Answer 19

Dystonia - sustained abnormal posture, torsions, twisting, contraction of muscle gorups, muscle spasms, including larygnospasms, torticollis, etc

if acute <5 days, treat with benzotropine (Cognetin = go gentle on it) or dephenhydramine (benadryl)

bSd - looks like twisted muscle

cogentin 2 mg PO or IM or IV OD (6 max)

di-phen-hydramine (Benadryl) 25-50 mg PO/IM QID

Question 20

PRNs for psychosis?

Answer 20

PRNs

Loxapine 5-10 mg PO/IM q1hour PRN for sleep, not to exceed 75 mg in 24 hours (typical antipsychotic)

“sleeps like a log” - start at 10 logs, but no more than 75

Benztropine “Cogentin” 1-2 mg PO/IM q1hour PRN for dystonia, not to exceed 6 mg in 24 hours

Lorazepam 1-2 mg PO/IM q2hours PRN for anxiety or agitation, not to exceed 10 mg in 24 hours (“Ativan” - anxiolytic (benzo))

Question 21

Med regiment for psychosis?

Answer 21

Risperidone:

Start at 0.5 mg PO qhs

Increase 1 mg per day q3days

Target dose = 1-6 mg

Max dose = 8 mg/day

Side Effects:

EPS

Dystonia (especially concerned with diaphragm dystonia)

Parkinsonism (tremor, rigidity, akinesia, postural instability)

Tardive dyskinesia (generally automatisms involving tongue)

Akathisia

NMS (restlessness, rigidity, agitation, HTN, tachycardia, sweating, fever, increased CPK)

Increased prolactin (galactorrhea, gynecomastia, amenorria)

Metabolic syndrome

Anticholinergic Sx (dry mouth, blurry vision, tachycardia, urine retention, constipation)

Antiadrenergic Sx (orthostatic hypotension, syncope)

Antihistamine Sx (drowsiness, weight gain)

Drug-induced hepatitis

Monitoring

Fasting glucose and lipids q3months (monitoring for metabolic syndrome)

Weight, waist circumference q3months (monitoring for metabolic syndrome)

CBC, liver, renal function q3months (monitoring for metabolic syndrome)

AIMS (monitoring for tardive dyskinesia)

ECG (monitoring for QT prolongation)

Question 22

Psychosocial Tx for psychosis?

Answer 22

PSYCHOLOGICAL – Short Term

Psychoeducation (supportive psychotherapy): decrease stigma, educate, provide resources.

Supportive psychotherapy: strengthen healthy defense mechanisms to help day-to-day functioning (ie. Reframing, venting, enhancing self-esteem)

Short-term/brief psychotherapy: resolution of particular emotional problems / acute crisis (agreed upon number of sessions)

Family therapy: reduce conflict, help members understand each other’s needs, help unit cope. Relevant if family involved in care.

Nutrition, exercise, sleep. Important in the mental health of any individual for both prophylactic and active treatment.

PSYCHOLOGICAL – Intermediate/Long Term

Psychoeducation (supportive psychotherapy): decrease stigma, educate, provide resources.

Psychoanalysis: exploration of early experiences and how they might affect current thoughts/emotions/behaviors. Provide insight into depression.

Interpersonal psychotherapy: looking at relationship patterns and teaching coping mechanisms

Supportive psychotherapy: goal is not insight but to reduce anxiety and strengthen healthy defense mechanisms to help day-today functioning (ie. Reframing, venting, enhancing self-esteem)

Family therapy: reduce conflict, help members understand each other’s needs, help unit cope. Relevant if family involved in care.

Group therapy: patients get feedback from peers, gain insight into condition by hearing from others. Self-understanding and acceptance.

CBT – weaken connections between thinking patterns, behaviors and actions.

Mindfulness-based cognitive therapy: aims to help people attend to thoughts, behaviors, and emotions non-judgmentally. Provides insight into their emotions/thoughts/behaviors.

Nutrition, exercise, sleep. Important in the mental health of any individual for both prophylactic and active treatment.

SOCIAL – Short Term

How to get home

Housing

Children/dependents

Work

Behavioral activation: socialize, encourage friends and family to visit

SOCIAL – Intermediate / Long Term – preparing for discharge and f/u in community

Remove means for suicide if identified. Ie. Ask family member to remove medications from home, limit # of pills dispensed by pharmacy.

Housing, detox centers

Finances

Community follow-up: MHT, GP, therapist/psychiatrist

Vocational training

Extended leave: worried about noncompliance and decompensation

Support groups: AA, NA

Plan G: for medication coverage

Question 23

Psychosis, differential:

Answer 23

PSYCHOSIS

DIFFERENTIAL DIAGNOSIS

Axis I: The major psychiatric disorders

Schizophrenia, schizoaffective d/o, schizophreniform, brief psychotic d/o, delusionsal disorder, malingering, factitious, dementia, delirium

Major depressive s/o, BAD type I, BAD type II

Substance Abuse: cocaine, alcohol withdrawal, benzodiazepine withdrawal, LSD, opiates, PCP, marijuana, amphetamines

Psychosis due to a general medical condition

Axis II: Personality disorders and intellectual disabilities

Cluster A: schizotypal, schizoid, paranoid

Cluster B: borderline

Axis III: General Medical Conditions

Endocrine: hypo/hyperthyroid, hypo/hypercalcemia, porphyria, hypo/hyperparathyroid, Cushing’s, Addison’s, Wilson’s, DM

Neurological: stroke, Parkinson’s, Huntington’s, MS, neoplasm, seizures/epilepsy, encephalitis

Other: kidney disease/uremia, liver disease/hepatic encephalopathy, SLE, RA, Vitamin B12/folate/niacin/thiamine deficiency, HIV, trauma, tertiary syphilis

Medications: corticosteroids, antiHTN, antibiotics, antituberculosis medications, digoxin, histamine receptor blockers (cimetidine, ranitidine), antineoplastic medications, analgesics, opiates, clonidine, methyldopa, metoclopramide, levodopa/carbodopa, benzodiazepines, barbiturates, heavy metals.

Axis IV: Psychosocial and Environmental Problems (Stressors)

Ie. Work, death, move, sickness, children, finances, housing, access to health care, legal problems.

Axis V: GAF

91-100: Superior functioning in a wide range of activities.

81-90: Absent or minimal Sx

71-80: If Sx present, they are transient and expected reactions to stressors.

61-70: Some mild Sx or some difficulty but generally functioning well

51-60: Moderate Sx or difficulty

41-50: Serious Sx or difficulty

31-40: Some impairment in reality testing/communication, impairment in several areas.

21-30: Behavior influenced by delusions/hallucinations or serious impairment in communication/judgment

11-20: Some danger of hurting self or others or occasionally fails to maintain minimal hygiene or gross impairment in communication

1-10: Persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene or serious suicideal act.

0: Inadequate information

Question 24

admission parameters - psychosis?

Answer 24

ADMISSION

Admit to psychiatry under Dr. X vs discharge: risk to self, others, decompensation.

Voluntary or involuntary

Diagnosis

DAT

Activity

No privileges until assessed in the AM

Hospital gown only

No passes

Restraints PRN

Seclusion PRN

Observation (regular – close – 1:1)

Vitals: routine, BID x 48 hours, then reassess q4-6 hours: no withdrawal or other pertinent reasons for more than routine vitals.

Investigations

Labs

CBC + diff

TSH

Vitamin B12, folate

Ferritin

Renal function (Cr, BUN, eGFR)

Liver function (AST, ALT, GGT)

Electrolytes, calcium, magnesium, phosphate

Fasting lipids and glucose

ECG

Urine drug screen

B-hCG

VDRL/RPR for syphillis

EEG + CT head (if suspicious – or first episode psychosis)

BMI, waist circumference, Vitals

Medication levels (valproic acid, lithium, clozapine)

HIV testing

Screen for safety/suicide

Blood toxicology (acetominophen, ASA, alcohol)

b. Collateral

Old chart

PARIS notes

MHT notes

Friends, family

GP

Previous hospitalizations

Police, ambulance reports

Pharmanet

Full physical exam

Question 25

What meds along with antipsychotics contribute to QT prolongation -> torsades -> cardiac arrest?

Answer 25

QT -> AAA

Antipsychotics

Antiarrhythmics

Antibiotics (clarithromycin a big one)

Antidepressant - TCA

Additive effects much worse