Psychosis (incl. Catatonia) Flashcards
What is catatonia?
Catatonia - reduced reaction to external environment
How do you diagnose catatonia via DSM 5?
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.
DDx for catatonia?
Ddx: catatonic disorder due to another medical condition, unspecified catatonia
Catatonia – decreased reactivity to environment
In which conditions can catatonia occur?
Can occur in psychosis, depression, bipolar,neurodevelopmental and other mental disorders.
What are some differentiating features between psychotic disorders (ex. brief psychotic d/o vs szhizoaffective)?
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
What is delusional disorder, how do you diagnose?
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
What are types of delusions?
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)
DDx for delusions?
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
How do you diagnose brief psychotic disorder?
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
How do you diagnose schizophreniform disorder?
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
How do you diagnose Schizophrenia?
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)
Ddx for schizophrenia?
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
What is substance/medication induced psychotic disorder?
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
How do you diagnose psychotic disorder due to another medical condition?
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
What are four types of extrapyramidal symptoms of antipsychotics?
- tardive dyskinesia
- dystonia
- pseudo-parkinsonian
- akathisia
What would tardive dyskinesia look like, how do you treat?
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
What would pseudoparkinsonism look like? how do you treat?
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”
What is akathisia in the context of psychiatry? how do you treat?
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)
What is dystonia in th econtext of EPS?
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
PRNs for psychosis?
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))
Med regiment for psychosis?
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)
Psychosocial Tx for psychosis?
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
Psychosis, differential:
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
admission parameters - psychosis?
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
